Treatment-emergent mania in pediatric bipolar disorder: a retrospective case review

Background: Pediatric bipolar disorder (BPD) can be misdiagnosed as a depressive, attention, conduct, or anxiety disorder and treatment with antidepressants and stimulants is common. Risk of adverse outcomes related to such treatment remains poorly defined. Methods: We analyzed clinical records of 82 children (mean age 10.6 years) meeting modified DSM-IV diagnostic criteria for BPD to evaluate risk and timing of operationally-defined treatment-emergent mania (TEM) or increased mood-cycling following pharmacological treatment. Results: Of 82 juvenile BPD patients, 57 (69%) had been given a mood-elevating agent at least once; 33/57 (58%) so-exposed met criteria for TEM, with median latency of 14 days; TEM was observed twice as often with antidepressants as stimulants (44% vs. 18%). TEM led to first-recognition of BPD in 14 cases (17%), and some drug-exposed children (4–9%) had prominent suicidal, homicidal or psychotic behavior. In addition to recent exposure to a mood-elevating agent, TEM was associated with early-onset anxiety and female gender. Limitations: Findings are retrospective in clinically diagnosed and treated outpatients, but involved otherwise unselected cases of juvenile BPD. Conclusions: TEM was reported in 58% of children with probable juvenile BPD within several weeks of new exposure to a mood-elevating agent.