Valproate use in children and adolescents with bipolar disorder

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.

Predictors of valproic acid steady-state serum levels in adult and pediatric psychiatric inpatients: a comparative analysis

RATIONALE

Valproic acid (VPA) is commonly used as a second-line mood stabilizer or augmentative agent in severe mental illnesses. However, population pharmacokinetic studies specific to psychiatric populations are limited, and clinical predictors for the precision application of VPA remain undefined.

OBJECTIVES

To identify steady-state serum VPA level predictors in pediatric/adolescent and adult psychiatric inpatients.

METHODS

We analyzed data from 634 patients and 1,068 steady-state therapeutic drug monitoring (TDM) data points recorded from 2015 to 2021. Steady-state VPA levels were obtained after tapering during each hospitalization episode. Electronic patient records were screened for routine clinical parameters and co-medication. Generalized additive mixed models were employed to identify independent predictors.

RESULTS

Most TDM episodes involved patients with psychotic disorders, including schizophrenia (29.2%) and schizoaffective disorder (17.3%). Polypharmacy was common, with the most frequent combinations being VPA + quetiapine and VPA + promethazine. Age was significantly associated with VPA levels, with pediatric/adolescent patients (< 18 years) demonstrating higher dose-adjusted serum levels of VPA (β = 7.6±2.34, p < 0.001) after accounting for BMI. Women tended to have higher adjusted VPA serum levels than men (β = 5.08±1.62, p < 0.001). The formulation of VPA (Immediate-release vs. extended-release) showed no association with VPA levels. Co-administration of diazepam exhibited a dose-dependent decrease in VPA levels (F = 15.7, p < 0.001), suggesting a potential pharmacokinetic interaction.

CONCLUSIONS

This study highlights the utility of population-specific pharmacokinetic data for VPA in psychiatric populations. Age, gender, and co-administration of diazepam were identified as predictors of VPA levels. Further research is warranted to establish additional predictors and optimize the precision application of VPA in psychiatric patients.

Surprising Anticancer Activities of Psychiatric Medications: Old Drugs Offer New Hope for Patients With Brain Cancer

Despite decades of research and major efforts, malignant brain tumors remain among the deadliest of all cancers. Recently, an increasing number of psychiatric drugs has been proven to possess suppressing activities against brain tumors, and rapid progress has been made in understanding the potential mechanisms of action of these drugs. In particular, the traditional mood stabilizer valproic acid, the widely used antidepressants fluoxetine and escitalopram oxalate, and the atypical psychiatric drug aripiprazole have demonstrated promise for application in brain tumor treatment strategies through multiple lines of laboratory, preclinical, and clinical evidence. The unexpected discovery of the anticancer properties of these drugs has ignited interest in the repurposing of other psychiatric drugs to combat brain cancer. In this review, we synthesize recent progress in understanding the potential molecular mechanisms underlying the brain cancer-killing activities of representative psychiatric drugs. We also identify key limitations in the repurposing of these medications that must be overcome to enhance our ability to successfully prevent and treat brain cancer, especially in the most vulnerable groups of patients, such as children and adolescents, pregnant women, and those with unfavorable genetic variants. Moreover, we propose perspectives that may guide future research and provide long-awaited new hope to patients with brain cancer and their families.

Inpatient psychiatric treatment is not always effective in adolescent sample

OBJECTIVE

Numerous studies confirm efficacy of psychiatric treatment as well as psychiatric placebo. The aim of the current study was the assessment of improvement rate and factors associated with treatment response in naturalistic group of adolescent inpatients.

METHODS

Eighty two consecutive adolescent inpatients were recruited. Each patient at the admission and discharge was assessed with brief psychiatric rating scale (BPRS), eating attitude test (EAT-26), clinical global impression scale (CGI-S) and children global assessment scale (CGAS). Individual and family history was assessed by semi-structured interview. Patients, who improved in at least two interviewer-based scales (IMP, n = 67) were compared to the rest (N-IMP, n = 15). For statistical analysis STATISTICA package was used.

