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Stimulants and Stabilizers for ADHD and Bipolar Disorder

Stimulant use did not appear to worsen mania, but it did improve ADHD symptoms in children with hyperactivity and bipolar disorders.

In a recent chart-review study (Journal Watch Psychiatry Oct 6 2004), pediatric patients with bipolar disorder and attention deficit hyperactivity disorder had poor outcomes after treatment with mood stabilizers. In a new study, researchers investigated whether adding treatment with stimulants to treat the comorbid ADHD would improve outcome.

Forty subjects with the two disorders (mean age, 9 years) were treated openly with divalproex for 8 weeks (mood-stabilization phase). The 32 subjects (80%) who had at least a 50% decrease in mood-scale scores then entered into a randomized, double-blind, crossover trial of add-on mixed amphetamine salts (10 mg/day) or placebo; each crossover arm lasted 2 weeks. After the crossover phase, the researchers conducted a 12-week follow-up phase with open treatment using both medications to determine longer-term safety and efficacy.

At the end of the mood-stabilization phase, three subjects (7.5%) met criteria for ADHD response, compared with 26 (89.6%) after the crossover phase. In the crossover phase, mania ratings did not differ significantly between the amphetamine and placebo arms. During the follow-up phase, the mean amphetamine dosage increased to 14.5 mg/day. Only one subject experienced a worsening of mania, and the mania reversed when amphetamine was discontinued.

Comment: Previous concerns about the possibility of worsening mania with stimulant use were largely based on case reports and retrospective studies and on the theory that psychotic behaviors might worsen by using stimulants that in part block dopamine reuptake at the transporter, thus increasing available dopamine. The compelling findings of the current study support considering the use of stimulants in addition to mood stabilizers for children who have symptoms of both bipolar and hyperactivity disorders.

— Barbara Geller, MD

Published in Journal Watch Psychiatry February 24, 2005

Citation(s):

Scheffer RE et al. Randomized, placebo-controlled trial of mixed amphetamine salts for symptoms of comorbid ADHD in pediatric bipolar disorder after mood stabilization with divalproex sodium. Am J Psychiatry 2005 Jan; 162:58-64.

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