Lithium in the Acute Treatment of Bipolar I Disorder: A Double-Blind, Placebo-Controlled Study

Pediatric Bipolar Disorder: Challenges in Diagnosis and Treatment

Despite an opportunity to prevent adult psychopathology associated with bipolar disorder through early diagnosis in children, there is insufficient information and awareness among healthcare providers about the unique features and treatment of mania and its comorbid conditions in children. Converging evidence from disparate sites describe a developmentally distinct presentation of bipolar disorder in youth that is highly morbid, persistent and responds to treatment with the mood stabilizer medications used in the treatment of adult bipolar disorder, such as divalproex sodium and carbamazepine. Some are additionally approved for use in pediatric populations including, for manic or mixed states, risperidone, aripiprazole, and asenapine for those aged 10-17 years and also including lithium and olanzapine for ages 13-17 years. Quetiapine is approved as monotherapy or as adjunct to lithium or divalproex sodium for manic states in those aged 10-17 years. Delayed or missed diagnosis, inappropriate treatment, worsening course, and treatment resistance unfortunately still occur. While an array of mood-stabilizing medications is available for treatment, such as second-generation antipsychotics, lithium, and anticonvulsants, these can be only partially effective and fraught with annoying and serious side effects. This article will review current practice in the diagnosis and treatment of pediatric bipolar disorder and its comorbid conditions, highlighting areas of need for future research.

Drugs used in psychiatry causing an increase in body weight in children-a review

Body weight gain is a prevalent adverse effect observed in psychiatric medication therapy. With the notable increase in mental health diagnoses among children and adolescents over the last decade, exacerbated by the COVID-19 pandemic, the use of medications associated with weight gain poses an additional risk for obesity development. This study aimed to identify psychiatric drugs that may induce weight gain in children as a side effect. Twenty-nine publications were included in this systematic review, investigating the effects of nineteen different drugs on children's weight. The majority of these drugs belonged to atypical antipsychotics and anticonvulsants. Nearly all included articles reported that the examined substances resulted in weight gain in children. As childhood obesity has become a significant problem with various metabolic, psychological and social consequences, it is crucial to carefully consider therapy options. In addition to evaluating effectiveness, it is important to also assess the potential for weight gain. Clinicians and nutrition specialists should individually evaluate patients' nutritional needs, evaluate obesity risk, and provide appropriate dietary guidance to minimalize the risk of weight gain.

Extended-Release Lithium Sulfate in Adolescents with Bipolar Disorder: Results from a Longitudinal Prospective Cohort Study

Objectives: Bipolar disorder (BD) in adolescence often associates with risky conducts, nonsuicidal self-injury (NSSI), and suicidal ideation. Lithium salts represent the first-line choice for BD in youth to manage manic symptoms and prevent both manic and depressive relapses. Our study aimed to assess efficacy and tolerability of extended-release lithium sulfate (ERLS) in youths with BD. Methods: A longitudinal perspective intervention study was thus conducted on a single cohort of 36 patients with BD aged 12-17 years treated with ERLS and followed up for 1 year. ERLS was titrated up to reach optimal plasma concentrations during the 3 months before baseline visit (T0). Then, patients underwent five follow-up visits after 1, 2, 3, 5, and 11 months and were administered with a battery of self- and parent-rated questionnaires and interviews to evaluate, at each timepoint, ERLS-related side effects, manic and depressive symptoms, emotional dysregulation (ED), NSSI and suicidality, and aggressiveness. Regular clinical assessments were also conducted, as well as blood tests, urinalysis, and EKG. Regression models were applied to examine the time course of outcome variables. Results: Twenty-four patients completed the follow-up. Regressions showed a significant reduction of most dependent variables included in the models, including depressive symptoms (β = -0.0006; adj-p = 0.0007), aggressiveness (β = -0.0031; adj-p < 0.0001), ED (β = -0.0002; adj-p = 0.0497), and unstructured suicidal ideation (β = -0.0058; adj-p = 0.0340). Fine distal tremor, increased thirst, and diuresis were among the most frequently reported side effects. Conclusions: Findings from the present study support the use of ERLS as an effective and well-tolerated agent for the management of BD in youth, with a beneficial effect on associated severe symptoms, including NSSI and suicidality.

Systematic Review and Network Meta-Analysis: Efficacy and Safety of Antipsychotics vs Antiepileptics or Lithium for Acute Mania in Children and Adolescents

OBJECTIVE

To compare second-generation antipsychotics (SGAs) and mood stabilizers (MSs) in youth with a bipolar disorder type I (BD-I) manic/mixed episode.

METHOD

A systematic PubMed/Embase/PsycInfo literature search until December 31, 2023, for randomized trials of SGAs or MSs in patients ≤18 years of age with BD-I manic/mixed episode was conducted. The study included a network meta-analysis comparing treatments regarding mania symptoms and mania response (co-primary outcomes), and secondary efficacy and tolerability outcomes.

RESULTS

Eighteen studies (n = 2844, mean age = 11.74, female participants = 48.0%, mean study duration = 5.4 weeks) comparing 6 SGAs (aripiprazole, asenapine, olanzapine, quetiapine, risperidone, and ziprasidone) and 4 MSs (lithium, oxcarbazepine, topiramate, and valproate) were meta-analyzed. All 6 SGAs outperformed placebo in reducing manic symptomatology, including risperidone (standardized mean difference [SMD] = -1.18, 95% CI = -0.92, -1.45, Confidence in Network Meta-Analysis [CINeMA] = moderate confidence), olanzapine (SMD = -0.77, 95% CI = -0.36, -1.18, low confidence), aripiprazole (SMD = -0.67, 95% CI = -0.33, -1.01, moderate confidence), quetiapine (SMD = -0.60, 95% CI = -0.32, -0.87, high confidence), asenapine (SMD = -0.54, 95% CI = -0.19, -0.89, moderate confidence), and ziprasidone (SMD = -0.43, 95% CI = -0.17, 0.70, low confidence), whereas no mood stabilizer outperformed placebo. Concerning mania response, risperidone (Risk ratio [RR] = 2.58, 95% CI = 1.88, 3.54, low confidence), olanzapine (RR = 2.42, 95% CI = 1.33, 3.54, very low confidence), aripiprazole (RR = 2.05, 95% CI = 1.44, 2.92, low confidence), quetiapine (RR = 1.89, 95% CI = 1.45n 2.47, moderate confidence), asenapine (RR = 1.81, 95% CI = 1.28, 2.55, very low confidence) and lithium (RR = 1.35, 95% CI = 1.00, 1.83, p = .049, very low confidence) outperformed placebo, without superiority of other MSs vs placebo. Individually, risperidone was more efficacious in reducing manic symptomatology than all other comparators, except olanzapine and topiramate, yet with low/very low confidence, and was associated with increased prolactin and glucose. Pooled together, SGAs outperformed both placebo and MSs for mania symptom reduction (SMD = -0.68, 95% CI = -0.86, -0.51 and SMD = -0.61, 95% CI = -0.82, -0.40, moderate confidence), and mania response (RR = 1.85, 95% CI = 1.53, 2.24 and RR = 1.65, 95% CI = 1.33, 2.04, moderate confidence) without differences between MSs and placebo. There were no significant treatment-placebo differences for all-cause discontinuation, whereas lithium, ziprasidone, and oxcarbazepine were associated with more adverse event-related drop-outs than placebo. Most SGAs were associated with more sedation, weight gain, and metabolic issues vs placebo and MSs.

CONCLUSION

SGAs were more efficacious than placebo and MSs in treating acute mania symptoms, however, their use must be carefully weighed against important side effects.

PLAIN LANGUAGE SUMMARY

In this systematic review, the authors compared second-generation antipsychotics and mood stabilizers in youth with bipolar disorder type I experiencing manic or mixed episodes. Drawing on data from 18 randomized trials involving 2,844 participants less than 18 years of age, the authors found that second-generation antipsychotics were more effective than both placebo and mood stabilizers in reducing manic symptoms. However, the authors recommended caution while using second-generation antipsychotics due to potential side effects such as sedation, weight gain, and metabolic issues.

STUDY PREREGISTRATION INFORMATION

Efficacy and Safety of Antipsychotics vs Antiepileptics or Lithium Used for Mood Stabilization in Bipolar Disorder in Children and Adolescents: A Systematic Review and Exploratory Network Meta-analysis of Head-to-Head Trials; https://www.crd.york.ac.uk; CRD42022370915.

