Bipolar disorders with ADHD

Offspring of parents with bipolar disorder have an almost three fold increased risk for developing a mental disorder, and a fourfold risk for an affective disorder, as compared to the offspring of parents with no mental disorder (LaPalme et ah, 1997). Families of patients with early-onset bipolar disorder have higher than expected rates of substance abuse, unipolar depression, antisocial personality, and comorbid bipolar disorder with ADHD. Biederman et al. (2000) have concluded that this comorbid bipolar plus ADHD condition is familial, as evidenced by the fact that the two conditions... 

For the expert, can occasionally combine with atypical antipsychotics in highly treatment-resistant cases of bipolar disorder or ADHD... 

Case 1 A 57-year-old female with bipolar disorder and ADHD, previously with multiple failed drug trials had IV ketamine twice weekly. After the third infusion, symptoms were starting to resolve however, relapse occurred at 10 days. IM ketamine (0.5-0.8 mg/ kg) was then administered daily which achieved complete resolution after 2-3 days. After five months there was a partial relapse which was treated by a dose escalation to 70 mg daily. She is currently functional but... 

Case 2 A 48-year-old female with bipolar disorder and ADHD and multiple drug failures. She tried oral ketamine with no effect and then was administered 50 mg intramuscularly every three da). There was improvement in one week and a partial relapse was treated with adjuvant bupropion. S5rmptoms have much improved over a six month period. Mild side effects were observed of headaches and irritability. 

Starting Treatment in Children. The importance of an accurate diagnosis confirmed by obtaining information from multiple sources cannot be overstated. The mainstay of treatment for ADHD, psychostimulants, are less helpful for the other disruptive behavior disorders of childhood and may worsen the course of bipolar disorder in patients misdiagnosed with ADHD. 

One of the major limitations in studies of the genetics of behavioural disorders in children arises from the overlap with other conditions. For example, nearly 50% of the patients with ADHD also have co-morbid conduct disorders. In addition, a subtype of the disorder may exist in those children in which the disorder persists into adulthood. An additional problem arises from the overlap between ADHD and bipolar disorder this has been estimated to be as high as 16%. 

Controlled studies involving lipid manipulation in children date back to the 1920s, when the ketogenic diet was pioneered to control treatment-resistant seizures in select pediatric populations (Freeman et al., 1998). However, no controlled evidence is available in children with depression, bipolar disorder, behavioral problems, or ADHD. In the absence of definite empirical data about effectiveness, treatment with EFA supplements should be considered unproven and patients ought to be advised accordingly. 

If relapse does occur, it should first be determined whether the patient was compliant with treatment. If the patient was not compliant, antidepressant medication should resume. If the patient was compliant and had been previously responding to the medication (without significant side effects), the existence of ongoing stressors (e.g., conflict, abuse) or comorbid medical or psychiatric disorders should be considered (anxiety disorder, ADHD, substance abuse, dysthymia, bipolar disorder, eating disorder). 

An emerging literature suggests that treatment of psychiatric illness may reduce the risk of developing SUD later in life. The findings are most dramatic for stimulant therapy of ADHD, as several studies have observed decreased SUD rates in children whose ADHD was treated with stimulants, compared to ADHD children who received no such treatment (Biederman et ah, 1999 Toney et ah, 1999 Molina et ah, 1999). There is also preliminary evidence that treatment of bipolar disorder can reduce future substance use (Wilens et ah, 2000). While these findings are encouraging, further research is needed to support the initial data and to... 

These authors also found that 65% (New York) and 67% (Ohio) of the sampled medicated patients who received an antipsychotic prescription were not diagnosed with a psychotic disorder. Similarly, 0% and 20% of the sampled medicated patients who received a stimulant medication were not diagnosed with ADHD, and 27% and 42% of the sampled medicated patients who received antidepressants were not diagnosed with major depression, dysthymia, bipolar disorder, or related conditions. In discussing the appropriateness of the medication treatments in the survey, the authors concluded that approximately 10% of the treatments in each sample were deemed inappropriate. 

