Can a patient with bipolar disorder and a history of Attention Deficit Hyperactivity Disorder (ADHD) be treated with Adderall (amphetamine and dextroamphetamine) and Lexapro (escitalopram) alone?

No – Adderall and Lexapro Alone Are Insufficient for Bipolar Disorder with ADHD

A patient with bipolar disorder and ADHD cannot be safely treated with only Adderall and Lexapro – bipolar disorder must first be stabilized with a mood stabilizer before any ADHD treatment is initiated, and antidepressants like Lexapro should never be used as monotherapy in bipolar disorder. 1, 2, 3

Critical Treatment Sequencing

The fundamental principle is that mood stabilization must precede ADHD treatment in patients with comorbid bipolar disorder and ADHD. 1

Why This Regimen Is Dangerous

Using Adderall without mood stabilization carries significant risk:

• The FDA label for amphetamines explicitly warns that "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." 2
• Patients should be "adequately screened to determine if they are at risk for bipolar disorder" before initiating stimulant treatment, including detailed psychiatric and family history. 2
• In a large clinical study, 40% of bipolar patients treated with stimulants experienced stimulant-associated mania/hypomania, and notably, only 43% were receiving concurrent mood stabilizers. 4

Using Lexapro (an SSRI) is problematic for multiple reasons:

• The FDA label for escitalopram mandates screening for "personal or family history of bipolar disorder, mania, or hypomania" prior to initiating treatment. 3
• SSRIs and other antidepressants "may destabilize the patient's mood or incite a manic episode" in bipolar disorder. 5
• Antidepressants are not recommended as monotherapy for bipolar disorder – they require concurrent mood stabilizer coverage. 5, 6
• In one retrospective study, 58% of youths with bipolar disorder experienced emergence of manic symptoms after exposure to mood-elevating agents, most commonly antidepressants. 5

The Correct Treatment Algorithm

Step 1: Establish Mood Stability First

• Initiate treatment with lithium or divalproex as first-line mood stabilizers. 1
• Lithium is FDA-approved for bipolar disorder down to age 12 years for acute mania and maintenance therapy. 5
• Alternative options include aripiprazole, valproate, olanzapine, risperidone, quetiapine, or ziprasidone for acute mania. 5
• Maintain the mood stabilizer regimen for 12 to 24 months minimum, as most patients with bipolar disorder require ongoing medication therapy to prevent relapse. 1

Step 2: Address ADHD Only After Mood Control

• Once mood symptoms are adequately controlled on a mood stabilizer, stimulant medications may be cautiously added for ADHD symptoms. 1
• Low-dose mixed amphetamine salts can be safe and effective for comorbid ADHD once mood is stabilized with divalproex. 1
• Atomoxetine is the preferred first-line ADHD medication for patients with concerns about mood destabilization or substance abuse history, providing effective symptom control without exacerbating mood instability. 1, 7

Step 3: Maintain Both Medications Indefinitely

• Continue the mood stabilizer regimen indefinitely while treating ADHD, as the use of stimulants for comorbid ADHD does not affect relapse rates when mood stabilizers are maintained. 1
• Over 90% of adolescents who were noncompliant with lithium treatment relapsed, compared to 37.5% relapse rate for those compliant with treatment. 1

Addressing Depression in Bipolar Disorder

If depressive symptoms persist after mood stabilization:

• Consider adding an antidepressant only as an adjunct to the mood stabilizer, never as monotherapy. 5
• The combination of olanzapine and fluoxetine is FDA-approved for bipolar depression in adults. 5
• Lamotrigine is FDA-approved for maintenance therapy and may help with depressive symptoms. 5

Critical Monitoring Requirements

• Regular monitoring of lithium levels, renal and thyroid function, and urinalyses once stable dose is obtained. 1
• Assess for emergence of manic symptoms when any ADHD medication is added. 2
• Monitor for cardiovascular effects of stimulants, including blood pressure and heart rate changes. 2
• Evaluate atomoxetine effectiveness after 6-8 weeks at therapeutic dose using standardized ADHD rating scales. 1

Common Pitfalls to Avoid

• Never initiate ADHD treatment before achieving mood stability – this significantly increases risk of mood destabilization and manic episodes. 1, 2
• Do not assume a single medication will treat both conditions effectively – comorbid ADHD predicts poorer response to bipolar treatment, necessitating adequate mood control first before addressing ADHD symptoms. 1, 8
• Avoid antidepressant monotherapy in bipolar disorder – this can trigger manic switches and mood destabilization. 5, 3
• Do not discontinue mood stabilizers once ADHD symptoms improve – maintenance therapy is essential to prevent relapse. 1