What is the optimal treatment for Attention Deficit Hyperactivity Disorder (ADHD) and bipolar disorder?

From the Guidelines

The best treatment for ADHD and bipolar disorder typically involves a combination of medication and psychotherapy tailored to each individual, with mood stabilizers like lithium or valproate forming the foundation of treatment for bipolar disorder, and stimulants like methylphenidate or amphetamine salts often effective for ADHD, as noted in studies such as 1. For bipolar disorder, mood stabilizers like lithium (600-1200 mg/day), valproate (750-1500 mg/day), or lamotrigine (100-200 mg/day) are commonly used, with atypical antipsychotics such as quetiapine (300-600 mg/day) or aripiprazole (10-30 mg/day) potentially added, as discussed in 1 and 1. For ADHD, stimulants like methylphenidate (Ritalin, 20-60 mg/day) or amphetamine salts (Adderall, 10-40 mg/day) are often effective, though non-stimulants like atomoxetine (Strattera, 40-100 mg/day) may be preferred when there are concerns about triggering mania, as seen in 1. Key considerations include:

• Treatment sequencing, with mood stabilization typically preceding ADHD treatment, as emphasized in 1
• Regular monitoring for side effects and symptom changes, with medication adjustments as needed, as noted in 1
• The importance of cognitive-behavioral therapy, psychoeducation, and establishing consistent sleep and daily routines in enhancing medication effectiveness, as discussed in 1
• The need for management by a psychiatrist experienced in treating both disorders, with ongoing communication between the patient and provider to optimize outcomes, as highlighted in 1 and 1. Given the complexity of this combination of conditions, a tailored approach considering the individual's specific needs and circumstances is essential, as emphasized in 1.

From the FDA Drug Label

Atomoxetine capsules are indicated as an integral part of a total treatment program for ADHD that may include other measures (psychological, educational, social) for patients with this syndrome. Prior to initiating treatment with atomoxetine, screen patients for a personal or family history of bipolar disorder, mania, or hypomania [see Warnings and Precautions (5.6)].

The best treatment for ADHD and bipolar is not explicitly stated in the label. However, atomoxetine can be used as part of a comprehensive treatment program for ADHD, and it is recommended to screen patients for bipolar disorder before initiating treatment.

• The label does not provide information on the treatment of bipolar disorder itself, only on the need to screen for it before treating ADHD with atomoxetine 2.

From the Research

Treatment Options for ADHD and Bipolar Disorder

• The treatment of ADHD and bipolar disorder can be complex, and a hierarchical approach is often desirable, with mood stabilization preceding the treatment of ADHD symptoms 3.
• Stimulants are the most effective medications for ADHD, but their use may be contraindicated in the presence of a comorbid drug abuse or in patients that simulate or exaggerate ADHD symptoms 3.
• Atomoxetine (ATX) 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.
• Mood stabilizers, such as lithium and anticonvulsants, are a first-line treatment for bipolar disorder and should be continued indefinitely due to the risk of patient relapse 4.

Augmentation Therapy for Bipolar Disorder

• Augmentation of mood stabilizers with atypical antipsychotics is a more effective therapy for bipolar disorder, and is recommended as first-line treatment for severe bipolar mania 5.
• Atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, have been shown to be effective in long-term maintenance treatment and may help control the depressive phase of bipolar disorder 5.

Combination Therapy for ADHD and Bipolar Disorder

• The combination of mood stabilizers and stimulants, such as methylphenidate (MPH), may be effective in reducing emotional dysregulation and improving ADHD symptoms in adults with ADHD and bipolar disorder 6.
• Atomoxetine (ATX) may also be effective in reducing negative emotionality and emotional impulsivity in adults with ADHD and bipolar disorder, although its effectiveness may be modest compared to MPH 6.

Lithium and Valproate in Bipolar Disorder

• Lithium and valproate are commonly used to treat bipolar disorder, and their effectiveness can depend on individual patient characteristics, such as family history and previous affective episodes 7.
• Lithium may be a better treatment choice for patients with a positive family history for bipolar disorder, mania-depression-interval pattern, and high risk for suicide, while valproate may be more effective for patients with many previous affective episodes and psychiatric comorbidities 7.