Depression or bipolar?

[pepperidge]

We go back to see the psychiatrist next week on difficult child 2. I am tearing out my hair, and am at the point where all I can think to do is find a way to try to help myself detach and try to destress in a major way--seems like I can't help my son at all. And he is only 9.

His major symptoms are irritabililty, whininess, need for instant gratification, difficulty letting things go (holds grudges etc), emotional disregulation, impulsiveness. Has had the full nine yds of neuropsychologist, no autistic spectrum stuff at all. I used to think of him as this happy child, but highly impulsive, didn't listen. That seems to have abated some (I think the abilify has helped). But what is becoming more evident is the constant irritability, whininess.

He has a high need for external stimulation and if he doing something fun, the whininess disappears. But he can't entertain himself at all. He enjoys school but it doesn't come easy for him. When he is at home that's when the whininess etc starts. Somewhat I am sure is the letdown from the day at school. While I am sure I wouldn't win any awards as mother of the year, we are pretty consistent, try to meet needs, etc, lots in Basket C, so at this point I don't see that there is a whole lot I can do to modify things at home.

He has responded poorly to all medications (stims, Tenex bad reaction), except abilify. Have not tried any SSRIs. His diagnosis is unclear--he certainly doesn't have the raging or cycling or mania that would make one think of bipolar. We got up to 125 mg of Lamictal with no positive impact at all it seems, Topamax hasn't helped very much if at all. We can't seem to go higher on the Abilify because of problems with TICs and urinary accidents.

so here's my question. I know all about anti-depressants and bipolar. But right now I am wondering, could this child have depression (as distinct from bipolar) and might he benefit from an anti-depressant? Are there any children who benefit, other than the obviously obsessive compulsive types? I believe Prozac is the only AD approved for children, but are there advantages to others?

His birthmother was a substance abuser, which I know (now) is a red flag for bipolar. But is it also common in depression as well?

Appreciate any thoughts.

Chris

 

[Lori4ever]

That is an interesting question. I have the same concerns in figuring out the difference. I was told that in children, the anger will come out in defience and anger. My son is bipolar, but they say they see depression as well. I am confused by all of it. I hope someone has an answer for you.

 

[BusynMember]

Since he's a child, and there are no blood tests, there is no way to know for sure, but the bipolar in a close relative makes him at high risk for bipolar. If it were me, I would ask if we could try a mood stabilizer first, because the history dictates this, and because ALL medication trials are hit or miss. I wouldn't want to try a stimulant or antidepressant before I tried a mood stabilizer. If it works, you have your answer. I have bipolar II--some hypomania with lots of depression. I do take an antidepressant, and need it, but I'm an adult. Antidepressants can be scary in kids. JMO

 

[oceans]

It sounds like there needs to be more of an evaluation done to rule in or out depression or bipolar. You have only tried one mood stabilizer. A different one might work. There are other AD's that my difficult child has tried in which the psychiatrist said have showed some promise in kids. Besides prozac, there is Zoloft and Celexa. He also mentioned Lexapro.

I think that you are smart to be going back and trying to figure out things more clearly.

 

[smallworld]

Hi Chris, I bet you knew I'd be popping in to weigh in.

As you know from our many email discussions, my kids don't entirely fit the BiPolar (BP) diagnosis (on the hypomania/mania side -- they're definitely depressed), but they flip out when they take SSRIs. We know this, of course, because the first medications they ever took (save stims for my son, which he tolerated well) were SSRIs. You probably already know this, but 30 to 50 percent of kids first diagnosed with depression actually have BiPolar (BP). It is very challenging to tease out what is unipolor vs. bipolar depression. So . . . what we have done is lay down mood stabilizers first and then add in small doses of ADs (difficult child 2 has been on Lexapro since early December, and difficult child 1 is starting Lexapro this weekend). We start really low (2.5 mg Lexapro) and then raise the dose every 2 weeks. That way we can sense problems early before flipping over into full-blown mania (which happened in 5 days when difficult child 1 trialed Effexor).

In easy child's case, because of family history, her psychiatrist prescribed Zyprexa first because it has both anti-anxiety and mood-stabilizing properties and then added in Prozac (for her choking phobia). The beauty of Prozac is that it comes in a liquid that can be given in tiny doses. We started at 2 mg and cautiously went up every 3 weeks. She's now at 12 mg, and honestly, we're having some issues with meltdowns. I don't know if we're seeing some activation, but husband and I are a tad concerned. I have a call into easy child's psychiatrist this morning.

