New drug-and-psychotherapy program for bipolar disorder in children

October 15, 2003

A psychiatrist at the University of Illinois at Chicago has devised a promising drug regimen for children with bipolar disorder.

In preliminary studies, the regimen, coupled with a psychotherapy program called RAINBOW, shows considerable success in alleviating the worst symptoms of the disease and enabling victims and families to cope.

"Bipolar disorder is often inappropriately treated," said Dr. Mani Pavuluri, director of the bipolar research program and the UIC pediatric mood disorders clinic, the only such clinic in the Chicago area.

"What's needed is a step-wise therapy that begins by stabilizing the child's mood and then moves on to address, each in turn, symptoms like attention deficit hyperactivity, residual depression and aggression that frequently accompany the illness," Pavuluri said. "Too often, children are treated first for attention deficit hyperactivity disorder (ADHD), resulting in a worsening of the mania."

According to Pavuluri, determining the correct medication for these children is crucial because drug therapies, such as antidepressants and stimulants, that are intended to alleviate symptoms can in fact trigger manic episodes, exacerbating the underlying condition.

Results of two studies by Pavuluri, one on her drug regimen and another on her RAINBOW program, will be presented Oct. 15 at a meeting of the American Academy of Child and Adolescent Psychiatry in Miami Beach, Fla.

Pavuluri formulated her treatment regime for the complex symptoms associated with pediatric bipolar disorder based on theoretical considerations and clinical findings in the literature that tested individual drugs.

"The aim is 'prescription hygiene,'" she said, "optimizing the number of drugs and their dosage so that only those that are effective are used and those that worsen symptoms are eliminated."

The regimen specifies four steps: 1) eliminating toxic drugs, 2) prescribing drugs that dampen the wild swings in mood, 3) aiming for a full recovery by adding a second mood stabilizer, if necessary, and 4) treating residual symptoms of inattention or aggression and sudden onset of other symptoms such as psychosis.

The preliminary trial compared outcomes for 64 children with bipolar disorder who underwent Pavuluri's drug regimen with outcomes for a group of children who received standard care. Ninety-four percent of the children in the test group improved, while none in the control group did.

Pavuluri's RAINBOW program, involving 12 hour-long psychotherapeutic sessions with both the children and their families, is based on cognitive behavioral therapy, which modifies undesirable emotions and behaviors by working on the thoughts that motivate them.

RAINBOW is an acronym to help families recall strategies for coping with the symptoms of the disease. Its letters stand for Routine; Affect (or emotional) regulation; "I can do it!" (promoting self-esteem); No negative thoughts; "Be a good friend!" or Balanced lifestyle, for parents; "Oh, how can we solve this problem?"; and Ways to get support.

With the changes in mood that occur with bipolar disorder, parents and siblings can be exhausted and strained, Pavuluri said. "One moment kids can be irritable, excitable, impulsive, intrusive, and loud; the next they are sullen, withdrawn and weepy," she said. "Families need coping and problem-solving strategies, which are incorporated into the RAINBOW framework."

In the preliminary study, 34 children who had been treated according to Pavuluri's drug regimen were enrolled in the RAINBOW program. They showed considerable reduction in symptoms, although Pavuluri cautions that the investigators were not blind to the treatment and consequently could have been biased.

Bipolar disorder is a devastating mood disturbance, characterized by cycling episodes of mania and depression, irritability and aggression, inflated self-esteem and grandiosity, decreased need for sleep, constant talking and activity and even psychosis. In children, it is associated with an alarming rate of suicide, failure in school, and engagement in high-risk behaviors such as sexual promiscuity and substance abuse. The disease is often misdiagnosed and, as a result, inappropriately treated.

"Advances in treating this serious disorder will come by combining a state-of-the-art medication regime with innovative and creative psychotherapy for the whole family," Pavuluri said.
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