Childhood bipolar disorder is a scary proposition and that’s what makes the treatment of bipolar disorder in children so critical. I recently came across a Psychiatric Times article by Chris Aiken, MD that talks about treating children with bipolar disorder with lithium and I wanted to outlay the research findings Dr. Aiken talks about as well as my own thoughts.
Treatment and the Stages of Bipolar Disorder in Children
Bipolar disorder is a degenerative condition when not treated. This means that the longer you leave bipolar to fester, the worse it gets. According to Dr. Aiken, the following are the stages of childhood bipolar disorder:
- Stage 0: Risk factors, such as family history, but no symptoms.
- Stage 1: Prodromal symptoms (early, not serious), often in non-specific forms like anxiety and inattention.
- Stage 3: First episode and recurrence.
- Stage 4: Frequent episodes, treatment resistance and a clinical picture marked by cognitive problems, disability and loss of brain volume.
I know those stages sound really scary but keep in mind, with proper childhood bipolar treatment, the progression through those stages can be halted. Several treatments are available of which lithium is one. (Lithium is Food and Drug Administration approved in ages 12 and up.)
Lithium in the Treatment of Bipolar Disorder in Children
Dr. Aiken states there are seven reasons why lithium is a good choice for the treatment of children with bipolar disorder.
- Lithium excels in long-term episode prevention. There is evidence both in adults and children that lithium treatment is one of the only treatments that predicts recovery in the long term. In other words, in the long term, lithium may prevent bipolar disorder from proceeding through the stages mentioned above.
- Lithium works best when started early. In bipolar I disorder, there is evidence that those who tried lithium after their first manic episode were more likely to respond to it.
- Lithium prevents suicide. Children and young adults with bipolar disorder can be at an even greater risk of suicide than adults with bipolar disorder. The risk of suicide is six times less in those who take lithium. This can mean major peace of mind for parents of children with bipolar disorder. (Other mood stabilizers do not have this anti-suicide effect.)
- Lithium prevents hospitalizations. Lithium has been shown to prevent hospitalizations more than other mood stabilizers (anticonvulsants) and antipsychotics.
- Lithium as medical benefits. You need to carefully weigh how true you feel this one is. Some medical benefits definitely do exist but so do some risks. On average, bipolar disorder shortens the lifespan by nine years. This fact can be crushing for parents of children with bipolar disorder, but it’s important to understand that many of the risks have lifestyle factors involved. The medical causes that decrease the lifespan in bipolar disorder are primarily: heart disease, stroke, cancer, diabetes and chronic obstructive pulmonary disease (COPD). The good news is that lithium lowers the risk of stroke, heart attacks and cancer. The bad news is that lithium increases the risk of “renal insufficiency;” more on that later.
- Lithium improves longevity. Lithium has actually been shown to increase lifespans in those with bipolar disorder and the population in general. It is not known exactly why this is.
- Lithium protects the brain. Most psychiatric medications enhance neuroplasticity (simply put, this means the brain’s ability to create new neural connections) but as lithium affects more regions of the brain, it might preserve cognitive function and prevent brain volume loss. Lithium treatment in adolescents has been linked to neuroplastic changes in regions of the brain associated with emotion processing.
Risks of Lithium Treatment in Children with Bipolar Disorder
For a complete list of risks associated with lithium treatment, click here. Side effects lists are always scary but keep in mind that just because it’s listed, doesn’t mean a particular person will experience it.
That said, I want to focus on one particular side effect risk: lowered kidney function / renal toxicity.
In my opinion, doctors wildly underrepresent this risk. With long-term lithium treatment in children (who will turn into adults, likely on the same medication) lowered kidney function to the point of chronic renal failure is a real issue.
I mostly have gathered this through anecdotal reports, but in 2015, some pretty clear evidence was presented on this topic.
In a study of 630 adults on lithium for 10 years or more:
- There was a yearly increase in median serum creatinine levels (This is an indicator of diminished kidney function. Small changes don’t mean much, but big differences do.)
- About 33% of patients who had taken lithium for 10-29 years had evidence of chronic renal failure; however, only 5% were in the “severe” or “very severe” category.