Unfortunately, medications are a crapshoot. You gotta try or you'll never know. Your difficult child is only on 5 mg Abilify, and clearly, it's not doing enough or targeting existing symptoms. I think you have a few choices -- try an AD with the current AP, try a different AP and then add in an AD, try a different mood stabilizer and then an AD if necessary. You're right that Prozac is the only AD approved to treat depression in children, but psychiatrists frequently prescribe others off-label.

Hope you can figure something out.

 

[Sara PA]

Only Prozac has been approved for the treatment of MDD (major depressive disorder) in children and adolescents and it is the only one that has been shown to be effective and that's only for about 10%. (Efficacy is calculated by comparing the results for kids taking the drug to kids taking a placebo. When the placebo efficacy rate is subtracted from the drug efficacy rate, the difference is considered to be net efficacy of the drug. Prozac's is around 10%, the others are nowhere near that. There are some researchers who believe that the methodology of the Prozac studies should not be considered reliable and that it shouldn't not have been approved either.)

Safety is separate from efficacy. ADs come with a high rate of psychiatric/central nervous system side effects, especially for children, which can occur regardless of the any conditions the child might have.

Prozac, Zoloft, Luvox, and Anafranil are approved for Obsessive Compulsive Disorder (OCD) in pediatric patients. Those not approved for the treatment of MDD are not approved because of lack of efficacy in treating MDD.

Celexa has been tested and it is not effective or safe for use by children and adolescents. The studies were not even submitted to the approval process or published because the results were so poor. If Lexapro (a close relative of Celexa) has been studied, the results are certainly not sufficiently good to gain FDA approval for it's use by children and adolescents or informaton about the studies would be circulating.

 

[dreamer]

remember that "depression" can manifest in diff ways in kids and irritability and whinieness can also be part of bipolar cycling becuz kids just do not always manifest exactly according to textbook descriptions.
UG! I am sorry, I am not wording well at the moment.
Um, irritability can be depression, it can be anger, it can be boredom, restlessness, hypomania, or anxiety. sometimes you have to look at these descriptive words and consider them and try to figure out just which descriptive words are the right ones, and sometimes some docs also have difficulty sorting thru the descriptive words------and then it is also hard to see the reason behind the behavior-------for example, is a kid irritable becuz they re feeling hyper, or tired, or nervous, or internally restless? sometimes when you look at it a lil differently it fits together just a lil differently. I know I get a short fuse when over tired, hungry or in pain. If you were going to describe my behavior to a doctor, you might on casual observation tell my doctor- she is so short tempered and crabby.....BUT the basis of my short temper and crabbiness is I am hungry overtired or in pain. See what I mean? (thats just an example, I am NOT implying your child is overtired, hungry or in pain, I was just trying to show the difference)

 

[tiredmommy]

I *think* that whininess and irritability can be a symptom of rapid cycling in a child with eobd. Adults tend to shift moods somewhat more completely (mania or hypo-mania versus depressed seem more distinct) versus a child continually shifting so that the child's overall mood may be muddled and difficult to read.

 

[pepperidge]

HI

Thanks for all the responses. I have read Bipolar child--even have it memorized I think. I wish in the next edition they would discuss children who don't meet their definition of bipolar--but clearly have more than ADHD going on.

Anyway, I was curious whether there had been any positive experiences out there with AD for certain subsets of children. Doesn't seem like it--though Smallworld, I hope with the mood stabs in place your kids get some further boost from the AD.

Don't know what we will do. psychiatrist may want to increase Focalin (he just started is on 5 mg, without much positive or negative impact. Since he had a real bad reaction to Ritalin and Adderall, I am not anxious to up it. but thanks to Smallworld I was willing to give it a try).

Am considering proposing medication wash, since he is on pretty small dose of Abilify at this point to see if it does do anything. I kind of wonder if Abilify hasn't pooped out, but we haven't had any luck raising the dosage due to side effects. But sometimes I have heard that certain drugs are not so effective if you stop them and restart.

