Omega-3 Fatty Acids Associated with Small Improvement in Depression in Children Aged 7–14

February 22, 2016 · Posted in Potential Treatments · Comment 

omega 3s

At the 2015 meeting of the American Academy of Child and Adolescent Psychiatry, researcher Mary A. Fristad reported that omega-3 fatty acid supplements had a small beneficial effect on depression in children aged 7–14. The supplements did not noticeably improve bipolar disorder not otherwise specified (NOS) or mania. The supplements consisted of several types of omega-3 fatty acids, including 1400mg of EPA, 200mg of DHA, and 400mg of others per day. The children were also undergoing psychotherapy during the study.

Children at Risk for Bipolar Disorder May Have Adverse Reactions to Antidepressants

February 11, 2016 · Posted in Current Treatments · Comment 

adverse reaction to antidepressantsAt the 2015 meeting of the American Academy of Child and Adolescent Psychiatry, researcher Jeffrey R. Strawn reported that among children at high risk for bipolar disorder (because of a family history of the disorder) who are prescribed antidepressants for depression and anxiety, adverse reactions are common. These reactions include irritability, aggression, impulsivity, and hyperactivity, and often lead to discontinuation of the antidepressant treatment.

Younger patients at risk for bipolar disorder were more likely to have an adverse reaction to antidepressants. Risk of an adverse reaction decreased 27% with each year of age.

RTMS Improves Executive Function in Kids with Schizophrenia and Autism

February 10, 2016 · Posted in Current Treatments · Comment 

rTMSResearcher Stephanie Ameis reported at the 2015 meeting of the American Academy of Child and Adolescent Psychiatry that following repeated transcranial magnetic stimulation (rTMS), a treatment in which a magnetic coil placed over the scalp delivers electric pulses to the brain, children with schizophrenia and autism spectrum disorders showed improvements in executive function, including working memory. The rTMS treatment targeted the left dorsolateral prefrontal cortex.

Offspring of Bipolar Parents at High Risk for Psychiatric Disorders

February 10, 2016 · Posted in Risk Factors · Comment 

children of parents with bipolar disorder are at high risk for the illness

Researcher Juan David Palacio reported at the 2015 meeting of the American Academy of Child and Adolescent Psychiatry that compared to offspring of non-ill parents, children of parents with bipolar I disorder are at high risk for psychiatric disorders, particularly bipolar spectrum disorders and substance use disorders. They were also at risk for symptoms of anxiety disorders and conduct disorder. Palacio’s findings from Colombia mirror those from other studies of familial risk and suggest the importance of vigilance to detect these disorders early and provide appropriate treatment. Our Child Network may help.

Diagnosing Childhood Bipolar Disorder: Mom Knows Best

January 15, 2016 · Posted in Diagnosis · Comment 

mother knows best

In a talk at the 2015 meeting of the International Society for Bipolar Disorders, researcher Eric Youngstrom showed that mothers’ evaluation of their children’s psychiatric symptoms was more valid than both teacher ratings and the children’s own evaluations. Parents were better at detecting irritability, while children were better at assessing their energy levels and the quality of their sleep.

Youngstrom reported that about 2% of children worldwide are diagnosed with bipolar disorder. However, when bipolar disorder not otherwise specified (BP NOS), a diagnosis given when symptoms do not meet the diagnostic criteria for Bipolar I or II, is included in the statistics, rates of bipolar disorder among children in the US reach about 6%.

Youngstrom mentioned that an epidemiological study by Kathleen Merikangas found that among children in the US with a bipolar spectrum diagnosis, only 22% were in treatment, compared to 38% of those with depression and 60% of those with ADHD.

Parents of children (aged 2–12) with mood, anxiety, and behavioral disorders are invited to join the Child Network, our program for tracking weekly symptoms which can then be printed out longitudinally to share with the child’s doctor.

Reduced Cognitive Function and Other Abnormalities in Pediatric Bipolar Disorder

January 6, 2016 · Posted in Course of Illness, Risk Factors · Comment 

pediatric bipolar disorderAt the 2015 meeting of the International Society for Bipolar Disorders, Ben Goldstein described a study of cognitive dysfunction in pediatric bipolar disorder. Children with bipolar disorder were three years behind in executive functioning (which covers abilities such as planning and problem-solving) and verbal memory.

