How is academic performance affected by mood stabilizing medication on school children - Research Paper Example

? RUNNING HEADING: How is academic performance affected by mood stabilizing medication on school children? School How is academic performance affected by mood stabilizing medication on school children? Introduction Mood stabilizing agents or ‘mood stabilizers’ or ‘thymoleptics’ are a group of drugs that have an antidepressant and an antimaniac effect, and are used in the treatment of acute mania, major depression and bipolar disorders. Some of the commonly used mood stabilizers include lithium, sodium valproate and carbamazepine. They belong to the group’s lithium, anticonvulsants, antidepressants and antipsychotics. Mood stabilizers are used in the treatment of a number of psychiatric disorders including recurrent conditions and acute disorders, and are more often known for their antimaniac effect rather than antidepressant effect. The range of disorders that mood stabilizers can be used to treat include bipolar disorder 1, bipolar disorder 2, cyclothymia, schizoaffective disorder, intermittent explosive disorder, any medical condition in which mania is a symptom (such as stroke, cancer, temporal lobe syndrome), recurrent depression as a prophylaxis, etc (Jacobson, 2001). Bipolar disorder is often seen in children suffering from ADHD, along with several other co-morbid conditions. Mood stabilizers are used to treat several disorders in which aggression, agitation and impulsivity are symptoms. Aggressive behavior is common in several other disorders such as conduct disorders, mood disorders, psychotic disorders, mental retardation, deliriums and dementia. Along with agitation, the child may also have accompanying psychosis, mood changes, anxiety, and insomnia. However, mood stabilizers have a range of positive and negative effects, and a lot of consideration is given to the effect of the drug over the academic performance of the child (Kane, 2004). In this paper, 10 handpicked studies from various databases including Cochrane, Pubmed, BMJ and Google Scholar were being analyzed for findings regarding the effect of mood stabilizers on the academic performance of school children. Taken into consideration were the impact of the disease itself, and the course of the disease with respect to the academic performance when treated or untreated with mood stabilizers. Though there are a number of effects of mood stabilizers on the academic performance, they are vital for effective management of the disease, and the treatment of such children has to be carefully evaluated. Body The first paper that is being reviewed is by Smarty and Findling 2007, in which they conducted a review of the psychopharmacology of a pediatric bipolar disorder. According to the researchers, the disorder itself is debilitating to the child and may have long-term and short-term implications in the school, home or in social settings, and can also affect the academic performance of the child. Besides several other disorders such as ADHD, OPP, substance abuse and conduct disorders can affect Bipolar disorder, which in turn can affect the effectiveness of the treatment of bipolar disorder. This is an important point to be taken into consideration whilst assessing the overall effectiveness of the drugs belonging to the mood stabilizers group. The authors conducted a Medline search over the articles published between 1995 and 2006 for treatment practices for bipolar disorders. The study found that lithium, anticonvulsants and antipsychotics were equally beneficial in the treatment of the mania phase bipolar disorders in youth, though data was lacking with the depressive phase of the disorder. Data even suggested that combination therapy was better than monotherapy especially in the maniac or mixed phases. Besides, many studies did not present much information on the treatment of cormobidities and relapses with the disease. The study in general suggested treatment of cormobidities and relapses using evidence-based guidelines, as these could affect the academic performance of the child. The second study by Lopez-Jaramillo et al (2010) attempted to study the impact of lithium treatment in students with bipolar 1 disorder, especially with cognitive functioning, as it has been found that lithium can impair with cognitive functioning of the child. A number of neuropsychological tests such as memory tests, attention tests and execution of function were done on 3 groups of 20 each, the first receive no treatment for bipolar disorder, the second group received treatment with lithium carbonate, and the third group was healthy and normal subjects. By far with normal children, children with bipolar disorder had significant performance deficit with visual verbal memory and episodic verbal memory status. There was not much of difference between the performance levels of the group that did not receive any medication and the group that received medication with lithium monotherapy. Hence, as per the conclusion of the study, the deficit in verbal performance has been attributed from the condition itself and not the effect of lithium. However, the study did not analyze the effect of combination drug therapy, and hence in question was the study by Smarty and Findling. The third study was a Greek study by Tsaltas and Kontis 2009 where they reviewed the effect of lithium on the cognitive functions. Recent data suggests that lithium may have a cognitive enhancing effect or cognitive neurotrophic effect, which goes against the older belief that lithium, resulted in cognitive blurring and memory deficits. Tsaltas et al drew 2 conclusions from the data that they had gathered. Firstly, lithium did not have a damaging effect on the cognitive function but instead had an enhancing effect. Secondly, they found that several conditions or factors tend to affect the treatment with lithium over the cognitive functioning. These factors included biological factors that deteriorated the CNS functions and includes stress, psychiatric disorders and neurodegenerative functions. However, it is not clearly understood wherever the neurocognitive deficit observed in patients treated for bipolar disorder are due to the disease itself or from the medications. 