Treatment of Comorbid Bipolar Disorder and ADHD

Critical Treatment Sequencing

The American Academy of Child and Adolescent Psychiatry recommends stabilizing bipolar disorder first with a mood stabilizer before addressing ADHD symptoms, then adding stimulant medication or atomoxetine once mood is controlled 1, 2
Mood stabilization must be achieved before initiating any ADHD treatment, as treating unstabilized bipolar disorder with ADHD medications significantly increases the risk of mood destabilization and can trigger manic or mixed episodes 3

The American Academy of Child and Adolescent Psychiatry suggests initiating treatment with lithium or divalproex as first-line mood stabilizers 1, 2
Maintaining the mood stabilizer regimen for 12 to 24 months minimum is recommended, as most youths with bipolar disorder require ongoing medication therapy to prevent relapse 1, 2

Once mood symptoms are adequately controlled on a mood stabilizer regimen, stimulant medications may be added for ADHD symptoms, with low-dose mixed amphetamine salts being safe and effective for comorbid ADHD once mood is stabilized with divalproex 1, 2
Atomoxetine is the preferred first-line ADHD medication for patients with concerns about mood destabilization or substance abuse history, providing effective symptom control without exacerbating mood instability 3

The American Academy of Child and Adolescent Psychiatry recommends continuing the mood stabilizer regimen indefinitely while treating ADHD, as the use of stimulants for comorbid ADHD does not affect relapse rates when mood stabilizers are maintained 1, 2
Over 90% of adolescents who were noncompliant with lithium treatment relapsed, compared to 37.5% relapse rate for those compliant with treatment 1, 2

Assessing atomoxetine effectiveness after 6-8 weeks at therapeutic dose using standardized ADHD rating scales is recommended 3
Regular monitoring of lithium levels, renal and thyroid function, and urinalyses once stable dose obtained is necessary 1

Never initiate ADHD treatment before achieving mood stability, as this significantly increases risk of mood destabilization 3
Do not assume a single medication will treat both conditions effectively, as comorbid ADHD predicts poorer response to bipolar treatment, necessitating adequate mood control first before addressing ADHD symptoms 1, 2, 3, 4