Navigating Stimulant Use for ADHD in Bipolar Disorder

This podcast episode addresses the complex question of whether individuals diagnosed with bipolar disorder can safely take stimulants to treat co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD). Dr. Tracey Marks uses a listener's case, 'Chad,' who has multiple diagnoses including bipolar disorder and ADHD, and whose new provider refused to refill his long-standing stimulant prescriptions. The general psychiatric recommendation is against stimulant use in bipolar disorder due to significant risks, including triggering psychotic episodes, inducing rapid cycling (at least four mood episodes per year), and precipitating mixed episodes where depressive and manic symptoms occur simultaneously. These effects can make bipolar disorder more difficult to treat and less responsive to standard mood stabilizers.

However, Dr. Marks emphasizes that stimulants are not universally prohibited, as these adverse effects do not occur in every individual. The decision to prescribe stimulants must be highly individualized, considering the severity of ADHD symptoms and the stability of the bipolar disorder. For those with mild ADHD symptoms exacerbated by bipolar disorder, effective mood stabilization might sufficiently improve attention and focus. Conversely, individuals with moderate to severe ADHD symptoms often require specific ADHD treatment beyond mood stabilization. Dr. Marks outlines a careful approach: ensuring the patient is on a robust mood stabilizer first, then cautiously introducing a small dose of stimulant while closely monitoring for signs of instability like mania, anxiety, or sleep disturbances. Stimulants' rapid onset and offset allow for quicker assessment of their impact compared to antidepressants or mood stabilizers.

A critical nuance discussed is the patient's history of stimulant use. If, like Chad, an individual has safely taken stimulants for years prior to a bipolar diagnosis without adverse effects, there is less concern about continuing the prescription, though vigilance for instability remains crucial. A significant red flag highlighted is the concurrent use of stimulants and antidepressants in bipolar disorder. Antidepressants themselves can induce mania or instability in bipolar patients, similar to stimulants, making the combination particularly risky. An optimal treatment strategy might involve tapering off antidepressants, optimizing mood stabilizer regimens (potentially using two mood stabilizers for added protection), and then continuing stimulants for ADHD.

Finally, Dr. Marks addresses the societal bias that adult ADHD symptoms are often dismissed as 'first-world problems,' leading to an overly cautious stance against stimulant use. She counters this by underscoring the profound functional impact of untreated ADHD, which can lead to severe consequences like academic failure, job loss, and accidents. The episode also touches on the practicalities of long-acting versus short-acting stimulants and the advanced topic of differentiating between overlapping symptoms of bipolar disorder and ADHD, reinforcing the complexity of managing these comorbid conditions.

"In general stimulants are not recommended for people with bipolar disorder."

"Stimulants trigger psychotic episodes especially in a manic person but it can also happen in in the depressed phase as well."

"Stimulants also cause Rapid Cycling."

"Stimulants can also trigger mixed episodes where you have a blend of depression and Mania occurring at the same time."

"Despite these effects stimulants are not prohibited because these effects don't happen to everyone with bipolar disorder who takes stimulants."

"If I were starting someone on a medication for ADHD who was already being treated for bipolar disorder I would make sure that they were fully loaded on a robust mood stabilizer for the bipolar disorder first and then carefully add a small dose of stimulant and watch and see what happens."

"Working in Chad's favor is the fact that he's safely taken stimulants before without them negatively affecting his bipolar disorder."

"I think it's risky to have two agents that could destabilize your condition with the two agents being stimulants and anti-depressants."

"An optimal treatment plan could be to taper off the anti-depressant and make sure he's on a good mood stabilizer and then continue the stimulants for the ADHD."

"I think there's a bias that ADHD symptoms in adults are first world problems and stimulants are bonus medications that you don't really need to have."

"The functional effects of untreat ADHD are pretty impactful failing school losing your job getting in car accidents are not minor consequences for people."