POSSIBLE APPROACHES TO CHILDHOOD ONSET BIPOLAR DEPRESSION IN CHILDREN AND ADOLESCENTS IN ABSENCE OF A GOOD EVIDENCE-BASED LITERATURE

(to be reviewed and revised as new information become available)

If my child were depressed after an episode of mania (ie had bipolar depression),  I would considersome of the following.

1.       Get good education about the illness and monitorthe child’s mood and behavior on the daily prospective NIMH-LCM.

2.       Get the child evaluated by an expert and beginsome form of psychotherapy for them and the family

3.       Encourage a good diet and as much exercise astolerated.

4.       Omega 3 fatty acids which may have someantidepressant efficacy and are probably good for him/her anyway

5.       Check for low Vit D levels and treat accordingly

6.       N-acetylcysteine (NAC) which has AD effects inadults and anti-irritability effects in children aged 4 to 17 with autism.  Ususal dose is 500mg capsules, one twice aday for one week, then 2 caps in Am and 2 caps in the PM.

7.       Consider NAC more strongly if he/she werebeginning to experiment with drugs such as alcohol or marijuana

8.       I would initially avoid the usual antidepressants for unipolar depression since early age of onset of depressionis a risk factor for switching on an antidepressant.  Also K. Chang of Stanford and  Joe Biederman of MGH see lots of activationand /or switching in youngsters with bipolar disorder treated with ADs.

9.       Starting lamotrigine at exceeding low doses12.5mg/day with very slow upward titration to avoid serious rash (1/5000 adultsvs about 1/2500 children)

10.  Folicacid (folate) as this can potentiate effects of ADs and there is some evidencethat lamotrigine can interfere with folate metabolism.   Consider using L-methyl folate 1 mg tabs twice in the AM in case the child has a MTHFR deficiency.

11.  If a child has early onset depression and a history of adversity (abuse or neglect) consider using the supplement acetyl-L-carnitine 500mg, one capsulethree times a day

12.  If needed, add an atypical with low wt. gain potential, such as lurasidone(Latuda) which is FDA-approved for children 10 to 17, and has a good profile of weight and metabolic neutrality; or consider quetiapine (Seroquel) especially if anxious and insomnic.  Caplyta and Vraylar are also good options and are less sedating than Seroquel.

13.  If needed, lithium augmentation should be considered.

14.  If still depressed, consider short term treatment with minute doses of an SSRI orbupropion under the cover of one or more mood stabilizers above

15.  If still depressed, consider a trial of rTMS (repetitive transcranial magnetic stimulation, as per reported effectiveness by the Mayo Clinic.

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