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Medications

Before starting medication, your doctor will want to determine your child's physical and mental health. This is called a "baseline" assessment. Your child will need regular follow-up visits to monitor treatment progress and side effects. Most children with bipolar disorder will also need long-term or even lifelong medication treatment. This is often the best way to manage symptoms and prevent relapse, or a return of symptoms.23

It's better to limit the number and dose of medications. A good way to remember this is to "start low, go slow." Talk to the doctor about using the smallest amount of medication that helps relieve your child's symptoms. To judge a medication's effectiveness, your child may need to take a medication for several weeks or months. The doctor or specialist needs this time to decide whether the medication is working or if they need to switch to a different medication. Because children's symptoms are usually complex, they commonly need more than one type of medication.24

Keep a daily log of your child's most troublesome symptoms. Doing so can make it easier for you, your child, and your doctor to decide whether a medication is helpful. Also, be sure to tell your doctor about all other prescription drugs, over-the-counter medications, or natural supplements your child is taking. Combining certain medications and supplements may cause unwanted or dangerous side effects.

Some of the types of medications generally used to treat bipolar disorder are listed below. Information on medications can change. For the most up-to-date information on use and side effects of medications, see the U.S. Food and Drug Administration (FDA) websiteExternal Link: Please review our disclaimer.. You can also find more information about medications in the NIMH Mental Health Medications booklet.

Mood stabilizers, such as lithium are usually the first choice to treat bipolar disorder. Lithium is approved for the treatment and prevention of manic symptoms in children ages 12 and older.25 In addition, lithium might act as an antidepressant and help prevent suicidal behavior.26 However, FDA's approval of lithium was based on treatment studies in adults, not children.

Anticonvulsant medications, originally developed to treat seizures, are also sometimes used as mood stabilizers. They are not approved by the FDA for treating bipolar disorder in children, but your doctor may prescribe one on an "off label" basis. They may be very helpful for difficult-to-treat bipolar episodes. For some children, anticonvulsants may work better than lithium. Examples of anticonvulsant medications include valproic acid or divalproex sodium (Depakote) and lamotrigine (Lamictal).

What are the side effects of mood stabilizers?

Lithium can cause side effects such as:

Lithium may cause other side effects not listed here. Tell the doctor about bothersome or unusual side effects as soon as possible.

If your child is being treated with lithium, it is important for him or her to see the doctor regularly. The doctor needs to check the levels of lithium in your child's blood, as well as kidney function and thyroid function.

Some common side effects of lamotrigine and valproic acid include:

Lithium Poisoning

Children may be showing early signs of lithium poisoning if they develop the following:

  • Diarrhea
  • Drowsiness
  • Muscle weakness
  • Lack of coordination
  • Vomiting.

Take your child to the emergency room if he or she is taking lithium and has these symptoms. The risk of lithium poisoning goes up when a child becomes dehydrated. Make sure your child has enough to drink when he or she has a fever or sweats a lot during very active play or work.

These medications may also be linked with rare but serious side effects. Talk with the doctor or a pharmacist to make sure you understand signs of serious side effects for the specific medications your child is taking.

In addition, valproic acid, lamotrigine, and other anticonvulsant medications carry an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Should girls take valproic acid?

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls. It could lead to a condition called polycystic ovarian syndrome (PCOS) in women who begin taking the medication before age 20.27,28 PCOS can cause obesity, excess body hair, an irregular menstrual cycle, and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid. Young girls and women taking valproic acid should be monitored carefully by a doctor.29

Atypical antipsychotics are sometimes used to treat symptoms of bipolar disorder. Those approved by the FDA to treat youth with bipolar disorder are risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), and olanzapine (Zyprexa). Short-term treatment with risperidone can help reduce symptoms of mania or mixed mania in children ages 10 and up. Some research has indicated that risperidone is more effective in treating mania in young children than other medications.30 Aripiprazole and quetiapine are approved to treat mania symptoms in children 10–17 years old who have bipolar I, while olanzapine is approved for use in children ages 13–17.31

What are the side effects of atypical antipsychotics?

Side effects of many atypical antipsychotics include:

Atypical antipsychotics can cause major weight gain and changes in metabolism, especially in children. This may increase the risk of developing diabetes and high cholesterol.32 While taking an atypical antipsychotic, your child's weight, glucose levels, and lipid levels should be monitored regularly by a doctor.

In rare cases, long-term use of atypical antipsychotics may lead to a condition called tardive dyskinesia (TD). The condition causes uncontrollable muscle movements that commonly occur around the mouth. TD can range from mild to severe. Sometimes people with TD recover partially or fully after they stop taking the drug, but others do not.

Antidepressants, such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are sometimes used to treat symptoms of depression in bipolar disorder. Doctors who prescribe antidepressants for bipolar disorder usually prescribe a mood stabilizer or anticonvulsant medication at the same time. If your child takes only an antidepressant, he or she may be at risk of switching to mania or hypomania. He or she may also be at risk of developing rapid cycling symptoms.33 Rapid cycling occurs when someone has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.34

However, results on effectiveness of antidepressants for treating bipolar depression are mixed. The STEP-BD study showed that, in adults, adding an antidepressant to a mood stabilizer is no more effective in treating depression than using a mood stabilizer alone.35

What are the side effects of antidepressants?

Antidepressants can cause:

Some antidepressants are more likely to cause certain side effects than other antidepressants. Your doctor or pharmacist can answer questions about these medications.

Antidepressants carry an FDA warning. Although they are generally safe and popular, some studies have suggested that they may have unintentional side-effects in some people, especially teens and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. The latest FDA information can be found hereExternal Link: Please review our disclaimer..

Unusual or severe side effects of any medication should be reported to a health care provider right away. Your child may need a change in the dose or a different medication.

Children and teens being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms, or other uncomfortable or possibly dangerous withdrawal effects.

Sexual Activity, Pregnancy, and Adolescents with Bipolar Disorder

Many teens make risky choices about sex. But having bipolar disorder is also linked with impulsive and risky choices. Teenage girls with bipolar disorder who are pregnant or may become pregnant face special challenges because medications for the illness may have harmful effects on a developing fetus or nursing infant.36 Specifically, lithium and valproic acid should not be used during pregnancy. Also, some medications may reduce the effectiveness of birth control pills.37 For more information on managing bipolar disorder during and after pregnancy, see the NIMH booklet Bipolar Disorder in Adults.

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