Transcript Treatment of Acute Mania in Pediatric Bipolar Disorder

Treatment of Acute Mania in
Pediatric Bipolar Disorder
Assessing the Evidence
Stewart S. Newman MD
Senior Child Fellow
Discussion Case
16 y/o WF with hx of bipolar disorder
presents to the PES in the custody of
AA police
Reportedly was in a physical
altercation with a fellow student at
Pioneer HS
Police indicate she was combative
and belligerent towards them upon
initial contact
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Discussion Case, cont’d
Patient is followed by a Child Fellow
in the Commonwealth outpatient clinic
Previously treated with divalproex and
risperidone in combination
Records indicate she has missed her
last three appointments, and her
medication supply should have been
exhausted two months ago
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Discussion Case, cont’d
Per the outpatient treatment notes,
the patient has been hospitalized
once previously for suicidal ideation
The patient has a history of
intermittent cannabis and alcohol
abuse
There is a family history of bipolar
disorder in a paternal grandfather
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Discussion Case, cont’d
On initial assessment, she is
hyperverbal, giddy and expansive, but
can rapidly become angry and
belligerent with staff
She is unable to give an account of
the altercation at school, simply
stating “The bitch deserved it.”
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Discussion Case, cont’d
Tells the evaluator repeatedly “You
don’t want to do this, you know I’m
too important to be put through this.”
When stopped by the police officer
from leaving PES, she begins to
make sexualized comments towards
him regarding being “handcuffed”
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Discussion Case, cont’d
The patient becomes combative with
staff members, tries to elope and
Security responds to PES
The patient is placed in the seclusion
suite due to elopement risk
She is refusing any medication to
calm her or organize her thoughts
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“The Question”
“What evidence do we have
to guide the treatment of
acute mania in pediatric
bipolar disorder?”
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Levels of Evidence
Level A: systematic review of RCTs with
narrow confidence intervals
Level B: systematic review of cohort
studies with homogeneity, individual cohort
study, or low quality RCT outcomes studies
Level C: systematic review of case-control
studies, individual case control studies,
case series, and expert opinions with
explicit critical appraisal
Adapted from the US Preventive Services Task
Force 1996
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Searching the Literature
Online resources only
Searches on Medline, EMBase,
Cochrane, Up To Date, MD Consult,
AACAP Website
Used keyword searches:
Pediatric bipolar disorder
Pediatric mania
Acute mania treatment
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Selected Articles
 M. N. Pavuluri et. al. “A Pharmacotherapy
Algorithm for Stabilization and Maintenance of
Pediatric Bipolar Disorder” JAACAP 43:7, July
2004
 M. Bourin, O. Lambert and B. Guitton “Treatment
of Acute Mania- from clinical trials to
recommendations for clinical practice” Human
Psychopharmacology 20, 2005
 J. McClellan and J. Werry “AACAP Practice
Parameters for the Assessment and Treatment of
Children and Adolescents with Bipolar Disorder”
JAACAP 1997
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Pavuluri et. al. 2004
Developed and studied a treatment
algorithm for stabilization and
maintenance of pediatric bipolar
disorder
Two phases of treatment- goal of the
first phase was mood stabilization
Discussed evidence used for
development of the algorithm
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Pavuluri et. al. 2004
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Pavuluri et. al. 2004
Noted Level B studies in children
indicate mood stabilizers as the
primary agents
Lithium or divalproex as first line
agents, followed by carbamazepine
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Pavuluri et. al. 2004
Good evidence for addition of atypical
antipsychotic agent for more severe
or psychotic mania cases
Atypical antipsychotic agent
monotherapy first line for predominant
irritability or aggression
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Pavuluri et. al. 2004
Positives:
Specific to the pediatric population
Development of treatment algorithm
Discussion of level of evidence used
Negatives:
Treatment not specific to acute mania
Use of three mood stabilizers, four
atypical antipsychotics
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Bourin et. al. 2005
Review of the literature regarding
treatment of acute mania
Highlights the conceptual differences
between the US and Europe
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Bourin et. al. 2005
Discusses individual medications
(mood stabilizers, antipsychotics, and
benzodiazepines) alone and in
combinations
Also discusses efficacy of certain
agents, forms of mania that predict
treatment response, and alternate
agent choices in a systematic manner
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Bourin et. al. 2005
Recommends first line use of mood
stabilizers lithium and divalproate,
with carbamazepine as second line
Also recommends use of atypical
antipsychotics as monotherapy or
adjunct to mood stabilizer treatment
Discussed use of “third gen”
anticonvulsants in detail
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Bourin et. al. 2005
Positives:
Specific to treatment of acute mania
Discusses available evidence in a
systematic fashion
Recent review of the literature
Negatives:
Not specific to children
Emphasis on US vs Europe
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McClellan, Werry 1997
“Practice Parameters” series
represent exhaustive review of the
available literature and expert
concensus
Specific section regarding treatment
of acute manic symptoms
Explicitly discusses rationale for
choice of medication
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McClellan, Werry 1997
Recommend mood stabilizers (lithium
and divalproex) as first line agents
Carbamazepine recommended as
second line mood stabilizer
Adjunctive treatment with atypical
antipsychotics or benzodiazepines
may be necessary
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McClellan, Werry 1997
Positives:
Focused on treatment of children
Section on acute mania treatment
Authority that establishes “standard of
care”
Negatives:
38 pages long!
Dated literature review with no recent
update available
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Conclusions
First line treatment for acute mania in
children and adolescents
Mood stabilizer: lithium or divalproex
Consider carbamazepine second
Consideration of adjunctive treatment
Atypical antipsychotics, especially in
mania with psychosis or agitation
Possibly antipsychotic monotherapy
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