Adolescents and Dual Diagnosis: Mood Instability and Medications

Daniel M. Medeiros, MD Assistant Clinical Professor of Psychiatry, Department of Psychiatry of Columbia University College of Physicians & Surgeons Director, Child and Family Institute, Chief of the Division of Child and Adolescent Psychiatry, St. Lukes and Roosevelt Hospitals NY, NY

Board Certified Psychiatry Child and Adolescent Psychiatry Addiction Psychiatry Psychosomatic Medicine

Conflicts of Interest None

Mood Instability in Dual Diagnosis Teens

 Not all mood swings are an indication of Bipolar Disorder, especially in

teens who are actively using drugs

 There is currently much discussion in Child Psychiatry regarding the

diagnosis of bipolar disorder, which is seen as being over-diagnosed as people have clinically broadened the criteria; many kids now Bipolar NOS

Mood Instability in Dual Diagnosis Teens

 Additional controversy exists regarding children who looked ADHD prior

to puberty and generally responded to ADHD meds, who then look more bipolar in adolescence and are switched to mood stabilizers.  Whether these children are actually co-morbid ADHD and Bipolar Disorder, or developmentally bipolar looks more like ADHD before puberty and is misdiagnosed as ADHD is unclear  This is especially confusing as these kids are also often Bipolar NOS, diagnosed with broader criteria

Mood Instability in Dual Diagnosis Teens

 Bipolar Disorder  Irritable Depression  Conduct Disorder/ADHD  PTSD  Anxiety Disorders  Borderline personality traits/disorder

 Alcohol/drug intoxication, withdrawal, craving

 Normal Adolescence

Mood Instability in Dual Diagnosis Teens

 Does the mood instability/mood swings need to be treated?

 

Impair functioning? Cause distress in the patient?

 How best to treat these symptoms?

 

Therapy Medication

Mood Instability in Dual Diagnosis Teens

Dialectical Behavior Therapy
 Skills groups
    

Mindfulness Distress Tolerance Emotion Regulation Interpersonal Effectiveness (walking middle path)

 Behavior chain analysis

Mood Instability in Dual Diagnosis Teens

Decision to medicate mood swings/mood instability
 Family history of diagnoses and medication trials  History of successful/unsuccessful trials with the patient, compliance

issues in the past  Observation over time, increasing/decreasing symptoms, related to drug use/abstinence  Effect of therapy on the symptoms  Cooperation/resistance of family/teen

Mood Instability in Dual Diagnosis Teens

 Generally, mood stabilizers are recommended if significant issues

continue with anger/irritability/hypomania

 Traditional mood stabilizers  Antipsychotics: new mood stabilizers

(Zajecka, J.M. CNS Spectr 11:11(Suppl 13), 2006)

Lithium (Lithobid, Eskalith)

 FDA approved for mania and maintenance phase  It is a salt that is excreted through the kidney  Usually begin 300mg twice a day  Therapeutic blood level 0.6-1.2mEq/L  Toxicity: vomiting, diarrhea, confusion, blurred vision, seizures  Pregnancy category D: Ebsteins anomaly  Can cause hypothyroidism  Acne, hand tremors, increased thirst  Studies show it can help with aggression, CD, self-injury, and may

decrease drug use in co-morbid BPD/SUD

Divalproex Sodium (Depakote, Depakote ER)

 FDA approved for mania (Depakote, Depakote ER) and mixed state      

(Depakote ER) Usually begin 250mg twice a day Blood level of 50-100ug/mL Metabolized by the liver and can cause liver damage Pregnancy category D: neural tube defects Polycystic ovaries, blood issues Nausea, stomach upset, sedation, irritability

 May increase the sedation of alcohol/sedatives

Carbamazepine ER (Tegretol ER)

 FDA approved for mania and mixed states  Induces metabolism in the liver  Usually begin 200mg twice a day  Need blood level: 6-12 mcg/ml  Blood disorder: aplastic anemia  Dizziness, drowsiness, nausea, vomiting  Pregnancy category D for birth defects

Lamotrigine (Lamictal)

 FDA approved for maintenance  Not recommended for under 16yo  25mg up to 400mg  Nausea, vomiting diarrhea, dizziness  Stevens-Johnson Syndrome severe skin rash  Pregnancy category C risk cannot be ruled out

Other Traditional Mood stabilizers

 Gabapentin (Neurontin) not shown as effective for adults but some

indication that it might help teens  Oxcarbazepine (Trileptal) may help with anger, irritability and aggression Topiramate (Topamax) 25mg twice a day up to a total of 400mg a day Not significantly metabolized, excreted from the kidney Diarrhea, loss of appetite, weight loss, concentration issues Pregnancy category C Not shown to be helpful for adult BPD but may be helpful for teens Studies showing it can reduce binge eating and alcohol binging

     

Antipsychotics for mood stabilization

Advantages
 These tend to work quicker  Will help with psychotic symptoms

Disadvantages  Tend to have complex liver metabolism, more likely interactions  Significant side effects, especially long-term  Atypical antipsychotics are category C for pregnancy

Olanzapine (Zyprexa)

 FDA approved for mania, mixed state and maintenance  Can begin as low as 2.5mg, up to max of 20mg a day  Weight gain, sedation, constipation, dizziness, dry mouth

Aripiprazole (Abilify)

 Also FDA approved for mania, mixed states and maintenance  More likely to be weight neutral - some lose weight; some gain but not

at the level of Zyprexa  Begin with 5mg, highest dose is 30mg but unlikely additional improvement beyond 15mg  Nausea and vomiting can be significant side effect

Risperidone (Risperdal)

 FDA approved for manic and mixed states  One of oldest and most studied of atypical antipsychotics  Often begin with 1mg, up to 6mg  Weight gain between Zyprexa and Abilify  Sedation, hyperprolactinemia  Used for aggression, self-injury, hyperactivity

Ziprasadone (Geodon)

 FDA approved for mania and mixed states  Begin with 20mg, up to maximum of 160mg  More significant cardiac issues than others: QTc  Tends to be less sedating, and less likely to cause weight gain

(although Abilify generally better)

Quetiapine (Seroquel)

 FDA approved only for mania  Can start with low dose of 25mg to maximum of 800mg a day  Side effects of sedation, weight gain, dizziness, constipation, dry mouth  Has street value: can make people feel spacey, often requested in

inpatient rehab for sleep

Summary based on clinical experience

Questions?