Strattera Use in Child of Bipolar Mother
Strattera (atomoxetine) can be safely used in a child with ADHD whose mother has bipolar disorder, as the mother's psychiatric history does not contraindicate atomoxetine use in the child. The critical question is whether the child has bipolar disorder, not the mother's diagnosis.
Key Clinical Decision Point
The mother's bipolar disorder is not a contraindication for atomoxetine use in her child. 1 The FDA label for atomoxetine does not list family history of bipolar disorder as a contraindication, though it does require disclosure of family psychiatric history for monitoring purposes. 1
If the Child Has ADHD Only (No Bipolar Disorder)
Atomoxetine is an appropriate first-line option for this child with standard dosing and monitoring:
- Starting dose: 40 mg daily, titrated every 7-14 days to 60-80 mg/day, with maximum dosing at the lesser of 1.4 mg/kg/day or 100 mg/day 2, 3
- Atomoxetine is effective and generally well tolerated in pediatric ADHD, with a negligible risk of abuse or misuse 4
- It is particularly useful for patients with family histories of mood disorders where stimulant-induced mood destabilization is a concern 4
If the Child Has Both ADHD and Bipolar Disorder
The treatment algorithm must prioritize mood stabilization before addressing ADHD symptoms:
Step 1: Stabilize Mood First
- Mood stabilizers (lithium, valproate) or atypical antipsychotics must be initiated and optimized before treating ADHD 2
- The probability of ADHD symptom improvement is 7.5 times greater after initial mood stabilization compared to before stabilization 5
- Attempting to treat ADHD before mood stabilization leads to poor outcomes and high relapse rates 2
Step 2: Add Atomoxetine After Mood Stabilization
- Atomoxetine can be safely added once mood symptoms are controlled on a mood stabilizer regimen 6
- In a case series of 7 children with bipolar disorder and ADHD treated with atomoxetine (6 of 7 also on mood stabilizers), all but one demonstrated significant ADHD improvement with no episodes of hypomania or mania 6
- Atomoxetine may be effective with a modestly increased risk of (hypo)manic switches when used with mood stabilizers, but this risk is manageable with close monitoring 7
Critical Monitoring Requirements
Enhanced surveillance is essential given the family psychiatric history:
- Monitor for new manic symptoms: new psychotic symptoms (hearing voices, believing things that are not true, being suspicious) or new manic symptoms require immediate dose adjustment or discontinuation 1
- Watch for mood destabilization: agitation, irritability, hostility, impulsivity, restlessness, or mania, especially in the first 24-48 hours after initiation or dose changes 3, 1
- Suicidal ideation monitoring: The FDA black-box warning indicates 4 out of every 1,000 pediatric ADHD patients developed suicidal thoughts in clinical trials 1
- Cardiovascular monitoring: Check blood pressure and heart rate regularly, as atomoxetine causes statistically significant (though not clinically significant) increases 1, 4
Common Pitfalls to Avoid
- Do not treat ADHD before mood stabilization if the child has bipolar disorder—this leads to treatment failure and mood destabilization 2, 5
- Do not assume family history alone contraindicates atomoxetine—the child's own diagnosis determines treatment approach 1
- Do not use tricyclic antidepressants for ADHD in children with bipolar features, as they significantly increase risk of manic relapse despite improving ADHD symptoms 5
- Do not miss emerging bipolar symptoms in the child—family history increases genetic risk, requiring vigilant monitoring for mood symptoms 1
Advantages of Atomoxetine in This Context
- Lower risk of mood destabilization compared to stimulants when used with mood stabilizers 6
- No abuse potential, making it safer in families with psychiatric complexity 4
- Effective for comorbid anxiety, which is common in children with family histories of mood disorders 4
- Once-daily dosing option improves adherence 4