COMMENTARY

8 Controversies in Bipolar Disorder Addressed

Nassir Ghaemi, MD, MPH; Stephen M. Strakowski, MD

Disclosures

June 30, 2016

Controversy 8: BD or ADHD?

Can attention-deficit/hyperactivity disorder (ADHD) and BD be distinguished? What is the role of stimulants in comorbid BD/ADHD?

Dr Ghaemi: As with borderline personality disorder, I would focus not on symptoms shared in common (inattention), but differences in genetics and course. If BD genetics and repeated mood episodes are present, then in my view the diagnosis should be BD, not ADHD.

I believe that the concept of comorbidity is mistaken when we fail to take a hierarchical approach and avoid diagnosing ADHD in persons with active anxiety, mood, and psychotic symptoms, all of which can cause inattention. We don't diagnose "fever disorder" in everyone with pneumonia; we should be diagnosing ADHD in persons with manic, depressive, or anxious symptoms. Thus, in general, I think we should also avoid using stimulants in such persons, in part because stimulants are also antidepressants and have all of the mood-destabilizing effects described above. Thus, they can worsen BD.

Instead, by avoiding stimulants, we find that attention will improve in many persons once mood is improved. In a minority of patients in whom this is not the case, we may be dealing with longer-term cognitive impairment, which is associated with long-standing BD. In the long run, lithium is neuroregenerative and may provide some eventual cognitive benefits.

Short-term improvement with amphetamine stimulants need to be weighed against the animal data indicating that those agents are neurotoxic, causing neuronal harm. This has never been disproven in humans, and we should not assume these agents are safe in humans but harmful in animals. My concern would be that long-term use of these agents could worsen the cognitive impairment that is part of active BD. Thus, in my view, stimulants are best avoided in general in BD.

Dr Strakowski: ADHD and affective episodes in BD share many similar symptoms that include inattention, distractibility, and impulsivity, which leads to diagnostic confusion across the age span. However, although mood symptoms can occur in individuals with ADHD, typically these will not rise to the level of affective and particularly manic syndromes.

Moreover, by definition ADHD starts before age 12 years (in DSM-5), whereas BD (ie, mania) is not expressed fully until the teenage years. ADHD is persistent; BD is episodic. Finally, per Dr Ghaemi's point, BD is much more heritable—so that a strong family history of mood disorders, or the absence of such, also may distinguish the two.

All of this is to say that a careful assessment can often determine whether, in persons with BD, the symptoms truly meet criteria for a second ADHD diagnosis or instead are simply part of the mood episode or interepisode symptoms. In my clinical consulting experience, I have encountered a frequent tendency to overdiagnose ADHD in adults, primarily by not attending to the onset age requirement of ADHD. That said, in younger patients, this co-occurrence is commonly reported in clinical research studies.

Minimal controlled research is available to guide treatment decisions, but clinical expert opinion currently appears to commonly land on the view that stimulants are probably safe, at least in the short term, for truly comorbid ADHD in BD if the BD has been optimally stabilized.

Moreover, in the treatment of BD, whether or not stimulants are truly destabilizing is not really known, although this is generally assumed. The long-term safety and efficacy of stimulants used as treatments for any reason in patients with BD remain unknown; more controlled clinical trials are needed in both children and adults (obviously, stimulant abuse worsens the course). Stimulants, then, probably remain in treatment algorithms for BD, but are third- or fourth-line after other treatments have failed.

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