Can you have bipolar disorder and Attention Deficit Hyperactivity Disorder (ADHD) at the same time?

Bipolar Disorder and ADHD Can Coexist as Comorbid Conditions

Yes, bipolar disorder and ADHD can definitely coexist as comorbid conditions, with approximately 20% of adults with bipolar disorder also having ADHD, and about 10-20% of patients with ADHD having comorbid bipolar disorder. 1 This comorbidity presents unique diagnostic and treatment challenges that require careful clinical consideration.

Diagnostic Considerations

Distinguishing Features

• Bipolar Disorder:

  • Episodic presentation with periods of normal mood between episodes 1
  • Mood symptoms (euphoria, depression) are always present during episodes 1
  • Typically begins after age 12 1
  • May include psychotic features 1
  • Characterized by marked sleep disturbance during episodes 2

• ADHD:

  • Chronic, non-episodic symptoms 1
  • Symptoms typically begin before age 7 1
  • No psychotic features 1
  • Attention difficulties are persistent rather than episodic 2

Overlapping Symptoms

• Impulsivity
• Distractibility
• Increased energy
• Rapid speech
• Emotional dysregulation
• Disorganization 1

Diagnostic Challenges

• Symptoms of juvenile mania can be confused with ADHD, particularly when irritability is the predominant mood symptom 2
• Premorbid psychiatric problems are common in early-onset bipolar disorder, especially difficulties with disruptive behavior disorders 2
• Most childhood cases of bipolar disorder are associated with ADHD 2

Treatment Approach

Treatment Sequence

1. First stabilize mood in bipolar disorder 3

   • Use mood stabilizers such as valproate, lithium, or atypical antipsychotics
   • Mood stabilization must precede ADHD treatment

2. Then address ADHD symptoms 3

   • Consider low-dose stimulants only after mood is stabilized
   • Monitor closely for emergence of manic symptoms

Medication Considerations

• Stimulants:

  • Can be used cautiously in patients with stabilized bipolar disorder 3
  • Methylphenidate: 5-20 mg three times daily 2
  • Dextroamphetamine: 5 mg three times daily to 20 mg twice daily 2
  • Warning: Stimulants may exacerbate manic symptoms in unstabilized patients 4

• Non-stimulant options:

  • Atomoxetine may be considered but carries a small risk of inducing (hypo)manic episodes 3
  • Alpha-2 agonists like clonidine or guanfacine may be effective for ADHD symptoms 3

Monitoring and Follow-up

• Schedule frequent appointments (at least monthly) during initial medication titration 3
• Monitor blood pressure and pulse at each visit 3
• Systematically assess for:
  • Emergence of manic or hypomanic symptoms
  • Common stimulant side effects (insomnia, anorexia, headaches) 3
  • Cardiovascular effects 4
• Use standardized rating scales to track symptoms 3

Clinical Implications

• Comorbid ADHD-bipolar disorder is associated with:
  • Earlier age of onset of bipolar disorder 1
  • More chronic and disabling course 1
  • Increased psychiatric comorbidity 1
  • Higher rates of suicide attempts 5
  • More frequent psychiatric hospitalizations 5

Common Pitfalls to Avoid

1. Misdiagnosis: Mistaking ADHD symptoms for bipolar symptoms or vice versa can lead to inappropriate treatment 6

2. Inappropriate medication sequencing: Treating ADHD before stabilizing mood can potentially trigger or worsen manic episodes 3

3. Overlooking comorbidity: Assuming symptoms are due to only one disorder when both may be present 1

4. Inadequate monitoring: Failing to closely monitor for emergence of mania when stimulants are introduced 4

5. Overreliance on self-report: Adults with ADHD may be unreliable reporters of their own behaviors 2

While most evidence supports treating bipolar disorder first before addressing ADHD symptoms, some recent case reports suggest that in carefully selected patients, psychostimulants might be used without mood stabilizers 7. However, this approach requires further research and should not be considered standard practice.