There were other abnormalities. Youth with bipolar disorder had smaller amygdalas, and those with larger amygdalas recovered better. Perception of facial emotion was another area of weakness for children (and adults) with bipolar disorder. Studies show increased activity of the amygdala during facial emotion recognition tasks.

Goldstein reported that nine studies show that youth with bipolar disorder have reduced white matter integrity. This has also been observed in their relatives without bipolar disorder, suggesting that it is a sign of vulnerability to bipolar illness. This could identify children who could benefit from preemptive treatment because they are at high risk for developing bipolar disorder due to a family history of the illness.

There are some indications of increased inflammation in pediatric bipolar disorder. CRP, a protein that is a marker of inflammation, is elevated to a level equivalent to those in kids with juvenile rheumatoid arthritis before treatment (about 3 mg/L). CRP levels may be able to predict onset of depression or mania in those with minor symptoms, and is also associated with depression duration and severity. Goldstein reported that TNF-alpha, another inflammatory marker, may be elevated in children with psychosis.

Goldstein noted a study by Ghanshyam Pandey that showed that improvement in pediatric bipolar disorder was related to increases in BDNF, a protein that protects neurons. Cognitive flexibility interacted with CRP and BDNF—those with low BDNF had more cognitive impairment as their CRP increased than did those with high BDNF.

Offspring of Parents with Psychiatric Disorders At Increased Risk for Disorders of Their Own

January 4, 2016 · Posted in Risk Factors · Comment 

children of parents with psychiatric disorders at risk

At a symposium at the 2015 meeting of the International Society for Bipolar Disorder, researcher Rudolph Uher discussed FORBOW, his study of families at high risk for mood disorders. Offspring of parents with bipolar disorder and severe depression are at higher risk for a variety of illnesses than offspring of healthy parents.

Uher’s data came from a 2014 meta-analysis by Daniel Rasic and colleagues (including Uher) that was published in the journal Schizophrenia Bulletin. The article described the risks of developing mental illnesses for 3,863 offspring of parents with schizophrenia, bipolar disorder, or major depression compared to offspring of parents without such disorders.

Previous literature had indicated that offspring of parents with severe mental illness had a 1-in-10 likelihood of developing a severe mental illness of their own by adulthood. Rasic and colleagues suggested that the risk may actually be higher—1-in-3 for the risk of developing a psychotic or major mood disorder, and 1-in-2 for the risk of developing any mental disorder. An adult child may end up being diagnosed with a different illness than his or her parents.

risk of psychiatric illnessAt the symposium, Uher focused on families in which a parent had bipolar disorder. These families made up 1,492 of the offspring in the Rasic study. The table at right shows the risk of an illness among the offspring of bipolar parents compared to that risk among offspring of healthy parents, otherwise known as relative risk. (For example, offspring of parents with bipolar disorder are 4.24 times more likely to be diagnosed with bipolar disorder themselves than are offspring of non-bipolar parents.) The table also shows the percentage of offspring of parents with bipolar disorder who have each type of disorder.

Editor’s Note: These data emphasize the importance of vigilance for problems in children who are at increased risk for mental disorders because they have a family history of mental disorders. One way for parents to better track mood and behavioral symptoms is to join our Child Network.

Treating Bipolar Disorder in Children and Adolescents

December 16, 2015 · Posted in Current Treatments · Comment 

bipolar disorder in children and teens

Bipolar disorder in childhood or adolescence can destroy academic, family, and peer relationships and increase vulnerability to drug use, unsafe sexual encounters, disability, and suicide. Treatment is critical to avoid cognitive decline. Given the potential tragic outcomes of undertreating bipolar illness, it is concerning that 40–60% of children and adolescents with bipolar disorder are not in treatment.

In a talk at the 2015 meeting of the International Society for Bipolar Disorder, researcher Cristian Zeni reviewed the existing research on the treatment of bipolar disorder in children and adolescents. A 2012 study by Geller reported response rates of 68% for the atypical antipsychotic risperidone, 35% for lithium and 24% for valproate. Risperidone was linked to weight gain and increases in prolactin, a protein secreted by the pituitary gland, while lithium was linked to more discontinuations and valproate to sedation.