RESULTS

The main difference between groups was ICD-10 diagnosis distribution: in the IMP group more anxiety-related disorders (F4), in the N-IMP group more personality disorders (F6). Other differences include history of paediatric hospitalisations and surgery (more in the N-IMP group). Most of the analysed factors did not differ between groups.

CONCLUSIONS

The inpatient treatment seems to be most effective in severe mental states and in anxiety-related disorders and least effective in personality disorders. Due to limited inpatient treatment efficacy we believe outpatients services are crucial in adolescent psychiatry.

Effects of long-term valproic acid treatment on hematological and biochemical parameters in adolescent psychiatric inpatients: a retrospective naturalistic study

The objective of this study was to determine the long-term hematological and biochemical side effects of valproic acid (VPA) in psychiatric adolescent inpatients. A retrospective naturalistic study design was used. Participants were psychiatric inpatients treated with VPA, alone or in combination with other medications. Electronic medical files were reviewed for changes in hematological and biochemical parameters following a course of VPA treatment. One hundred and four adolescents aged 12-18 (mean 15.76±1.58) years fulfilled the study criteria. The mean blood level and duration of VPA treatment were 65.81±22.18 mcg/ml and 98.57±135.94 days, respectively. The mean levels of thyroid-stimulating hormones and triglyceride levels increased significantly from the first to the last measurement. Platelet count decreased significantly following VPA treatment. No correlation was observed between these parameters and age, duration of treatment, or VPA levels. No serious adverse events were reported. Long-term VPA treatment in adolescents with psychiatric disorders is associated with significant increases in triglyceride levels. Moreover, VPA-treated adolescent psychiatric inpatients may be at risk of developing pituitary-thyroid axis dysregulation and decreased platelet count. Therefore, baseline measurement of thyroid functions and metabolic and hematological parameters and monitoring throughout the treatment are recommended.

Thyroglobulin antibodies and risk of readmission at one year in subjects with bipolar disorder

Thyroid autoimmunity has been proposed as an endophenotype for Bipolar Disorder (BD), although its relationship with clinical outcomes remains unclear. We aimed to determine whether thyroid autoimmune status (thyroperoxidase antibodies [TPO-Abs] and thyroglobulin antibodies [TG-Abs]) in BD is associated with a greater risk for readmission at one year. We studied 77 inpatients with BD admitted for an index manic or mixed episode. Serum thyroid antibodies (TPO-Abs and TG-Abs) were determined at admission. We compared the readmission risk at 1 year, based on patients׳ thyroid autoimmunity profile using survival analyses. Cox regression was used to control covariates. TG-Abs+ but not TPO-Abs+ was associated with a lower risk of relapse. The Kaplan-Meier mean estimated survival times were 341.6 days (CI95% 316.4-366.8) for the TG-Abs+ group and 261.9 days (CI95%: 221.8 to 302.0) for the TG-Abs- group. Cox proportional hazards regression indicated that subjects with TG-Abs+ were 3.7 (1/OR=1/0.27) times less likely to get admitted during the follow-up period than those with TG-Abs-. Our study suggests that an autoimmune biomarker in patients with BD (i.e., the presence of TG-Abs) is associated with a lower risk of psychiatric readmission after an index hospitalization for a manic or mixed episode.

23Na magic-angle spinning and double-rotation NMR study of solid forms of sodium valproate

Sodium valproate is a pharmaceutical with applications in the treatment of epilepsy, bipolar disorder, and other ailments. Sodium valproate can exist in many hydrated and acid-stabilized forms in the solid state, and it can be difficult to obtain precise structural information about many of these. Here, we present a 13C and 23Na solid-state NMR study of several forms of sodium valproate, only one of which has been previously structurally characterized by single-crystal X-ray diffraction. 23Na magic-angle spinning (MAS), double-rotation (DOR), and multiple-quantum magic-angle spinning (MQMAS) NMR spectra are shown to provide useful information on the number of molecules in the asymmetric unit, the local coordination geometry of the sodium cations, and the presence of amorphous phases. Two previously identified forms are shown to be highly similar, or identical, according to the 23Na NMR data. The utility of carrying out both DOR and MQMAS NMR experiments to identify all crystallographically unique sites is demonstrated. 13C cross-polarization MAS NMR spectra also provide complementary information on the number of molecules in the asymmetric unit and the crystallinity of the sample.