Otherwise I guess it is on to trying a different MS. psychiatrist is not pushing AD at all, but I thought it worth considering whether it might have a place. Lamictal didn't show any positive benefits at all even at 125 mg so I don't know if it is worth pushing up the dose.
guess it is onto Trileptal or Depakote. I am reluctant to try the latter because of the weight issue, which Abilify hasn't helped.

Sigh. It is such a crap shoot.

The Child and Adoles. Bipolar Foundation newletter has some interesting studies--one on ADHD and Bipolar (giving some evidence that in some kids ADHD may be an early form of Bipolar) and one on giving glucophage along with APs to prevent weight gain.

I appreciate you all sharing your experience. This mood thing is interesting. My other son was irritable most of the time, otherwise it seemed like he was being silly. With #2, he is often in a good mood until something crosses him, and he has trouble shaking it off until something presses the reset button. I don't tend to think of that as cycling, more just strong emotional reactivity.

Thanks again. Chris

 

[Sara PA]

Lamictal is a long term treatment meant to decrease the amount and severity of cycling; you may not see any short term benefit. The normal target does is generally 200 mg, though if a satisfactory result is seen at lower doses, naturally you would use the lowest effective dose. It is thought that Lamictal has a positive effect on acute depressive phases but it doesn't improve manic phases at all.

 

[oceans]

Chris- My son has tried almost all of the SSRI's and even a SNRI and nothing at all has helped him. We are going to try to add Lamictal to the Zoloft his is once again on. Our psychiatrist refuses to do a mood stabilizer first and then add the AD.

What about Tegretol or Lithium?

My difficult child has weight problems from once being on Risperdal, and would not want him on Depakote because of that.

 

[ROE]

Hello,

I don't have any advice on medication.s. My son has taken an SSRI since he was 10, it was first prescribed for his Obsessive Compulsive Disorder (OCD). It is believed that there is an element of depression to his diagnosis as well. Paxil has worked well for his Obsessive Compulsive Disorder (OCD), and since he has gotten older, an increased dose helps his mood too. However, as a small child I'm not so sure that it didn't cause some of the outrageous mood swings that he had (clonidine was later added and has stopped since then).

Your post caught my attention because your son sounds alot like my son at that age. As my son has gotten older, alot of those behaviors changed for the better. He's less impulsive, less intense about instant gratification, less whiney etc. The bad news is that it took many years to get to this point. I like to think that it is a sign of maturity. He still has issues but on a different scale.

Hang in there. I hope you find some answers soon.

To answer your question, I do believe that substance abuse is a symptom of depression as well as bi-polar. My father was an alcoholic and he was diagnosis. with SAD (but I guess that may be on the bi-polar spectrum).

 

[BusynMember]

I want to chime in that Abilify isn't a mood stabilizer nor is Risperdal, Zyprexa, Geodon or Seroquel. They are antipsychotics that are used mostly for short-term raging. In the long run, they tend to poop out when they are tried as mood stabilizers. Mood staiblizers take up to eight weeks or longer to kick in, but, once they do, they can last for years or a lifetime. The dose has to be therapeutic--not too low or too high. Prozac may be approved for kids, but I'll share my kid's experiences with it. Remember, your kid may be different, but Prozac was scary for both of my kids. My son was eight at the time, and never a behavior problem. He is on the autism spectrum. On his very first pill, he acted manic and kept climbing on his desk in school, yelling, "I can flyyyyyyyyyyyyyy!" He never took another Prozac. My daughter was a teen, and she pulled a knife on herself. She hated how she felt on Prozac. If your child takes an SSRI be sure you are watching her very carefully. I've taken my fair share of them and they can trigger some very bizarre behavior, even psychosis, especially if it really is bipolar. Good luck!

 

[smallworld]

MWM, you are right that atypical antipsychotics aren't mood stabilizers, but as I said in my post, they have mood-stabilizing properties (there's a difference). I agree that SSRIs can be scary -- my own son had a prolonged intense manic reaction to Prozac -- but sometimes there are no other options. When easy child wouldn't eat at all because she was afraid she would choke, we had no choice but to use an SSRI to help conquer her completely irrational fears (all the psychiatrists consulting on her case said there were no alternatives). In her case, Prozac helped her start eating again, and yes, we and her psychiatrist watch her very carefully for bad medication reactions.