Chat With Janet Wozniak, M.D.
The Balanced Mind Foundation Live Event Transcript

Did you miss our chat with Janet Wozniak, M.D? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Summer. Watch your email for more details. 
 

Biography 

Dr. Janet Wozniak is the Director of the Pediatric Bipolar Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital, and a member of The Balanced Mind Foundation's Professional Scientific Advisory Council. Dr. Wozniak's research focuses on the characteristics, longitudinal course and treatment of pediatric bipolar disorder.
                                    

Nanci
Dr. Wozniak, along with Mary Ann McDonnell, A.P.R.N, has recently published a new book on pediatric bipolar disorder, Is Your Child Bipolar? The Definitive Resource on How to Identify, Treat and Thrive with a Bipolar Child.  It is an excellent resource and is available in our online bookstore. Dr. Wozniak, would like to make any opening remarks? 

Janet Wozniak, MD   
Thank you for inviting me today. 

Nanci   
We're glad to have you and we have lots of questions coming in already.

Kim   
What are your feelings on stability for kids with BP--what's the best you have seen and how much break-through symptoms should we expect?

Janet Wozniak, MD   
Stability is difficult to achieve. There are no studies addressing this, most medication and treatment studies are too short term. In clinical practice, we are always rolling with the punches. Children are a moving target with changes occurring due to age, course of illness and stressors. Usually we must settle for a reduction of symptoms, a decrease in frequency and intensity. If we try to stamp out symptoms 100% we run into med side effects. 

This is a common question in follow up visits: Should we try for better control with unknown side effects or unknown new med effects? Or should we settle for what we have? The answer is guided by how impairing the current state of affairs is. If a child is really struggling, we try to address better mood control or treatment of co-morbid conditions.

bsm   
If a child is on the highest amount of Abilify or any other medication, and the mood is still not stabilized, would you add another type of medication or try something new altogether?

Janet Wozniak, MD   
Whether to switch or add may depend on how useful treatment #1 has been. If it has offered partial help, for say rages, but irritability or elation or depression remain, I might add. If the treatment has only helped a tiny amount or maybe not at all, we switch to a new one. 

Usually a clinician would do this with a cross taper, starting a new med in the setting of the old. Even if the intention is to stop the first med, there is an opportunity to see the result of the combined treatment. 

questions   
If you have one child diagnosed with bipolar disorder and another child diagnosed ADHD but had a bad response to both Strattera and Concerta what is the likelihood that the diagnosis might really be bipolar disorder?  If so, what medications would you recommend to start with? Would you go right to a mood stabilizer or would you use Tennex or another medication first to try another way to treat the ADHD?

Janet Wozniak, MD   
It is a question of which medication to start with and which to add. Currently research and treatment guidelines have been vague about this, leaving it up to clinician judgment as to which mood stabilizer to use. If the diagnosis is ADHD and there is a bad effect to an ADHD med then the general plan would be to try a different ADHD medication. There is an awful lot of inter-individual variation to treatment response and it’s worth trying a different medication.

If the bad outcome you allude to is a clear manic picture (medication induced bipolar disorder), then we still consider the diagnosis to be ADHD, but proceed cautiously.  Often the discussion with the parents would be to consider using an anti-manic treatment in order to make the ADHD treatment work without the manic effect. The anti-manic agent alone might but is unlikely to treat those ADHD symptoms you were after in the first place.

As this is a more complicated solution, we have to consider whether the ADHD treatment should be non-pharmacologic. Your idea of second line ADHD treatments, like Tenex, is also reasonable, as this might not make moodiness worse (although it could!) but unfortunately may not be a great ADHD treatment! 

JennyPenny   
My son 15, diagnosed EOBP approx 2 years ago, asked the other night if he could drink alcohol when he got to college. He said, "If I can't because of the meds, I will go off them so I can....I don't want to be the only one that can't have fun going out". How do you handle this type of challenge?

Janet Wozniak, MD   
I am rather strict, mean and nasty about alcohol because I have seen the terrible effects of alcoholism first hand in my sister and father. I tell teens (and younger kids too) that the reasons to abstain or limit alcohol are not because 'they will die' from an adverse reaction with meds (this just isn't true unless the amount consumed was massive, like with alcohol poisoning). The reason to stay clear is the meds won't work as well with alcohol clouding your brain, and you are on those meds for a reason. You might get depressed, fail classes, become irritable, etc. Also, you are receiving treatment for bipolar and/or ADHD and both are associated with higher rates of abuse and addiction.

