Pediatric Bipolar Affective Disorder Medication

Updated: Jun 08, 2021
  • Author: Bettina E Bernstein, DO, DFAACAP, DFAPA; Chief Editor: Caroly Pataki, MD  more...
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Medication Summary

Mood stabilizers, such as lithium carbonate, sodium divalproex, and carbamazepine, have traditionally been the mainstays of treatment of patients with bipolar disorder. However, atypical antipsychotics are increasingly used in bipolar disorder, with or without psychotic symptoms. This class of medications includes asenapine, risperidone, quetiapine, olanzapine, aripiprazole, ziprasidone, and clozapine. In 2018, the FDA approved lurasidone for the treatment of major depressive episodes associated with bipolar I disorder in children and adolescents aged 10 to 17 years. [65] Benzodiazepines may be used to improve sleep and to modulate agitation during hospitalization.

Potential problems include the possibility of neuroleptic malignant syndrome with treatment with valproate. [83]


Mood stabilizers

Class Summary

Mood stabilizers are indicated for control of manic episodes occurring in bipolar disorder. They include lithium carbonate, valproic acid or sodium divalproex, and carbamazepine.

Lithium (Lithobid)

Lithium is considered a first-line agent for long-term prophylaxis in bipolar illness, especially classic bipolar disorder with euphoric mania. It is also used to treat acute mania, though it cannot be up titrated to an effective level as quickly as valproic acid can. Evidence suggests that lithium, unlike any other mood stabilizer, may have a specific antisuicide effect. Monitoring of blood levels is critical with this medication.



Class Summary

Anticonvulsants have been effective in preventing mood swings associated with bipolar disorder.

Valproic acid (Depacon, Depakene, Depakote)

Valproic acid has proven effectiveness in treating and preventing mania. It is classified as a mood stabilizer and can be used alone or in combination with lithium. It is useful in treating rapid-cycling bipolar disorders and has been used to treat aggressive or behavioral disorders. A combination of valproic acid and valproate has been effective in treating persons in manic phase, with a success rate of 49%.

Carbamazepine (Equetro)

Carbamazepine's anticonvulsant action may involve depressing activity in the nucleus ventralis anterior of the thalamus, reducing polysynaptic responses and blocking posttetanic potentiation. Carbamazepine reduces sustained, high-frequency, repetitive neural firing. It is a potent enzyme inducer that can induce its own metabolism. Because of potentially serious blood dyscrasias, weigh benefit and risk before therapy.

Therapeutic plasma levels are 4-12 µg/mL for analgesic and antiseizure response. Serum levels peak in 4-5 h. Serum half-life is 12-17 h with repeated doses. Carbamazepine is metabolized in the liver to its active metabolite (epoxide derivative) with a half-life of 5-8 h. Metabolites are excreted in feces and urine.

Carbamazepine is effective in cases that do not respond to lithium therapy. It has been effective in treating rapid-cycling bipolar disorder.


Atypical Antipsychotics

Class Summary

Atypical antipsychotics are being used increasingly for treatment of both acute mania and mood stabilization.

Aripiprazole (Abilify, Abilify Discmelt)

Aripiprazole is an atypical antipsychotic that is approved for bipolar disorder in children aged 10-17 years. It can be used as monotherapy or adjunctively with lithium or valproate. For children younger than 10 years, the safety and efficacy has not been established. It is a partial dopamine D2 and serotonin 5HT1A agonist, and it antagonizes serotonin 5HT2A.

Risperidone (Risperdal, Risperdal Consta, Risperdal M-Tab)

Risperidone binds dopamine D2-receptor with a 20 times lower affinity than it has for 5-HT2 receptor. It is indicated for short-term (3-wk) treatment of acute mania associated with bipolar disorder. It may be used alone or combined with lithium or valproate. Risperidone is approved for bipolar mania in children aged 10-17 years.

Quetiapine (Seroquel, Seroquel XR)

Quetiapine is indicated for acute treatment of manic episodes that are associated with bipolar I disorder. It is approved for bipolar mania in children aged 10-17 years. Quetiapine may act by antagonizing dopamine and serotonin effects. It is a newer antipsychotic used for long-term management. Improvements over earlier antipsychotics include fewer anticholinergic effects and less dystonia, parkinsonism, and tardive dyskinesia.

Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprew)

Olanzapine's mechanism of action for acute manic episodes associated with bipolar I disorder is unknown. It is approved by the US Food and Drug Administration (FDA) for adolescents with bipolar I disorder. It is available in tablet, oral disintegrating tablets (Zyprexa, Zydis), and intramuscular (IM) dosage forms. It is approved for children aged 13 years and older.

Ziprasidone (Geodon)

Indicated for acute bipolar mania, including manic and mixed episodes. Antagonizes dopamine D2, D3, 5-HT2A, 5-HT2C, 5-HT1A, 5-HT1D, alpha1 adrenergic. Has moderate antagonistic effect for histamine H1. Moderately inhibits reuptake of serotonin and norepinephrine. Although effective for bipolar disorder, the mechanism of action in bipolar disorder is unknown.

Asenapine (Saphris)

Asenapine is an atypical antipsychotic. It is indicated as monotherapy for the acute treatment of manic or mixed episodes associated with bipolar I disorder in pediatric patients aged 10-17 years. Its mechanism of action is unknown, but is thought that its efficacy is attributed to antagonism of dopamine-2 and serotonin-2a receptors.