From the Guidelines
Stimulant medications, rather than atomoxetine, are recommended for treating ADHD in patients with bipolar disorder, but only after the bipolar disorder is well-controlled with mood stabilizers. When considering the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in a patient with bipolar disorder, it's crucial to prioritize the management of the bipolar disorder first. According to the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1, stimulant medications may be helpful for addressing ADHD symptoms once the patient’s mood symptoms are adequately controlled on a mood stabilizer regimen. Key points to consider in the treatment approach include:
- Optimizing the bipolar disorder treatment first, typically using mood stabilizers like lithium, valproate, or lamotrigine.
- Avoiding atomoxetine due to its potential to trigger manic episodes.
- Introducing stimulants at low doses with gradual titration while closely monitoring for mood changes, as evidenced by a randomized, controlled trial demonstrating the safety and effectiveness of low-dose mixed amphetamine salts for comorbid ADHD in bipolar children and adolescents whose mood symptoms were stabilized with divalproex 1.
- Incorporating non-pharmacological interventions like cognitive behavioral therapy and organizational skills training as part of the comprehensive treatment plan. Regular follow-up appointments are essential to assess both ADHD symptom improvement and any signs of mood destabilization, ensuring that the treatment approach prioritizes the patient's overall morbidity, mortality, and quality of life.
From the Research
Medication Options for ADHD in Bipolar Disorder
- Atomoxetine may be considered as a treatment option for ADHD in patients with bipolar disorder, as it has been shown to be effective in reducing ADHD symptoms with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers 2.
- 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 in order to obtain stimulants for diversion or abuse 2.
- A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms 2, 3.
Considerations for Treatment
- Comorbid ADHD and bipolar disorder may be associated with more severe symptoms, course, and worst outcome of both conditions 2, 4.
- The frequent coexistence with alcohol and substance abuse may further complicate treatment management 2.
- Treatment-induced manic switch is a concern when using stimulants and other medications for ADHD in patients with bipolar disorder 2, 4.
Treatment Approach
- A sequential approach is favored, with the bipolar condition being brought under control first before initiating any stimulant medication for the ADHD 3.
- Mood stabilizers, such as lithium, valproate, and lamotrigine, are recommended as first-line therapy for bipolar disorder 5.
- Atomoxetine may be considered as a non-stimulant option for ADHD treatment in patients with bipolar disorder, especially when stimulants are contraindicated or not tolerated 2, 6.