Medications
Pharmaceutical medications are a central pillar in the treatment of childhood Bipolar Disorder, along with psychosocial education (to understand the illness and treatment) and environmental interventions. There are alternative treatments available which are useful in some circumstances but in general less widely tested than pharmaceutical medications.
Each child is different and responds differently to the meds, making it sometimes a long process to find meds that help enough for the child to return to or begin having a stable or functional life. One way to understand effective treatment for Bipolar is to study treatment guidelines. These guidelines can even be printed out and taken with you to doctor appointments to help you communicate concerns and ideas for treatment planning. The guidelines can also help you know when your child is recieving quality treatment- or not.
Three common types of medications commonly used are: Mood Stabilizers, Antipsychotics, and Anti-anxiety. Antidepressants are sometimes used, but much caution must be taken when used to treat Bipolar Disorder as these medications can cause worsening of some symptoms.To find out more about a specific medication type the name of the medication and prescribing information into your favorite search engine or a site like RXlist.com. These searches hsould link you to the the actual manufacturer's prescribing information pages; other times you will find a generic page that often addresses a number of medications in a specific class. You can also get this information directly from the pharmacy for your child's specific medications.
Before starting or changing medications you may want to check all medications plus any over the counter medications on a drug interaction tool like drugstore.com drugchecker to help prevent any possible problems. By following a few guidelines when working with the pharmacy and giving meds you can eliminate many errors.
It's important that as parents, we familiarize ourselves with the possible side effects by reading the prescribing information for our children's medication. Please be sure to familiarize yourself with the serious side effects of many of the medications, as well as information on weight gain with some meds. Avoiding Medication Errors is one of the most important things we can do in heling to manage our children's illness.
Mood stabilizers, antipsychotics and anti-anxiety meds are not the only types of medications that are used. Sometimes medications from one class are used to treat symptoms across many categories of illness. For instance, Risperdal, Zyprexa and Seroquel, apart from their antipsychotic action, have significant anti-manic action and are used in acute treatment of mania in many cases. They are also used to address aggression or as a rescue medication at home. A very good book with even more information to help in parental decision making is :
University of Illinois Pediatric Mood Disorders Clinic, Dr. Mani Pavuluri has written an online guide to "Psychopharmacotherapy" that can be very useful for understanding the meds, their pros and cons and making medication decisions. Another helpful book is Straight Talk about Psychiatric Medications for Kids, by Dr. Timothy Willens available in our bookstore. |
And getting practical, here is an article to help you when Teaching Children How to Swallow a Pill.
3 Rules to Effective Medication Use
There are 3 big rules that most experts recommend for using psych medications effectively.
* Start low and go slow.
Start low and go slow means to start with a very small dose of a medication and titrate up slowly to avoid un-necessary side effects.
* Maximize each medication before adding another.
Push doses to the max before discarding it as a failed med trial. Some people metabolize medications more quickly than others and even small changes can make a huge difference in weather the med works or not.
* One change at a time.
If you change more than one thing at a time you'll never be able to tell cause and effect if a med is helping or causing more problems. Make sure to allow enough time for improvements to manifest themselves. Some meds can take up to 8 weeks to show improvement and there are case reports of a first response to Lithium after two years of treatment.
Recently a genetic test has been developed to help doctors determine appropriate medication and dosage choices. Learn more in this Medscape article: FDA Approvals: AmpliChip, Stratis ST, QuantiFERON-TB GOLD, and Others.
Alternative Treatments
Aside from pharmaceutical medication, there are lots and lots of treatment choices for childhood Bipolar. How do we know which are helpful, which are harmful, and which don't have much chance of working? Here is a place to sort through some information and opinion.
Talk therapy can be useful for some Bipolar children. It is important to know what kind of therapist to look for and what types of therapy typically work and which ones don't. Talk therapy can include:
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Cognitive Behavioral Therapy is a brief, time limited talk therapy designed to help change the negative or unproductive thoughts that cause negative emotions and behaviors. CBT has a good body of research showing it's effectiveness in many disorders such as anxiety, OCD and Bipolar Disorder. You can find self help information in the book Mind Over Mood by Dennis Greenberger, Christine Padesky in our Bookstore.
Play therapy is an option that works for some, especially young children or those whom are developmentally delayed. Play therapy can be used to teach coping skills, social skills, and other important concepts to surprisingly young children.
