Treatment of ADHD and Comorbid Bipolar Disorder

Treatment of ADHD and Comorbid Bipolar Disorder

Methods:
A chart review was conducted of patients consecutively referred to a pediatric psychopharmacology clinic. Study subjects were 38 patients (mean age, 10 years; 32 boys) who met DSM-IV diagnostic criteria for both bipolar disorder and ADHD. The average age at onset of ADHD was 3 years, and of bipolar disorder, 5.4 years. Five (13%) patients had bipolar disorder, manic type, and 33 (87%) had concurrent major depression (considered bipolar disorder, mixed type.) Patients were assessed using structured interviews administered on their initial evaluation. Follow-up chart reviews were obtained for each treatment visit. Outcomes were measured using ratings on syndrome-specific Clinical Global Impression (CGI) severity and improvement scales. A patient's improvement or deterioration was rated on each clinic visit and assigned to the medication prescribed on that visit. The medications prescribed were grouped by drug class; mood-stabilizers, SSRIs, tricyclic antidepressants (TCAs), and stimulants. ADHD improvement was measured by the proportion of visits on which ADHD symptoms were rated as improved.

Results:
Manic symptoms improved in 13 (34%) children. Improvement of ADHD was limited to these 13 children, and it was 7.5 times more likely to follow than to precede the improvement in mania. In the 13 children, manic relapses were documented in 40 or 75 of postimprovement visits. Improvements in ADHD was extremely unlikely to follow a recurrence of mania.

Medication effects on ADHD were analyzed exclusively for the period following the stabilization of manic symptoms. TCAs were associated with a significant increase in ADHD improvement following initial improvement. (Stimulants had a positive but statistically nonsignificant effect.) However, TCAs were associated with an increase in the aready high probability of recurrence of mania in these patients. Relapse was documented in 76% of visits on which TCAs were used, compared with 42% of visits on which TCAs were not used. The beneficial effect of TCAs on ADHD symptoms was limited to the 6 children who did not experience a recurrence of mania. Child & Adolescent Psychiatry Alerts/April 2000.

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