Lithium, the gold standard drug for bipolar disorder: analysis of current clinical studies

Lithium is the gold standard drug in the treatment of bipolar disorder. Despite increasing scientific interest, relatively few patients with bipolar disorder receive lithium therapy. Lithium is the only drug that is effective in the prophylaxis of manic, depressive, and suicidal symptoms. Lithium therapy is also associated with a variety of adverse drug reactions and the need for therapeutic drug monitoring. Numerous studies have focussed on the efficacy and safety of both lithium-monotherapy and lithium-add-on therapy. The aim of this study is to provide a systematic overview of clinical studies on lithium therapy for bipolar disorder from the last 7 years and to present a critical analysis of these studies. The results provide an up-to-date overview of the efficacy, tolerability, and safety of lithium therapy for bipolar disorder and thus improve the pharmacotherapy of bipolar disorder. A total of 59 studies were analysed using various analysis parameters. The studies were also categorised into different subgroups. These are lithium-monotherapy, lithium vs. placebo/drug, and lithium + adjunctive therapy. The majority of the studies (N = 20) had a duration of only 3-8 weeks. Only 13 studies lasted for > 40 weeks. Lithium was superior to aripiprazole, valproic acid, and quetiapine in terms of improving manic symptoms. Lithium therapy resulted in a lower relapse rate compared to valproic acid therapy. Lithium was more neuroprotectively effective than quetiapine. Fourteen of the 22 add-on therapies to lithium showed a predominantly positive effect on the treatment outcome compared to lithium-monotherapy. Only the add-on therapy with sertraline led to a higher rate of study discontinuations than lithium-monotherapy. Lithium is a safe and effective treatment option for children. However, risperidone and quetiapine were superior to lithium in some aspects, which is why these drugs should be considered as an alternative treatment option for children. Collectively, current clinical studies highlight the relevance of lithium in the treatment of bipolar disorder.

Efficacy and Safety of Lithium for Suicide and Suicide-Related Behaviors in Youth: A Review of the Literature

OBJECTIVES

This systematic review evaluates the anti-suicidal properties of Lithium in children and adolescents with Bipolar Disorder (BD), addressing gaps in evidence regarding its efficacy and safety in reducing suicidality and self-harming behaviors.

METHODS

A comprehensive literature search was conducted across PubMed, Web of Science, and Scopus up to February 2024. Eligible studies were those focusing on patients aged 25 years or younger, examining Lithium therapy and its impact on suicidal ideation and behaviors. The review included randomized controlled trials, longitudinal prospective and retrospective studies, and cross-sectional studies, while excluding expert opinions and case reports.

RESULTS

Evidence generally supports the efficacy of Lithium in reducing suicidal ideation and self-harming behaviors in youth with BD, though results are mixed. Randomized controlled trials demonstrated its effectiveness in mitigating suicidal thoughts during acute manic episodes, with effects persisting post-treatment. Longitudinal studies suggested that Lithium might offer superior outcomes compared to other mood stabilizers, although its specific impact on suicidality remains inconclusive. Cross-sectional studies and retrospective analyses reveal associations between Lithium use and reduced self-harming behaviors, but causality remains uncertain. While mood-stabilizing effects of Lithium offer potential benefits for reducing suicidality in youth, evidence on its direct impact on emotional dysregulation (ED) and long-term efficacy is limited. Variability in individual responses and adherence issues underscore the need for further research. Future studies should include larger, diverse samples, focus on ED symptoms, and explore Lithium mechanisms in suicidality prevention.

CONCLUSIONS

Lithium remains a promising treatment for mood stabilization and reduction in suicidality in youth with BD.

Extended-Release Lithium Treatment for Adolescents with Bipolar Disorder with or Without Comorbid Autism Spectrum Disorder: Protocol of a Longitudinal Prospective Naturalistic Study for the Assessment of Efficacy and Tolerability

Background: Lithium is the gold-standard treatment for Bipolar Disorder (BD) in both adults and adolescents, effectively managing mood episodes and reducing suicide risk. While its efficacy in neurotypical youth is well established, its use in adolescents with Autism Spectrum Disorder (ASD) and comorbid BD remains under-researched. Here, we present the protocol for a study aiming to evaluate the efficacy and tolerability of Extended-Release Lithium Salts in treating adolescents with BD and comorbid ASD compared to neurotypical BD patients. Methods: This longitudinal prospective naturalistic comparative study will enroll lithium-naïve adolescents aged 12-18 with BD, with or without comorbid ASD, from the Department of Child and Adolescent Psychiatry and Psychopharmacology. Participants will be followed for six months while receiving Extended-Release Lithium Salts treatment. Primary outcomes will include mood instability, suicidality, emotional dysregulation, and aggression, assessed through a range of clinical rating scales and diagnostic tools at baseline, three months, and six months. Secondary outcomes will focus on the safety and tolerability of Extended-Release Lithium Salts, with measures including side effect ratings, physical exams, and laboratory tests. Results: We hypothesize that Extended-Release Lithium Salts will demonstrate non-inferiority in treating BD symptoms in adolescents with comorbid ASD compared to those without ASD. Conclusions: This study is poised to fill a significant gap in the literature by providing critical data on the use of lithium for adolescents with BD and ASD. Findings will inform clinical practice and future research, potentially guiding more personalized treatment approaches for this complex and vulnerable population.

Advances in the management of bipolar disorder in children and adolescents: an update on the literature

INTRODUCTION

Early diagnosis and treatment concerning bipolar disorder (BD) are related to a better functioning over the long-term period. Although pharmacotherapy is indicated for approximately all youths with BD, nearly one-third of patients do not receive adequate medications for their condition.

AREAS COVERED

The authors discuss the available scientific evidence from the current literature about the management of BD in both children and adolescents, giving particular focus to the efficacy and tolerability of the available pharmacological agents. Studies were identified searching MEDLINE and retrieved from reference listings of relevant articles and through consultation with experts in the field.

EXPERT OPINION

Many D2-blockers, approved by the Food and Drug Administration (FDA) based on their antimanic properties in youths, are related to both short- and long-term side effects. Lurasidone was found to be effective for the treatment of acute juvenile bipolar depression, while lithium for the treatment and recurrence prevention of manic/mixed episodes. The most common anticonvulsants were found to be most useful as adjunctive antimanic agents in non-responders to first-line monotherapies. No data was found to support the use of antidepressants in juvenile BD.

What Patients with Bipolar Disorder Need to Know about Lithium

Lithium is the superior first-line treatment for bipolar disorder (BD). Yet the percentage of patients receiving lithium is abysmally low, especially in the US. Since psychiatrists have failed to place lithium in its appropriate role, we make the case that patients with BD themselves need to be better educated about the unique characteristics and pre-eminence of the drug so that it can be used more often and appropriately. Lithium has a highly unfavorable popular reputation among would-be patients and many psychiatrists. Thus, a direct appeal to patients with BD appears appropriate to try to remediate this situation. The unique assets of lithium are underappreciated or not well known. Conversely, the side effects profile of lithium are overestimated. Here, we make the case that lithium's image needs to be revised not only with better and more accurate information but also with a wholesale renaming and rebranding of the drug. We will not only outline the unique qualities and new information about the side effects of the drug but attempt to change some of the terminology conventionally used to refer to lithium so that its use may be appropriately applied earlier and at an increased frequency for patients with BD.

A systematic review and network meta-analysis on comparative efficacy, acceptability, and safety of treatments in acute bipolar mania in youths

BACKGROUND

The evidence of treatment options' efficacy on acute bipolar manic episodes is relatively less in youths than adults. We aimed to compare and rank the drug's efficacy, acceptability, tolerability, and safety for acute mania in children and adolescents.

METHOD

We systematically reviewed the double-blinded, randomized controlled trials (RCTs) comparing drugs or placebo for acute manic episodes of bipolar disorder in children and adolescents using PRISMA guidelines. We searched PubMed/MEDLINE, EMBASE, Web of Science, EBSCO, Scopus, the Cochrane Central Register of Controlled Trials, and https://clinicaltrials.gov from inception until November 20, 2022. Response to treatment was the primary outcome, and random-effects network meta-analyses were conducted (PROSPERO 2022: CRD42022367455).

