Treating ADHD/ADD & Bipolar Disorder in the Same Patient
Reprinted with permission from the Journal of Clinical Neuroscience
A 33-year old woman was successfully treated for both Bipolar disorder (BD) and Attention Deficit Hyperactivity Disorder (ADHD). She presented with a history of brief supportive psychotherapy for two months and paroxitine 20 mg. treatment for two weeks. It gave her only nausea and anxiety. On intake, her Beck Depression Inventory (BDI) was high at 30 and her Beck Anxiety Inventory (BAI) was very high at 51. Over the course of 2-1/2 years the working diagnosis for this patient was Major Depression (MD) with comorbid ADHD, then Bipolar Disorder. She then evolved into a clear case of combined Bipolar Disorder and ADHD.
In one pilot study, which investigated the families of children with mania, it was concluded that there was familial evidence for the validity of Bipolar Disorder and ADHD comorbidity in children. Further it was suggested that the comorbid condition of ADHD and Bipolar Disorder may be a distinct nosological entity. This patient had an extensive evaluation of her family history.
Her brother has Schizoaffective Disorder. Her alcoholic father suffers from "anxiety and severe depression" and has intermittent irritable mood, decreased sleep, and other symptoms which meet DSM-IV criteria for hypomania. She has a "schizophrenic uncle." An aunt and mother have major depression, a paternal aunt Bipolar II, a paternal uncle, paranoid schizophrenia, and a paternal great-grandmother, periods of "moodiness and breakdowns" with irritability. For no reason, she picked fights, threw dishes, and was agitated. Then, at other times, she got depressed and slow. She functioned poorly in either state.
Further, the patient's son was diagnosed with ADHD and was placed on only 5 mg of methylphenidate twice a day. He became profoundly euphoric, sleepless, with psychomotor agitation and worse hyperactivity. Off this medication, he was very irritable and had trouble sleeping for days. A low dose of sertraline or Zoloft (12.5 mg) caused him to become totally sleepless, more irritable, non-functional in school and at home, and also profoundly oppositional. Subsequently, off all medications, he had periods of inappropriate euphoria, hypersexuality, and decreased sleep need (4 hours less than the standards for his age). At times, he meets criteria for bipolar disorder, and at other times only criteria for ADHD. His best behavior so far has come on response to therapeutic levels of Lithium. (Valproic acid or Depakote at a blood level of 140 for 12 weeks had no effect). Lithium stabilized his mood, but still leaves him moderately hyperactive, allowing him to meet full criteria for ADHD. (Presently, he appears to have both a Bipolar and an ADHD disorder).
When his mother was initially asked about manic criteria. She clearly said she never had such an experience. Using the Wender Utah Rating Scale, the mother met criteria for ADHD. The mother also met full DSM-IV criteria for ADHD from clinical history, e.g., life-long history of inattention, careless mistakes, distractibility, poor follow through, poor organization, regularly losing things, constantly being forgetful in her daily activities, fidgety, and talking slightly excessively. She was also evaluated with the Barkley Semistructured ADHD Interview for Adults . The patient was also diagnosed at this point with Major Depression with a significant anxiety component. Her paroxetine (Paxil) was increased. It caused a significant decrease in her depression. She was placed on clonazepam (Klonopin) with a decrease in her anxiety. Indeed, on 30 mg of paroxetine, her IDD score (Inventory to Diagnosis Depression) became normal - 10, and her anxiety fell to a mere 4 on the Beck Anxiety Inventory on clonazepam 0.125mg in the AM and 0.25mg at bedtime. Yet, she remained forgetful, scattered, and had trouble with procrastination. Her distractibility was still significant.
She was treated with dextroamphetamine (Dexadrine) for comorbid ADHD, and eventually increased to 15 mg in the AM and 12.5 mg at noon. These doses, she felt, caused her to be focused during the initial first two weeks. Then, she became more "energized," and felt like she was "in a daze." The benefits from that two weeks degenerated. Her normally crisp and clean dressing was poor. She was scrubbing a very clean floor, and had tremendous amounts of energy for house cleaning. Her excessive cooking, washing, and floor cleaning were felt by two of her relatives to be completely out of character. Indeed, the dextroamphetamine dosage that originally helped her focus, after two weeks, changed the patient into somebody who manifested all the criteria for Bipolar Disorder - Manic.
She was taken off the dextroamphetamine, and the paroxetine was reduced to 5 mg. She was not able to return to care for approximately two weeks. At that time, she was still persistently euphoric, expansive, with inflated self-esteem, a decreased need for sleep (three to four hours a night). She was unusually talkative, pressured, and had a flight of ideas. She was more distractible than at her typical baseline, and very goal directed toward house cleaning. She manifested no signs of depression and felt "very very good."
These symptoms remained for two weeks despite no dextroamphetamine and the tapering of her paroxetine. So, she was started on valproic acid sprinkles (500 mg/day gave her a blood level of 72 units). Her symptoms remitted within 12 days. The patient's low dose paroxetine was discontinued to prevent further manic symptoms without withdrawal signs.
The months later the patient became depressed. She received bupropion (Wellbutrin), because of her dislike of paroxetine's anorgasmia side effect, up to 75 mg in the AM, 75 mg at noon and 150 mg at bedtime. This dose completely ameliorated her depression and did not cause recurrence of her manic symptoms in the presence of valproic acid.
At this point, she recalled times before her clear manic episode and any psychiatric treatment, in which she had periods for "a week or weeks" in which she felt "increased energy," and had a "mild" decrease in sleep, felt "unusually good about herself," "slightly high", "would be a bit more talkative," would have "more distractibility than is typical" for her, and would have an increase in "stupid mistakes." Indeed at a detailed follow-up evaluation she gave a history of bipolar disorder.
Over nine months, the patient had a normal score on her depression scales, without manic symptoms. However, the therapist, husband, and she, reported only "adequate" functioning. For example, she was always late, made careless mistakes with her checkbook and in her childcare responsibilities. She found it hard to sustain attention on household tasks. She was unable to finish a year's training in organizational skills by her therapist. She lost things of significance approximately once a week, e.g., keys, glasses, etc. She was very distracted in our clinical setting and in the report of her therapist and her husband. She continued to fidget mildly. She seemed to always be on the go and would occasionally interrupt people's talking.
At this point, it was felt that she did not have residues of bipolar disorder or an agitated depression, since she did not meet DSM-IV criteria for mania, depression, or an anxiety disorder, but full criteria for ADHD. She was placed on dextroamphetamine 5 mg in the AM, 5 mg at noon, and 2.5 mg in the late afternoon. She initially talked about having some increase in insomnia with the dextroamphetamine, but she habituated to it after a week. Indeed, her third dose was increased to 5 mg, because she felt more irritable from withdrawal after seven days on the medication. That drug increased the patient's productivity strikingly. She was able to accomplish much more, but not in a way felt to be abnormal by husband, mental-health workers or her family. She was cognitively sharper with better impulse control and less distractibility. On the Brown ADD Scale (Adult Version), she showed a striking decrease from many high 2 & 3 scores to virtually all 0's and some 1's, i.e., significantly improved This has continued for approximately seventeen months with the patient experiencing no depression, and no symptoms of ADHD. She, her husband, her therapist and we feel that the success of the treatment has been "striking and profound."
In conclusion, our treatment of her with a mood stabilizer, adding an antidepressant, and finally adding a very low dose of stimulant, seems the best route in such cases. Unfortunately it took many months to uncover or clarify comorbidities, get a more accurate history, and finally to adjust the medications to treat all facets of her comorbidity.
James L. Schaller, M.D., M. A. R.