Neuroconnectivity and valproic acid: the myelin hypothesis

Neuropsychiatric medications that directly alter the epigenome, such as valproic acid, can under certain conditions reactivate critical developmental periods and thus impact adult neuroconnectivity. In animal models valproic acid was shown to inhibit the process of postnatal myelination and to replicate age-dependent decline in remyelination efficiency. The human central nervous system's myelination process, unlike that of non-human primates commonly used in the experimental models, is an intricate heterochronous process that continues well into adult life and which probably underlies later life neurocognitive changes and plasticity. Chronic exposure to valproic acid, especially in patients with epilepsy and neuropsychiatric disorders, may profoundly affect this process and its developmental trajectory. Further studies using novel MRI methods that allow in vivo mapping of myelination trajectories across the lifespan are urgently required to address the potential effects of valproic acid on brain development.

Metabolic, digestive, and reproductive adverse events associated with antimanic treatment in children and adolescents: a retrospective cohort study

OBJECTIVE

To identify factors associated with incident metabolic and reproductive adverse events in children and adolescents.

METHOD

A retrospective cohort design evaluating Medicaid medical and pharmacy claims made in South Carolina between January 1996 and December 2005 was employed for 3,657 children and adolescents (aged 17 years old and younger) prescribed 1 of 3 antimanic medications (ie, lithium, carbamazepine, or valproic acid derivatives) and a random sample of 4,500 children and adolescents not treated with psychotropic medications.

RESULTS

Compared to the control sample, the treated cohort was more likely to be diagnosed with obesity/weight gain (odds ratio [OR] = 1.89), type 2 diabetes mellitus (OR = 2.50), dyslipidemia (OR = 1.89), nausea (OR = 1.61), anorexia (OR = 3.85), and sexual/reproductive adverse events (OR = 2.04). Within the treated cohort, incident dyslipidemia was more likely for those prescribed carbamazepine (OR = 1.52) compared to valproate and coprescribed antipsychotics (OR = 1.47) or selective serotonin reuptake inhibitors (SSRIs) (OR = 1.49) compared to those not taking antipsychotics or taking serotonin-norepinephrine reuptake inhibitor/heterocyclic (SNRI/other) antidepressants. The odds of developing nausea/vomiting were higher for those prescribed carbamazepine (OR = 1.70) or lithium (OR = 1.49) compared to valproate, and those coprescribed psychostimulants (OR = 1.25) compared to those not taking psychostimulants. The odds of developing obesity/weight gain and type 2 diabetes mellitus were higher for those coprescribed SSRIs (ORs = 1.72, 2.58) or antipsychotics (ORs = 1.69, 1.77) compared to those taking SNRI/other antidepressants or not taking antipsychotics. Incident sexual/reproductive adverse events were more likely for those coprescribed SSRIs (OR = 2.02) compared to those taking SNRI/other antidepressants.

CONCLUSION

Commonly employed psychotropic agents are associated with clinically significant metabolic, digestive, and reproductive-related adverse events. Treatment decisions in young populations are usefully informed by the somatic consequences of the medication options.

Identifying genomic and developmental causes of adverse drug reactions in children

Adverse drug reactions are a concern for all clinicians who utilize medications to treat adults and children; however, the frequency of adult and pediatric adverse drug reactions is likely to be under-reported. In this age of genomics and personalized medicine, identifying genetic variation that results in differences in drug biotransformation and response has contributed to significant advances in the utilization of several commonly used medications in adults. In order to better understand the variability of drug response in children however, we must not only consider differences in genotype, but also variation in gene expression during growth and development, namely ontogeny. In this article, recommendations for systematically approaching pharmacogenomic studies in children are discussed, and several examples of studies that investigate the genomic and developmental contribution to adverse drug reactions in children are reviewed.

Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder

OBJECTIVE

To determine the relative effects of risperidone and divalproex in pediatric mania.