RESULTS

Of 10,134 citations, we included 15 RCTs, including 2372 patients (47 % female), 15 psychotropic drugs, and the placebo. Risperidone 0.5-2.5 mg/day, aripiprazole 30 mg/day olanzapine, quetiapine 400 mg/day, quetiapine 600 mg/day, asenapine 5 mg/day, asenapine 10 mg, ziprasidone, and aripiprazole 10 mg were found to be effective (in comparison with placebo) in children and adolescents, respectively (τ2 = 0.0072, I2 = 10.2 %). The tolerability of aripiprazole 30 mg/day was lower than risperidone 0.5-2.5 mg/day and olanzapine. Oxcarbazepine had the highest discontinuation due to the adverse effects risk ratio.

LIMITATIONS

Efficacy ranking of the treatments could be performed by evaluating relatively few RCT results, and only monotherapies were considered.

CONCLUSIONS

Efficacy, acceptability, tolerability, and safety are changing with the doses of antipsychotics for children and adolescents with acute bipolar manic episodes. Drug selection and optimum dosage should be carefully adjusted in children and adolescents.

Lithium in breast milk transiently affects the renal electrolytic balance of infants

BACKGROUND

The use of lithium during breast-feeding has not been comprehensively investigated in humans due to concerns about lithium toxicity.

PROCEDURE

We analyzed lithium in the kidneys of nursed pups of lithium medicated mothers, using analytical spectroscopy in a novel rat model. The mothers were healthy rats administered lithium via gavage (1000 mg/day Li2 CO3 per 50 kg body weight).

RESULTS

Lithium was detected in the breast milk, and in the blood of pups (0.08 mM), of lithium-exposed dams at post-natal day 18 (P18), during breast-feeding. No lithium was detected after breast-feeding, at P25 (4 days after cessation of nursing). The lithium pups blood had elevated urea nitrogen at P18 and reduced total T4 at P18 and P25, indicating a longer-term effect on the kidneys and the thyroid gland. Multivariate machine-learning analysis of spectroscopy data collected from the excised kidneys of pups showed elevated potassium in lithium-exposed animals both during- and after breast-feeding. The elevated renal potassium was associated with low nephrin expression in the kidneys measured immunohistochemically during breast-feeding. After lithium exposure is stopped, the filtration of lithium from the kidneys reverses these effects. Our study showed that breastfeeding during lithium use has an effect on the kidneys of the offspring in rats.

A Critical Review of the Psychomotor Agitation Treatment in Youth

(1) Background: To systematically review evidence on the safety and efficacy of psychopharmacological treatments available for psychomotor agitation (PA) in children and adolescents. (2) Methods: Studies assessing the safety and efficacy of psychopharmacological treatments for acute PA in children and adolescents that were published between January 1984 and June 2022 on PubMed were systematically reviewed. We included: (i) papers that presented a combination of the search terms specified in the "Search strategy" sub-paragraph; (ii) manuscripts in English; (iii) original papers; (iv) prospective or retrospective/observational studies and experimental or quasi-experimental reports. The exclusion criteria were: (i) review papers; (ii) non-original studies including editorials and book reviews; (iii) studies not specifically designed and focused on the selected topic. (3) Results: We selected 42 papers: 11 case series (11/42, 26.19%), 8 chart reviews (8/42, 19.05%), 8 case reports (8/42, 19.05%), 6 double-blind placebo-controlled randomized studies (6/42, 14.29%), 4 double-blind controlled randomized studies (4/42, 9.52%), 4 open-label trials (4/42, 9.52%) and 1 case control (1/42, 2.38%). (4) Conclusions: The drugs most frequently used to treat agitation in children and adolescents were ziprasidone, risperidone, aripiprazole, olanzapine and valproic acid. Further studies are needed to evaluate the efficacy/safety ratio, considering the limited number of observations in this field.

Use of Lithium in Pediatric Bipolar Disorders and Externalizing Childhood- related Disorders: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Lithium is the standard treatment for bipolar disorders (BD) in adults. There is a dearth of data on its use in the pediatric age. This review aimed to investigate the use of lithium in pediatric bipolar disorder (BD) and other externalizing childhood-related disorders.

METHODS

We applied the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria (PRISMA) to identify randomized controlled trials evaluating the use of lithium in pediatric (BD), conduct disorder (CD), attention deficit hyperactivity disorder, oppositional defiant disorder, and disruptive mood dysregulation disorder. The primary outcome of our study was to evaluate the efficacy of lithium compared to a placebo or other pharmacological agents. The secondary outcomes were acceptability and tolerability.

RESULTS

Twelve studies were eligible, 8 on BD and 4 on CD. Overall, 857 patients were treated with lithium. No studies for externalizing disorder diagnoses were identified. Regarding BD patients (n = 673), efficacy results suggested that lithium was superior to placebo in manic/mixed episodes but inferior to antipsychotics. Lithium efficacy ranged from 32% to 82.4%. Results on maintenance need to be expanded. Comorbidity rates with other externalizing disorders were extremely high, up to 98.6%. Results in CD patients (n= 184) suggested the efficacy of lithium, especially for aggressive behaviors. No severe adverse events directly related to lithium were reported in BD and CD; common side effects were similar to adults.

CONCLUSION

This systematic review supports the use of lithium in BD and CD as an efficacious and generally well-tolerated treatment in the pediatric age. However, evidence is limited due to the paucity of available data.

Pharmacologic Treatment and Management of Bipolar Disorder in Adolescents

INTRODUCTION

The importance of the appropriate therapeutic interventions in children and adolescents with bipolar disorder (BD) cannot be overstated since treatment choices and their consequences may have effects into adulthood.

AREAS COVERED

Randomized clinical trials (RCTs) investigating treatment of mania, bipolar depression, and maintenance in adolescents with BD are reviewed. When RCTs are not available or are inadequate, naturalistic data or open studies are also reviewed.

EXPERT OPINION

Efficacy and safety of pharmaceutical agents in adolescents with BD appear to mirror adults with BD. Lithium/mood stabilizers are preferred first line agents over antipsychotic medications, but the latter are second line agents particularly in bipolar depression. When lithium is used, serum levels approaching 1.0 mEq/L are reasonable since younger people appear to require/tolerate higher levels. Among the antipsychotics, quetiapine appeared to be minimally better than risperidone while risperidone was associated with greater adverse events. Antipsychotics with antidepressant activity in adults, also appear to have antidepressant effects in youths. Use of antidepressants in bipolar depression is generally not recommended although it may be reasonable in specific clinical situations. The similarities between adolescent and adult outcomes suggest that it is reasonable to utilize adult data to aid with clinical decision making in adolescents with BD, especially when pediatric-specific data are unavailable.

Findings from a pilot open-label trial of N-acetylcysteine for the treatment of pediatric mania and hypomania

BACKGROUND

Pediatric bipolar disorder is a highly prevalent and morbid disorder and is considered a prevalent public health concern. Currently approved treatments often pose the risk of serious side effects. Therefore, this study assessed the efficacy and tolerability of N-acetylcysteine (NAC), in children and adolescents with bipolar spectrum disorder.

METHODS

We conducted a 12-week open-label trial of NAC for treatment of mania and hypomania in children and adolescents ages 5-17 with bipolar spectrum disorder including participants with full and subthreshold manic symptoms, accepting those with and without mixed states with co-occurring depression, and Young Mania Rating Scale scores ≥ 20 and < 40. Symptoms of mania and depression were assessed using the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Children's Depression Rating Scale (CDRS), and Clinical Global Impression (CGI) Severity (CGI-S) and Improvement (CGI-I) scales for mania and depression.

RESULTS

This study had a high drop-out rate with only 53% completing all 12 weeks. There was a significant reduction in YMRS, HDRS, and CDRS mean scores from baseline to endpoint. Of the 24 exposed participants, 54% had an anti-manic response measured by a reduction in YMRS ≥ 30% and 46% had a CGI-I mania score ≤ 2 at endpoint. Additionally, 62% of participants had an anti-depressive response measured by a reduction in HDRS ≥ 30%, 31% had an anti-depressive response measured by a reduction in CDRS ≥ 30%, and 38% had a CGI-I depression score ≤ 2 at endpoint.

CONCLUSIONS

These pilot open-label findings in a small sample provide preliminary data supporting the tolerability and safety of NAC in a pediatric population. The findings of this pilot scale study indicating improvement in mania and depression are promising, but require replication with a monotherapy randomized placebo controlled clinical trial and larger sample.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02357290 . First Registration 06/02/2015.