26 patients being treated for bipolar disorder and 17 healthy patients were studied by Pavuluri, West and Hill (2008) to assess their cognitive functions at the time of treatment and 3 years later. A number of neurocognitive tests were conducted including tests to study attention, executive functioning, verbal memory, working memory, visual memory, etc. Between the baseline and follow-up there was a deficit noticed in patients with bipolar disorder with treatment. Compared to the healthy patients, the patient with bipolar disorder had a deficit. However, following the 3 year follow-up with treatment there were improvements with the executive functioning and verbal memory, though it was found to be less in bipolar disorder. Hence, although there is improvement, the patient would be accepted to be affected with a cognitive dysfunction for the rest of life. The dysfunction may be an effect of the medication or the condition. Henin, Mick, Fried et al (2009) attempted assess the effect of mood stabilizers on the neuropsychological functioning in children and youth with bipolar disorder. Children between the ages of 6 and 17 years took part in this study that was diagnosed by the DSM-IV criteria to be affected with bipolar disorder. During the study, several tools such as diagnostic interviews, and neuropsychological measures were being used to assess the neuropsychological functioning between children who received medications and those who did not. With regards to memory processing speed and working memory, children who were not treated with mood stabilizers faired better than untreated children. The finding of this study opposed the finding of earlier studies including Taslatas et al and Lopez-Jaramillo et al. However, an important finding in this study was that the neuropsychological adverse effects were not significant with antipsychotics. Hence, as per Mick et al, it is very important to carefully select and choose the correct mood stabilizer for treating a child with bipolar disorder, as mood stabilizers are known to cause neuropsychological impairment. Lamotrigine (LTG) is an anticonvulsant drug that can be used in a range of convulsive disorders, and is often considered as a safer alternative to carbamazepine and valproic acid for the treatment of resistant bipolar disorder (especially type 2). However, nothing much is known about the effect on the cognitive function and in this study performed by Daban, Martinez-Aran and Torrent, et al 2006, 33 bipolar patients with type 1 and type 2 were being studied for range cognitive functions including verbal memory, attention and executive functions. They were divided into 2 groups – Group 1 received LTG whereas group 2 received carbamazepine or valproate. In patients treated with LTG, the depressive symptoms were more, though the maniac episodes were greatly controlled, and the number of hospitalizations was less. Their cognitive function with relation to verbal fluency tasks was much better than Group 2, and there was a slightly better result with the verbal memory test done through the California Verbal Learning test. In this way, the safety profile of LTG was much better with carbamazepine or valproate. Hence, it strongly supported the previous study Henin et al, that careful selection of the appropriate mood stabilizer was essential at ensuring that the academic performance is optimum. However, it would be wise to study if the effects over cognitive function especially with regards to short term spatial memory storage, sensitivity to negative feedback or reward processing that may occur during the illness due to the illness itself or from mood-stabilizing agents used to treat the illness. Roiser, Cannon and Gandhi (2009) conducted a study to determine if the neuropsychological effects that were reported in bipolar disorders were due to the disorder itself or from the medications. The study examined patients with bipolar disorder who did not receive medications and were currently depressed through various cognitive assessments. 49 patients that fulfilled the DSM-IV protocol for bipolar disorder were included into the study who did not receive any medication and they were compared with 55 control subjects who were healthy. Two types of cognitive tasks were performed, hot which included emotionally-dependent tasks, and cold which were emotionally-independent tasks, and were assessed using the Cambridge Neuropsychological Test Automated Battery. Both the groups had similar demographics and intelligence levels. The un-medicated group should deficits with relation to the hot tests where their cognitive processing was found to be impaired. Most of the cold tests were similar between the un-medicated and the controlled group. Several effects with relation to reward processing, sensitivity to negative feedback and short-term spatial memory storage were affected seemingly from the disease itself, rather than by the medication. The findings of this study were similar to the Lopez-Jaramillo, were deficits were attributed to memory tests, attention tests and execution