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 Scientific Advisory Council. Dr. Wozniak's research focuses on the characteristics, longitudinal course and treatment of pediatric bipolar disorder.     

sagabeanie    
How are bipolar disorder and anxiety issues connected? Which comes, first the chick or the egg?

Janet Wozniak MD    
There is a strong bidirectional overlap between anxiety disorders and bipolar disorder. That is, in a sample of bipolar youth, at least half have significant anxiety of various forms, and in anxious children we see higher than expected rates of bipolar disorder; so we know that they 'travel together' but we do not understand the nature of the relationship. It may be likely the genes that are associated with bipolar also produce changes that bring anxiety. 

Sometimes the child has anxiety first, sometimes mood first, and sometimes both come on together. A lot of kids start off with significant separation anxiety along with the moodiness of preschool age and then go on to have full-blown mania depression. We do not know the 'chicken and egg' part, but many parents feel that if their child’s anxiety is treated, the mood reactions would diminish. The problem with this approach is that the best medications for anxiety are the SSRI antidepressants, and these will make mania much, much worse!  

So if both co-occur, our standard treatment approach is to use a mood stabilizer, anti-manic treatment then sequence in an anti-anxiety treatment. We tend to use benzodiazepines, BuSpar, or Neurontin for the anxiety, as these won't make mania worse.

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?