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EARLY AGE MANIA Anything New ? Paramjit T. Joshi, M.D. PJOSHI@cnmc

EARLY AGE MANIA Anything New ? Paramjit T. Joshi, M.D. PJOSHI@cnmc.org Children’s National Medical Center George Washington University School of Medicine. EPIDEMIOLOGY PEDIATRIC BIPOLAR DISORDERS. No prevalence studies in pre-pubertal BPD 1% lifetime prevalence rate in adolescents

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EARLY AGE MANIA Anything New ? Paramjit T. Joshi, M.D. PJOSHI@cnmc

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  1. EARLY AGE MANIA Anything New ? Paramjit T. Joshi, M.D. PJOSHI@cnmc.org Children’s National Medical CenterGeorge Washington University School of Medicine

  2. EPIDEMIOLOGY PEDIATRIC BIPOLAR DISORDERS • No prevalence studies in pre-pubertal BPD • 1% lifetime prevalence rate in adolescents • 5.7% lifetime prevalence of sub-syndromal BPD • Irritability the rule rather than the exception • Grandiosity, poor judgement • Impaired concentration • DO NOT MEET DURATION CRITERIA • Adolescents with BPD and sub-syndromal BPD had significant psychosocial impairment by age 24 years Lewinshon et al., 2000

  3. As Adults ! • Childhood onset subjects were MOST likely to: • Have non-remitting BPD • Prolonged episodes • Antisocial PD • Childhood & adolescent onset subjects had increased prevalence of Drug Use Disorders • Prevalence of mixed episodes or irritability did not differ significantly between groups Goldstein & Levitt, AJP 163:1633-1636, 2006

  4. MANIC EPISODE DSM - IV: Lasting at least one week with A and three of B persistent symptoms: A. Expansive mood / irritability B. 1.Inflated self-esteem / grandiosity 2. Decreased need for sleep 3. More talkative / pressured speech than normal 4. Racing thoughts / flight of ideas 5. Easily distracted 6. Increase in goal-directed activity 7. Poor judgement or excessively involved in pleasurable but risky activities, hypersexuality

  5. Core Symptoms of Bipolar Disorder • Extremely elevated mood • Racing thoughts / flight of ideas • Decreased need for sleep • Grandiosity • Poor judgement: • hypersexuality • daredevil acts • silliness, laughing • uninhibited people seeking

  6. BPD vs ADHD Geller et al., 2002

  7. Robert Post et al., Presented at the 3rd Annual NIMH P-BPD Conference, 2005

  8. Rx of Early Age Mania (TEAM STUDY)Funded by the NIMH (2003-2009) AIM: • To investigate the effectiveness of medications for C&A who have DSM-IV BP-1 (manic or mixed phase) mania • 540 subjects aged 6-15 years of age • Narrow BP phenotype based on WASH-U K-SADS interviews video-taped and reviewed by the coordinating site for consensus diagnosis

  9. RESEARCH PLAN • Investigate the effectiveness of Lithium (Li), Valproate (Val) and Risperidone (Rsp) as monotherapy and as add-on agents for childhood BP-1 (manic or mixed phase) mania • Explore the effects of psychosocial factors (e.g. parental warmth, parental BPD, family tension), discontinuation, compliance and outcome

  10. TREATMENT OF EARLY AGE MANIA (TEAM) FLOW CHART Screening for Eligibility Baseline Assessments Ineligible Given Clinical Referrals Baseline Assessments If eligible, assigned to one of Three Strata 8 Week Protocol Ineligible Given Clinical Referrals Stratum One Drug free strategy Baseline: Antimanic drug free Randomize: Li, Val, Rsp Stratum Two Add-on strategy Baseline: On one drug with partial response Randomize: To add-on one of two other drugs Stratum Three Cross-taper strategy Baseline: On one drug with poor response Randomize: To Cross-taper one of two other drugs Partial Responders Re-randomize: Within stratum two for another 8 weeks Poor Responders Re-randomize: Within stratum three for another 8 weeks

  11. Subjects Randomized: (All sites 315) AT CNMC: • Total number of baseline subjects = 101 • Males 74% • C: 46% AA: 44% H: 5% Other: 5% • Number of randomized subjects = 67 • Strata 1 = 48 • Strata 2 = 5 • Strata 3 =14 (Lost 34 due to either lack of diagnostic consensus agreement between sites or not meeting diagnostic criteria at the completion of the baseline interviews)

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