METHODS

This is a double-blind, randomized, outpatient clinical trial with 66 children and adolescents (mean age= 10.9 ± 3.3 years; age range= 8-18 years) with mania who were randomly assigned to either risperidone (0.5-2 mg/day, n= 33) or divalproex (60-120 μg/mL, n= 33) for a six-week period. Measures included the Young Mania Rating Scale (YMRS) and Child Depression Rating Scale-Revised (CDRS-R).

RESULTS

Mixed-effects regression models, with interaction between time and the active drug as predictors, found that the risperidone group had more rapid improvement than the divalproex group (p < 0.05), although final scores did not differ significantly between groups. Mixed models using only those subjects who completed the six-week study found similar results. The response rate on YMRS was 78.1% for risperidone and 45.5% for divalproex (p < 0.01). The remission rate for risperidone was 62.5%, compared with 33.3% for divalproex (p < 0.05). Improvement on the CDRS-R was significantly higher for the risperidone group relative to the divalproex group (p < 0.05). There were no significant differences between groups in safety, but subject retention was significantly higher at study endpoint in the risperidone group (p < 0.01). Dropout rate was 24% in the risperidone group and 48% in the divalproex group, with increased irritability being the most common reason for dropout in the latter. There was no significant weight gain in either group.

CONCLUSION

Results suggest that risperidone was associated with more rapid improvement and greater reduction in manic symptoms compared to divalproex. Although the results suggest that both drugs are safe, risperidone's lower attrition rate and lower rate of adverse events may suggest better toleration. Clinical trials with larger samples are required to confirm these preliminary findings.

[Therapeutic drug monitoring of valproate]

Valproic acid is an anticonvulsant drug available in France since 1967. It is a broad spectrum molecule indicated in various forms of epilepsy of the adult and the child, but it is also prescribed in the treatment of different other pathologies of nervous system. The divalproate sodium is indicated in the treatment of bipolar disorders. The valproic acid is marketed under various pharmaceutical forms, with different corresponding tmax values. But, whatever the administered preparation, the circulating active molecule is the ion valproate. Elimination half-life is from 11 to 20 h. Metabolization of valproate is important and represents its main route of elimination. Valpromide is comparable to a prodrug which metabolizes in valproate. The inter and intraindividual variability of the plasma concentrations are important. Several studies show a concentration-effect relationship, but two interventional trials ended in the lack of interest of the Therapeutic Drug Monitoring (TDM), although it is of current practice. However, numerous drug interactions may modify the plasma concentrations of valproate. The therapeutic range is from 50 to 100 mg/L (346-693 micromol/L). The level of proof of the interest of the TDM for this molecule was estimated in: recommended.

Pharmacotherapy of bipolar disorder in children and adolescents: recent progress

Child and adolescent bipolar disorder (BPD) is a serious psychiatric disorder that often causes significant impairment in functioning. Pharmacological intervention is the cornerstone of treatment for bipolar youth, although psychotherapeutic interventions may be beneficial as adjunctive treatment. Medications used for the treatment of BPD in adults are still commonly used for bipolar children and adolescents. With the recent US FDA indication of risperidone, aripiprazole, quetiapine and olanzapine for the treatment of bipolar youth, the atypical antipsychotics are rapidly becoming a first-line treatment option. However, these agents are associated with adverse effects such as increased appetite, weight gain and type II diabetes mellitus. Although several evidence-based medications are now available for the treatment of BPD in younger populations, additional studies to evaluate the short- and long-term efficacy and potential for adverse events of these and other medications are needed.

Association between mood stabilizers and hypothyroidism in patients with bipolar disorders: a nested, matched case-control study

OBJECTIVES

This study investigated whether lithium, carbamazepine, and valproate increased the risk for hypothyroidism using Taiwan's National Health Insurance Dataset.

METHODS

The sample included 557 bipolar disorder patients with incident hypothyroidism first diagnosed between 1998 and 2004, and 2,228 sex-, age-, and index date-matched bipolar disorder patients without hypothyroidism from 1996-2004. We compared the use of lithium, carbamazepine, and valproate before the onset of hypothyroidism between the two groups using a conditional logistical regression model.

