title: Guidelines for treatment-resistant mania in children with bipolar disorder.
abstract: OBJECTIVE
  To implement a treatment algorithm to operationalize treatment-resistance and improve patient outcomes in youth with pediatric bipolar disorder (PBD). The term "treatment resistance" was operationally defined as significant persistent symptoms following the application of a treatment algorithm.
  
  
  METHODS
  Youth (6-17 years of age, n=120) with treatment-refractory bipolar I or II disorder, currently in a manic or mixed episode, were treated in accordance with the following 3 step algorithm: (1) removal of destabilizing agents (antidepressants, gamma aminobutyric acid [GABA]-agonists, and stimulants), (2) optimization of antimanic agents, and (3) use of a limited number (E 2) of mood stabilizers. The primary efficacy measure was change in scores on the Young Mania Rating Scale (YMRS) over the 6-month treatment course. Response was defined as repeated YMRS scores E 12.
  
  
  RESULTS
  The sample was dichotomized into responders and non-responders. Both responders and non-responders improved significantly, with responders improving by a greater margin (d=3.2). At the end of 6 months, 75.8% of subjects demonstrated a significant and stable decrease in manic symptoms consistent with symptomatic remission (YMRS E 12). None of the subjects withdrew from the clinical process due to adverse events.
  
  
  CONCLUSIONS
  The application of this proposed treatment algorithm allows for more accurate identification of true treatment resistance and can significantly reduce manic symptoms in patients previously described as having treatment-refractory bipolar disorder.
authors.affiliation: Department of Psychiatry, University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS 67214, USA. Rscheffer@kumc.edu
authors.forename: Russell E
authors.initials: RE
authors.lastname: Scheffer
authors.forename: Aveekshit
authors.initials: A
authors.lastname: Tripathi
authors.forename: Forest G
authors.initials: FG
authors.lastname: Kirkpatrick
authors.forename: Tara
authors.initials: T
authors.lastname: Schultz
mesh_terms: D000293:Adolescent; D000342:Affective Symptoms / Q000188:drug therapy*; D018692:Antimanic Agents / Q000008:administration & dosage / Q000493:pharmacokinetics; D001714:Bipolar Disorder / Q000175:diagnosis / Q000188:drug therapy* / Q000523:psychology; D002648:Child; D016903:Drug Monitoring; D004351:Drug Resistance; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D054539:Medication Therapy Management; D010045:Outpatients; D017410:Practice Guidelines as Topic; D011569:Psychiatric Status Rating Scales; D012074:Remission Induction; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D018692:Antimanic Agents