Carbamazepine, approved for treatment of seizures and trigeminal neuralgia, is structurally related to

the TCAs. Based on anedoctal reports, carbamazepine may be useful in some pediatric patients with
mania. The plasma half-life after chronic administration of carbamazepine is between 13 and 17 hours.
The therapeutic plasma concentration has been reported at 4 to 12 ng/ml, with recommended daily
doses in children ranging from 10 to 20 mg/kg administered twice per day. Because the relationship
between dose and plasma level is variable and uncertain with marked inter-indvidual variability, plasma
level monitoring is recommended. Common short-term side effects include dizziness, drowsiness,
nausea, vomiting, and blurred vision. Idiosyncratic reactions, such as bone marrow suppression, liver
toxicity, and skin disorders (including Stevens-Jhonson syndrome), have been reported but appear to be
rare. However, given the seriousness of these reactions, careful monitoring og blood counts and liver
and renal function is warranted initially and during treatment. Carbamazepine induces its own
metabolism, which is usually complete after 3 to 5 weeks on the medication. Carbamazepine interacts
with many medications, inducing the metabolism of substrates of 3A4 (e.g., haloperidol, phenytoin), and
may reduce levels of valproic acid and increase lithium levels by reducing lithium clearance. Inhibitors of
3A4 (e.g., erythromycin) may also increase levels of carbamazepine.

Oxacarbazepine (trileptal) has been used in place of carbamazepine recently because of reports of fewer
medications interactions and adverse effects (e.g., less effect on bone marrow and skin), and because it
does not require blood monitoring. Although trials are ongoing, minimal data are currently available on
oxcarbazepine’s safety, tolerability, and efficacy in pediatric bipolar disorder. Clinicians who prescribe it
should monitor for hyponatremia and be aware that it can induce the metabolism of ethinyl estradiol.

Despite a pucity of dat, several other anticolvusants have been used in the treatment of pediatric
bipolar disorder Lamotrigine (Lamictal) is an anticonvulsant approved in the maintenance treatment of
bipolar type I adults. Lamotrigine’s labeling contains a boxed warning that serious rashes including
Stevens-Johnson, occur in about 1 % of patients younger than 16 years old. The risk for rash seems to
increase if lamotrigine is increased too quickly, the initial dose is greater than recommended, or it is
administered with VPA. However, benefits have been reported with VPA and lamotrigine combination
therapy in pediatric bipolar disorder. 34

Other anticonvulsant may also be useful, perhaps as adjungtive agents for specific or for residual
symptoms, for juvenile bipolar disorder. Gabapentin ( neurontin) is approved as an adjunct therapy for
seizures. It is not significantly metabolized in humans and has few medication interactionstrials with
gabapentin for bipolar disorder in adults have been