RESULTS

Compared with patients who had never used any of the three mood stabilizers, patients were more likely to have hypothyroidism if they only used carbamazepine [odds ratio (OR) = 1.68; 95% confidence interval (CI): 1.07-2.65]; or comedication of lithium and valproate (OR = 2.40; 95% CI: 1.70-3.40), lithium and carbamazepine (OR = 1.52; 95% CI: 1.10-2.08), and three mood stabilizers (OR = 2.34; 95% CI: 1.68-3.25). There was a dose-response relationship between the number of mood stabilizers and risk for hypothyroidism (OR = 1.34, 95% CI: 1.21-1.49) and a significant interaction between lithium and valproate on the risk for hypothyroidism (p = 0.020).

CONCLUSIONS

Our findings indicate that lithium, carbamazepine, and valproate may increase the risk for hypothyroidism, particularly if combined, and suggest regular monitoring of thyroid function and monotherapy of mood stabilizers for treating patients with bipolar disorders.

The emerging modern face of mood disorders: a didactic editorial with a detailed presentation of data and definitions

The present work represents a detailed description of our current understanding and knowledge of the epidemiology, etiopathogenesis and clinical manifestations of mood disorders, their comorbidity and overlap, and the effect of variables such as gender and age. This review article is largely based on the 'Mood disorders' chapter of the Wikibooks Textbook of Psychiatry http://en.wikibooks.org/wiki/Textbook_of_Psychiatry/Mood_Disorders.

Neurological and cardiovascular adverse events associated with antimanic treatment in children and adolescents

To identify the factors associated with incident neurological and cardiovascular adverse events in children and adolescents treated with antimanic agents, a retrospective, longitudinal study was conducted. Medicaid medical and pharmacy claims between January 1996 and December 2005 were used to identify 3657 children and adolescents prescribed antimanic medications, and a random sample of 4500 children not treated with psychotropic medications. All adverse events examined (sedation/drowsiness, headaches, involuntary movements/extrapyramidal symptoms (EPS), cardiovascular events, hypertension, and orthostatic hypotension) were more prevalent in the antimanic-treated cohort. The odds of developing incident sedation/drowsiness and headaches were significantly higher for those prescribed carbamazepine, and co-prescribed selective serotonin reuptake inhibitors or antipsychotics. The odds of incident involuntary movements/EPS were significantly higher for those co-prescribed antimanic and antipsychotic agents, and those with comorbid central nervous system (CNS), organic brain disorders/mental retardation, or epilepsy. Incident cardiovascular events, hypertension, and orthostatic hypotension odds were significantly higher for those co-prescribed antimanic agents and antipsychotics, or those with comorbid epilepsy or metabolic conditions. Co-prescription of antimanic and antipsychotic agents is more likely associated with neurological and cardiovascular adverse reactions, especially in young patients with preexisting CNS/neurological disorders.

The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments

OBJECTIVES

Safety monitoring is an important aspect of bipolar disorder treatment, as mood-stabilising medications have potentially serious side effects, some of which may also aggravate existing medical comorbidities. This paper sets out the International Society for Bipolar Disorders (ISBD) guidelines for the safety monitoring of widely used agents in the treatment of bipolar disorder. These guidelines aim to provide recommendations that take into consideration the balance between safety and cost-effectiveness, to highlight iatrogenic and preventive clinical issues, and to facilitate the broad implementation of therapeutic safety monitoring as a standard component of treatment for bipolar disorder.

METHODS

These guidelines were developed by an ISBD workgroup, headed by the senior author (MB), through an iterative process of serial consensus-based revisions. After this, feedback from a multidisciplinary group of health professionals on the applicability of these guidelines was sought to develop the final recommendations.

RESULTS

General safety monitoring recommendations for all bipolar disorder patients receiving treatment and specific monitoring recommendations for individual agents are outlined.

CONCLUSIONS

These guidelines are derived from evolving and often indirect data, with minimal empirical cost-effectiveness data available to provide guidance. These guidelines will therefore need to be modified to adapt to different clinical settings and health resources. Clinical acumen and vigilance remain critical ingredients for safe treatment practice.