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Long-acting injectables (LAIs) represent a valuable therapeutic approach for individuals with Bipolar I disorder, offering sustained delivery of antipsychotic medication to maintain consistent blood levels and promote stability in adolescents. In contrast to oral medications, LAIs necessitate less frequent administration, thereby minimizing daily disruptions and mitigating the prominence of the illness in daily life. This alternative treatment modality allows patients to manage their condition effectively. Bipolar disorder (BD) (formerly called manic-depressive illness or manic depression) is a mental illness that causes people to experience noticeable, sometimes extreme, changes in mood and behavior. It is a common misperception that children cannot have BD. Although most people are diagnosed with BD in adolescence or adulthood, the symptoms can appear earlier in childhood. This study is aimed at observing the effect of long-acting injectables (LAIs) on reducing the symptoms associated with BD. Functional recovery is important for patients as it enables a return to their regular lives. Consequently, it should be a pivotal consideration for clinicians and a principal objective in the maintenance treatment of BD. Factors contributing to nonadherence to medication in the adolescent population include adverse medication effects, intricate medication regimens, unfavorable patient attitudes toward medication, poor insight, rapid-cycling BD, comorbid substance misuse, and a deficient therapeutic alliance and peer pressure. BD is markedly linked to heightened risks of relapse, recurrence, hospitalization, and suicide attempts. It also diminishes the probability of remission and recovery and contributes to escalated overall treatment costs. In clinical practice, injectable medications are often reserved for patients exhibiting severe illness, multiple hospitalizations, or medication trials, as well as those at an increased risk of nonadherence, relapse, and poorer outcomes. Long-acting injectable (LAI) antipsychotics play a pivotal role in ensuring medication adherence, thereby contributing to more favorable outcomes. Our study focused on four adolescent patients presenting similar symptoms of BD who underwent treatment with a LAI antipsychotic. Utilizing the Young Mania Rating Scale, assessments were conducted at the initial presentation, before administering the LAI, and subsequently at 2-, 4-, 6-, and 12-month post-administration. The observed differences in the scales indicated positive responses to the treatment. Patient 1, a 14-year-old adolescent male, presents symptoms of impulsivity and grandiosity. He exhibits anxiety regarding his medications and displays defiance when prompted to take them. The patient's noncompliance with oral medications results in extended periods without their use. He demonstrated remarkable intellect and deep knowledge. However, his ability to learn and comprehend was significantly impeded in the absence of his medication. His initial score of 30 on the Young Mania Rating Scale underscored pronounced elevations in mood, fragmented thought content, language, and sleep patterns. Following a series of LAI antipsychotic treatments, the patient's Young Mania Rating Scale exhibited a decline to 24 at the 2-month follow-up, further decreasing to 20 at 4 months, 14 at 6 months, and ultimately reaching 3 within a year, with a score of 0 in most domains. Subsequent follow-up visits indicated a stable Young Mania Rating Scale score within this range. Patient 2, a 17-year-old adolescent male, presents with BD, alongside comorbid diagnoses of obsessive–compulsive disorder (OCD) and anxiety disorder. The patient frequently experienced symptoms such as racing thoughts and reduced need for sleep over 5 days while feeling well rested and frequent panic attacks. Initial assessment using the Young Mania Rating Scale yielded a score of 39, with notably elevated ratings in sexual interest, mood elevation, irritability, disrupted thought patterns, and sleep disturbances. Subsequent treatment involving LAI antipsychotic medication led to a progressive reduction in the Young Mania Rating Scale score: 31 at the 2-month mark, 23 at 4 months, and 12 at 6 months. Ultimately, the score diminished to 0 within 1 year and has since remained stable. Patient 3, a 16-year-old male adolescent, presented with symptoms including decreased need for sleep, impulsive behavior, and self-harm. He has a history of noncompliance with oral medications prescribed for ADHD due to impulsivity and rapid mood changes. Initial assessment using the Young Mania Rating Scale indicated a score of 42, with high scores in thought content, aggressive/disruptive behavior, elevated mood, lack of sleep, and impulsivity. The patient also expressed feelings of guilt and being lost. Following a single round of LAI antipsychotic treatment, Patient 3's Young Mania Rating Score decreased to 31, particularly in the areas of thought content and elevated mood. Although the duration of treatment has been only 1 month, there are promising indications of improvement with enhanced medication compliance and psychotherapy. Patient 4, a late-teen male, was admitted to the crisis stabilization unit after manifesting a pattern of prolonged wakefulness for five consecutive days, engaging in smoking, and displaying defiant behavior. Despite previously maintaining a functional status, he developed impulsivity, as evidenced by reckless online shopping and interpersonal disputes, which resulted in his suspension from school. After a diagnosis of bipolar mania without psychosis, he was initially prescribed olanzapine and lithium, yet failed to comply with the medication regimen. Following this, he was transitioned to oral aripiprazole, initially demonstrating improvement, but subsequently ceased usage and experienced another manic episode involving