Stimulants and Antidepressant Medications for Bipolar Disorder

As noted earlier, stimulants and antidepressants, given without an accompanying mood stabilizer, can throw a bipolar child into a tailspin. Their use is controversial in bipolar children, but physicians sometimes turn to them to treat disorders that co-occur with Bipolar Disorder.

The stimulants, such as Ritalin, Concerta, Dexedrine, and Adderall, are used to treat ADHD symptoms. Though it may seem counterintuitive, stimulants can have a calming and focusing effect on individuals with ADHD. It's akin to the alertness grown-ups feel after having caffeine.

Some evidence suggests that stimulants may be beneficial in the bipolar population.¹ But many of us who treat bipolar children would recommend stabilizing the mood before even considering treating Attention-Deficit/Hyperactivty Disorder.

Stimulant treatment can also cause some children to experience a phenomenon called rebound. This effect begins about four to five hours after the last stimulant dose (for short-acting stimulants). The child appears overactive, excitable, impulsive, and hypertalkative and basically seems to have the same symptoms that you treated him for in the first place—sometimes even more than he started out with. Parents are often good at recognizing the time period that rebound begins and ends. In a child with Bipolar Disorder, it is very important to be able to tease out which symptoms are related to the mood disorder and which are manifestations of rebound. Remember, this phenomenon occurs after the medication has been taken and is wearing off, not during the time it is supposed to be effective. Generally, parents tell me that the rebound effects last one to two hours.

Antidepressants are also the subject of intense debate, for the treatment of both bipolar children and those with major depression.² The most commonly used antidepressants are the Selective serotonin reuptake inhibitors (SSRIs): Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram), Lexapro (escitalopram), and Luvox (fluvoxamine). Older antidepressants such as Tofranil (imipramine), Norpramin (desipramine), Pamelor (nortriptylene), Elavil (amitriptylene), and Anafranil (clomipramine), commonly known as Tricyclic antidepressants, are used less frequently because of their potential side effects. Other antidepressants prescribed include Well-butrin (bupropion) and Effexor (venlafaxine). Thus far, the only medications that have FDA approval for use in children are Prozac (in ages eight and older for depression; age seven and older for OCD), Zoloft (age six and over for OCD, Luvox (age eight and older for OCD), and Anafranil (age ten and over for OCD).

In 2004, the FDA placed a black box warning, the strongest warning the it can require to be placed on a prescription drug, on all antidepressants used in children and adolescents. Named for the border around the warning section on the package insert, the black box indicates there are medical studies showing that the drug can cause serious and potentially life-threatening side effects. The warning indicates that there is some evidence of increased suicidal thinking and behavior in short-term studies in children and adolescents with major depressive disorders and other psychiatric disorders treated with these medications. Keep in mind, however, that there were no actual suicides in any of the children studied (data from 2,400 children and adolescents in antidepressant trials pooled together were reviewed).

Is there ever a time when stimulants and antidepressants should be used for bipolar kids? The answer, in my opinion, is "yes," sometimes. Stimulants may be helpful for a bipolar child with ADHD whose mood is stabilized. Antidepressants, often in very low doses, may benefit depressed children or those with Obsessive-Compulsive Disorder. Given the possibility that either antidepressants or stimulants can cause mood shifts in a bipolar child who was previously stable, these medications should be prescribed with caution in a child who is suspected of having Bipolar Disorder.

1. J. Biederman, E. Mick, J. Prince, et al., Systematic chart review of thepharmacologic treatment of comorbid attention deficit hyperactivity disorder in use with bipolar disorder, Journal of Child and Adolescent Psychopharmacology 9 (1999): 247.
2. A. C. Leon, P. M. Marzuk, K. Tardiff, et al., Antidepressants and youth suicide in New York City, 1999-2002, Journal of the American Academy of Childand Adolescent Psychiatry 45 (2006): 1054.

Excerpted from:

Excerpted from Bipolar Kids: Helping Your Child Find Calm in the Mood Storm © 2007 by Rosalie Greenberg. All rights reserved including the right of reproduction in whole or in part in any form. Used by arrangement with Perseus.

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