Treatment resistant pediatric bd
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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

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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


Treatment resistant pediatric bd

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


Treatment resistant pediatric bd

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


Treatment resistant pediatric bd

Consider whether symptoms persist as a result of:

  • Inadequate response to treatment

  • Or as an expected response to inadequate treatment


Treatment resistant pediatric bd

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)


Treatment resistant pediatric bd

  • 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)


Treatment resistant pediatric bd

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)


Treatment resistant pediatric bd

  • 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


Treatment resistant pediatric bd

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


Treatment resistant pediatric bd

  • 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.


Treatment resistant pediatric bd

  • 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.


Treatment resistant pediatric bd

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


Treatment resistant pediatric bd

  • 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)


Treatment resistant pediatric bd

First-line medication for BP depression:

  • Lamotrigine

  • Lithium

  • Valproate

  • Atypical antipsychotics


Treatment resistant pediatric bd

For partial or non-responders combine with:

  • Another atypical antipsychotics

  • SSRIs

  • Bupropion


Treatment resistant pediatric bd

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.


Treatment resistant pediatric bd

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.


Treatment resistant pediatric bd

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.


Treatment resistant pediatric bd

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


Treatment resistant pediatric bd

  • 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)


Treatment resistant pediatric bd

  • 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)


Treatment resistant pediatric bd

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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