Fall 2007
                                                        Stanford Pediatric Bipolar
Current Research
         One main goal of our group is to work with families of children who have at least one parent wit...
Currently Abilify is suggested to treat manic and mixed episodes of bipolar disorder. Under the
            direction of D...
Acknowledgments from the PBDP
                 We would like to thank all of the families who make this research possible ...
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  1. 1. Fall 2007 Stanford Pediatric Bipolar Volume 5, Issue 1 Disorders Program Newsletter The Pediatric Bipolar Research Team Kiki Chang, MD- Director Dr. Chang is Associate Professor at Stanford and also is Director of the Pediatric Bipolar Disorders Program and Clinic. Amy Garrett, PhD- Researcher & Neuroimaging Manager Dr. Garrett manages and assists in all aspects of neuroimaging data acquisition and analysis. Meghan Howe, MSW- Clinical Research Manager Ms. Howe manages and assists in all aspects of clinical data acquisition and analysis. Manasi Rana, MD- Clinical Trials Doctor Dr. Rana is a post-doctoral researcher assisting in clinical research trials. Naama Barnea-Goraly, MD- Researcher Dr. Barnea-Goraly is a researcher, specializing in neuroimaging. Manpreet Singh, MD- Researcher Dr. Singh is a post-doctoral researcher, specializing Happy Fall! Welcome to the fifth newsletter of the Pediatric Bipolar Disorders Program (PBDP) in neuroimaging research. at the Stanford University School of Medicine! We publish this newsletter every Nancy Adleman, BA- Graduate Student Researcher year to keep you abreast of current information regarding our ongoing research Ms. Adleman is a neuroscience doctoral student studies as well as breaking news in the field of pediatric bipolar disorder. Many of researcher, aiding in neuroimaging in the lab. you may already be familiar with our group from having participated in past Asya Karchemskiy, MS- Neuroimaging research studies, some of you are currently participating in our research, and a few Research Assistant of you may be waiting for the right study to join. This newsletter will also be Ms. Karchemskiy processes and analyzes structural available to other individuals, families, and health professionals that may be brain images. interested in our work. Please feel free to give us feedback about this newsletter, and if you wish to be added or removed from our mailing list, please contact us Ryan Kelley, BA- Neuroimaging Research Assistant immediately (contact information is on the back cover). We hope this newsletter is Mr. Kelley acquires and processes MRI and fMRI informative to you and provides a service not usually available to the general brain data.. public. We especially hope those of you participating on our research feel part of Erica Weitz, MA- Clinical Research Assistant the Stanford family as you join us in our mission to learn better ways of Ms. Weitz assists in all aspects of clinical and understanding, identifying, treating and eventually preventing bipolar disorder (BD) behavioral research. in children and adolescents. Daphne Nayar, BA- Clinical Trials Research Assistant Mission Ms. Nayar assists in the clinical trials research. Pediatric BD is an understudied disorder that may affect at least 1% of children and Melissa Pease, BA- Clinical Research Assistant adolescents. The cause is unknown, though we do know that it is largely inherited. Ms Pease assists in all aspects of clinical and There are no genes or biological tests that can help to diagnose BD. There are very behavioral research. few conclusive studies regarding effective medications in pediatric BD. Dylan Alegria- Student Research Assistant Mr. Alegria assists in the processing of structural We wish to use all our available resources to study pediatric bipolar disorder in the brain images. hopes of learning more about the causes and effective treatments. We are conducting various studies of children with BD as well as children of parents with Allison Fitzmaurice- Student Research Assistant BD, who are at generally higher risk of developing BD. Eventually, we hope to Ms. Fitzmaurice assists in all the research.. find ways of detecting children at very high risk for BD and ways to prevent them from developing BD.
