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Complicating Factors

A number of psychiatric and medical conditions can be confused with bipolar disorder, particularly in children and adolescents. Here is a short and by no means complete list:

  • Schizophrenia
  • Schizoaffective disorder
  • Childhood disruptive behavior disorders (ADHD, ODD, CD)
  • Borderline personality disorder
  • Posttraumatic stress disorder
  • Substance abuse or medications
  • Neurological disorders
  • Metabolic conditions such as thyroid disorders

A number of psychiatric and medical conditions tend to occur concurrently with bipolar disorder. Co-morbidity is very common. 75% of bipolar 1 patients have some other condition going on. Here is a short list:

  • Drug abuse
  • Conduct disorder
  • Oppositional defiant disorder
  • ADHD- hyperactive subtype (100% in children under 12 and 57% in adolescents)
  • Panic disorder
  • Obsessive compulsive disorder (3% in bipolar 1)
  • Tourette's syndrome
  • Anxiety disorder (24% in bipolar 1)
  • Panic disorder (16% in bipolar 1)
  • Phobia (11% in bipolar 1)


We don’t know what causes bipolar disorder, but it seems to be a combination of genetic and environmental factors. Bipolar patients have some neurotransmitter abnormalities, however the actual neurophysiological mechanism is still not clear.


Overall, we have about a 50% chance of getting bipolar patients back to normal levels of functioning. The prognosis for children and adolescents is initially worse. This is because they often present with mixed features, psychotic symptoms, and/or comorbid behavior/substance abuse problems, all of which do not respond well to lithium therapy.

The major concern of bipolar disorder is suicide. 20% of children and adolescents attempt suicide. Overall, the completed suicide rate for all bipolar patients is 19%.


Treatment of bipolar disorder is rather complicated. This is because the treating the depression may push the patient into a manic phase or increase the cycling rate. To make things worse, we have very little research on the treatment of bipolar adolescents and children. Most of the treatment plans are based upon extrapolations from adult studies. However, data from adults do not necessarily apply to younger patients.

The initial treatment depends upon in which phase of the disorder the patient presents.

Manic or Mixed Episodes

The goal of treating a patient suffering from an acute manic episode is to control the mania and to help him return to normal levels of psychosocial functioning.

Treatment of bipolar disorder is with medication. Either lithium or valproic acid is the drug of choice, either by themselves or in combination with other medications. Short-term adjunctive treatment with a benzodiazepine may also be helpful. Electroconvulsive therapy (ECT) may also be considered for patients with severe or treatment-resistant illness.

The following are some of the drugs used to treat the manic phase of bipolar disorder:


Lithium is a mood stabilizer that has been used to treat bipolar mania for over 50 years. Up to 75% of patients treated with lithium experience some side effects. These side effects vary in clinical significance.

The side effects of lithium include:

Lithium has been associated with thyroid abnormalities, including hypothyroidism, goiters, and thyroid autoantibodies. Hypothyroidism occurs in 5%–35% of patients treated with lithium.

Lithium inhibits reabsorption of water leading to excessive urination and thirst.

Lithium disrupts the cardiac conduction system and can cause arrhythmias.

Lithium can induce or exacerbate dermatological problems, including acne, which may be a significant concern to adolescent patients.

Lithium may produce a variety of neurological effects, including muscle weakness, tremor, lethargy, cognitive blunting, and headaches. In children, lithium has been reported to alter EEG patterns and to decrease performance on cognitive testing.

Lithium can be toxic in high doses. Signs of toxicity are marked tremor, nausea and diarrhea, blurred vision, vertigo, confusion, and increased deep tendon reflexes. Hemodialysis is the only reliable method of rapidly removing excess lithium from the body.

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