The Safety of Stimulants for Treating Bipolar Disorder and ADHD

In people who have comorbid ADHD and bipolar disorder, treating both conditions leads to the best outcome, but deciding whether to use stimulants to treat ADHD in people with bipolar can be complicated. The prevailing concern has been that stimulants can de-stabilize a person with bipolar and, while this is a valid concern for people who are not on optimized mood stabilizers, recent research suggests the risk may be low for bipolar patients whose symptoms are well-managed with medication.

The study that’s frequently cited to justify the use of stimulants in stabilized bipolar disorder is the Swedish National Registry, which involved 2,300 patients over the course of 8 years.1 These were patients who were admitted into the hospital for mania or a change in their mood-stabilizing medication. They were studied from zero to three months, and then from three to six months. This is important because if you add in even a short-acting medication like a stimulant, the effect of that medication on the stability of the patient may not become evident right away.

The study found that, for people with bipolar and ADHD, when methylphenidate was added in:

The Canadian Network for Mood and Anxiety Treatment and the International Society for Bipolar Disorder put the same recommendations in their 2018 guidelines, saying that stimulants may be used for ADHD in stable youth with bipolar taking optimal doses of anti-manic medication. Within controlled trials, both mixed amphetamine salts and methylphenidate were well tolerated and shown to be effective in addressing symptoms of ADHD in these people.2

A study published in Current Psychiatry Reports conducted by a research group in Italy also concluded that in patients with comorbid ADHD and bipolar, the bipolar should be treated first. Unless mood stabilizers are optimized first, stimulants are not recommended in patients with comorbid ADHD and bipolar.3

We understand from this that international researchers are looking at different data sets, bringing to bear different clinical experiences, and coming to the same conclusion. Certainly, we need further studies, but this offers preliminary evidence that stimulants may not destabilize bipolar ADHD patients who are on optimized mood stabilizers.

In my clinical practice, I stabilize the bipolar disorder first, then evaluate the cognitive aspects of the patients’ ADHD, before proceeding with treatment of ADHD. It’s important to re-visit the cognitive symptoms after optimizing the bipolar treatment because, if a patient has untreated bipolar disorder and untreated ADHD, there will be cognitive deficits that are attributable to both disorders, not just the ADHD. Once you stabilize the bipolar disorder, you’ll see what residual ADHD cognitive symptoms remain. That’s when you establish your target ADHD symptoms and treat accordingly with stimulants, starting low and going slow for best results.

The content for this article was derived, in part, with permission from “ADHD, Bipolar and Substance Use: Translating Data from Clinical Data into Your Practice.” presented by David Goodman, M.D., LFAPA at the APSARD 2023 Annual Conference.

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