Approach Considerations
Initial tests for substance and alcohol abuse are usually necessary to exclude drugs and alcohol as causative agents for behavior. No specific blood or other laboratory tests aid in diagnosing bipolar disorder. Among bipolar youth aged 9 years and older, frequency of comorbid alcohol or drug use is significant. In one study, 34% of bipolar youth used alcohol at least once and 11.9% reported regular alcohol use; 30.1% used drugs at least once and 16.2% reported regular drug use. [47]
Go to Bipolar Affective Disorder for complete information on this topic.
Blood Studies
Thyroid hormones
Thyroid studies may help to rule out a thyroid disorder as a cause of an altered mood. Triiodothyronine (T3) levels may be elevated in agitated patients who have normal thyroid function. Additional thyroid tests, such as thyroid-stimulating hormone (TSH) and thyroxine (T4) studies, can be helpful, as well as consultation with an endocrinologist.
Serum blood chemistries
Serum blood chemistries, such as basic metabolic panels and liver function tests, may help assess renal and hepatic health before certain medications are started or continued to help regulate or ameliorate bipolar symptoms.
Mania and depression may both involve states of malnutrition secondary to the psychiatrically diminished awareness of or ability to maintain one’s health and well-being. Thus, a metabolic panel, in addition to thiamine, albumin, and prealbumin studies (in extreme cases), may help determine the extent of self-neglect and compromised nutritional state. levels of vitamin D, folate, vitamin B-12, vitamin B-6, and total protein can also be abnormal and should be checked, especially in the presence of acute mania or hypomania.
Other tests
Routine screening for substance misuse is not indicated; however, clinical history of substance misuse or pregnancy may indicate the need for such screening such as urine or blood testing for substances of abuse and alcohol. In patients with known hypersexuality, a very careful sexual history should be taken. An HIV test should also be administered, as well as HIV prevention counseling.
Serum cortisol levels may be elevated, but this is neither of diagnostic nor clinical value.
Drug Level Monitoring
After pharmacotherapy is implemented, periodic laboratory tests may be required to monitor drug levels and to ensure that no adverse response to the medication is harming renal or hepatic function or bone marrow. Medications that are strong CYP2D6 inhibitors such as fluoxetine, bupropion, and lamotrigine may cause increases in risperidone concentration and increased risk of adverse side effects, such as elevated prolactin, especially in individuals who are poor metabolizers. [60, 61]
Neuroimaging
Initial studies suggest that developmental changes with maturity in children and adolescents with bipolar disorder differ from those in healthy peers. Neuroimaging modalities are not yet diagnostically helpful in diagnosing bipolar disorder in individuals, but studies are ongoing to determine if they would be helpful in diagnosis.
In some studies, neuroimaging (ie, functional magnetic resonance imaging [fMRI]) in child and adolescent patients with bipolar disorder has shown abnormal neural activation for faces with negative emotions along with face-processing deficits. [62] Adolescent patients failed to show normal developmental maturity changes with respect to total hippocampal volume in comparison to healthy controls.
Other studies have shown abnormal corpus callosum myelination and enlarged ventricles with an increased number of hyperintensities compared with healthy control subjects. [35]
Electrocardiography and Echocardiography
Before a psychotropic medication is started, baseline electrocardiography (ECG) and echocardiography, with measures of cardiac contractility, should be performed; many medications (lithium, trazodone, ziprasidone, risperidone, quetiapine, verapamil) may alter QT intervals or other features of the cardiac rhythm, thereby affecting cardiac contractility and output. This is especially critical if the patient has a family history of a structural or electrical heart abnormality.