For children or adolescents with aggression, researcher Robert Kowatch recommends quetiapine, aripiprazole, and risperidone. For those with a family history of bipolar disorder, he recommends lithium or alternatively, valproate plus an atypical antipsychotic.

Reseacher Robert Findling has found that lamotrigine has positive effects in childhood mania, and Duffy et al. found in a study of 21 children with mania that 13 remained stable on monotherapy with quetiapine for 40 weeks without relapse, while 5 others required combination treatment with more than one drug.  In studies by Karen Wagner, oxcarbazepine was significantly better than placebo at reducing mania in younger children (ages 7–12), but not older children (13–18).

Studies by Duffy and colleagues in 2007 and 2009 recommend lithium for those with a family history of bipolar disorder, atypical antipsychotics for children with no family history of bipolar disorder, and lamotrigine for those with a family history of anxiety disorders.

In children with bipolar disorder and comorbid attention deficit hyperactivity disorder, there is universal agreement that mood should be stabilized first, and then small amounts of stimulants may be added for residual ADHD symptoms. Too often, the opposite occurs, with stimulants given prior to mood stabilization with lithium, anticonvulsants (valproate, lamotrigine, carbamazepine/oxcarbazepine) and/or an atypical antipsychotic. Read more

Several Types of Psychotherapy Effective in Childhood Bipolar Disorder

December 14, 2015 · Posted in Current Treatments · Comment 

psychotherapy

Childhood onset bipolar disorder can be highly impairing. Treatment usually includes medication, but several types of psychotherapy have also been found to be superior to treatment as usual. These include family focused therapy, dialectical behavior therapy and multifamily psychoeducation groups, including Rainbow therapy.

Family focused therapy, developed by David Miklowitz, consists of psychoeducation about bipolar disorder and the importance of maintaining a stable medication routine. Families are taught to recognize early symptoms of manic and depressive episodes, and how to cope with them. Families also learn communication and problem solving skills that can prevent stressful interactions.

Dialectical behavior therapy was developed by Marsha Linehan, initially for the treatment of borderline personality disorder. It can be useful in bipolar disorder because participants learn how to manage stressors that might otherwise trigger depression or mania. DBT teaches five skills: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self management.

Multifamily psychoeducation was developed by Mary Fristad. In groups, children and parents learn about mood disorders, including how to manage symptoms, and also work on communication, problem solving, emotion regulation, and decreasing family tension.

Rainbow therapy is a type of multifamily approach also known as child and family-focused cognitive-behavioral therapy (CFF CBT). It integrates individual cognitive-behavioral therapy with family psychoeducation and mindfulness skills training. In a recent article in the journal Evidence Based Mental Health, Miklowitz reviewed the current research on Rainbow therapy. While the research to date has many limitations, he highlighted some benefits of Rainbow therapy: its flexibility, and its focus on treating parents’ symptoms along with children’s illness.

Lithium Safely Reduces Mania in Kids 7–17

December 11, 2015 · Posted in Current Treatments · Comment 

reduced mania

The first large, randomized, double-blind study of lithium in children and teens has shown that as in adults, the drug can reduce mania with minimal side effects. The study by researcher Robert Findling was published in the journal Pediatrics in October. Lithium is the best available treatment for adults, but until now little research had been done on treatments for children and teens with bipolar disorder.

In the study, 81 participants between the ages of 7 and 17 with a diagnosis of bipolar I disorder and manic or mixed episodes were randomized to receive either lithium or placebo for a period of eight weeks. By the end of the study, those patients taking lithium showed greater reductions in manic symptoms than those taking placebo. Among those taking lithium, 47% scored “much improved” or “very much improved” on a scale of symptom severity, compared to 21% of those taking placebo.

Dosing began at 900mg/day for most participants. (Those weighing less than 65 lbs. were started at 600mg/day.) Dosing could be gradually increased. The mean dose for patients aged 7–11 was 1292mg/day, and for patients aged 12–17 it was 1716mg/day.

Side effects were minimal. There were no significant differences in weight gain between the two groups. Those taking lithium had significantly higher levels of thyrotropin, a peptide that regulates thyroid hormones, than those taking placebo.  If thyroid function is affected in people taking lithium,  the lithium dosage may be decreased, or patients may be prescribed thyroid hormone.

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