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Bipolar Disorder in Children and Adolescents

By

Josephine Elia

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision May 2019| Content last modified May 2019
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Topic Resources

Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time. Diagnosis is based on clinical criteria. Treatment is a combination of mood stabilizers (eg, lithium, certain anticonvulsants, antipsychotic drugs), psychotherapy, and antidepressants.

Bipolar disorder typically begins during mid-adolescence through the mid-20s. In many children, the initial manifestation is one or more episodes of depression. (See also Bipolar Disorders in adults.)

Bipolar disorder is rare in children. In the past, bipolar disorder was diagnosed in prepubertal children who were disabled by intense, unstable moods. However, because such children typically progress to a depressive rather than bipolar disorder, they are now classified as having disruptive mood dysregulation disorder.

Etiology

Etiology of bipolar disorder is unknown, but heredity is involved. Dysregulation of serotonin and norepinephrine may be involved, as may a stressful life event.

Certain drugs (eg, cocaine, amphetamines, phencyclidines, certain antidepressants) and environmental toxins (eg, lead) can exacerbate or mimic the disorder. Certain disorders (eg, thyroid disorders) can cause similar symptoms.

Symptoms and Signs

The hallmark of bipolar disorder is the manic episode. Manic episodes alternate with depressive episodes, which can be more frequent. During a manic episode in adolescents, mood may be very positive or hyperirritable and often alternates between the 2 moods depending on social circumstances. Speech is rapid and pressured, sleep is decreased, and self-esteem is inflated. Mania may reach psychotic proportions (eg, “I have become one with God”). Judgment may be severely impaired, and adolescents may engage in risky behaviors (eg, promiscuous sex, reckless driving).

Prepubertal children may experience dramatic moods, but the duration of these moods is much shorter (often lasting only a few moments) than that in adolescents.

Onset is characteristically insidious, and children typically have a history of always being very temperamental and difficult to manage.

Diagnosis

  • Clinical evaluation

  • Testing for toxicologic causes

Diagnosis of bipolar disorder is based on identification of symptoms of mania as described above, plus a history of remission and relapse.

A number of medical disorders (eg, thyroid disorders, brain infections or tumors) and drug intoxication must be ruled out with appropriate medical assessment, including a toxicology screen for drugs of abuse and environmental toxins. The interviewer should also search for precipitating events, such as severe psychologic stress, including sexual abuse or incest.

Prognosis

Prognosis for adolescents with bipolar disorder varies. Those who have mild to moderate symptoms, who have a good response to treatment, and who remain adherent and cooperative with treatment have an excellent prognosis. However, treatment response is often incomplete, and adolescents are notoriously nonadherent to drug regimens. For such adolescents, the long-term prognosis is not as good.

Little is known about the long-term prognosis of prepubertal children diagnosed with bipolar disorder based on highly unstable and intense moods.

Treatment

  • Mood stabilizers and antidepressants

  • Psychotherapy

For adolescents and prepubertal children, mood stabilizers are used to treat manic or agitated episodes, and psychotherapy and antidepressants are used to treat the depressive episodes.

Mood stabilizers (see table Selected Drugs for Bipolar Disorder) roughly fall into 3 categories:

  • Mood-stabilizing anticonvulsants

  • Mood-stabilizing antipsychotics

  • Lithium

All mood stabilizers have a potential for troubling and even dangerous adverse effects. Thus, treatment must be individualized. Furthermore, drugs that are highly successful during initial stabilization may be unacceptable for maintenance because of adverse effects, most notably weight gain.

Antidepressants may trigger a switch from depression to mania; therefore, they are usually used with a mood stabilizer.

Pearls & Pitfalls

  • In patients with bipolar disorder, antidepressants may trigger a switch from depression to mania, so they are usually used with a mood stabilizer.

