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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