No one sets out and say 'I hope I become an alcoholic.' Addictions and patterns of abuse sneak up on you, cloud your thinking, and misuse occurs as your brain becomes confused about what is best for you. Alcohol plays nasty tricks on logical thinking! Also, alcohol is fun and safe for some people, but if you already have a mood disorder or ADHD, the likelihood is that for you, it will turn from a short bit of fun to more depression and poor judgment.

Alcohol is a depressant; it makes depression worse or brings it on. And then it makes you think that you need the alcohol to feel better. If you can point to any blood relatives with alcoholism or drug problems, you should, so your young one understands that he/she is at even greater risk. Addictions run in our genes!  Well, it is a subject that makes me passionate, I have a 15 year old daughter and see kids again and again get stuck on alcohol and drugs.

Nanci   
Dr. Wozniak, we have several questions about co-morbidities or multiple diagnoses. In your book you talk about 'bipolar plus'. Could you share some of your perspectives on this issue?

Janet Wozniak, MD   
Bipolar disorder rarely occurs alone. The most 'plus' condition is ADHD and of course if you have mania, then depression is also common. Both ADHD and depression can be misdiagnosed as either ‘yes bipolar’ or ‘no bipolar’, because of overlapping symptoms. But it is important to note that treating the bipolar may leave a child with left over issues of untreated depression and ADHD.

Other common (50%) disorders are the anxiety disorders. Some parents note that the emotional outbursts seen in bipolar disorder start in scenarios which cause anxiety (public speaking, meeting new people, something going wrong, separations, etc.).

Another important plus condition is autism spectrum. Bipolar children often have poor social skills, can be bossy, difficult or have poor reciprocal play. But it is part of a good evaluation to also consider the possibility of aspergers/pdd/ autism spectrum as a complicating 'plus' condition as well. (Hey, thanks for reading my book!).  
genejeanie   
Regarding weight gain with the meds, do you have any specific suggestions for controlling this?

Janet Wozniak, MD   
As much as possible, we use medications that have less weight gain associated with them. Among the atypical anti-psychotics this usually means Abilify. However, children may not respond to this or have weight gain with this (even if the studies say it is minimal, for some children the weight just comes on). Sometimes the weight gain is early and fast in treatment. If the symptoms are severe, we may continue, but if there is any option to stop the treatment, this is the best way to reverse the trend.

Finally, if we must use a medication that causes weight gain, we may combine it with a different med that could be useful (or at least do no harm) and also lead to weight loss. Sometimes this can happen with stimulant meds, used to treat co-occurring ADHD.

Another medication is topiramate (Topomax). Not a great mood stabilizer, but maybe a bit helpful. Not a great anti-anxiety agent, but maybe helps a bit. BUT its side effect is appetite suppression and weight loss, so a low dose addition of 100-200mg may have few annoying side effects (of sedation or cognitive clouding) and lead to weight loss or lack of weight gain.

Another is Naltrexone, used to quell drug/alcohol cravings. Also leads to weight loss and decd appetite. Another is Metformin, used for adult onset diabetes. There is one study of Metformin plus atypicals, a few of Topomax and none to date of Naltrexone. All short term. Weight gain is a problem in America in general, and a major problem for our children using psychotropics.

Charlie   
What is your opinion on brain scan technology as a diagnostic tool to help determine what is really going on from at least a biological perspective?

Janet Wozniak, MD   
One mother begged me for a brain scan. She wanted to carry around a picture to 'prove' to others why her child was so problemed. The brain scans generally look totally normal, even though we know the problem with bipolar disorder is 'in the brain.' That is because our technology can hardly capture the amazing complexity of the brain. The published studies you see in medical journals are group effects. Even in those studies no one brain scan could be determined as bipolar or not.

However, the brain scan studies increasingly are zeroing in on the limbic system as the site of abnormal structure and functioning. This increases our knowledge of what is actually going wrong when people have mania or depression. BUT we are still a far way away from really understanding it or intervening with treatments specific enough.

Any program that tells you that a brain scan can aid in diagnosis is lying. Maybe in 10 years, we will have some ability to use brain scans to aid diagnosis and treatment, but likely in combination with clinical judgment and other tests, like genetics or neuropsych testing. 

Nanci   
Let's talk a little about parenting issues.

bsm   
With the increased frequency of divorce in families with special needs children, are there any books or other types of support to help with co-parenting issues?

Janet Wozniak, MD   
I am not certain about books, but the families in which I have seen the best success use a mental health professional as a consultant to rough times. Even if divorced, 2 parents can meet with a counselor or therapist to discuss the best course of action for a special needs child. The discussions can range around using medications or not, the elements of an education plan, when and how to issue consequences. When and how to get homework and projects done. Where to send to camp and how to pay. When to hire tutors or in home behavioral support (trained nannies). Whether to allow sleepovers!

