From the Guidelines
The recommended treatment for ADHD in patients with bipolar disorder is to avoid stimulants if possible and use atomoxetine, starting at a dose of 40 mg daily, with titration every 7-14 days to 60 then 80 mg/d, not exceeding a maximum dose of 1.4 mg/kg/d or 100 mg/d, as it carries less risk of triggering mania compared to stimulants. This approach prioritizes minimizing the risk of inducing manic episodes while managing ADHD symptoms. According to the most recent and highest quality study 1, atomoxetine does not seem to be associated with major congenital malformations or other significant adverse outcomes, making it a safer option.
When considering treatment, it's essential to first stabilize the bipolar disorder before addressing ADHD symptoms, using mood stabilizers such as lithium, valproate, or lamotrigine, or atypical antipsychotics like quetiapine or aripiprazole, as suggested by earlier studies 1. However, the primary focus should be on using non-stimulant medications like atomoxetine as the first-line treatment for ADHD symptoms in patients with bipolar disorder, given its safety profile and efficacy.
Key considerations in the treatment approach include:
- Avoiding stimulants if possible due to their potential to trigger or worsen manic episodes
- Using atomoxetine as a preferred first-line treatment for ADHD symptoms in bipolar patients
- Close monitoring for mood changes, sleep disturbances, or emerging manic symptoms, with regular follow-up appointments
- Titration of atomoxetine dose according to the patient's response and tolerance, up to the recommended maximum dose.
From the FDA Drug Label
Particular care should be taken in using stimulants to treat ADHD patients with comorbid bipolar disorder because of concern for possible induction of mixed/manic episode in such patients Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.
The recommended treatment approach is to avoid stimulants if possible and consider alternative treatments, such as atomoxetine, to minimize the risk of inducing manic episodes in patients with bipolar disorder. 2
From the Research
Treatment of ADHD in Patients with Bipolar Disorder
- The treatment of Attention Deficit Hyperactivity Disorder (ADHD) in patients with bipolar disorder requires careful consideration due to the potential risk of inducing manic episodes 3, 4, 5.
- Stimulants are effective treatments for ADHD, but their use in patients with comorbid bipolar disorder may be problematic due to the risk of mood destabilization and induction of (hypo)manic switches 3, 4, 5.
- Atomoxetine, a non-stimulant medication, may be a viable alternative for the treatment of ADHD in patients with bipolar disorder, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers 3, 6.
Recommended Approach
- A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms 3.
- The use of stimulants and atomoxetine in adults with comorbid ADHD and bipolar disorder should be carefully evaluated once the patient has been stabilized 3.
- Clinicians should be aware of the potential risks and benefits of using psychostimulants and non-stimulant medications in patients with bipolar disorder, and carefully monitor patients for signs of (hypo)mania or mood destabilization 4, 5.
Key Findings
- The use of psychostimulants in bipolar disorder was not associated with increased scores on the Young Mania Rating Scale in patients who were in a euthymic or depressed state 5.
- A qualitative synthesis of studies revealed a limited risk of medication-induced manic symptoms 5.
- More extensive studies evaluating the safety and efficacy of these medications are warranted 6, 5.