From the Guidelines
Stimulant medications can be used safely in patients with ADHD and comorbid mood/affective disorders, but should be monitored closely for potential worsening of anxiety or mood cycling, and mood stabilization should be achieved first in bipolar patients. According to a study published in the Journal of the American Academy of Child and Adolescent Psychiatry 1, stimulant medications may be helpful for addressing ADHD symptoms in patients with bipolar disorder, once the patient's mood symptoms are adequately controlled on a mood stabilizer regimen. A randomized, controlled trial of 40 bipolar children and adolescents with ADHD demonstrated that treatment with low-dose mixed amphetamine salts was safe and effective for the treatment of comorbid ADHD once the child's mood symptoms were stabilized with divalproex.
Some key considerations for managing ADHD in patients with comorbid mood disorders include:
- Stimulants like methylphenidate and amphetamine-based medications can be used, but require close monitoring for potential adverse effects on mood
- Non-stimulant options, such as atomoxetine, may be preferred for patients with significant mood disorder concerns
- Alpha-2 agonists, like guanfacine and clonidine, are also mood-neutral options
- Treatment should be individualized based on symptom severity, previous medication responses, and the specific mood disorder present
- Regular monitoring for mood changes, sleep disturbances, and irritability is essential regardless of medication choice
A more recent study published in Pharmacology and Therapeutics 1 provides an overview of available medications for the treatment of ADHD, including stimulants and non-stimulants, and highlights the importance of individualizing treatment based on patient-specific factors, such as symptom severity and presence of comorbidities. The study also notes that medication adherence is a common problem in ADHD treatment, and that regular assessment and open discussion of potential issues can help improve adherence.
Overall, while stimulant medications can be used safely in patients with ADHD and comorbid mood/affective disorders, careful medication selection and monitoring are essential to minimize potential risks and optimize treatment outcomes.
From the FDA Drug Label
Atomoxetine hydrochloride is not approved for major depressive disorder Co-morbidities occurring with ADHD may be associated with an increase in the risk of suicidal ideation and/or behavior Patients who are started on therapy should be monitored closely for suicidality (suicidal thinking and behavior), clinical worsening, or unusual changes in behavior Bipolar Disorder- Screen patients for bipolar disorder.
Key Considerations:
- Mood/Affective Disorder Comorbidity: The FDA drug label does not provide direct information on the safety of atomoxetine for mood/affective disorder comorbidity.
- Suicidal Ideation: There is an increased risk of suicidal ideation in patients with ADHD, particularly in those with co-morbidities.
- Bipolar Disorder: Patients should be screened for bipolar disorder before starting atomoxetine therapy.
- Monitoring: Patients should be closely monitored for suicidality, clinical worsening, or unusual changes in behavior while on atomoxetine therapy 2. The FDA drug label does not answer the question.
From the Research
Safety of ADHD Medications for Mood/Affective Disorder Comorbidity
- The use of stimulants and atomoxetine in adults with comorbid ADHD and bipolar disorder has been studied, with results indicating that ADHD-BD may be associated with more severe symptoms, course, and worst outcome of both conditions 3.
- Atomoxetine may be effective in the treatment of ADHD symptoms in BD patients, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers 3.
- Lamotrigine, an anticonvulsant, has been reported to be effective in adult ADHD comorbid with bipolar II disorder, with 77.5% of patients improving with lamotrigine 4.
Treatment Approaches for ADHD Comorbid with Mood or Anxiety Disorders
- In adult ADHD comorbid with bipolar disorders, it is important to stabilize mood change before treating ADHD symptoms 5.
- In adult ADHD comorbid with depressive disorders, it is acceptable to treat depressive and ADHD symptoms at the same time 5.
- Atomoxetine can reduce anxiety as well as ADHD symptoms in adult ADHD with anxiety disorders 5.
- Combining mood stabilizers with standard pharmacotherapy may be effective in reducing emotional dysregulation in adults with ADHD, with or without comorbid bipolar spectrum disorders 6.
Effectiveness of Atomoxetine and Stimulant Combination
- The combination of atomoxetine and stimulants, such as methylphenidate, may be effective in reducing ADHD severity in treatment-resistant patients 7.
- However, the evidence is limited, and further studies are needed to investigate the effectiveness of this combination therapy in specific ADHD patient subpopulations 7.