ADHD and Bipolar Disorder, Part 2
4. Rapidity of Mood Shift: Because ADHD mood shifts are almost always triggered, the shifts themselves are often experienced as being instantaneous complete shifts from one state to another. Typically they are described as "crashes" or "snaps" which emphasize this sudden quality. By contrast, the untriggered mood shifts of BMD take hours or days to move from one state to another.
5. Duration of Mood Shifts: People with ADHD report that their moods shift rapidly according to what is going on in their lives. The response to severe losses and rejections may last weeks but typically mood shifts are much shorter and are usually measured in hours. The mood shifts of BMD are usually sustained. For instance, to get the designation of "rapid cycling" bipolar disorder the person need only experience four shifts of mood from high to low or low to high in a 12 month period of time. Many people with ADHD experience that many mood shifts in a single day.
6. Family History: Both disorders run in families but people with BMD usually have a family history of BMD while individuals with ADHD have a family tree with multiple cases of ADHD.
Treatment of combined ADHD and BMD
There is a grand total of three published articles about the treatment of people who have both ADHD and BMD. Despite this lack of published data the great number of patients involved and the high degree of impairment experienced by people with both disorders has lead their physicians to push the envelope of treatment. For the present, however, what follows must be viewed as anecdotal and experimental. Before embarking on any course of treatment a full exploration of the anticipated risks and benefits of that treatment must be done between the patient and his or her treating clinician.
My own experience with more than 40 patients and the similar experience of other practitioners is that co-existing ADHD and BMD can be treated very well and with extraordinarily good outcomes. The mood disorder MUST be stabilized first. This can be done with any of the standard mood stabilizing agents — lithium, valproic acid or carbamazepine. Mood stabilizers are necessary even when the bipolar patient is without symptoms between episodes of illness. Otherwise there is a significant risk of triggering a manic episode. Once the mood has stabilized and any psychotic level symptoms have resolved the first-line stimulant class of medications can be used without significant risk of triggering either a mania or a return of psychotic symptoms.
There is one published article on the treatment of co-existing ADHD and cyclic mood disorders, mostly bipolar type 2. This research looked at the combination of mood stabilizers plus a second line medication for ADHD, bupropion (Wellbutrin; not FDA approved for the treatment of ADHD). This study also demonstrated the efficacy and safety of treating both disorders with medications initially thought to have the risk of making the bipolar worse. As with the first line stimulant medications, bupropion provided significant benefits for ADHD symptoms and significantly greater levels of mood stability.
The outcomes for my patients treated for both ADHD and BMD have thus far been good. No one has had to be re-hospitalized and all but 3 have been able to return to work. Perhaps more importantly, they report that they feel more "normal" in their moods and in their ability to fulfill their roles as spouses, parents, employees, and as productive human beings. It is impossible to determine at this early stage whether these significantly improved outcomes are due to enhancement of intrinsic mood stability or whether adequate treatment of the ADHD component makes medication compliance better. The key to these better outcomes, however, lies in the recognition that both diagnoses are present and that they will respond to independent but coordinated treatment.