Table
icon

Selected Drugs for Bipolar Disorder*

Drug

Indication

Starting Dose

Maintenance Dose

Comments

Lithium

Lithium extended-release‡,§, in adolescents ≥ 12 years

Acute mania and maintenance

450–900 mg twice a day

Dose titrated to a blood level of 0.8–1.2 mEq/L (or mmol/L)

Lithium, immediate-release‡,§, in adolescents

Acute mania and maintenance

200–300 mg three times a day

300–600 mg three times a day up to 2400 mg

The maximum daily dose is 40 mg/kg

Antipsychotics

Aripiprazole§ in children ≥ 10 years

Acute mania

Psychosis

2–5 mg once a day

Up to 30 mg once a day

Limited experience in children

Chlorpromazine in children > 5 years‡,§

Acute mania

Psychosis

0.6–1.5 mg/kg every 6 hours up to 200 mg/day

Rarely used (in children who do not respond to newer drugs) because newer drugs have a more favorable adverse effect profile

Lurasidone in children > 10 years

Bipolar depression

20 mg once a day

Up to 80 mg/day

Olanzapine in children > 13 years§

Acute mania

Psychosis

2.5–5 mg once a day

Up to 10 mg twice a day

Causes weight gain, which may limit use in some patients

Olanzapine/fluoxetine fixed combination in children > 10 years‡,§

Bipolar depression

3 mg/25 mg once a day

Up to 12 mg/50 mg once a day

Limited experience in children

Paliperidone in children > 12 years ‡,§

Acute mania

Psychosis

3 mg once a day

Up to 3 mg twice a day

Closely related to risperidone

Very limited experience in children

Quetiapine, immediate-release, in children > 10 years§

Acute mania

Psychosis

25 mg twice a day

Up to 200 mg twice a day

Causes sedation that may limit dose increases

Risperidone in children > 10 years§

Acute mania

Psychosis

0.5 mg once a day

Up to 2.5 mg/day

Maintenance dose highly variable

Doses up to 6 mg/day have been studied, but they provide no additional benefit and increase risk of neurologic adverse effects

Ziprasidone in children > 10 years§

Acute mania

Psychosis

20 mg once a day

Up to 40 mg twice a day

Very limited experience in children

Anticonvulsants

Carbamazepine

Acute mania and mixed episode

200 mg twice a day

Up to 600 mg twice a day

Metabolic enzyme induction, possibly requiring dose adjustments

May cause Stevens-Johnson syndrome, especially in patients with HLA-B*1502 genotype, which is most common in patients of Asian ancestry, who should probably have HLA genotyping

Divalproex

Acute mania

5 mg/kg two or three times a day

Up to 10–20 mg/kg three times a day

Dose titrated to a blood level of 50–125 mcg/mL

Lamotrigine

Maintenance

25 mg once a day

Up to 100 mg twice a day

Requires that dosing guidelines in the package insert be followed closely

*These drugs pose a small but serious risk for a wide variety of major adverse effects. Therefore, benefits must be carefully weighed against potential risks.

Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable. This table is not a substitute for the full prescribing information.

These drugs have not been studied in children. For dosing in children under 12 years of age, see the prescribing information.

§These drugs increase the risk of weight gain, negative effects on the lipid profile, increases in glucose and prolactin levels, and QT prolongation.

Key Points

  • Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time.

  • Bipolar disorder typically begins during mid-adolescence through the mid-20s; it is rare in children.

  • Typically, onset is insidious; children have a history of being very temperamental and difficult to manage.

  • In adolescents and prepubertal children, treat manic or agitated episodes with mood stabilizers and depressive episodes with psychotherapy and antidepressants (usually with a mood stabilizer).

Drugs Mentioned In This Article

Drug Name Select Trade
No US brand name
LEVOPHED
TEGRETOL
INVEGA
ABILIFY
GEODON
RISPERDAL
LAMICTAL
LATUDA
PROZAC, SARAFEM
ZYPREXA
SEROQUEL
LITHOBID
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