One Expert’s Personal Treatment Algorithm for Bipolar Disorder in Young Children

October 26, 2010 · Posted in Current Treatments, Resources 

EDITOR’S NOTE:  Dr. Gagin Joshi of Massachusetts General Hospital, who presented the work on carbamazepine and lamotrigine on page 1 provided us with his own general treatment algorithm for youngsters with bipolar disorder.

Omega-3 Fatty Acids

Omega-3 Fatty Acids (photo from

Joshi typically starts with 0.5 to 2 gms of omega-3 fatty acids because of their benign side-effects profile, the many studies suggesting they are effective in adult mood disorders, and a recent article indicating that they were effective in preventing the conversion of prodromal schizophrenia into full-blown illness in a randomized double-blind controlled study in Australia.

After the omega-3 fatty acids, Joshi’s second choice is typically the atypical antipsychotic aripiprazole (Abilify) because of its lesser degree of weight gain compared to atypicals quetiapine (Seroquel) or risperidone (Risperidol). Risperidone can be a third option if aripiprazole is not effective or tolerated.

Depending on the presentation of the individual, particularly if substantial amounts of depression are present, Joshi would next utilize lamotrigine.  However, if mania was more problematic, he would use either lithium or valproic acid.

Editor’s Note: When dealing with BP-NOS and other presentations involving depression or mild mania, a number of childhood bipolar investigators like Joshi do prescribe lamotrigine. This is despite the fact that lamotrigine lacks acute antimanic efficacy in adults and that children are more prone to severe rashes on lamotrigine. (One in 2,500 children will develop a rash on lamotrigine versus 1 in 5,000 adults.) When used in children, insomnia can also be a side effect.

Other childhood experts with whom this editor has communicated indicate that they like to start with the combination of valproate and quetiapine for children with Bipolar I disorder, while still others report good effects with lithium plus valproate. Other sequences used by several experts in the field for a BP NOS child (age 6) and a BP I child (age 9) are detailed in an article this editor and Janet Wozniak contributed to Psychiatric Annals in 2009.


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