NEW YORK – Because of the current lack of data and consensus on the treatment of bipolar depression in children and adolescents, pharmacotherapeutic options need to be discussed with family members on a case-by-case basis, Dr. Gabrielle A. Carlson said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.
No controlled studies of bipolar depression in children or adolescents exist and no results from such trials can be expected for the foreseeable future, said Dr. Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook. A few recent open-label trials with lithium and lamotrigine (Lamictal) provide all the data that are available on pharmacotherapy in these patients.
In one study, a 6-week open trial of lithium in hospitalized adolescents with bipolar depression, 13 of the 27 patients had a 50% reduction in Children's Depression Rating Scale-Revised (CDRS-R) scores at some point during the study. At the end of the 6 weeks, however, only 8 patients met the study's response criteria, defined as a CDRS-R score of 28 or less and a Clinical Global Impressions (CGI) score of 2 or less. Most of the patients' improvement occurred during the first 2 weeks of the trial, when they were in the hospital.
In an open study of 20 adolescents with bipolar I, II, or depression not otherwise specified, 16 patients responded to lamotrigine after 8 weeks, as defined by a CGI score of 2 or less. Eleven patients were in remission after 8 weeks. Seven of the patients also were taking other psychotropic medications.
“Until there are placebo-controlled trials [of children and adolescents] in bipolar depression, don't get too excited because we all know that there are high rates of placebo response in depression,” Dr. Carlson said.
When treating a first-episode case of depression, clinicians should consider that bipolar disorder is prevalent in only 5% of children and adolescents who have a parent with the condition, according to one study, whereas unipolar depression and other affective disorders are prevalent in 9% and 27% of children and adolescents with such parents, respectively, she said.
Clinicians will need to consider different scenarios when treating a first episode of major depression in adolescents and children with bipolar disorder, or even recurrent unipolar major depression in pediatric patients with a history of bipolar disorder in their families. In both cases, the clinician will have to decide on whether to prescribe an antidepressant–which requires a discussion of its risks and benefits in light of the black box warning on suicidal ideation–or a mood stabilizer that may not be needed, Dr. Carlson said.