On average, symptom severity diminishes by 50% every 5 years between the ages of 10 and 25 years (55, 56). Hyperactivity declines more quickly than impulsivity or inattentiveness. However, symptoms of the condition persist into adulthood in many cases. The strongest predictors of symptomatic persistence are psychiatric co-morbidity, particularly with conduct or bipolar disorder and a family history of ADHD or substance abuse ( 57). A prospective study followed up a cohort of patients older than 16 years old with persistent ADHD symptoms and an age-matched control group and found an 11-fold increase in ongoing ADHD symptoms, a nine-fold increase in antisocial personality disorder, and a four-fold increase in substance abuse ( 58). 

The relationship between ADHD and substance abuse disorders is complex. There is no increased risk of substance abuse in ADHD patients relative to age-matched control subjects younger than 14 years old (41). Persistence of significant ADHD symptoms beyond 16 years of age coupled with both a family history of ADHD and substance abuse are significant risk factors for subsequent substance abuse. These patients frequently have co-morbid conduct or bipolar disorder. 

FIGURE 10-5. Aggressive symptoms and hostility are associated with several conditions in addition to schizophrenia, including bipolar disorder, attention deficit hyperactivity disorder (ADHD) and conduct disorder (conduct dis.), childhood psychosis, Alzheimer s and other dementias, and borderline personality disorder, among others. 

In terms of approved medical use, the neuroleptics are often prescribed for children with autism, attention-deficit hyperactivity disorder (ADHD), and Tourette s syndrome. In addition, the popularity of the newer atypical neuroleptics for childhood bipolar disorder is growing rapidly, and sometimes these drugs are the only treatment offered. The neuroleptics are also commonly prescribed for the elderly in nursing homes or other insti-... 

Thus, administer with caution to ADHD patients who may also have bipolar disorder... 

Some ADHD patients and some depressed patients may experience lack of consistent efficacy due to activation of latent or underlying bipolar disorder, and require either augmenting with a mood stabilizer or switching to a mood stabilizer... 

Methylphenidate shares the pharmacological properties and the abuse potential of the amphetamines. When given intravenously, it activates psychotic symptoms in schizophrenic patients if administered during the active phase of their illness, but not after remission. It failed to produce a psychotic reaction in most manic or depressed patients or in healthy subjects (27). Adults with childhood-onset ADHD had an earlier onset of psychoactive substance use disorders, independent of any psychiatric co-morbidity (33). However, bipolar disorders conferred a significantly increased risk for early onset psychoactive substance use disorders independent of ADHD. The question arises as to the contribution of stimulant treatment to psychoactive substance use disorders. There were no differences in medicated versus unmedicated adolescents with ADHD in a review of eight outcome studies comprising 580 adolescents briefly treated with stimulants for six months to five years (34). 

Some studies have reported associations of serotonin receptor variants with clinical phenotypes. Cys23Ser and Gly22Ser 5-HTiA receptor variants, for example, have been associated with phenotypes such as intractable suicidal ideation [98], ADHD [100], bipolar disorder, and schizophrenia [98, 99, 109-116] and the -1348 A/G polymorphism of the 5-HT receptor has been associated with schizophrenia, eating disorders, and psychotic symptoms in Alzheimer s patients [94, 100, 117, 118], although these associations are not consistent across different studies. 

It is critical to clarify the diagnosis of ADHD in individuals with these symptoms. Inattention and distractibility can be symptoms of an anxiety disorder, depression, or bipolar disorder. - In other cases, these anxiety or mood disorders can coexist with ADHD, just as learning deficiencies and conduct or oppositional disorders are common comorbid conditions. The presence of multiple comorbid conditions, particularly conduct or oppositional disorder, may increase the likelihood of ADHD chronicity. ... 

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