  2. 2. Current Research One main goal of our group is to work with families of children who have at least one parent with bipolar disorder (BD). These children are at relatively high risk for eventually developing BD, and therefore may help us find factors that might bring about the onset of pediatric BD. We call these children “bipolar offspring.” We feel that certain bipolar offspring may be at even greater risk for developing BD – those who already have mood and/or behavioral problems. Most of our studies involve bipolar offspring, but some involve any child with a bipolar disorder Neuroimaging and Genetic Studies Clinical Trials Atomoxetine as an adjunct therapy in the We are conducting a NEW five-year study of bipolar treatment of comorbid ADHD in children and offspring. Participants must be children 9-15 years old adolescents with Bipolar Disorder I or II with ADHD and mood problems, who also have a parent We are conducting a research study designed to with BD and sibling without any diagnosis. We require assess the effectiveness of atomoxetine that the parent who has BD is available for an interview (Strattera) in the treatment of attention deficit for confirmation of the diagnosis. We are administering hyperactivity disorder in children with pediatric MRI, fMRI, MRS, as well as many behavioral measures BD. Eligible children must be between the ages both at the beginning of the study and 1-5 years later. of 6 and 18, have bipolar I or II, and be Additionally, we are gathering genetic information from considered euthymic. Participants will be able to all family members. These children receive a diagnostic continue to take their current medications. They interview, pictures of their brain, and financial will then take atomoxetine for eight weeks. reimbursement each time they get an MRI. This study is During the eight weeks they will be closely an attempt to discover which brain activation patterns, monitored and will receive several forms of neurochemistry, and biological markers put bipolar assessment. This study is funded by Eli Lilly. offspring at higher risk for developing BD. Many of the children who have already participated in one of our MRI studies may be invited back for a follow-up scan. This study is funded by the NIH Family Focused Therapy Family Focused Therapy with families with Bipolar Disorder What is neuroimaging? We are studying psychoeducational therapeutic Neuroimaging is an non-invasive method of techniques in families with bipolar disorder. looking at the brain. It is also called a brain scan, Participating families must have at least one and it does not hurt. Powerful magnets are used parent or child with bipolar disorder and at least to create pictures of the brain, similar to an x-ray. one child who has significant mood problems or At Stanford, we use neuroimaging for research has ADHD. Family members receive thorough purposes only. It is not yet possible to diagnose diagnostic evaluations and 12 weeks of family someone with bipolar through the use of a brain focused therapy. This study is funded by the scan. NIH as well. Children at risk for developing bipolar disorder Children who are offspring of parents with bipolar disorder are at increased risk for developing bipolar disorder. Identical twin studies suggest a concordance rate as high as 70%. This does not suggest that all children with parents with bipolar disorder will eventually develop the disorder themselves. It only highlights the significant role genetics play in the development of bipolar disorder. At the PBDP, we have been studying Families in which bipolar disorder runs, as we consider the children to be at relatively high risk for bipolar disorder. Children who have behavioral disorders, such as attention deficit hyperactivity disorder (ADHD), or depression are at particularly high risk bipolar disorder. We have seen how children of parents with bipolar disorder often develop a severe form of ADHD at an early age. Quite often we are also noticing a number of other comorbid disorders such as separation anxiety disorder or general anxiety disorder. Depression is also clearly a risk factor Evidence Based Treatment for Pediatric BipolarDisorder for later mania. Eventually some of these at risk children go on to develop pediatric bipolar disorder while others do not.Research continues to explore the impact medications have on the understandof pediatric children develop The purpose of our current neuroimaging and genetic study is to treatment why these bipolar disorder. disorder. Our goal is to eventually develop medications and therapeutic techniques in adult bipolar For example, aripiprazole (Abilify ) and quetiapine (Seroquel ) have been well studied that will help in bipolar disorder and are FDA approved for the use in altogether. adults; however, very little information is delaying or preventing the onset of bipolar disorder bipolar in available on how these atypical antipsychotics effect children and adolescents and if they effectively treat pediatric mania or depression. New research suggests that both medications could be beneficial in the treatment of pediatric bipolar disorder
  3. 3. Currently Abilify is suggested to treat manic and mixed episodes of bipolar disorder. Under the direction of Dr. Delbello, researchers at the University of Cincinnati recently conducted a retrospective chart review of children and adolescents who were treated with Abilify for two consecutive weeks. They found a decline in mania-symptom severity during treatment. The patients reported some adverse effects, including gastrointestinal distress, headache, and sedation, but the medication was generally well tolerated. Although these side effects are common for psychotropic medications in children, the severity and rate of such side effects may be decreased with Abilify than with other medications for bipolar disorder, such as mood stabilizers. The study concluded that Abilify may be effective and well-tolerated by children and adolescents for the treatment of bipolar disorders, and opened the door for controlled studies. For the past two years, researchers, including our program, have been participating in a multi-site study evaluating the use of Abilify in children and adolescents with bipolar disorder I and currently in a mixed or manic episode. The results should be published soon and will first be presented by Dr. Chang in October 2007 at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry. Another atypical antipsychotic is Seroquel, which is effective in treating mania and depression ion adults with BD. Two recent double-blind randomized studies have explored the use of Seroquel in treating adolescents with bipolar disorder. In a 28-day study of adolescents with bipolar I disorder, who were currently experiencing a manic or mixed episode, researchers found that Seroquel is as effective as divalproex (Depakote) for the treatment of acute