I am treating a child for the last 1 and 1/2 years and after 8 months, made a diagnosis if Bipolar disorder, mixed episodes. He has periods of sad, low mood with suicidal thoughts. he also has periods when he is easily frustrated, and has tantrums when he is very irritable, dyphoric and is talking about killing himself. He has attempted to us a tie to choke self and has asked his mother to kill him also. He has used parents credit card without permission to buy from the internet. More recently, he is preoccupied with being like the Beatles, and has asked to perform at a High school (he does not have the skills, he plays Rockband Wii). He has been checking mail everyday awaiting a response. He is reading the Percy Jackson movie and is into reading the series. He questioned if he was Percy jackson, and wanted to fly to Greece to learn more about greek mythology, researching tickets to fly to Greece. Like Percy Jackson, he would like to be expelled from school. He wonders if his parents are real parents. I see these as grandiose and delusional. These is no active AH, VH, paranoia.

Parents have struggled with these behaviors, esp suicidal thinking for many years. They call it the "go to phrase" and call it "attention seeking". Inability to differentiate between reality and imagination is new.

I am treating his with Tegretol ER 400 bid presently. He is also on Abilify 5 mg bid. Given continued mood lability, and these symptoms as above, I wonder if I should add Lithium, taper Abilify and add Risperdal.

Any insights, input, will be helpful.

Some general considerations:

Diagnosis:

--Diagnostic clarity is key. Depression often presents as irritability in latency-age children. However, the presence of periods of intense mood dysregulation can be consistent with bipolar disorder.

--Do preoccupations or fantasies meet criteria for delusions? Is there truly impaired reality testing and functional impairment due to the beliefs?

--Are symptoms/behaviors present and consistent in all domains of life—home, school, social activities? What are the social and academic consequences of the symptoms?

--Is there evidence of a Pervasive Developmental Disorder? Hyperfocus and circumscribed interests as well as explosive behaviors related to limit-setting can be consistent with the PDD spectrum.


Psychopharmacology (assuming bipolar disorder is diagnosed):

--None of the atypical antipsychotics or traditional mood stabilizers has FDA indications for the treatment of pediatric bipolar disorder. While prescribing these agents is often warranted, it is off-label.

--Carbamazepine induces its own metabolism. If a patient was initially doing well on the medication and then began to worsen, it is important to check a carbamazepine level to see if the blood level has dropped due to autoinduction.

--Lithium and valproic acid (VPA) are reasonable considerations in pediatric bipolar disorder. VPA has a lower response rate in children than in adults. Lamotrigine is also a reasonable choice, but typically requires strict parental oversight to insure dosing instructions are followed, and usually takes several weeks to reach a therapeutic dose.

--There is a paucity of data guiding atypical antipsychotic choice in children. If aripiprazole is causing over-activation, it is reasonable to consider a different atypical antipsychotic. Metabolic side effects are a significant health problem caused by many atypical antipsychotics. Therefore, if atypical antipsychotics need to be used in children, they would ideally be used short-term.

--If there is an adequate mood stabilizer regimen and depressive symptoms persist, a trial of low-dose antidepressant medication can be considered.


Other:

--Family stabilization teams can be helpful to give perspective on how children function in their home environment.

--Collaboration with school mental health providers (if present) can provide additional information regarding academic and social functioning.