Neobook — clinical reference

ICD-10 code: F31

DESCRIPTION

The bipolar disorder presentation in children and adolescents differs from the adult discrete manic or depressive episodes. They usually present with mixed mood states and significant mood lability that fluctuates within a day resembling a rapid cycling pattern and rage attacks or ‘affective storms’.

Short-lived episodes of exuberance are normative in children and adolescents, while temper outbursts and mood lability can present in many other psychiatric disorders, e.g. anxiety disorders, autism spectrum disorder (ASD). There is a risk of misdiagnosis or ‘over-diagnosis’ of bipolar disorder in children and adolescents presenting with severe aggression and ‘dysregulated’ moods.

DIAGNOSTIC CRITERIA (DSM 5)

Manic Episode
A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal-directed activity or energy. This should represent a significant change in the patient’s baseline mental status, last for at least 1 week and be present, most of the day, nearly every day.

During the period of mood disturbance, the patient should display the following symptoms:

Elevated self-esteem or grandiosity.
Decreased need for sleep.
More talkative than usual or pressured speech.
Flight of ideas or feeling that thoughts are racing.
Distractibility
Increased goal-directed activity (socially, at school or hyper-sexuality) or psychomotor agitation.
Involvement in activities with potentially painful consequences, e.g. sexual indiscretions.

Depressive episode
Similar to symptoms of major depressive episode except that the onset may be more rapid and may be associated with psychomotor retardation, anxiety symptoms and/or psychotic symptoms.

Mixed mood state
This includes the presence of a major depressive episode with at least 3 manic/hypomanic symptoms present during the depressive episode. These are more common in children and adolescents.

Causes distress or impairment in functioning.
Exclude other psychiatric disorders, medical conditions, the effects of substances and manic/hypomanic episodes.

MEDICINE TREATMENT

Acute phase treatment

Refer patients with a suspected manic episode or suicidal ideation to a psychiatrist immediately for assessment and possible admission.
Sedate before transfer. Refer to: Sedation of an acutely disturbed child or adolescent.
If no previous medication used, while awaiting admission and in consultation with a psychiatrist, initiate atypical antipsychotic and mood stabilizer.

Atypical antipsychotic:

Risperidone, oral.
- 5-12 years (under 50 kg):
  - Starting dose: 0.01 mg/kg/day.
  - Maintenance dose: 0.02 - 0.04 mg/kg/day.
- 13-17 years:
  - Starting dose: 0.5 mg daily.
  - Maximum dose: 3 mg daily.
  - Use lowest effective dose to limit adverse long-term side effects and to facilitate adherence.
  - Increase dose by 0.25 - 0.5 mg daily every 1 - 2 weeks, depending on tolerability and age.

Mood stabiliser: lithium carbonate or sodium valproate (sodium valproate not recommended in females) or a second-generation antipsychotic (risperidone/olanzapine) with specialist consultation:

Lithium carbonate, oral (for patients aged 12–17 years).
- Initial dose: 20 mg/kg/day in 2 - 3 divided dosages. Lithium level after 5 days. Increase accordingly. Therapeutic range: 0.6 - 0.8 mmol/l. Be careful of narrow therapeutic margin – risk of toxicity.
- Ensure investigations are done prior to initiation of treatment.
- Blood investigations: FBC, U&E, CMP, TSH and BHCG.
- Cardiac investigation includes ECG.
- Ongoing monitoring: Lithium levels 1 - 3 monthly, TSH and creatinine 6 - 12 monthly.
- Contraception if sexually active.
Sodium valproate, oral (teratogenic and to be avoided in females).
- 20 mg/kg/day divided 12 hourly.
- Usual range: 20 - 30 mg/kg/day.
Risperidone, oral.
- 5–12 years (under 50 kg):
  - Starting dose: 0.01 mg/kg/day.
  - Maintenance dose: 0.02 - 0.04 mg/kg/day.
- 13–17 years:
  - Starting dose: 0.5 mg daily.
  - Maximum dose: 3 mg daily.
  - Use lowest effective dose to limit adverse long-term side effects and to facilitate adherence.
  - Increase dose by 0.25 - 0.5 mg daily every 1 - 2 weeks, depending on tolerability and age.
Olanzapine, oral, for children 13 years and older.
- Initially: 2.5 - 5 mg once daily.
- Increase to 10 mg daily if necessary.

LoE III¹

Maintenance treatment

If previously on maintenance medication: re-initiate treatment in consultation with a psychiatrist.
Ongoing psycho-education regarding the illness, medication, compliance etc.
Once stabilised, the patient can be referred for individual psychotherapy.
The family may benefit from referral for family therapy.

REFERRAL

Refer all patients with suspected bipolar disorder for an assessment by a psychiatrist.
Sedate or stabilise prior to transfer.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter 14: Child & Adolescent Psychiatry, 14.4 Mood Disorders, 14.4.2 Bipolar Disorder

Drugs mentioned