mania. Seroquel may also reduce manic symptoms more rapidly than Depakote, and increase remission rates (how many adolescents stopped experiencing symptoms). Sedation, dizziness, and gastrointestinal upset were the three most common side effects. Another study compared Seroquel and Depakote for the treatment of impulsivity and reactive aggression in adolescents with co- occurring bipolar disorder and disruptive behavior disorder(s). The two medications showed similar effectiveness for the treatment of impulsivity and reactive aggression. The most common adverse effects were sedation, gastrointestinal upset, and headaches in both groups. These results are promising for the future of the treatment of pediatric bipolar disorder because they both describe positive findings that suggest Abilify and Seroquel can be tolerated and used in the treatment for pediatric bipolar disorder. Our research program recently completed a placebo controlled study of Seroquel to treat depression in adolescents with BD – results should be presented soon! While we still need longer studies to understand the long-term effects (both positive and negative) of these medications on children, we are making much progress in this area, and new studies are being published every year. Stay tuned… Family Resources Camp New Hope Camp New Hope is an opportunity for youth ages 9-17 to experience an outdoor camp that has been designated specifically for Youth Bipolar Foundation children and adolescents with bipolar disorder. The camp is of Northern California sponsored by the Taylor Family Foundation and The YBFNC is a nonprofit the Youth Bipolar Foundation of Northern California. organization dedicated to For more information please contactthat the best treatment for pediatric bipolar developing therapeutic and Research suggests Nancy disorder (BD) should include both Phone: pharmacotherapy (medication) and psychotherapy. Medication should berecreational programs for youth in order 925-934-1216, the first line of treatment used Often we hear or use the words mood swings, episodes. and cycling to describe symptoms Email: to stabilize mood and prevent future episode, Once the child’s moods are relatively stabilized, a therapeutic campnewhope_arroyo@yahoo.com. with bipolar. More information on Website: hppt://www.campnewhope.net. pediatric population? According to the National can be found at the process model that incorporates psychoeducation should be added to the treatment plan. Psychoeducation is of BD, but what do these words really mean for the YBFNC of Health (NIMH), “mood swings” are a symptom of BD information the time symptoms, treatment, and self- Institute of Mental teaching patients about bipolar disorder, including and refer to regarding http://www.ybfnc.cfsites.org/ when a person goes from an overly high This form of therapysadnecessary to assist and then back a stable mood, and it has been regulatory techniques. or irritable state to a is and hopeless state in maintaining shown to lead to better medication adherence. There are four types of therapies that have shown to improve again. Often, there are periods of stable mood in between these mood swings. For most adults, anof BD inischildren: Cognitive-Behavioral oneWebsite symptoms episode the period of timeInformational would(CBT), Dialectical Behavioral Therapy (DBT), during which Therapy experience one Multi-family Groups, and Family weeks) or mania (at least 1 week). Some people, Focused Therapy (FFT). Treatment Modalities for Pediatric Bipolar Disorder: particular mood state, either depression (at least 2 official website of the Child and Adolescent Bipolar Foundation, which http://www.bpkids.org The especially children, have All four of theseininformation experience both depression andof these therapies vary slightly on the type mixed episodes, include a psychoeducation approach. Each mania includes educational which they for children and families. simultaneously. Medication +Therapy of techniques used and the structure of the sessions, but often the main goal of these therapies is to bring children, families, and mental health providers together to work as a team in recognizing symptoms before they become Cycling, rapid cycling, and ultraradian cycling are all terms to describe the course of mood symptoms. Cycling is the FFT, which was designed by David Miklowitz at University of Colorado –Boulder, has been full episodes. pattern of transitioning from one mood state to another. Rapid cycling refers to proven toin whichrelapse rates and decrease stressful family one year. in adult populations with BD. FFT is a pattern reduce four or Adult bipolar episodes occur within interactions more Bipolar Disorder Research Ultraradian cycling occurs when someone cycles because you or mood states as teaching symptom If you do not qualify for pediatric research incorporates methods such are above 18, there based in psycho-education and through several your childrenwithin the same day. is recognition, communication Page 3 of 4 This pattern is more common family negotiating skills. Stanford Adult Bipolar are collaborating with Dr. Miklowitz in a research opportunity to participate in adult research in the Here, BD than adults. Disorders Clinic. This clinic is training, and in children and adolescents with at Stanford, we directed by Dr. Terence Ketter. For a FFTinformation works with families withresearch opportunities for developing BD. study designed to develop more model that regarding the clinic and children with and at risk Mood Swings, Episodes, and Cycling: What and perhaps evenmean the full development of BD by focusing on please contact goal is to prevent further mood episodes these terms prevent The Shelly Hill at 650-498-4801, email shill@stanford.edu, or go to educating the family as a whole. http://psychiatry.stanford.edu/research/bipolar.html.
  4. 4. Acknowledgments from the PBDP We would like to thank all of the families who make this research possible by volunteering for our studies. We would also like to thank our donors, without whom this research would not be possible. In addition to our anonymous family donors, we would like to recognize the following funding institutions and donors: The Hahn Family, Abbott, AstraZeneca, GlaxoSmithKline, the NIMH, the KTGF, NARSAD, and the Prechter Fund. STANFORD PEDIATRIC BIPOLAR DISORDERS PROGRAM Stanford University School of Medicine Department of Psychiatry and Behavioral Sciences 401 Quarry Rd Stanford, CA 94305-5719 Pediatric Bipolar Disorders Program Research Team Welcomes New WONDERFUL Families! SUBJECTS We continue to look for paid Street Address research subjects. Please City, State 00000 contact us via any of the following: Phone: 650-736-2688 Fax: 650-723-5531 Email: PBDPStanford@gmail.com OR meghowe@stanford.edu Any donations made to help fund our innovative research would be greatly appreciated. Please contact us if you would like to contribute.