Mood Stabilizers For Bipolar Children

Many children are prescribed Depakote (divalproex sodium) but all too often the Depakote dosage was 250-500 mg a day and "it didn't work."

Most children will require far higher doses to achieve therapeutic blood levels, and while all children will reach different blood levels at different dosages, it's important to get the right levels and wait a few weeks before making any judgment about the effectiveness of the drug.

Lamictal (lamotrigine) is an anti-seizure medication that may have a significant place in the treatment of bipolar disorder. What sets it apart from most the other mood stabilizers is that it seems to have a significant effect on the depressive symptoms of bipolar disorder. The other mood stabilizers work to act to prevent future episodes of depression and mania, but do not work as well on acute depression. This medication might allow doctors to treat the depressive symptoms of bipolar disorder without antidepressants which tend to cause increased cycling or to flip patients into mixed or manic states. However, Lamictal seems to have weaker ant-imanic effects, and at higher doses - above 175 mg - it can be activating.

There are no blood levels to be taken, and the side effect profile is mild: But as with all things in life, there is no free lunch. As with the sulfa drugs and penicillin--and even some other anti-seizure medications - Lamictal can produce an allergic response that manifests as a rash and, on rare occasions, the rash can be a serious one that signals a life-threatening condition known as Stevens-Johsnon Syndrome.

A rash is most likely to develop when the dosing schedule starts too high or is increased too rapidly (start low and go slow is the pertinent phrase here). Dr. Andrew Stoll of Harvard Medical School who has quite a bit of experience with the drug said that he often takes three months to reach the target dose.

Other cases of rash occurred when Lamictal was given with Depakote - the Depakote doubled the Lamictal levels. Typically the rash occurs in the first eight weeks of treatment.

Lamictal remains "Black label" for now (it cannot be given to adolescents younger than 16 and is approved only for children with the severe seizure disorder Lennox-Gaston). Reports of its use for bipolar depression are compelling, and future studies should decide how helpful a medicine it will be for bipolar disorder.

Lithium is considered the gold standard for the treatment of bipolar disorder in adults, and an estimated 70-80 percent of patients have a positive therapeutic response to it. But there has long been an idea that rapid-cyclers may not do as well on lithium as they do on the anti-convulsant drugs--Tegretol or Depakote and so on.

Is this true for adults and/or children who have such ultra-rapid cycles? Not necessarily. Some children have an excellent response to the drug or to its use in combination with another mood stabilizer.

Very important, there is emerging evidence from research literature that lithium has a strong and possibly unique effect against suicidal behavior in people with bipolar disorder. And this is not true of the other mood stabilizers as far as we know. According to Ross J. Baldessarini, M.D. of Harvard Medical School "If the anti-suicidal side effects are not shared with other mood-altering agents, this may be due to the cerebral serotonin-enhancing properties of lithium, properties that are not known to be associated with anti-convulsants.

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Neurontin (gabapentin) is an anti-seizure medication that seems to have few side effects except for its potential to cause sedation. It does not cause weight gain. Neurontin can also be used safely with other medications needed by a child or adolescent with bipolar disorder. There are no blood levels to be determined. However, it has a short half-life and must be administered three times a day.

Although only limited studies have been mounted, the initial results are not impressive. Several highly respected clinicians find it does not work well as a mood stabilizer when given as a monotherapy (when it is the only mood stabilizer). One study reported by Atul C. Pande, M.D. at the Third international Conference on Bipolar Disorder in Pittsburgh examined the use of Neurontin as an add-on to lithium or Depakote versus a placebo add-on and found that the patients taking the placebo actually had a better response.

However, it seems to be useful as an anti-anxiety agent and is definitely useful as a sedating agent for individuals who experience evening or late-night activation.

Tegretol (carbamazepine) has acute anti-manic effects and also acts to prevent future episodes of illness in bipolar disorder. Some studies have reported that Tegretol has anti-agressive properties, something that might make it particularly useful for children with frequent rage attacks.

Topamax (topiramate) is an anticonvulsive drug chemically unrelated to any other anticonvulsant or mood stabilizing medication. It has been reported to control rapid-cycling and mixed bipolar states in patients who have not responded well to Tegretol or Depakote, but its long-term prevention of cycling has not been established.

What makes this drug of particular interest is that it causes no weight gain. In fact, it may reduce the intense food cravings that may occur with other commonly used psychiatric drugs such as Depakote, Risperdal, and Zyprexa. It can also be used as a sedating agent.

See also:

Mood Stabilizers - The Bipolar Child Newsletter
Trileptal: A Promising New Mood Stabilizer