Efficacy, Safety, and Tolerability of Flexibly Dosed Ziprasidone in Children and Adolescents with Mania in Bipolar I Disorder: A Randomized Placebo-Controlled Replication Study

Objective: To evaluate the acute efficacy, safety, and tolerability of flexibly dosed ziprasidone in children and adolescents with Bipolar I Disorder (BD-I). Methods: Participants, 10-17 years of age, meeting The Diagnostic and Statistical Manual of Mental Disorders, 5th edition criteria, were randomized 1:1 in a 4-week double-blind (DB) study, to receive ziprasidone (20-80 mg/twice a day) or placebo. Some were then enrolled in a 26-week open-label extension (OLE) study. The primary efficacy measure was the Young Mania Rating Scale (YMRS) total score. Results: A total of 171 participants entered this randomized DB study and 23 continued into the OLE study. The mean (SD) age of the combined sample was 13.4 (2.1) years, 44.4% were male, and 66.7% were white. The demographic characteristics of participants who received ziprasidone (n = 86) or placebo (n = 85) were similar. The primary objective was met: the mean difference for ziprasidone versus placebo in the YMRS total score was -4.23 (95% confidence interval: -7.14 to -1.32; p = 0.005) indicating an effect size of 0.58. The most common adverse events (AEs) in the ziprasidone group were somnolence (31.4%), fatigue (22.1%), and nausea (14%). The mean Fridericia-corrected QT interval (QTcF) intervals in the ziprasidone group were moderately prolonged relative to the placebo group at all study visits. No participants had QTcF intervals ≥480 msec or an increase from baseline ≥60 msec. No AEs indicative of QT prolongation occurred. Weight, body mass index (BMI), and BMI z-scores, and metabolic measures were similar in both treatment groups. The data from the OLE study will be reported separately. Conclusions: Ziprasidone was effective in children and adolescents with BD-I in a manic episode, replicating the results of a previous study with a similar design (Findling et al. 2013). Overall, ziprasidone was safe and well tolerated with no meaningful effects on weight or metabolic parameters. Trial registration: ClinicalTrials.gov. NCT02075047 and NCT03768726.

Long-Term Effects of Lithium Use on Children and Adolescents: A Retrospective Study from Turkey

Background: The aim of this study was to evaluate the long-term effects of lithium treatment on white blood cell (WBC) count, serum creatinine, and thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorder (BD) and non-BD in a Turkish children and adolescent sample. Methods: The study is based on retrospective chart review. Children and adolescent patients with BD and non-BD prescribed lithium in a mental health and neurological disorders hospital between 2012 and 2017 were included in the study. Data were collected from the electronic medical files. Laboratory values for WBC count, serum creatinine, and TSH levels at baseline within the week before the onset of lithium, and at 1st, 3rd, 6^th, and 12th month of treatment were recorded. Results: A total of 143 patients (82 females, 61 males; 100 BD, 43 non-BD) aged 9-18 were included. Non-BD diagnoses were psychotic and schizoaffective disorders, unipolar depression, attention-deficit/hyperactivity disorder, conduct disorder, severe mood dysregulation syndrome, borderline personality disorder, and autism. Mean age of the participants were 15.90 ± 1.16 years for the bipolar group and 14.88 ± 1.79 years for the nonbipolar group. Patients with BD reported more adverse effects. There was a statistically significant increase in WBC counts and TSH levels at any time point. A statistically significant elevation in serum creatinine was found at 3rd and 12th month of treatment. During the course of lithium treatment, WBC counts exceeded 13,000 in 14 (9.8%) patients, and TSH levels exceeded 5.5 mU/L in 41 patients (28.6%). Twenty-one (14.68%) patients were started on thyroxin replacement. Basal TSH levels and duration of the lithium treatment were higher in the participants with TSH levels exceeding 5.5 mU/L. Lithium maximum dose, lithium blood level, basal TSH level, and duration of treatment were higher in the participants receiving thyroxin replacement. No patients had serum creatinine levels exceeding the normal reference values. Conclusion: Our study suggests that lithium is a generally safe and tolerable agent for children and adolescents with BD and non-BD; however, close monitoring of thyroid functions particularly in patients with a higher basal TSH level and longer duration of lithium use is important.

Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing

It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.

A Randomized, Double-Blind, Controlled Trial of Lithium Versus Quetiapine for the Treatment of Acute Mania in Youth with Early Course Bipolar Disorder

Objective: To compare the efficacy and tolerability of lithium versus quetiapine for the treatment of manic or mixed episodes in youths with early course bipolar I disorder. Methods: Six-week, randomized, double-blind clinical trial of lithium versus quetiapine for the treatment of adolescents with acute manic/mixed episode. Target dose of quetiapine dose was adjusted to a target dose of 400-600 mg and target serum level for lithium was 1.0-1.2 mEq/L. Primary outcome measure was baseline-to-endpoint change in the Young Mania Rating Scale (YMRS). Secondary outcomes were treatment response (50% or more decrease from baseline in YMRS score) and remission (YMRS score ≤12, Children's Depression Rating Scale-Revised [CDRS-R] total score ≤28 and Clinical Global Impression Bipolar Severity Scale [CGI-BP-S] overall score of ≤3, respectively). Results: A total of 109 patients were randomized (quetiapine = 58 and lithium = 51). Participants in the quetiapine treatment group showed a significantly greater reduction in YMRS score than those in the lithium group (-11.0 vs. -13.2; p < 0.001; effect size 0.39). Response rate was 72% in the quetiapine group and 49% in the lithium group (p = 0.012); no differences in remission rates between groups were observed. Most frequent side effects for lithium were headaches (60.8%), nausea (39.2%), somnolence (27.5%), and tremor (27.5%); for quetiapine somnolence (63.8%), headaches (55.2%), tremor (36.2%), and dizziness (36.2%) were evidenced. Participants receiving quetiapine experienced more somnolence (p < 0.001), dizziness (p < 0.05), and weight gain (p < 0.05). Conclusions: Treatment with both lithium and quetiapine led to clinical improvement. Most study participants in this study experienced a clinical response; however, less than half of the participants in this study achieved symptomatic remission. The head-to-head comparison of both treatment groups showed quetiapine was associated with a statistically significant greater rate of response and overall symptom reduction compared with lithium. Trial registration: clinicaltrials.gov NCT00893581.

Mood Stabilizers in Psychiatric Disorders and Mechanisms Learnt from In Vitro Model Systems

Bipolar disorder (BD) and schizophrenia are psychiatric disorders that manifest unusual mental, behavioral, and emotional patterns leading to suffering and disability. These disorders span heterogeneous conditions with variable heredity and elusive pathophysiology. Mood stabilizers such as lithium and valproic acid (VPA) have been shown to be effective in BD and, to some extent in schizophrenia. This review highlights the efficacy of lithium and VPA treatment in several randomized, controlled human trials conducted in patients suffering from BD and schizophrenia. Furthermore, we also address the importance of using induced pluripotent stem cells (iPSCs) as a disease model for mirroring the disease's phenotypes. In BD, iPSC-derived neurons enabled finding an endophenotype of hyperexcitability with increased hyperpolarizations. Some of the disease phenotypes were significantly alleviated by lithium treatment. VPA studies have also reported rescuing the Wnt/β-catenin pathway and reducing activity. Another significant contribution of iPSC models can be attributed to studying the molecular etiologies of schizophrenia such as abnormal differentiation of patient-derived neural stem cells, decreased neuronal connectivity and neurite number, impaired synaptic function, and altered gene expression patterns. Overall, despite significant advances using these novel models, much more work remains to fully understand the mechanisms by which these disorders affect the patients' brains.

Lithium therapy and weight change in people with bipolar disorder: A systematic review and meta-analysis

Lithium remains the gold standard maintenance treatment for Bipolar Disorder (BD). However, weight gain is a side effect of increasing relevance due to its metabolic implications. We conducted a systematic review and meta-analysis aimed at summarizing evidence on the use of lithium and weight change in BD. We followed the PRISMA methodology, searching Pubmed, Scopus and Web of Science. From 1003 screened references, 20 studies were included in the systematic review and 9 included in the meta-analysis. In line with the studies included in the systematic review, the meta-analysis revealed that weight gain with lithium was not significant, noting a weight increase of 0.462 Kg (p = 0158). A shorter duration of treatment was significantly associated with more weight gain. Compared to placebo, there were no significant differences in weight gain. Weight gain was significantly lower with lithium than with active comparators. This work reveals a low impact of lithium on weight change, especially compared to some of the most widely used active comparators. Our results could impact clinical decisions.