of function, from the condition itself and not the medications. Ryan, Batara and Perel (2010) conducted a study to determine the efficacy of mood stabilizers on children and youngsters. The aim of this study was to develop guidelines for the use of these agents in children. The study conducted a review of literature from various databases including Medline, PsychInfo, and CRISP and searched for cases in which children were given mood-stabilizers. Across all databases, it was found that in general with children, lithium, carbamazepine, and valproate are effective as mood-stabilizing agents and data was not available that the other agents were as effective as these three. However, a rational basis for choosing the agents needs to be found and hence the findings of this study were similar to that of Henin et al. The study found that carbamazepine and valproate were not known to cause any kind of deficit with performance of the child at school. Lithium on the other hand may provoke substance-abuse behavior by the school students, and acts more slowly than valproate. Lithium effect in children was found to be similar to that of adults, though lithium had a negative effect over growth and development. However, the relapse rate of the disorder was found to be higher in those who discontinued lithium. Other studies proved that lithium is very useful in children with aggressive behavior. Asenapine is an atypical antipsychotic that has been approved for treatment of bipolar disorder either alone or in combination with other medications including lithium or valproate. The study was performed in monkey, where there were two groups. The monkeys were treated with PCP so as to deteriorate their cognitive function. One group was administered Asenapine and the other group was given saline. Following administration of Asenapine, there was improvement with dopamine and serotonin turnover and there was improvement with the executive functioning following long-term administration. Asenapine significantly help to improve the cognitive dysfunction and could be used in patients with bipolar disorder and schizophrenia. Asenapine administration is needed over a long period of time in order to study its profound effect. This study was performed by Elsworth, Groman, Jentsch (2012) and could be a potential solution to handling cognitive dysfunctions in children with bipolar disorder. This study gives a huge ray of hope for children suffering from bipolar disorder who have cognitive dysfunction. Even though it may be difficult to assess the exact cause for the cognitive dysfunction, atypical antipsychotics have the potential to improve this dysfunction. The last study of this paper, reemphasis on the points discussed by Ellsworth et al regarding the positive effect of atypical (newer) antipsychotics on the cognitive function for treatment in children with bipolar disorder. The study performed by Macqueen and Young (2003) noted that in bipolar disorder recollection memory, visual processing visual memory, and attention are affected, and even with administration of medication such as valproate, lithium or carbamazepine, there would be varying degrees of cognitive dysfunction noted in children. However, treatment with atypical antipsychotics was associated with an improvement in the cognitive function and hence the child’s performance at school improved. The data available for schizophrenia suggest immense beneficial effect over cognitive function, but not much data is available for bipolar disorder. However, preliminary studies suggest that the effect could be similar. Though, it has been highly recommended that further studies are required to reassess the ability of atypical antipsychotics to improve, delay, and decrease the cognitive dysfunction that is noted in bipolar disorder. Conclusion From the studies conducted, it is found that lithium, valproate and carbamazepine, are equally beneficial in the treatment of bipolar disorder. Combined drug therapy for the condition is always better compared to monotherapy, and besides it is also important to address the cormobidities and prevent relapse using proper guidelines so as to prevent cognitive deterioration that ultimately leads to poor academic performance. The verbal memory deficits that occur in children treated with bipolar disorder are attributed to the condition itself and not medications. There might not be much evidence that suggests that lithium has a cognitive enhancing effect though biological factors like stress are likely to disrupt the cognitive functions. Even though the patient is being treated for bipolar disorder, the neurocognitive deficit would tend to worsen with time, and this may not be due to the medication per se but may be due to the condition itself. Following few years treatment with mood stabilizers, there would be an improvement in cognitive functioning, but at a level below that of normal children. A few studies go on to show that mood stabilizers have a negative effect on cognitive function compared to untreated patients. With groups receiving no treatment, the deficits were found to exist with hot tests where cognitive functioning was tested and was based on emotions. Other studies tried to prove the point that mood stabilizers had to be carefully be selected and the choice be made based on the patient’s condition and requirements. Lamtrigine is a safer alternative to carbamazepine, lithium or sodium valproate as it does not disrupt the cognitive functioning. However, one of the best alternatives would be the newer atypical antipsychotic drugs which are known to improve the cognitive functioning and result in improvement in the cognitive performance of the child at school. However, further studies are needed in order to determine the precise effect of the drug on the performance of the child at school. List of Conclusions Annotated Bibliography Daban, C., Martinez-Aran, A., Torrent, C. (2006). ‘Cognitive functioning in bipolar patients receiving lamotrigine: preliminary results.’ J Clin Psychopharmacol. 26(2):178-81. http://www.ncbi.nlm.nih.gov/pubmed?term=valproate%20impact%20cognitive%20functioning%20bipolar The Study provides a positive benefit of an anticonvulsant over conventional drugs used for mood stabilization. The patient’s performance at the verbal memory tests are much better compared to other current mood stabilizers. Elsworth, J. D., Groman, S. M., Jentsch, J. D. Et al (2012). ‘Asenapine effects on cognitive and monoamine dysfunction elicited by subchronic phencyclidine administration.’ Neuropharmacology. 62(3):1442-52. http://www.ncbi.nlm.nih.gov/pubmed/21875607 The paper demonstrates the usefulness of newer antipsychotics in treating mental conditions with improving cognitive functions in animal. Further studies are needed in man. Henin, A., Mick, E., Biederman, J. Et al (2009). ‘Is psychopharmacologic treatment associated with neuropsychological deficits in bipolar youth?’ J Clin Psychiatry;70(8):1178-85. http://www.ncbi.nlm.nih.gov/pubmed/19573494 The authors suggests that certain cognitive dysfunctions may be noted with certain mood stabilizers and hence there is the need to carefully select the right drug based on patient’s need and condition. Jacobson, J. L. (2001). Jacobson: Psychiatric Secrets, 2nd ed, Philadelphia: Hanley & Belfus. This is a book that discusses the topic on mood stabilizers, indications, drug interactions, doses, classifications, and other details. It is important as an introduction to mood stabilizers and its impact in treating child psychiatric disorders. Kane, A. (2004). ADHD Child Behavior Treatment and Medication, Retrieved March 1, 2012, from Web. http://anthony-kane-md.wrytestuff.com/swa4334.htm The author discusses about mood stabilizers which is potentially used in a number of conditions such as bipolar disorders, ADHD, conduct disorders, OPP, etc, and can be used to relieve several symptoms. Lopez-Jaramillo, C., Lopera-Vasquez, J., Ospina-Duque, J. Et al (20100. ‘Lithium treatment effects on the neuropsychological functioning of patients with bipolar I disorder.’ J Clin Psychiatry. 71(8):1055-60. http://www.ncbi.nlm.nih.gov/pubmed/20361895 The authors tries to prove that lithium has no negative effect on the neuropsychological functioning and the same is attributed to the condition itself. Further the author also mentions the importance of combination therapy drug for the treatment of bipolar disorder. Macqueen, G., & Young, T. (2003). ‘Cognitive effects of atypical antipsychotics: focus on bipolar spectrum disorders.’ Bipolar Disord. 5 Suppl 2:53-61. http://www.ncbi.nlm.nih.gov/pubmed/14700013 The study provides an insight on the beneficial aspects of a newer group of drugs that are useful in the treatment of bipolar disorders and could potentially improve the cognitive function and help children. Roiser, J. P., Cannon, D.M., Gandhi, S. K. Et al (2009). ‘Hot and cold cognition in unmedicated depressed subjects with bipolar disorder.’ Bipolar Disord. 11(2):178-89. http://www.ncbi.nlm.nih.gov/pubmed/19267700 The study emphasizes on the various deficits with cognition occurring due to the condition and not from medications given for treatment. Most of the emotionally-dependent functions were poor in the un-medicated patients, and the emotionally-independent functions were normal. Ryan, N., Bhatara, V., & Perel, J. (2010). ‘Mood Stabilizers in Children and Adolescents.’ Journal of the American Academy of Child & Adolescent Psychiatry, 38(5): 529-536. http://www.thebalancedmind.org/learn/library/mood-stabilizers-in-children-and-adolescents The study goes on to demonstrate that current data may support certain efficacy with relation to lithium, carbamazepine and valproate, though currently data on other mood stabilizers is not available. Smarty, S., & Findling, R.L. (2007). ‘Psychopharmacology of pediatric bipolar disorder: a review.’ Psychopharmacology (Berl), 191(1): 39-54. http://www.ncbi.nlm.nih.gov/pubmed/17093980 The author Smarty and Findling review the treatment of bipolar disorder in children and emphasize on the need for evidence-based protocols for the treatment of the same. They also mention that the data currently available is limited and hence further studies are needed in the area. Tsaltas, E., & Kontis, D. (2009). ‘[A review of the effects of lithium on cognitive functions: Effects on the neuropsychiatrically challenged CNS].’ Psychiatrike, 20(2):132-44. http://www.ncbi.nlm.nih.gov/pubmed/22218130 The author suggests that lithium in fact boost the cognitive function, though this cannot be substantiated from other evidences. Further the author mentions that cognitive dysfunction that is seen in association with drug administration may be due to biological factors like trauma or stress. West, A., Hill, S. K., Jindal, K. Et al (2009). ‘Neurocognitive Function in Pediatric Bipolar Disorder: 3-Year Follow-up Shows Cognitive Development Lagging Behind Healthy Youths.’ Journal of the American Academy of Child and Adolescent Psychiatry, 48(3). http://www.mdconsult.com/das/article/body/321335701-4/jorg=journal&source=MI&sp=21742336&sid=1276110406/N/687912/1.html?issn=0890-8567 The author emphasis that children with bipolar disorder treated with mood stabilizers have a poorer cognitive function than normal children, and this deficit is attributed due to the condition. Read More