To the Editor: Although studies have suggested that topiramate is helpful in the treatment of bipolar disorder, no study, to our knowledge, has examined its usefulness in treating co-occurring bipolar disorder and disruptive behavior disorders in children and adolescents (1). The literature on co-occurring bipolar disorder and disruptive behavior disorders is rather limited.
In our case study presented here, we defined response with an endpoint Clinical Global Impression (CGI) improvement rating of 1 (“very much improved”) or 2 (“much improved”) for both mania and overall illness (including bipolar disorder and disruptive behavior disorders). Six (67%) out of nine of our hospitalized patients (ages 10 to 14) with bipolar disorder and disruptive behavior disorders responded to adjunctive topiramate with good tolerability. The mean dose was 78 mg/day (range=50–150 mg/day).
“Miss A” was a 14-year-old African American girl with conduct disorder, bipolar disorder, and reactive attachment disorder. She had no history of substance abuse. She was arrested for domestic violence and had a history of lying, running away, felony assault, stealing, carrying firearms, truancy, destroying property, and arson. Approximately 2 months prior to being detained in juvenile detention, the patient had discontinued her medications, which included haloperidol, aripiprazole, quetiapine, and glucophage because of weight gain. She subsequently lost approximately 40 pounds. While in juvenile detention, the patient continued to display prominent disruptive behaviors of arguing, physical fighting, destroying property, deceitfulness, oppositionality, and defiance. Besides mood lability, distractibility, and acts of self-harm, there was no evidence of depression or mania. The patient refused mood stabilizers and atypical antipsychotics because of the possibility of weight gain.
Doses of topiramate started at 25 mg once in the morning for 5 days and then increased to 25 mg twice daily. After 15 days taking 50 mg/day, the patient’s dose of topiramate was increased to 25 mg in the morning and 50 mg at bedtime. For the next 7 days, she was administered a dose of 75 mg/day and had no behavioral outbursts. She became more cooperative with staff and did not require restraints. The staff noted a significant improvement in her disruptive behaviors as well.
Although her mania was much improved, she continued to display some emotional lability and distractibility. Therefore, her disruptive behavior symptoms improved independently and more significantly than her mood-related symptoms. She had CGI improvement ratings of 2 for mania and 1 for overall illness. Despite her reports of poor concentration and transient hyperactivity, there was no evidence for these or other side effects, such as weight gain or difficulties with verbal communication.
As illustrated, topiramate monotherapy may be effective in treating disruptive behavior disorders, independent from its therapeutic effect for mania that is possibly related to its efficacy in decreasing impulsivity in binge eating disorder, borderline personality disorder, and pathological gambling disorder in adults. Because of a favorable side effect profile, including possible weight loss, medication compliance may be less of a problem. Further randomized controlled studies of adjunctive and monotherapy topiramate treatment are needed. Future studies should assess aggression as an outcome measure with the Overt Aggression Scale.
1.Barzman DH, DelBello MP, Kowatch RA, Warner J, Rofey D, Stanford K, Rappaport K, Daniels JP, Strakowski SM: Adjunctive topiramate in hospitalized pediatric patients with bipolar disorders. J Child Adolesc Psychopharmacol 2005; 15:931–937