The Challenges of Children with Bipolar Disorder

Childhood onset bipolar disorder (CO-BD) presents a panoply of difficulties associated with early recognition and treatment. CO-BD is associated with a variety of precursors and comorbidities that have been inadequately studied, so treatment remains obscure. The earlier the onset, the longer is the delay to first treatment, and both early onset and treatment delay are associated with more depressive episodes and a poor prognosis in adulthood. Ultra-rapid and ultradian cycling, consistent with a diagnosis of BP-NOS, are highly prevalent in the youngest children and take long periods of time and complex treatment regimens to achieve euthymia. Lithium and atypical antipsychotics are effective in mania, but treatment of depression remains obscure, with the exception of lurasidone, for children ages 10-17. Treatment of the common comorbid anxiety disorders, oppositional defiant disorders, pathological habits, and substance abuse are all poorly studied and are off-label. Cognitive dysfunction after a first manic hospitalization improves over the next year only on the condition that no further episodes occur. Yet comprehensive expert treatment after an initial manic hospitalization results in many fewer relapses than traditional treatment as usual, emphasizing the need for combined pharmacological, psychosocial, and psycho-educational approaches to this difficult and highly recurrent illness.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

The Management of Prodromal Symptoms of Bipolar Disorder: Available Options and Future Perspectives

The onset of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder could be considered as an important alarm bell for the development of the disease and should be carefully detected. The management of prodromes in bipolar high-risk patients appears to be an important means of prevention; nevertheless, at the moment, there aren’t clear and widely shared treatment indications. The aim of this review is to summarize the available treatment options (pharmacological, psychosocial and nutraceutical) for the management of prodromal symptoms in subjects who are at familial or clinical risk for bipolar disorder.

Attention-Deficit Hyperactivity Disorder and the Dysregulation of Emotion Generation and Emotional Expression

Individuals with attention-deficit/hyperactivity disorder (ADHD) frequently experience strong reactions to emotionally evocative situations. Difficulties modulating anger and other upsets have clinically significant behavioral consequences. Those with ADHD may have anomalies in emotion generation, emotion expression, or both that predispose to these problems. The association between ADHD and emotion dysregulation raises Important clinical and research issues, including possible heterogeneity in the mechanisms by which they are related. Although first-line treatments for ADHD often help to resolve emotional dysregulation symptoms as well, the evidence base for widespread practice of combination pharmacotherapy remains sparse. Psychosocial treatments that engage processes underlying emotional dysregulation are in development.

Advances in the psychopharmacotherapy of bipolar disorder type I

INTRODUCTION

Research into the pharmacologic management of bipolar type I illness continues to progress.

AREAS COVERED

Randomized clinical trials performed with type I bipolar disorder in the years 2015 to August 2020 are reviewed. There are new indications for the use of cariprazine, for bipolar mania and depression, and a long-acting injectable formulation of aripiprazole has also been approved for relapse prevention in bipolar illness. Most of the randomized clinical trials are effectiveness studies.

EXPERT OPINION

Over the 20 years from 1997 through 2016, the use of lithium and other mood stabilizers has declined by 50%, while the use of both second-generation antipsychotics (SGAs) and antidepressants has increased considerably. Over the same time period (1990-2017), disability-adjusted life years (DALYs) increased by 54.4%, from 6.02 million in 1990 to 9.29 million in 2017 which is greater than the 47.74% increase in incidence of the disease, suggesting that the changes in prescribing patterns have not been helpful for our patients. Furthermore, recent effectiveness studies continue to confirm the superiority of lithium and other mood stabilizers in the management of bipolar illness for both psychiatric and medical outcomes, reaffirming their role as foundational treatments in the management of type I bipolar disorder. Clinicians need to reassess their prescribing habits.

Medication Adherence in Pediatric Patients with Bipolar Disorder: A Systematic Review

Objectives: Pediatric bipolar disorder is a severe disabling condition affecting 1%-3% of youth worldwide. Both acute and maintenance treatment with medications are mainstays of treatment. It is well established in adult literature that adherence to medications improves outcomes and many adult studies have examined factors impacting adherence. This systematic review set out to identify the current state of research examining adherence to medications and characteristics influencing adherence in pediatric bipolar disorder. Methods: We performed a systematic literature review in the Medline, PsycINFO, CINAHL, EMBASE, Wiley Clinical Trials, and Cochrane databases. New research regarding characteristics and measurement of adherence to psychotropic medication for bipolar disorder (I, II, or not otherwise specified) in patients ≤18 years old were included for review. Exclusion criteria included no bipolar diagnosis, inclusion of patients >18 years old, no pharmacologic treatment, and lack of adherence measurements. Results: Initial search generated 439 articles after duplicate removal. One hundred thirty-three full-text articles were reviewed, 16 underwent additional review and 6 were selected for final inclusion. The majority of articles were excluded for patients >18 years old. Included articles were extremely heterogeneous for multiple measures, including methodology, determination of adherence, adherence rates, and characteristics influencing adherence. Of medications evaluated, 6/6 studies included mood stabilizers, 4/6 antidepressants, 3/6 antipsychotics, and 2/6 psychostimulants. Three out of six articles included patients <12 years old. Some significant factors affecting adherence included polypharmacy, comorbid psychiatric diagnoses, socioeconomic status, sex, family history and functioning, side effects, race, stability of bipolar diagnosis, and number of follow-up visits attended. Conclusions: Pediatric-specific information on medication adherence in bipolar disorder is very limited. Information on patient characteristics that may influence adherence rates is critical to target interventions to improve adherence. No articles reported on interventions to improve adherence. Given the different psychosocial situations of pediatric patients versus adults, it is likely that targets for improving adherence differ in pediatric patients.

Psychiatric Diseases in Children and Adolescents

Pharmacotherapy of psychiatric illnesses in children and adolescents has grown significantly over the last few decades. However, the body of research examining pharmacological treatments for psychiatric illnesses is much smaller in children and adolescents than it is in adults. As most treatments for psychiatric disorders are more effective if started early in the course of illness, treatment options for youth are especially important in order to ensure better treatment outcomes. This chapter discusses currently approved medications to treat psychiatric disorders in children and adolescents. Research on medications that may be effective treatments but are not yet FDA approved is also discussed. The medications are broken down into major categories used in youth with psychiatric disorders including antidepressants, mood stabilizers, ADHD medications, and antipsychotics.

Lithium Versus Other Mood-Stabilizing Medications in a Longitudinal Study of Youth Diagnosed With Bipolar Disorder

OBJECTIVE

Lithium is the mainstay for bipolar disorder (BD) treatment in adults, but evidence in youths is limited. We used data from the Course and Outcome of Bipolar Youth (COBY) study to assess whether lithium vs other mood-stabilizing medication (OMS) was associated with improved outcomes, including mood symptoms and suicidality.

METHOD

COBY is a naturalistic, longitudinal study of 413 youths, 7 to 17.11 years old at intake, with BD. At each visit, medication exposure, psychiatric symptoms, and psychosocial function over the preceding follow-up period were assessed using the Adolescent Longitudinal Interval Follow-Up Evaluation. Using mixed models, we determined whether participants taking lithium vs OMS (but not lithium) differed regarding mood symptoms, suicidality, psychosocial function, hospitalization, aggression, and substance use.

RESULTS

A total of 340 participants contributed 2,638 six-month follow-up periods (886 lithium, 1,752 OMS), over a mean follow-up of 10 years. During lithium (vs OMS) follow-up periods, participants were older, less likely to have lifetime anxiety, and less likely to be on antidepressants (p values<.005). After covariate adjustment, the lithium group (vs OMS) had half as many suicide attempts (p = .03), fewer depressive symptoms (p = .004), less psychosocial impairment (p = .003), and less aggression (p = .0004). Similar findings were observed in the subgroup of follow-up periods in which participants were <18 years old.

CONCLUSION

Findings are consistent with adult studies, showing that lithium is associated with decreased suicidality, less depression, and better psychosocial functioning. Given the paucity of evidence regarding lithium in children and adolescents, these findings have important clinical implications for the pharmacological management of youths with BD.

Toward prevention of bipolar disorder in at-risk children: Potential strategies ahead of the data

BACKGROUND

Despite the well-documented negative impact of untreated bipolar illness, approaches to early intervention in childhood-onset bipolar and related disorders are not well delineated.