I’m not saying this to scare you, I’m not saying people shouldn’t take lithium and I’m definitely not suggesting you throw your lithium out the window. What I’m saying is, you should know these numbers going in. And you should absolutely, positively, make sure kidney function is monitored at all times with lithium treatment. (Blood lithium levels must be consistently tested as well. Too high a lithium level is toxic.)
And you should absolutely know these number if you plan on putting a child with bipolar disorder on lithium treatment. Keep in mind, lithium might be the right choice for the child, but it still pays to be cognizant of the risks (and communicate the risks to your child so that when your child becomes an adult, he or she can make informed choices too).
But as I stated above, there are many possible benefits to lithium treatment as well, and only you and your child’s doctor can weigh these factors to come up with the best treatment for your child.
Sources
Aiff, H et al, Effects of 10 to 30 Years of Lithium Treatment on Kidney Function. Journal of Psychopharmacology. May 2015.
Aiken, Chris MD, 6 Pearls to Consider When Treating Pediatric Bipolar Disorder. Psychiatric Time. Jun 14, 2018.
Banner image by Flickr user r. nial bradshaw.
Image by James Heilman, MD [CC BY-SA 4.0 ], from Wikimedia Commons.
Your lack of skepticism with regards to pediatric bipolar is astonishing, given that as a distinct clinical phenotype it was rejected soundly by both the DSM !V and DSM V.
Personally, I’ve suffered severe OCD symptoms since I was a child, and the unwarranted enthusiasm for PBD left me with a years long BD diagnosis, lithium-induced tremor, untreated severe Pure O OCD, and a childhood of trauma and biomedical reductionism. I would also be skeptical of Aiken, given that he has a very loose definition of hypomania and dysphoric hypomania.
https://www.psychiatrictimes.com/bipolar-disorder/how-diagnose-mixed-features-without-over-diagnosing-bipolar
Personally, all of the doctors I’ve talked to since having the bipolar diagnosis redacted have been horrified that I was put on lithium at a young age. No doubt classical bipolar occurs at a young age in some people, but the diagnosis and treatment of “bipolar kids” seems like another dangerous medical fad more than a medical breakthrough.
Thank you, Natasha, for a very informative article. I also appreciate the feedback from Dr. Laitman. I am going to ask my doctor to read his statement and recommendation. I am on a low dose of lithium and my doctor is concerned. Perhaps the information about amiloride 5 mg daily would would put my doctor’s mind and mine at ease. It is not advisable for me to stop the lithium as it is part of a meds cocktail that has helped to keep me “normal” for 4 years. We don’t want to risk upsetting that balance by stopping the lithium.
I am reading your book and am finding myself saying, “Aha, I experience that too. I didn’t realize “it” was something (eg: thinking) that was affected by bipolar. I thought is was my fault.” I’m looking forward to reading the rest of your book. Thanks for writing it.
Hi Jeanette,
I hope that information helps you. Lithium can be great for many people.
I’m glad you like the book. :)
– Natasha Tracy
Lithium is my second favorite psychotropic medication behind clozapine. Like clozapine it is underutilized, anti-suicidal, and more often then not inappropriately managed. Now let me address the renal concerns with lithium. First I am a Nephrologist by training and I continue to not only take care of people with PSMI but continue on as a nephrologist. We know that in the kidney lithium is handled like sodium. We also know that much of lithium’s renal toxicity is secondary to it’s preferential accumulation in the principal cell in the kidney’s cortical collecting duct. Loss of function of this cell leads to the kidney being unable to concentrate the urine “diabetes insipidity”. We also have known since 1986 that simply adding the mild diuretic amiloride 5 mg daily ( NEJM 1986) blocks lithium entry into the principal cell and prevents this damage. Also we know that other toxicity of lithium on the kidney , chronic interstitial nephritis, are most associated with levels above the therapeutic range. So in summary what I am saying is that with careful, I do monthly bloods, and the use of amiloride we can greatly reduce risks and enhance benefits. People with PSMI deserve this.
Hi Robert,
Thank you so much for this information. I appreciate an MD chiming in.
– Natasha Tracy
Thank you for this valuable information.