drug use. His condition deteriorated, leading to successive manic episodes and drug use. Upon being switched to a LAI antipsychotic, a noticeable amelioration in his symptoms was observed. Consistent treatment and weekly psychotherapy contributed to a reduction in his Young Mania Rating Scale score from 45 to 36 in 2 months to 28 in 4 months to 18 within 6 months and eventually to zero within 1 year. Additionally, he adopted a healthier overall lifestyle. The data presented in Table 1 outlines the medications administered to patients before the initiation of a LAI to address noncompliance. These patients initially demonstrated improvement with oral antipsychotic treatment; however, subsequent noncompliance led to manic episodes (Figures 1 and 2). The case series presents four adolescent patients who exhibited symptoms of mania and demonstrated noncompliance with oral medication. These patients were effectively treated with a long-acting antipsychotic injectable. The decision to use LAIs was influenced by insurance coverage and drug availability. Three patients exhibited significant improvement over a year, while the fourth patient is currently undergoing follow-up at 4-, 6-, and 12-month intervals. Notably, this patient also demonstrated significant improvement within 2 months, with a reduction in their score from 42 to 31. Importantly, all four patients tolerated the injectable treatment well without any adverse events except for pain at the injection site. Furthermore, no significant changes in vital signs were observed in any of the patients either before or after the administration of the long-acting antipsychotic injectable. Research on medication adherence rates among adolescents with BD is limited. Existing studies suggest that adolescents adhere less to psychotropic medications compared to younger children and adults. For example, DelBello et al.1 found that 65% of adolescents with BP were nonadherent to their medication 1 year after being discharged from the hospital following an acute mood episode, based on self and parent reports. Overlapping symptoms are observed in adolescents with ADHD and BD, such as impulsivity, hyperactivity, and mood swings, which are clinically significant. However, these conditions exhibit clear differences in the manifestation and necessitate distinct treatment approaches.2 The differences that clinicians seek while formulating diagnoses are that ADHD symptoms persist consistently from early childhood, while BD is typified by episodic mood fluctuations, typically surfacing in later adolescence. The diagnostic challenge posed by symptom overlap underscores the need for tailored treatments for each condition to mitigate the risk of symptom exacerbation. Moreover, the potential co-occurrence of ADHD and BD demands a nuanced therapeutic strategy. Adolescents' ongoing maturation in decision-making and impulse control poses challenges to consistent adherence to medication regimens. Their heightened emotional reactivity and ongoing brain development can mimic bipolar symptoms, potentially resulting in misdiagnosis. Resistance to treatment may arise from the pursuit of independence and identity formation, while the overlap of symptoms with other conditions such as ADHD further complicates diagnosis. BD disrupts cognitive development, potentially leading to lasting implications for reduced functional capacity. Notably, addressing bipolar symptoms does not appear to ameliorate the delay in mental development.3 This delay may stem from the direct impact of the illness on brain function or reflect indirect consequences of psychopathology or medications on cognitive development. The intricate interplay of cognitive and emotional development during adolescence complicates the diagnosis and treatment of BD. Effective strategies include involving adolescents in treatment planning, providing age-appropriate education, engaging families in a supportive manner, and leveraging technology to foster medication adherence. A comprehensive search of data for the use of LAIs in the adolescent population showed LAI use in youth with serious mental illness may improve clinical outcomes and adherence. Side effects of LAIs among youth appear similar to oral preparations.4 However, no systematic review has been done on this topic. Therefore, further research is required to address the limitations of LAIs in adolescents with BD. The potential of LAI medications in the maintenance treatment of BD has attracted significant interest due to their ability to improve medication adherence and lower the risk of relapse. LAIs showed a 30% reduction in the risk of rehospitalization compared to the oral forms of the same medications.5 This is because LAIs enhance adherence to treatment by reducing the need for daily dosing, which helps in managing symptoms more effectively. As a result, there are fewer psychiatric emergencies and hospital visits. The use of LAIs can lead to more stable mental health and fewer disruptions in the adolescent's daily life. It is essential to acknowledge that despite patients expressing willingness to consider LAI treatments, these options are notably underutilized, especially among individuals discharged following hospitalization for a psychotic episode. Further research is necessary to address the barriers hindering the adoption of LAIs, with the potential to improve treatment adherence and optimize outcomes for individuals managing Bipolar Disorder and Schizoaffective disorder-bipolar type. The collection and evaluation of all protected patient health information was performed in a health insurance Portability and Accountability Act (HIPPA) compliant manner. The data supporting this study's findings are available on request from the corresponding author PP. The data are not publicly available due to information that could compromise the privacy of research participants.
Sood et al. (Sun,) studied this question.