METHODS

We reviewed the extant treatment literature on children at high risk for bipolar disorder, with definitions based on family history, childhood adversity, and prodromal symptoms.

RESULTS

A panoply of approaches have been described, but most interventions are based on an inadequate database to support their routine implementation. We classify early stage interventions as a function of their safety and tolerability with the hope that these might generate more rigorous study and a stronger database.

LIMITATIONS

Critics may rightly argue that identifying viable treatment methods is premature given our lack of ability to reliably predict illness trajectory in very young children. However, many of the psychosocial and pharmacological interventions we present could have nonspecific positive effects across a variety of symptoms, syndromes, and diagnoses, further enhancing the rationale for more rigorous study.

CONCLUSIONS

Early stage interventions have the potential to improve functioning in prodromal illness and exert long-term positive effects on the course of illness. Many of the safest interventions deserve consideration for implementation and dissemination studies.

Lithium Treatment Over the Lifespan in Bipolar Disorders

Lithium has been the treatment of choice for patients with bipolar disorder (BD) for nearly 70 years. It is recommended by all relevant guidelines as a first-line treatment for maintenance therapy. In this review, we outline the current state of evidence for lithium in the treatment of BD over the lifespan. First, we summarize the evidence on efficacy in general, from relapse prevention to acute anti-manic treatment and its role in treating mood episodes with mixed features and bipolar depression. As patients are often treated for many years and different aspects have to be considered in different phases of life, we discuss the particularities of lithium in the treatment of paediatric BD, in older aged individuals and in pregnant women. Lastly, we discuss the evidence on lithium's proposed suicide-preventive effects, the dangers of rapid discontinuation and lithium's adverse effects, particularly with regard to long-term treatment.

Effect of lithium on suicide and mortality in mood disorders: A systematic review

OBJECTIVE

To assess if lithium treatment in patients with mood disorders, for instance depression, bipolar disorders, and schizoaffective disorders, has an effect on total mortality and suicide.

DESIGN

Systematic review and meta-analysis.

MAIN OUTCOME MEASURE

Total mortality. Secondary outcome was suicide.

DATA SOURCES

PubMed and ClinicalTrials.gov. Eligible trials were randomized double-blind trials comparing lithium with placebo in patients with mood disorders who were not already on lithium before randomization in order to avoid withdrawal effects in the placebo group.

DATA EXTRACTION AND ANALYSIS

Two researchers extracted data independently. Data were analysed with Review Manager 5.3 (Peto odds ratio).

RESULTS

We found 45 eligible studies. Only four studies reported any suicides or other deaths in the lithium or placebo group. There was a significant reduction in total mortality (two versus nine), odds ratio 0.28 (95% confidence interval 0.08 to 0.93). There was no statistically significant reduction in suicides, (none versus three), odds ratio 0.13 (0.01 to 1.27).

CONCLUSION

According to our study, lithium reduces total mortality in mood disorders but not suicide. Because of small numbers and unreliable data, the findings should be interpreted with caution.

Mixed States in Early-Onset Bipolar Disorder

Pediatric bipolar disorder (PBD) is a severe and chronic illness. The occurrence of mixed symptoms might add further risk of recurrence of treatment resistance and suicidality. Early recognition and treatment of mixed symptoms might prevent illness progression and development of suicide attempts. This article provides an update on the epidemiology, clinical profile, and treatment of youth with PBD with mixed states. Mixed states in PBD are characterized by higher rates of suicide and more chronic symptoms, and are associated with younger age of onset and greater comorbidity. A careful assessment for mixed states using standardized criteria is essential.

An Adolescent Female with Bipolar Disorder Presenting with Lithium-Induced Hyperthyroidism

Lithium therapy has been associated with several endocrine disorders including thyroid dysfunction, diabetes insipidus, and hyperparathyroidism. While its suppressive effect on thyroid function is well known, it is very rare to observe lithium-induced hyperthyroidism especially in the pediatric population. Here, we describe a case of lithium-induced hyperthyroidism in an adolescent female with bipolar disorder. The patient is a 17-year-old female who was treated with lithium for bipolar disorder and presented with symptoms and laboratory findings consistent with hyperthyroidism. Since thyroid autoantibodies were negative, thyroid dysfunction was attributed to lithium toxicity. Indeed, her clinical and biochemical hyperthyroid state resolved after stopping lithium therapy. Lithium-associated hyperthyroidism can occur in the pediatric population. We propose close monitoring of thyroid hormone levels in children on lithium therapy.

Safety considerations in the psychopharmacology of pediatric bipolar disorder

Introduction: The standard of treatment of pediatric bipolar disorder (BPD) often requires life-long psychopharmacological management. Several pharmacological agents are approved by the US FDA for the treatment of pediatric BPD. However, each medication may cause adverse events (AEs). Provider awareness of AE profiles of common pharmacologic agents would serve to better inform patients and families in evaluating and selecting between treatment options. Areas covered: This review focuses on medications that, in our clinical experience, are commonly prescribed for youth with BPD and were evaluated in prospective clinical trials for the treatment of pediatric BPD. This paper highlights acute and long-term AEs described in these studies. Expert opinion: Most medications increase risk of AEs in youth with BPD. Treatment with lithium may lead to thyrotropin elevations, but generally does not cause significant weight gain. Divalproex may lead to weight gain; however, this finding was not consistent in comparison studies with lithium. Olanzapine, risperidone, quetiapine, and asenapine are associated with metabolic abnormalities and weight gain. Studies of ziprasidone, aripiprazole and lurasidone do not suggest significant metabolic AEs. More studies are needed to assess efficacy and safety of medications in managing pediatric BPD. Special focus on long-term maintenance trials is required to further identify long-term AEs in this population.

Comparison of common side effects from mood stabilizers and antipsychotics between pediatric and adult patients with bipolar disorder: a systematic review of randomized, double-blind, placebo-controlled trials

INTRODUCTION

To compare common side effects of mood stabilizers (MSs) and antipsychotics in pediatric and adult bipolar disorder (BD).

AREAS COVERED

MEDLINE, EMBASE, PsycINFO was searched for randomized, double-blind, placebo-controlled trials (RCTs) in the treatment of pediatric and adult BD. Twelve RCTs for pediatric patients and 30 for adult patients were included. The risk for the discontinuation due to adverse events, ≥7% weight gain, somnolence, akathisia, nausea and vomiting from a medication relative to placebo was estimated with absolute risk increase and the number needed to harm. The relative risk of these measures in pediatric and adult patients was compared.

EXPERT OPINION

Overall, the relative risk for ≥7% weight gain, somnolence, nausea, or vomiting was higher, and akathisia was lower in pediatric patients than in adults. The magnitude of difference among MSs and antipsychotics and between pediatrics and adults varied widely. The risk for pediatric patients could be underestimated because in most pediatric studies, doses of studied medications were lower and flexibly dosed, and titration speeds were slower than in adult studies. Clinicians should pay attention to differences in study designs to understand the risk for common side effects when prescribing a medication for BD.

Lithium for acute mania

BACKGROUND

Bipolar disorder is a common condition associated with high morbidity; developing efficacious, safe treatments is therefore essential. Lithium is an effective maintenance treatment for bipolar disorder. It acts as mood stabiliser and reduces the risk of suicide. However, evidence assessing the efficacy of lithium in the treatment of acute mania is less robust. Current evidence-based guidelines cite multiple anti-dopaminergic and mood-stabilising agents as initial treatments: more definite evidence is needed to decide if lithium should be the first-line therapy.

OBJECTIVES

1. To assess the effects of lithium in comparison with placebo or other active treatment in alleviating the acute symptoms of a manic or mixed episode in people with bipolar disorder.2. To review the acceptability and tolerability of treatment with lithium in comparison with placebo or other active treatments in alleviating the acute symptoms of a manic or mixed episode in people with bipolar disorder.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register, CENTRAL, MEDLINE, Embase, and PsycINFO. We also searched the World Health Organization trials portal (ICTRP) and ClinicalTrials.gov. We checked the reference lists of all included studies and relevant systematic reviews. We have incorporated studies from searches to 18 May 2018 into the current analyses.

