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September 24 – 26, 2015 | JW Marriott Miami | Miami, Florida
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Melissa P. Del Bello, MD, MS University of Cincinnati College of Medicine Cincinnati, OH
Pediatric Bipolar Disorder vs. ADHD: Diagnosis and Management
Melissa P. DelBello, MD, MS
● Research/Grants: Amylin Pharmaceuticals; Eli Lilly and Company; GlaxoSmithKline; Lundbeck; Merck & Co.; Martek; Otsuka America Pharmaceutical, Inc.; Pfizer Inc.; Purdue Pharma L.P.; Shire Pharmaceuticals, Inc.; Sunovion Pharmaceuticals Inc.
● Speakers Bureau: Bristol-Myers Squibb Company; Otsuka America Pharmaceutical, Inc.
● Consultant: Dey Pharma; Lundbeck; Otsuka America Pharmaceutical, Inc.; Pfizer Inc.; Sunovion Pharmaceuticals Inc.; Supernus Pharmaceuticals, Inc.
Disclosures
Describe the common comorbidities that occur with pediatric bipolar disorder
Learning Objective 1
Analyze the impact of comorbid ADHD on the clinical management of bipolar disorder
Learning Objective 2
Distinction Between Bipolar Disorder and ADHD
89% 86% 71%
40% 43%
14% 5% 10% 6% 6%
0%
20%
40%
60%
80%
100%
Elevated Mood Grandiosity Flight of ideas Decreased sleep
Hypersexuality
Bipolar disorder (n = 93 outpatient children) ADHD (n = 81 outpatient children)
Geller B, et al. J Child Adolesc Psychopharmacol. 2002;12(1):11-25. PMID: 12014591.
Pediatric Bipolar Disorder: ADHD Comorbidity
Study N Mean Age ADHD
West, et al. 1995 14 15.1 57%
Wozniack, et al. 1995 43 7.9 98%
Faraone, et al. 1997 68 6.1 93%
Geller, et al. 2000 60 11 98%/72%
Kafantaris, et al. 1998 48 16 29%
Kowatch, et al. 2000 42 11 71%
DelBello, et al. 2001 34 15.7 65%
Rates of Comorbidity and Age of Onset of Bipolar Disorder
0
10
20
30
40
50
60
70
80
< 13 yrs 13-18 yrs > 18 yrs
Per
cent
of P
atie
nts
Anxiety ADHD Alcohol Drug Bulimia Anorexia
Perlis RH, et al. Biol Psychiatry. 2004;55(9):875-881 PMID: 15110730.
DelBello MP, et al. Am J Psychiatry. 2007;164(4):582-590. PMID: 17403971.
Impact of Co-occurring ADHD on Outcome of Youth with Bipolar Disorder
ADHD & Lithium Response in Bipolar Adolescents
Strober M, et al. J Affect Disorder. 1998;15(3):255-268. PMID: 2975298.
Time to Onset of Sustained Improvement C
umul
ativ
e %
R
emai
ning
Uni
mpr
oved
Time from Start of Treatment in Days
0 5 10 15 20 25 30
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
No prior ADHD Early ADHD
Impact of ADHD on Treatment Outcomes
Consoli A, et al. Can J Psychiatry. 2007;52(5):323-328. PMID: 17542383.
Atomoxetine* for ADHD in Bipolar Youth
*Atomoxetine is indicated for ADHD only Chang K, et al., J Child Adolesc Psychopharm, 2009:(5):547-551. PMID: 19877979.
Divalproex
Adderall*
PBO
Adderall*
PBO 6-10 Weeks
Treatment of ADHD & Bipolar Disorder
Adderall is not indicated by the FDA for the treatment of bipolar disorder Scheffer RE, et al. Am J Psychiatry. 2005:162(1):58-64 PMID: 15625202.
Positive Mood Response
N = 23
2 Weeks 2 Weeks
5 -10 mg BID
N = 30
90
10
0 10 20 30 40 50 60 70 80 90
100
% Responders
%
Treatment Group
DVP + MAS DVP + PBO
Percent ADHD Responders
Response = 1 or 2 on CGI-I, MAS = mixed amphetamine salt, DVP = divalproex Scheffer RE, et al., Am J Psychiatry. 2005:162(1):58-64 PMID: 15625202
p < .0001
Bipolar + ADHD: YMRS Scores
DVP = divalproex sodium, MAS = mixed amphetamine salts *p < .05 Scheffer RE, et al., Am J Psychiatry. 2005:162(1):58-64 PMID: 15625202
0
5
10
15
20
25
30
Baseline DVP DVP + MAS DVP + placebo
YM
RS
Sco
re
*
Disruptive Mood Dysregulation Disorder (DMDD) ● Severe temper outbursts at least three times a week ● Sad, irritable or angry mood almost every day ● Reaction is bigger than expected ● Child must be at least six years old ● Symptoms begin before age ten ● Symptoms are present for at least a year ● Child has trouble functioning in more than one place
(e.g., home, school and/or with friends) ● No elated/expansive mood and the abnormally
elevated or expansive mood was accompanied by the onset, or worsening, of 3 of the “B” criteria of mania
Tourian L, et al. J Can Acad Child Adolesc Psychiatry. 2015;24(1):41-54. PMID: 26336379.
Axis I Diagnoses in Parents
Axelson D, et al. Am J Psychiatry. 2015;172(7):638-46. PMID: 25734353.
19
33
40
21
38 40
2
43
19
30
0
5
10
15
20
25
30
35
40
45
50
No Axis I DX Bipolar Dis Depressive Dis Anxiety Dis SUD
%
Narrow Phenotype
SMD
Questions & Answers