TUCSON, ARIZ. -- There is growing support for the notion that two mood stabilizers are more effective than one in the treatment of bipolar disorder in children and adolescents--despite little comprehensive data on the subject, Dr. Patrick M. Burke said at a psychopharmacology conference sponsored by the University of Arizona.
According to Dr. Burke, ongoing studies point to a combination of lithium and divalproex sodium as one reasonable approach.
The general thinking among experts in the disorder is that adjunctive medications such as stimulants and neuroleptics may be needed as well.
One reason for such scanty data on bipolar disorder in children is the longstanding controversy about the disorder, said Dr. Burke, chief of child and adolescent psychiatry at the University of Arizona, Tucson.
Until the late 1970s, it was believed that bipolar disorder did not occur until adulthood. Even now, a dispute rages about whether bipolar disorder and attention-deficit hyperactivity disorder overlap, he said.
"Research groups can't even talk to each other at meetings," he said.
In general, though, most child psychiatrists now believe bipolar disorder has a prevalence of about 1% in children and adolescents, and they concede that it is associated with significant morbidity.
Dr. Pablo Davanzo and Dr. James McCracken of the University of California, Los Angeles, have proposed a suggested regimen that calls for lithium treatment in uncomplicated cases, divalproex sodium for patients with mixed bipolar disorder, and carbamazepine for preadolescent patients and those with complicating aggression. (See accompanying chart for dosages.)
Lithium is the best-studied medication, Dr. Burke said, although some experts believe that pediatric patients with rapid cycling will not respond well to lithium.
One as-yet unpublished study found that 46% of pediatric bipolar patients responded to lithium, 42% to valproate, and 34% to carbamazepine.
"The small numbers [of patients enrolled] preclude an understanding of what's significant" about the data, Dr. Burke commented.
Nonetheless, the study points out that at least half of patients appear to need a combination of medications.
A similar dearth of data guides psychiatrists who wonder if they should add a stimulant.
Dr. Burke said the general belief is that stimulants should be prescribed as needed.
A study in adults with bipolar disorder found that those who were prescribed stimulants during childhood and adolescence fared no worse in the long term than those who received only mood-stabilizing drugs.
One pediatric study similarly showed no adverse effects from stimulants, he added.
Dr. Burke warned colleagues that insufficient data exist to support the use of the newer anticonvulsants in pediatric bipolar disorder. …