There are so many things to negotiate, and all more complicated with special needs kids. If you are not divorced but have a special needs child, recognize what a major stress this is going to exert on your relationship and take measures to be proactive. Divorce is common, and may be more common when children have problems. Recognize that as a risk factor and take time to work with rather than against your spouse.

JTmom
Several medications run the risk of tardive dykinesia.  Can you comment on this side effect?

Janet Wozniak, MD   
When I prescribe Abilify and the other atypical antipsychotics I warn about obesity/potential for diabetes as being a common outcome (but luckily reversible and easy enough to monitor). BUT I also warn about the rare risk of Tardive Dykinesia (TD). We in psychiatry know a lot about because the old time antipsychotics (thorazine, mellaril, haldol, which by the way were miracles to have and have saved many lives) these meds carry a high risk of TD, as many as 40% of those who used them over time developed TD.

TD is not dangerous, doesn't hurt, doesn't shorten your life. But it can be odd looking, even 'disfiguring.' TD is an involuntary movement disorder that involves the muscles most commonly around the lips, nose and mouth. It can look like lip smacking, lip licking or tongue movements. It can be mild, like a little habit, or odd with grimacing and distracting movements. Once it gets set in motion, it might not go away, even if you stop the medication.

While it was common with the old time meds, this new 'second generation' of anti-psychotics has very, very low rate of TD. But what is this rate? Because length of treatment increases the risk (i.e. the med for 10 years carries more risk that 5 years), we do not fully know how many will develop this over time. Higher dose is also associated with it occurring, a good reason to keep doses as low as possible (but enough to do the treatment job, of course).

Some quote the rate as 1%, some as high as 3-5%, others think it just does not occur. Because TD can look like motor tics (very common, 1% risk, higher in psychiatric populations), sometimes we don't know if the movement is TD or a tic. Some people have also been on the old time agents, so the TD is from that.
Tardive in part means that this is a side effect that occurs late in treatment, not in the first weeks or months. So I often tell parents, let's see if the med is useful and how useful. If it provides dramatic relief, then the risk of TD seems like a small price to pay. If the improvement is not much, then why risk anything? Stop the med and try something else.

Nanci   
We are almost out of time. Dr. Wozniak would you like to talk briefly about your new book (which is available in our bookstore online)?

Janet Wozniak, MD   
Thanks, Nanci. I call it 'cast of thousands' because of all the help that has gone into it, mostly the stories and wisdom of families we have known. My co-author is Mary Ann McDonnell, active in parent advocacy and expert nurse clinician. We also have the wonderful voice of Judy Brenneman, mother and writer extraordinaire. 
I hope it can 'clone' us and bring the words we usually deliver to families one at a time to many families at a time. I think it provides information, support and suggestions that parents of bipolar children will find helpful. Please send me your feedback! I already wish we included a chapter for children to read when they find the book on their mom's bedside table....

Nanci 
I have to say that it really connected with me when I read it so I think you succeeded in the cloning! I felt that you truly understood what parents go through and the questions we struggle with.

Janet Wozniak, MD 
I enjoyed this chat! Invite me again!

Nanci 
We will! Do you have time for one more question?

Janet Wozniak, MD 
yes

Nanci 
We haven't talked about complementary treatments at all; this next question is about the effect of diet. Perhaps you could also comment briefly on some of the other complementary treatments such as vitamin/mineral supplements, Omega 3's or light therapy.

Janet Wozniak, MD 
No links yet, but many parents have shared with me their stories of stumbling on allergies which helped their children, everything from red dye to potatoes! I do not routinely recommend diet restrictions, because for many it is likely barking up the wrong tree.

I do like omega-3s and have been very influenced by epidemiologic data demonstrating lower rates of mood disorders in countries that consume a lot of omega-3s and the fact that our brain cells 'prefer' omega 3s in the cell membranes,, but will use the less flexible omegas if we don't take in enough of the 3s.  The research leads me to believe that omega-3s are a useful supplement to conventional treatments. It will be the rare individual who has a mood problem completely cleared up by these supplements. But maybe it offers some extra support.

Janet Wozniak, MD 
I am about to work on a chapter on alternative treatments for a special edition of the Psychiatric Clinics of North America. I’ll have more to say then.

Nanci 
Dr. Wozniak, thank you so much for your time and for sharing such comprehensive and detailed information with our members. We very much appreciate your contributions.

Janet Wozniak, MD 
My heart goes out to anyone who frequents your website. I know your life is full of struggle.