Tables
| Behavior | Bipolar | DMDD | ADHD | Conduct Disorder |
|---|---|---|---|---|
| Self-esteem | Inflated | Deflated/irritable | Inflated and/or deflated | Inflated and/or deflated |
| Pleasure | Euphoric in mania Dyphoric in mixed or depressed state |
Variable | Often dysphoric or euthymic | Pleasure in violating societal norms, especially if not caught |
| Attention | Distractible | Distractible | Distractible | Normal to vigilant |
| Hyperactivity | Goal directed | Variable | Unproductive | Goal directed |
| Sleep | Episodic disturbances such as decreased need in mania | Often poor due to avoiding bedtime | Chronic poor sleep; often late bedtimes | Not known to be disrupted except with substance abuse |
| Speech | Pressured or rapid in mania; slow in depression | Rapid/normal rate | Often rapid; may be pressured | May be normal |
| Impulsivity | Externally driven/reactive | Reactionary | Internally driven | May engage in predatory or reactionary acts |
| Social | Often good | Often poor | Often poor | Often poor |
| Academic | Often good | Varies | Often poor | Often poor |
| Psychomotor activity | Agitated in mania or mixed states; retarded in depressed states | Easily agitated | Chronically agitated | Easily agitated |
| ADHD—attention deficit/hyperactivity disorder |
Medication |
Common Adverse Effects |
Pediatric Doses |
Special Concerns |
Lithium carbonate (Lithobid) |
GI distress, lethargy or sedation, tremor, enuresis, weight gain, alopecia, cognitive blunting |
10-30 mg/kg/d; dose must be adjusted by monitoring serum level and patient response; up-titrate on twice-daily schedule |
Hypothyroidism, diabetes insipidus, toxic in dehydration, polyuria, polydipsia, renal disease; drug-drug interactions and sodium intake may alter therapeutic serum levels Approved for patients 12 y and older |
Sodium divalproex/valproic acid (Depakote, Depakene) |
Sedation, platelet dysfunction, liver disease, alopecia, weight gain |
15-30 mg/kg/d; dose must be adjusted by monitoring serum levels; up-titrate on twice- or thrice-daily schedule |
Elevated liver enzymes or liver disease, drug-drug interactions, bone marrow suppression Approved for patients 12 y and older |
Aripiprazole (Abilify, Abilify Discmelt) |
Less likely to cause prolactinemia than risperidone; may cause Stevens-Johnson syndrome; as with other atypical antipsychotics, may cause tardive dyskinesia, dystonia, parkinsonism, hyperglycemia; use with caution in seizure disorders and cardiac disorders, including problems with cardiac contractility and electrical activity |
2 mg once daily can be increased to 5 mg, 10 mg, 15 mg, to a maximum of 30 mg to start titrate upwards at weekly to bimonthly intervals |
levels may need to be adjusted in patients who are concurrently receiving lamotrigine, topiramate, Depakote, lithium, or other serotonin-norepinephrine reuptake, selective serotonin reuptake, or cytochrome P450 inhibitors Do not administer if there is an unstable seizure disorder Approved for patients 12 y and older |
Carbamazepine (Equetro) |
Suppressed WBCs, dizziness, drowsiness, rashes, liver toxicity (rare) |
10-20 mg/kg/d; dose must be adjusted by monitoring serum blood levels; up-titrate on twice-daily schedule |
Drug-drug interactions, bone marrow suppression |
Asenapine (Saphris) |
Somnolence, oral paraesthesia |
2.5 mg SL q12h initially; may increase to 5 mg SL q12hr after 3 days and to 10 mg SL q12hr after 3 additional days |
Pediatric patients are more sensitive to dystonia with initial dosing when recommended escalation schedule not followed Approved for patients 10 y and older |
Risperidone (Risperdal, Risperdal Consta, Risperdal M-Tab) |
Weight gain, sedation, orthostasis |
0.25 mg bid or 0.5 mg at bedtime initially; titrate as tolerated to target dosage of 2-4 mg/d; not to exceed 6 mg/d |
Galactorrhea, extrapyramidal symptoms Approved for patients 10 y and older |
Quetiapine (Seroquel, Seroquel XR) |
Sedation, orthostasis, weight gain |
50 mg bid initially; titrate as tolerated to target dosage of 400-600 mg/d |
Decrease dosage with hepatic impairment, may cause neuroleptic malignant syndrome or hyperglycemia Approved for patients 10 y and older |
Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) |
Weight gain, dyslipidemia, sedation, or orthostasis |
2.5-5 mg at bedtime initially; titrate as tolerated to target dosage of 10-20 mg/d |
Metabolic syndrome, extrapyramidal symptoms |
Clonazepam (Klonopin) |
Sedation, abnormal coordination, ataxia |
0.01-0.04 mg/kg/d PO at bedtime or divided bid |
Caution with renal/hepatic impairment and asthma |
Fluoxetine (Prozac) |
Headache, nausea, insomnia, anorexia, anxiety, asthenia, diarrhea, somnolence |
10 mg PO qd; may consider increasing to 20 mg/d after 1 wk |
Long half-life; potential to exacerbate manic symptoms when not coadministered with an antimanic or mood-stabilizing agent |
Ziprasidone (Geodon) |
Akathisia, nausea |
Off-label: 20 mg PO at bedtime; can increase to 40 mg (not to exceed 60 mg), usually in 2 divided doses for children |
Risk of sudden cardiac death due to torsades des pointes due to prolonged QT prolongation, which makes this medication undesirable for individuals with a family history of cardiac sudden death related to cardiac conduction abnormalities |
WBC—white blood cell. |
|||
