Week 9: Bipolar Treatment Flashcards
Medication
Mood stabilizers
Antipsychotics
Anti-depressants
Mood Stabilizers
Lithium
Common treatment for adult bipolar disorder
Mood stabilizer
Approved for use in children aged 12 and older
Serious side effects
Toxicity
Difference between an effective dose of lithium and a toxic dose is very small
Renal and thyroid problems
Weight gain
Compliance with instructions VERY important and here, weight gain is often an issue
DISCUSS WITH DOC
Have to visit physician regularly to monitor side effects
Two RCTs as well as an open-label trial suggest that lithium is effective for reducing symptoms of mania in youth
Open label trials mean it is not blind. Easier to run, not as strong
Atypical Antipsychotics
Wide-ranging class of antipsychotics
Also called 2nd generation
No psychomotor effects
Ten RCTs have demonstrated that these medications are effective
for treatment of bipolar disorder in youth
Anti-Depressants
Depression can be chronic and severe
Mania management is not enough
Mood stabilizer/antipsychotics may not help that
Can that be treated with anti-depressant medication?
Bipolar switch – induces mania
Sometimes taking anti-depressants switches to mania (not clear research wise)
Research is mixed
Research with adolescents has suggested that those treated with antidepressant alone were more likely to experience a manic episode than those treated with an atypical antipsychotic
Research with adults has suggested anti-depressants were not associated with inducing mania, but follow up was very short term
Anti-depressants may be prescribed in combination with an atypical antipsychotic or lithium
ALWAYS IN COMBINATION
Psychopharmacology and Bipolar
Pharmacotherapy is indicated for nearly all youth with bipolar
disorder
Many youth with bipolar will not receive medication
Many may be treated with the wrong medication (e.g., an antidepressant by itself)
Medication
Recommendation for treating mania in youth is as follows:
Begin with one atypical antipsychotic
If patient does not respond, or cannot tolerate the drug, taper, and then try a second atypical antipsychotic
If patient does not respond to two or three atypical
antipsychotics, switch to lithium
If patient partly responded to antipsychotic, add lithium
This makes it quite hard to manage for psychiatrists
Psychosocial Treatments
Medication is first line treatment
Family Education
Understanding disorder and symptoms
Reducing conflict in the family
Medication management
- Poor compliance to medication regimes is a major source of relapse
- Medications can be toxic
- Important for family to be educated about the medications
Evidence for Psychosocial
Treatment
RCTs have shown support for two family treatments
(1) Multifamily Psychoeducational Psychotherapy (Fristad et al.,
2009)
(2) Family-focused therapy (Miklowitz et al., 2014)
- Education, communication, problem-solving skills
In both studies, participants who received family therapy showed an improvement in mood symptoms compared to those who did not
Child- and Family-Focused CBT
RAINBOW
Routine
-Establish a predictable routine that will reduce tantrums, negativity, conflict
Affect regulation
- Parents taught behavior management techniques
- Children taught to monitor and recognize moods
I can do it!
-Increase children’s and parents’ beliefs that they can manage bipolar symptoms
No negative thoughts
-Retraining cognitive distortions associated with depression
(it is not just mania in bipolar)
Be a good friend and balanced lifestyle
- Taught skills necessary to be a good friend and given opportunities to practice
- Help parents learn to develop a balanced lifestyle
- Everything can become about the kid with Bipolar, not good for family or siblings (or parents)
Oh, how can we solve this problem?
-Help parents and children learn to problem-solve together like how can we make sure you take meds every day
Ways to get support
-Help parents learn how to seek help, as well as advocate for their child at schoo
CFF-CBT for Pediatric Bipolar Disorder
69 children (aged 7 to 13 years) diagnosed with bipolar disorder
Inclusion criteria: stabilization on medication
Still symptomatic, but not in acute distress (if have this, much need for medication)
Randomized to:
CFF-CBT (individual therapy) or TAU
Assigned a therapist (not trained in CFF-CBT) in the same clinic (if you are trained, might accidentally do it)
Clinic had easy parking therefore no one was late or missed sessions
Makes groups similar
CCF-CBT for Pediatric Bipolar Disorder
Outcome measures:
Parent report of mania and depression
Clinician report of depression
Results :
At post-treatment, youth in CBT group had lower mania
symptoms than youth in control group
88% of youth in CBT group were below the clinical cutoff for manic symptoms, at post-treatment, compared to 21% in the control group
Saw similar pattern for parent-reported depression
No difference for clinician-reported depression
They were already on meds therefore this is improvement BEYOND meds
Summary
Pharmacotherapy indicated for treatment of pediatric bipolar disorder
Psychotherapy also important and may further reduce symptoms for patients who are stabilized on medication