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Equine (horse) therapy has long been used for the physically handicapped but it is becoming popular and beneficial to those with emotional handicaps as well. Psychiatric equine therapy helps children build confidence and relationships, learning coping and social skills.
Occupational therapy is used to help things such as fine motor skills, address motor or tactile defensiveness, gross motor deficits and sensory integration issues that can cause frustration and exacerbate BP symptoms..
Physical therapy is geared more towards gross muscle movement patterns, balance and coordination. The methods used can often be helpful in reducing stress as an added benefit.
Light Therapy involves using a light source with either full spectrum light or specific wavelengths scheduled on a daily basis to help with symptoms of depression. It has long been known that seasonal depression can be treated with light therapy, but recent research is showing promise for other forms of depression as well. Again, further scientific research is necessary to assess safety and dosage, but some researchers are very enthusiastic about the prospects of light therapy for people with Bipolar Disorder with seasonal depression who are on mood stabilizers. Caution is urged, if you notice hypomania, back off on the time of the light therapy.
Intellihealth on Light Therapy
Omega 3 Oils- There have been some studies that show that Omega 3 oils which are found in fish can be helpful for depression and Bipolar disorders, as well as schizophrenia, dementia, heart disease, and other problems. Research is still in process, so caution must be used, and there are anecdotal reports of mania in some children and teens. Omega 3 oils are available in capsules from many sources including Nordic Naturals and even an orange flavored gel called Coromega. For more information the see the book The Omega-3 Connection: The Groundbreaking Anti-depression Diet and Brain Program by Andrew Stoll MD from our Bookstore.
Dr. Phelps on Omega 3
McMan on Omega 3
Bipolar Child Newsletter
Some Alternative Treatments that should be looked at with a great deal of caution are:
EMPower TrueHope
First, here is an analysis of the "studies" that were shared on our message board by a mom who's child is on EMpower. Studies
EMPower Truehope is a very controversial product, and we hope you will follow the links, do your own research, and come to your own conclusion.
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Quackwatch Synergy Evaluation
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Dr.Phelps at psycheducation.org
Opinion:
It's clear that Tony Stephan has an amazing ability to convert others into true believers, which results in a truly impressive level of grass-roots Internet marketing, political lobbying, and even publications in respected academic journals.
The most passionate case against TrueHope is clearly the Pig Pills book. I think the authors do themselves a disservice by being so vitriolic. It plays right into the narrative of "unappreciated research into alternative medicine being squashed by drug-company funded establishment".
Fortunately, there is quite a bit of objective material available as well, of which my favorite is the collection of Freedom of Information and ATIP (the Canadian equivalent) files put together by Circare, apparently a legitimate nonprofit which fights unethical human subject research.
The "research" on this product is, in my opinion, not convincing. The most promising study, upon close examination turns out to be "open-label", which means that both doctor and patient knew that they were getting the supplement. Even when the researcher is skeptical, it's well known that this type of trial often produces falsely encouraging results. Until the results are replicated by a better trial (ideally randomized, controlled, and double-blind), it's misleading at best claim, that it "proves" the effectiveness of their product.
The principal researcher, Bonnie Kaplan, is obviously a "true believer". From her Application for Funding:
As explained in the Executive Summary, the entity that will benefit financially the most from a successful demonstration of the efficacy of these supplements is our Provincial Government. A simple look at the economics of even one patient should be convincing. The cost of the supplement ranges from $100-$400/month (depending on dosage). In some cases, the patients whose mental health has normalized on this supplement had previously spent weeks or months as inpatients on psychiatric hospital wards. The potential for savings is staggering.
Let me just conclude by saying that a revolutionary paradigm shift is occurring in the field of mental illness. In the US., the National Institutes of Health are currently commencing clinical trials of nutritional supplements for schizophrenia and bipolar disorder. Clinical trials are going on in the U.K., Japan, France, and elsewhere. From the preliminary results, it appears that the intervention we are investigating in Alberta has the potential to be far more therapeutic: hence, Alberta could be a major guiding light in this area if we move quickly.
I believe Dr. Kaplan is well-meaning, but these are clearly not the words of a skeptical scientific researcher. In any case, her study on EMPower+ in fibromyalgia turned up negative. Note that this study was double-blind and controlled. In any case, you'd certainly not find out about this negative result from looking at TrueHope's marketing materials. Evaluating the validity of any study in essential before accepting the results.