SELECTION CRITERIA

Prospective randomised controlled studies comparing lithium with placebo or alternative drug treatment in treatment of acute mania. We included anyone with bipolar disorder, male and female, of any age.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed methodological quality. We used odds ratios (ORs) to analyse binary efficacy outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuously distributed outcomes. We used a fixed-effect model unless heterogeneity was moderate or substantial, in which case we used a random-effects model. We used Review Manager 5 to analyse data. We assessed the certainty of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We found 36 randomised controlled studies comparing lithium with placebo, one of 12 drugs, or electroconvulsive therapy for treatment of acute mania. Studies included male and female participants (n = 4220), of all ages, who all fitted criteria for a manic episode within the context of a diagnosis of bipolar disorder.Risk of bias was variable; 12 studies had a high risk of bias in one domain and 27 gave inadequate information on randomisation leading to an 'unclear' rating for selection bias.Lithium versus placeboHigh-certainty evidence found that lithium was an effective treatment for acute mania and was more effective than placebo at inducing a response (OR 2.13, 95% confidence interval (CI) 1.73 to 2.63; participants = 1707; studies = 6; I² = 16%; high-certainty evidence), or remission (OR 2.16, 95% CI 1.73 to 2.69; participants = 1597; studies = 5; I² = 21%; high-certainty evidence).Lithium was more likely than placebo to cause tremor (OR 3.25, 95% CI 2.10 to 5.04; participants = 1241; studies = 6; I² = 0%; high-certainty evidence), and somnolence (OR 2.28, 95% CI 1.46 to 3.58; participants = 1351; studies = 7; I² = 0%; high-certainty evidence).There was insufficient evidence to determine the effect of lithium for all-cause dropouts (OR 0.76; 95% CI 0.46 to 1.25; participants = 1353; studies = 7; I² = 75%; moderate-certainty evidence), and weight gain (OR 1.48, 95% CI 0.56 to 3.92; participants = 735, studies = 3; I²= 51%; moderate-certainty evidence).Lithium versus antipsychotics or mood stabilisersFor the outcome of inducing a response, there was only very low-certainty evidence regarding lithium compared to haloperidol (MD -2.40, 95% CI -6.31 to 1.50; participants = 80; studies = 3; I² = 95%), quetiapine (OR 0.66, 95% CI 0.28 to 1.55; participants = 335; studies = 2; I² = 71%), and carbamazepine (SMD 0.21, 95% CI -0.18 to 0.60; participants = 102; studies = 3; I² = 0%).Lithium was probably less likely to induce a response than olanzapine (OR 0.44, 95% CI 0.20 to 0.94; participants = 180; studies = 2; I² = 0%; moderate-certainty evidence).Lithium may be less likely to induce a response than risperidone (MD 7.28, 95% CI 5.22 to 9.34; participants = 241; studies = 3; I² = 49%; low-certainty evidence).There was no evidence of a difference between lithium and valproate (OR 1.22, 95% CI 0.87 to 1.70; participants = 607; studies = 5; I² = 22%; moderate-certainty evidence).There was moderate-certainty evidence that lithium was more effective than topiramate at treating acute mania (OR 2.28, 95% CI 1.63 to 3.20; participants = 660; studies = 1).Data on adverse events for these comparisons contained too few studies to provide high-certainty evidence.

AUTHORS' CONCLUSIONS

This systematic review indicates that lithium is more effective than placebo as a treatment for acute mania but increases the risk for somnolence and tremor. Limited evidence suggests little or no difference between lithium and other mood stabilisers (valproate, carbamazepine) or antipsychotics (risperidone, quetiapine, haloperidol). Olanzapine may be an exception, as it is probably slightly more effective than lithium. There is uncertain evidence that risperidone may also be more effective than lithium. Lithium is probably more effective at treating acute mania than topiramate. When compared to placebo, lithium was more likely to cause adverse events. However, when compared to other drugs, too few studies provided data on adverse effects to provide high-certainty evidence. More, rigorously designed, large-scale studies are needed to definitively conclude if lithium is superior to other interventions in treating acute mania.

Lithium for the Maintenance Treatment of Bipolar I Disorder: A Double-Blind, Placebo-Controlled Discontinuation Study

OBJECTIVE

This study examined the role of lithium in the maintenance treatment of pediatric patients with bipolar I disorder (BP-I).

METHOD

Participants aged 7 to 17 years who presented with a manic or mixed episode received 24 weeks of lithium treatment in one of two multiphase studies, the Collaborative Lithium Trials (CoLT 1 and CoLT 2). Responders were randomized to continue lithium or to be cross-titrated to placebo for up to 28 weeks. The primary outcome measure was relative risk of study discontinuation for any reason.

RESULTS

A Cox regression analysis found that those who continued treatment with lithium (n = 17) had a lower hazard ratio compared to those who received placebo (n = 14) (p = .015)]. The vast majority of discontinuations were due to mood symptom exacerbations, with most of these occurring in the placebo-treated group. Discontinuation for other reasons occurred at similarly low rates across both group. Most adverse events were mild to moderate in severity, and only one study participant was discontinued from the trial owing to a serious adverse event (aggression). There was no statistically significant difference with respect to weight gain in participants receiving lithium compared to those receiving placebo.

CONCLUSION

This randomized, double-blind, placebo-controlled Discontinuation Trial builds support for the role of lithium as a maintenance treatment in pediatric patients with bipolar disorder and for the safety and tolerability of 28 weeks of maintenance lithium treatment.

CLINICAL TRIAL REGISTRATION INFORMATION

Lithium for the Treatment of Pediatric Mania; https://clinicaltrials.gov/; NCT00442039 (CoLT 1). Safety and Efficacy Study of Lithium for the Treatment of Pediatric Mania; https://clinicaltrials.gov/; NCT01166425 (CoLT 2).

Putative Mechanisms of Action and Clinical Use of Lithium in Children and Adolescents: A Critical Review

BACKGROUND

Lithium is a first-line treatment for bipolar disorder in adults, but its mechanism of action is still far from clear. Furthermore, evidences of its use in pediatric populations are sparse, not only for bipolar disorders, but also for other possible indications.

OBJECTIVES

To provide a synthesis of published data on the possible mechanisms of action of lithium, as well as on its use in pediatric samples, including pharmacokinetics, efficacy, and safety data.

METHODS

Clinical trials in pediatric samples with at least one standardized measure of efficacy/ effectiveness were included in this review. We considered: i) randomized and open label trials, ii) combination studies iii) augmentation studies iv) case series including at least 5 patients.

RESULTS

Different and non-alternative mechanisms of action can explain the clinical efficacy of lithium. Clinical studies in pediatric samples suggest that lithium is effective in managing manic symptoms/episodes of bipolar disorder, both in the acute phase and as maintenance strategy. Efficacy on depressive symptoms/phases of bipolar disorder is much less clear, while studies do not support its use in unipolar depression and severe mood dysregulation. Conversely, it may be effective on aggression in the context of conduct disorder. Other possible indications, with limited published evidence, are the acute attacks in Kleine-Levin syndrome, behavioral symptoms of X-fragile syndrome, and the management of clozapine- or chemotherapy- induced neutropenia. Generally, lithium resulted relatively safe.

CONCLUSIONS

Lithium seems an effective and well-tolerated medication in pediatric bipolar disorder and aggression, while further evidences are needed for other clinical indications.

Understanding suicide: Focusing on its mechanisms through a lithium lens

BACKGROUND

Current intervention strategies have been slow in reducing suicide rates, particularly in mood disorders. Thus, for intervention and prevention, a new approach is necessary. Investigating the effects of a medication known for its anti-suicidal properties on neurobiological and neurocognitive substrates of suicidal thinking may provide a deeper and more meaningful understanding of suicide.

METHOD

A literature search of recognised databases was conducted to examine the intersection of suicide, mood disorders, and the mechanisms of lithium.

RESULTS

This review synthesises the extant evidence of putative suicide biomarkers and endophenotypes and melds these with known actions of lithium to provide a comprehensive picture of processes underlying suicide. Specifically, the central importance of glycogen synthase kinase-3β (GSK3β) is discussed in detail because it modulates multiple systems that have been repeatedly implicated in suicide, and which lithium also exerts effects on.

LIMITATIONS

Suicide also occurs outside of mood disorders but we limited our discussion to mood because of our focus on lithium and extending our existing model of suicidal thinking and behaviour that is contextualised within mood disorders.

CONCLUSIONS

Focusing on the neurobiological mechanisms underpinning suicidal thinking and behaviours through a lithium lens identifies important targets for assessment and intervention. The use of objective measures is critical and using these within a framework that integrates findings from different perspectives and domains of research is likely to yield replicable and validated markers that can be employed both clinically and for further investigation of this complex phenomenon.

