Pediatric Bipolar Affective Disorder Workup

Updated: Mar 28, 2018
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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Workup

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. [45]

Go to Bipolar Affective Disorder for complete information on this topic.

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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.

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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. [58, 59]

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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. [60] 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. [33]

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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.

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