Treatment for Bipolar Disorder with Comorbid ADHD and Substance Abuse

Initial Treatment Priorities

Mood stabilization is the primary goal before addressing ADHD or substance use, according to the American Academy of Child and Adolescent Psychiatry 1, 2
Bipolar symptoms should be controlled with appropriate mood stabilizers (lithium, valproate, or atypical antipsychotics), as recommended by the American Academy of Child and Adolescent Psychiatry 1, 3
Lithium maintenance therapy is important as withdrawal is associated with increased risk of relapse, as noted by the American Academy of Child and Adolescent Psychiatry 1
Medication trials should be systematic with 6-8 week trials of mood stabilizers at adequate doses before adding or substituting others, according to the American Academy of Child and Adolescent Psychiatry 1
Regular monitoring of symptoms, side effects, and laboratory values is essential, as recommended by the American Academy of Child and Adolescent Psychiatry 1

Stimulants may be used for ADHD symptoms ONLY after mood symptoms are adequately controlled with mood stabilizers, as recommended by the American Academy of Child and Adolescent Psychiatry 1, 2
Low-dose mixed amphetamine salts have been shown safe and effective for treating ADHD in bipolar patients once mood is stabilized with divalproex, according to the American Academy of Child and Adolescent Psychiatry 1, 2
Non-stimulant options like atomoxetine may be considered, but the American Academy of Child and Adolescent Psychiatry notes that they carry a modest risk of triggering manic switches is not a cited fact, however non-stimulants (atomoxetine, clonidine, guanfacine) may be preferable first-line options in patients with comorbid substance use disorders, as recommended by Pharmacology and Therapeutics 4

Acamprosate, disulfiram, or naltrexone should be offered as part of treatment to reduce relapse in alcohol dependence, as recommended by PLoS Medicine 5
Cognitive Behavioral Therapy (CBT) combined with pharmacotherapy is more effective than usual care for substance use disorders, according to JAMA network open 6

Begin with mood stabilizer (valproate preferred if alcohol abuse is present) and ensure adequate dose and duration (6-8 weeks) before adjusting treatment, as recommended by the American Academy of Child and Adolescent Psychiatry 1, 2
Add naltrexone or acamprosate for alcohol dependence, as recommended by PLoS Medicine 5
Implement CBT focused on substance use, according to JAMA network open 6

Regular assessment of mood symptoms, substance use, and ADHD symptoms is essential, as recommended by the American Academy of Child and Adolescent Psychiatry 1
Monitor for medication interactions and side effects, according to the American Academy of Child and Adolescent Psychiatry 1
Long-term maintenance therapy is often needed, with some individuals requiring lifelong treatment, as noted by the American Academy of Child and Adolescent Psychiatry 1

Discontinuing mood stabilizers prematurely can lead to high relapse rates (>90% in non-compliant patients), as warned by the American Academy of Child and Adolescent Psychiatry 1