I'd generally be willing to try a nutritional supplement on the basis that it might help and probably won't hurt. However, EMPower+ is clearly not food, and has some scary stuff in it, at doses pretty close to the acceptable limits. Among the ingredients are toxic metals such as Zinc, Manganese, Vanadium, Boron, and Selenium, all at levels right around the upper tolerable intake. The prospect of giving high doses of this stuff to my child on a daily basis is not appealing.
I have a lot of problems with the lack of answers on the part of Truehope, including their trumpeting of questionable research studies as "proof", their complex corporate structure involving a web of for-profit and nonprofit companies, giving their salespeople the phony title of "Research Assistant", secrecy about their ingredient list ("CNS Proprietary Blend"), and so on. I understand that they need to operate somewhat clandestinely because their business is in violation of Health Canada regulations on supplements, but I just don't trust them. Another reason not to trust them is that the actual contents of the pills don't match the label very well.
When a person takes E.M.Power products they are told to discontinue pharmaceutical medications, even though Bipolar disorder has a mortality rate from suicide of 18%, as well as being a painful and debilitating ilness for the ill person and tremendous difficulty for the entire family. When a person stops taking their psychiatric medications that are based on current state of the art treatments in order to use a treatment that is unproven it can have dire results. Initiating Lithium treatment appears to cause the suicide rate to drop 7 fold compared to the rate before treatment. Likewise, discontinuing Lithium treatment appears to cause a 14 fold increase in suicide rates above the rate when the patient was being treated with Lithium. The Antisuicidal Effects of Lithium
I've bashed pretty hard on the company and the science, but I haven't really addressed the big question: does it work? You may be surprised that I think that in many cases the answer is "yes". The message that the Truehope people put out is immensely reassuring, so much more so than the uncertainties of the traditional medical establishment. For one, because the pills are so effective against a broad spectrum of ills, an accurate diagnosis is not needed. Even though they're primarily a marketing tool, the "Truehope Assistants" probably offer a lot more human contact than the average psychiatrist in this managed-care world is able to. I think it's possible, even likely, that this positive attitude and consistent message of success has powerful healing properties for some families. (Some text used by permission of "Thoughtful")
Natural Lithium~ Serenity and others .
What about lithium orotate or lithium aspartate, they are natural so aren't they better?
First of all, lithium is a natural substance. It is a mineral and is on the periodic table of elements, atomic number 3. Lithium through the pharmaceutical companies is no less natural and is delivered in the form of lithium carbonate. Lithium carbonate consists of two lithium molecules bonded to one carbon and three oxygen molecules. Carbon and oxygen are two of the 6 most abundant elements on earth and vital to life.
The difficulty with the orotate and aspartate versions lies in the extremely low quantity of lithium that is present. Each capsule contains so little lithium (one brand states 4.6mg/capsule) that it requires massive quantities of capsules to deliver the equivalent amount of lithium that is available in just a few tablets/capsules in pharmaceutical grade products.
In order for lithium to be effective, it must be present in the blood in a specific range of serum concentration. This range is most generally reported at .6-1.2 mcg/mL. An average adult dose range for this therapeutic range would be 600mg-1800mg with some requiring 3000mg or more. Each individual is different and often children require increased doses due to their metabolic differences. Having enough lithium is not the only issue, lithium must be monitored continuously to avoid toxic levels in the blood. Just as we can develop vitamin toxicity when taking excessive quantities of them, so can one become toxic if lithium levels become too high.
These alternative lithium delivery formulations are dangerous in that nothing is regulated, is not supervised by a physician and has not yet been evaluated by the FDA to verify the claims made by their manufacturers.
Metabolizing lithium
Lithium carbonate formulations are simple compounds that are highly water soluble, which makes them capable of crossing the cell membrane through passive transport, requiring no energy from the cell. It is then metabolized by the cell.
Orotate and aspartate formulations bind lithium to complex amino acid chains. Amino acids are synthesized in the liver first into lipoproteins, plasma proteins and finally structural or functional proteins and non-protein molecules such as amine hormones and neurotrasnmitters. Typically the body will break down the amino acid to build the needed components. Any portions that are not utilized in constructing the amino or protein in this process remain attached to the lithium molecule. It may or may not be water soluble therefore, may or may not be capable of passive transport. If not water soluble, it will require an active transport into the cell. This requires a carrier to process it through special channels in the cell membrane and the expenditure of cell energy.
The process of metabolizing lithium is quite complex and in no way is it fully explored here. However, it is easy to see how the two compounds differ vastly in their availability to the body for use.
Crackerjack (copyright 1/30/04)