Lithium Treatment Is Safe in Children With Intellectual Disability

Lithium is a widely used and effective treatment for individuals with psycho-neurological disorders, and it exhibits protective and regenerative properties in multiple brain injury animal models, but the clinical experience in young children is limited due to potential toxicity. As an interim analysis, this paper reports the safety/tolerability profiles of low-dose lithium treatment in children with intellectual disability (ID) and its possible beneficial effects. In a randomized, single-center clinical trial, 124 children with ID were given either oral lithium carbonate 6 mg/kg twice per day or the same dose of calcium carbonate as a placebo (n = 62/group) for 3 months. The safety of low-dose lithium treatment in children, and all the adverse events were monitored. The effects of low-dose lithium on cognition was evaluated by intelligence quotient (IQ), adaptive capacity was assessed by the Infant-Junior Middle School Students Social-Life Abilities Scale (IJMSSSLAS), and overall performance was evaluated according to the Clinical Global Impression-Improvement (CGI-I) scale. After 3 months of lithium treatment, 13/61 children (21.3%) presented with mild side effects, including 4 (6.6%) with gastrointestinal symptoms, 4 (6.6%) with neurological symptoms, 2 (3.3%) with polyuria, and 3 (4.9%) with other symptoms—one with hyperhidrosis, one with alopecia, and one with drooling. Four children in the lithium group had elevated blood thyroid stimulating hormone, which normalized spontaneously after lithium discontinuation. Both IQ and IJMSSSAS scores increased following 3 months of lithium treatment (F = 11.03, p = 0.002 and F = 7.80, p = 0.007, respectively), but such increases were not seen in the placebo group. CGI-I scores in the lithium group were 1.25 points lower (better) than in the placebo group (F = 82.66, p < 0.001) after 3 months of treatment. In summary, lithium treatment for 3 months had only mild and reversible side effects and had positive effects on cognition and overall performance in children with ID.

Clinical Trial Registration: Chinese Clinical Trial Registry, ChiCTR-IPR-15007518.

Progress in diagnosis and treatment of bipolar disorder among children and adolescents: an international perspective

Bipolar disorder (BPD) is a potentially lifelong condition characterised by extreme changes in mood that may begin in childhood and cause substantial impairment. Over the past decades, BPD has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in children and adolescents. This report addresses these controversies by reviewing the extant evidence base, providing clinicians with a summary of the literature on diagnosis, phenomenology and treatment of paediatric BPD. The debate regarding diagnosing children with BPD based on severe irritability and aggression is mostly resolved. The current data support utilising the diagnostic criteria based on episodic changes of mood polarity. Therefore, longitudinal course of illness should be explored in detail when diagnosing BPD. Given high rates of genetic predisposition for BPD, assessment of youth should focus on obtaining accurate family history of this condition. Additionally, there has been a substantial increase in randomised placebo-controlled clinical trials evaluating pharmacological agents for mood stabilisation in children and adolescents, which we summarise in this review. Despite significant progress being made in the field of paediatric BPD, more research is needed in the areas of phenomenology, pathophysiology, course and treatment of this condition in youth.

Efficacy and tolerability of lithium for the treatment of acute mania in children with bipolar disorder: A systematic review: A report from the ISBD-IGSLi joint task force on lithium treatment

OBJECTIVES

To assess the efficacy and tolerability of lithium for the treatment of acute mania in children and adolescent diagnosed with bipolar disorder.

METHODS

A systematic literature search up to August 2017 was conducted for clinical trials that included lithium in males and females up to 18 years of age with a diagnosis of bipolar disorder and experiencing a manic or mixed episode according to standardized diagnostic criteria. The protocol was registered in PROSPERO (CRD42017055675).

RESULTS

Four independent studies described in seven manuscripts met the inclusion criteria. Overall, 176 patients were treated with lithium either as a monotherapy or adjunct to risperidone. Efficacy results suggest that lithium may be superior to placebo (standardized mean difference [SMD] -0.42, 95% confidence interval [CI] -0.88 to 0.04), comparable to sodium divalproex (SMD -0.07, 95% CI: -0.31 to 0.18), but significantly less effective than risperidone for treating protracted manic/mixed episodes and comorbid attention-deficit hyperactivity disorder (ADHD) in prepubertal children (SMD 0.85, 95% CI: 0.54 to 1.15). Lithium was not associated with serious adverse events, and was generally well tolerated with common side effects similar to those reported in adults.

CONCLUSIONS

Limited data suggests that lithium may be an effective and tolerable treatment for some forms of paediatric mania. However, lithium is clearly inferior in efficacy to risperidone in prepubertal patients diagnosed with protracted manic/mixed episodes and comorbid ADHD. There is a lack of data concerning the efficacy and tolerability of lithium as an acute treatment for classical mania in adolescents and important clinical issues remain unaddressed.

Using Lithium in Children and Adolescents with Bipolar Disorder: Efficacy, Tolerability, and Practical Considerations

Lithium has been an intriguing treatment option in psychiatry for over a century. While seemingly just a simple elemental compound, it has powerful treatment effects for both depression and bipolar disorder. The evidence base for treatment of pediatric bipolar disorder is relatively small, but, in recent years, additional clinical trial data have enabled lithium to re-emerge as a valuable and, in many cases, preferred treatment. Pharmacologically, lithium is complex, with varied effects at both intracellular and extracellular levels. As a treatment for bipolar disorder in pediatrics, lithium is challenging, given its narrow therapeutic window and myriad of potential side effects. However, the efficacy of lithium continues to match that of newer pharmacologic agents, and its tolerability has been shown to be comparable with more commonly prescribed medications. Lithium is still one of few drugs that have been proven to reduce the risk of suicidality, and it may have utility in illnesses beyond affective disorders. Practically, as a primary agent or as an adjunct, lithium continues to claim a rightful place in the treatment armamentarium of child psychiatry. New dosing paradigms have improved tolerability and reduced potential side effects. Recent evidence affirms that lithium is effective for pediatric bipolar disorder in multiple phases of the illness.

Safety and efficacy of lithium in children and adolescents: A systematic review in bipolar illness

Introduction:

Many clinicians are reluctant to use traditional mood-stabilizing agents, especially lithium, in children and adolescents. This review examined the evidence for lithium’s safety and efficacy in this population.

Methods:

A systematic review was conducted on the use of lithium in children and adolescents with bipolar disorder (BD). Relevant papers published through June 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

Results:

30 articles met inclusion criteria, including 12 randomized controlled trials (RCTs). Findings from RCTs demonstrate efficacy for acute mania in up to 50% of patients, and evidence of long-term maintenance efficacy. Lithium was generally safe, at least in the short term, with most common side effects being gastrointestinal, polyuria, or headache. Only a minority of patients experienced hypothyroidism. No cases of acute kidney injury or chronic kidney disease were reported.

Conclusions:

Though the available literature is mostly short-term, there is evidence that lithium monotherapy is reasonably safe and effective in children and adolescents, specifically for acute mania and for prevention of mood episodes.

Further evidence of high level of persistence of pediatric bipolar-I disorder from childhood onto young adulthood: a five-year follow up

Background:

Pediatric bipolar (BP)-I disorder affects a sizeable minority of children and is associated with high levels of morbidity. Relatively few studies have assessed the persistence of the disorder over time.

Objective:

The main aim of this study was to extend our findings from our 4-year follow-up study examining rates of persistence of pediatric BP-I disorder onto late adolescent years and young adulthood 5 years after our original study.

Methods:

We conducted a 1-year extension to our original prospective study of 78 youth, ages six to 17 years, with BP-I disorder at ascertainment, who were followed up into their adolescent and young adult years (14.9 ± 3.8). All subjects were comprehensively assessed with structured diagnostic interviews and psychosocial, educational, and treatment history assessments.

Results:

Of the 78 BP-I participating youth, 68 were re-accessioned one year following the 4-year follow-up study, thus effectively 5 years since the original study. Of these, 63% continued to meet full (50%) or subthreshold (13%) diagnostic criteria for BP-I and 18% continued to have full or subthreshold major depressive disorder. Only 19% of BP-I youth were euthymic at the 5-year follow up.

Discussion:

This 1-year extension study further documents the high level of persistence of pediatric BP-I from childhood onto late adolescence and young adulthood. The results provide compelling evidence of the morbidity and dysfunction associated with this disorder and its many forms.

Clinical significance:

This study adds to a small amount of literature on the persistence of pediatric BP disorder and the critical need for early identification and intervention.