Antidepressants make your anxious kid go BONKERS??? . . . a fine time for a mood stabilizer!!

My seven yr old son was diagnoised with Generalized Anxiety Disorder 1 1/2 yrs ago when it appeared he had a panic attack in school which led to two months of severe anxiety to the point where he could not leave the house. He was put on zoloft and went manic on that. We had never seen manic behavior in him before. He was then switched to 5mg of lexapro and 1 mg abilify. He pulled out of that spiral and went on for the next year with very few anxiety attacks. If we did encounter anxiety, it would go away the same day. This past summer we saw more incidents of the anxiety that cropped up at camp. Since we were seeing more anxiety this summer, his dr. bumped him to 10mg lexapro. Within two weeks I noticed more manic behavior. Manic behavior for my son is similiar to how an adhd child may act. Not super severe but not how he normally acts.
We backed him back down to the 5mg of lexapro. Two weeks ago he started school and it has been a disaster. There was discussion of a fire drill and now he is severely anxious about it. He cries and shakes for a few hours a day during school(wonderful teacher who has implemented some great strategies for him) and he worries about it at home.
Dr. felt we should up the abilify to 2 mg and either take him off the lexapro or up to 10mg once the abilify is upped for a few weeks. He feels our son could have Bipolar III due to his sensitivity to the anti depressants.

I agree with your doc.  The pattern of behavior that your child seems to be experiencing is that of a Bipolar III.  For those of you not familiar with that designation, it is a relatively new name for an old concept.  It has been known for many years that there is a small subset of patients who respond to antidepressants with significant manic or hypomanic symptoms.  Off these medications, there is no sign of mania . . . just depression.  Hence, the dilemma.  How do you treat these patients successfully and safely.  Well, you do just what your doc is doing.  You place the patient on a mood stabilizer (like Abilify) and titrate the antidepressant very carefully.  It could potentially indicate an underlying tendency toward Bipolar Disorder but the research on this is unclear, especially in a young child.  In any case, it would be important to consider him as having a Bipolar variant.  This would allow you to approach any medication issue in a way that would maximize his safety.  

Another way of treating depression in a patient with Bipolar III is with Lamictal.  But the issue here is not depression, but anxiety.  Plus, using Lamictal in patients below the age of 12 can be a bit tricky and must be done very, very carefully.

So, I am in complete agreement with your doc.  I would increase the dose of the Abilify to 2 mg and then titrate the Lexapro up.  Remember, you can also titrate up a bit slower by using the 5 mg tab and going up by 2.5 mg.  If hypomanic symptoms again present themselves, you can titrate the Abilify up further.

–Dan Hartman, MD

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