GRÁFICO 1 MEDIA DE INTERACCIONES POR USUARIO DEL FORO ACB

While current guidelines emphasize the importance of avoiding polypharmacy, and no controlled-trial data support combining medication classes in youth with non-psychotic bipolar disorder,1 in practice it appears that a majority of children receive treatment with several psychotropic medications simultaneously.143 Even more notable, some of the combinations that are being prescribed are explicitly noted as being guideline discordant treatment combinations. For example, use of antidepressants (particularly SSRIs) and stimulants in this population are highly controversial,18, 76, 115, 198-204 but they are often prescribed with or without mood stabilizers. This practice is unacceptable based on current practice standards for adults, let alone children.52

Studies of prescribing behavior have revealed high levels of combination therapy use in youth and adults with bipolar disorder. Although pharmacoepidemiologic studies are limited in this area, those that have been conducted have provided some interesting information regarding medication prescribing in children with bipolar disorder. One study of the National Ambulatory Medical Care Survey (NAMCS) was particularly useful for outlining the

practice patterns for outpatient treatment of pediatric bipolar disorder.1 In this study, Moreno and colleagues noted that for youth with a diagnosis of bipolar disorder: 90% of office visits resulted in a prescription of one or more psychotropic medications; mood stabilizers were prescribed in approximately 2/3 of the visits; antidepressants were prescribed without mood stabilizers for 34% of the sample; stimulants were prescribed without mood stabilizers for 36% of the sample; antipsychotics were prescribed in over 47% of the sample; combination

36

treatment occurred in approximately 63% of the sample; and psychotherapy occurred in approximately 42% of the sample.

Two other studies that utilized the National Ambulatory Medical Care Survey (NAMCS) found similar medication use patterns for children with bipolar disorder. First, a study by Aparasu and colleagues, outpatient visits for which 11 typical and 6 atypical antipsychotic agents were prescribed were selected and characteristics of children and adolescents that received these drugs from 2003-2004 were described.205 They found that 40% of the visits in which these medications were prescribed were for children with bipolar disorder diagnoses, and that specialists prescribed 82% of these drugs. They also noted that children who were 10-14 and 15-19 were significantly more likely to get an antipsychotic than those under the age of 10 years. 205

A separate study looked at the treatment of bipolar disorder and how treatment has changed from 1992-1995 as compared to 1996-1999. While this study focused mainly on the treatment of adults, they did not exclude those under the age of 18. What they found was that nearly a third of patients with a bipolar diagnosis did not receive any mood stabilizer and over 45% of the visits resulted in a prescription for an antidepressant (generally SSRIs).206 Over the study period, the use of lithium decreased by 40%, while the use of valproate

increased by 250% and the use of anticonvulsants nearly doubled. The use of antidepressants, particularly without a mood stabilizer is concerning because of potential for drug-induced mania in this population. However, one antidepressant was shown to have lower manicogenic properties but this particular drug, bupropion, only represented 8% of the antidepressant prescriptions in this group.206

37

Bhangoo and colleagues also explored the use of a variety of psychotropic medications among children and adolescents with bipolar disorder using a sample of 111 patients who were receiving treatment for bipolar disorder through a psychiatrist.207 They found that a variety of agents were used in practice, including mood stabilizers, antipsychotics,

stimulants, SSRIs and tricyclic antidepressants, and that polypharmacy was common. In fact, the mean number of current psychotropic agents among the sample was 3.4 agents.

Approximately 18% of the children were taking five or more medications and only 30% were taking 2 or fewer medications. Children had, on average, over 6 past medication trials; over 20% had 10 or more medication trials and 25% had 3 or fewer trials.207 In the sample, 98% had received a trial of a mood stabilizer (79% received valproate, 51% lithium, 29%

gabapentin). However, 15% of the sample received treatment with gabapentin, topiramate or lamotrigine without having received a trial of lithium.207 These drugs currently have the weakest evidence for use in children, indicating that their use should only be considered after a lithium trial has failed. A trial of lithium, depakote, and/or possibly carbamazepine would be indicated prior to use of a newer anticonvulsant.207 Additionally, 77% of the children received an antipsychotic medication (58% received risperidone, 35% olanzapine, 26% quetiapine, 12% a neuroleptic, 4% ziprasidone and 1% clozapine).207

Use of medications has also been studied using the National Comorbidity Survey Replication (NCS-R).41 Although this study focused on adult populations, the use of a nationally representative survey and the 9,282 patients made it particularly useful for studying patterns of medication use for patients with bipolar disorder. In this study, medication use was classified as "appropriate" or "inappropriate." Medications were

38

"appropriate" if they were mood stabilizers, anticonvulsants or antipsychotics; and

"inappropriate" if they were antidepressants or other psychotropic medications used without an antimanic agent. At the 12 month treatment mark, appropriate medication use was higher among patients receiving psychiatric care (45%) versus those receiving general medical care (9%). Inappropriate treatment was received by 73.1% of patients treated by a general medical professional and by 43.4% of those treated by a psychiatrist.41