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Treatment Resistant Pediatric BD. Elham Shirazi M.D. Board of General Psychiatry Board of Child & Adolescent Psychiatry. Pediatric BD: Less adequate treatment response More prolonged & treatment-refractory course More relapse rates More recurrent & intractable

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treatment resistant pediatric bd

Treatment Resistant Pediatric BD

Elham Shirazi M.D.

Board of General Psychiatry

Board of Child & Adolescent Psychiatry

slide2

Pediatric BD:

  • Less adequate treatment response
  • More prolonged & treatment-refractory course
  • More relapse rates
  • More recurrent & intractable
  • More episodes over the course of a year
  • Reduced interepisode recovery
slide3

Factors associated with nonresponse:

  • Misdiagnosis
  • Poor adherence to treatment
  • Comorbid psychiatric and medical conditions
  • Ongoing exposure to negative events(family conflict, abuse)
  • Quality of treatment
slide4

Consider whether symptoms persist as a result of:

  • Inadequate response to treatment
  • Or as an expected response to inadequate treatment
slide5

Step 1

Discontinue potentially destabilizing agents:

  • Antidepressants
  • Can promote mania, mixed states, or rapid cycling in children/ adolescents with BD
  • Can increase the frequency & severity of mood symptoms

(Russel E. Scheffer, 2011)

slide6

Stimulants

  • Can be problematic in patients at risk for BD disorder.
  • Try to discontinue stimulants while stabilizing patients’ mood symptoms
  • Once the patient’s mood symptoms are controlled on a mood stabilizer regimen
  • Using stimulants for comorbid ADHD did not affect relapse rate

(Russel E. Scheffer, 2011)

slide7

Step 2

Optimize the antimanic agents the patient is currently receiving:

  • Serum Li levels between 0.8–1.2 mEq/dl
  • VPA levels between 80–120 mEq/dl
  • Risperidone up to 4 mg/day
  • Olanzapine up to 20mg/day
  • Quetiapine up to 800 mg/day
  • Now lack of adequate response after a 4-weektrial is a “true” treatment failure.

(Russel E. Scheffer, 2011)

slide8

If there is no improvement on a treatment after several months, don’t continue that treatment

  • Use combinations other than the one that hasn’t worked
slide9

For partial or nonresponders to monotherapy:

  • Combination of 2mood stabilizers
  • Or of a mood stabilizer with an atypicalantipsychotic is indicated

Medication combinations are additive both in:

  • Effectiveness
  • & in side effects
slide10

If remission is achieved on a particular regimen, it should be continued as long as possible

  • At least until the child/adolescent has navigated his mostimportant develpmental, academic, & social milestones.
slide11

Majority of subjects relapse after the switch to monotherapy

  • A child stabilized on 2 medications needs to be maintained as such since the relapse rate on one drug is high.
  • Even in most treatment responsive youth with PBD, it is common to need 2 mood stabilizers
  • Lithium alone has not been successful in this age group as a maintenance medication.
slide12

BD + ADHD?

In cases where clinicians can not decide between mania & ADHD:

  • If the child becomes more irritable or aggressive with ADHD treatment
  • Use an atypical antipsychotic or a mood stabilizer
  • Followed by retrying the ADHD treatment
slide13

Keep in mind that “rebound”

the apparent return of worse ADHD symptoms at the end of the day

  • Has no diagnostic implications
  • & sometimes subsides over time

(Carlson 2003)

slide14

First-line medication for BP depression:

  • Lamotrigine
  • Lithium
  • Valproate
  • Atypical antipsychotics
slide15

For partial or non-responders combine with:

  • Another atypical antipsychotics
  • SSRIs
  • Bupropion
slide16

DMDD + ADHD + ODD

  • Comorbid DBD predict a poorer response to treatment.

(Masi 2004, State 2004)

  • A treatment algorithm for ADHD & aggression might be a reasonable course of action (Carlson 2007)
  • Antimanic medications have efficacy as antiaggression medication.
slide17

Clozapine:

  • Is reserved for the most treatment-resistant cases
  • Because of its side-effect profile.
  • TMSor augmentation with omega-3 fatty acids are yet to be evaluated for treatment of BP depression in youth.
slide18

ECT:

  • May be indicated for adolescents with severe & most treatment resistant disorders

Considered for adolescents with well-characterized BDI who have:

  • Severe episodes of mania or depression
  • Are nonresponsive
  • Or unable to take standard medication therapies.
slide22

For subjects who do not respond to the initial monotherapy:

  • Treat with one of the other mood stabilizers
  • Or an atypical antipsychotic not previously tried

For subjects with a partial response to monotherapy:

  • Combination of 2mood stabilizers
  • Or of a mood stabilizer with an atypicalantipsychotic is indicated
slide23

Even in most treatment responsive youth with PBD, it is common to need 2 mood stabilizers

  • & a stimulant to treat ADHD symptoms.
  • The clinical course of PBD includes many affective & behavioral bumps.
  • If you attempt to treat all of these bumps it results in excessive polypharmacy.

(Russel E. Scheffer, 2011)

slide24

Also discontinue GABA-ergic agents

  • Gabapentin, Tiagabine, Levetiracetam, Pregabalin
  • GABA-ergic agents frequently cause disinhibition in children
  • Are not effective in treating manic symptoms

(Russel E. Scheffer, 2011)

slide25

Step 3

  • Use a limited number of mood stabilizers (one or two)
  • Nonconventional & empirically unsupported medications (e.g., oxcarbazepine) are discontinued
  • & replaced with a first-line treatment agent (e.g., Li, VPA, risperidone, olanzapine, or quetiapine)

(Russel E. Scheffer, 2011)

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