Treatment of a Case of Comorbid Bipolar Disorder and Attention-Deficit/Hyperactivity Disorder

SIR: We successfully treated a 33-year old woman for both bipolar disorder (BD) and attention-deficit/hyperactivity disorder (ADHD). Her case shows the need for a careful genetic evaluation, longitudinal diagnostic reevaluation, and, perhaps most important, a proposed pharmacology protocol for those with both BD and ADHD.

In one pilot study, which investigated the families of children with mania, it was concluded that there was familial evidence for the validity of bipolar disorder and ADHD comorbidity in children. Further, it was suggested that the comorbid condition of ADHD and bipolar disorder may be a distinct nosological entity.^1,2

We feel that our extensive evaluation of our patient's family history provided clues that she was vulnerable to BD; unfortunately, she learned key parts of this history only long after her intake. The patient has a number of relatives with cycling mood disorders; for example, her brother has schizoaffective disorder and her alcoholic father suffers from “anxiety and severe depression” and has intermittent irritable mood, decreased sleep, and other symptoms that meet DSM-IV criteria for hypomania. Her paternal aunt has bipolar II disorder, and a paternal great-grandmother had periods of “moodiness and breakdowns” with irritability, and reportedly for no reason “picked fights and threw dishes.”

Further, the patient's son was originally diagnosed with ADHD 3 years ago, but on only 5 mg of methylphenidate he became profoundly euphoric and sleepless, with psychomotor agitation and worse hyperactivity. A low dose of sertraline (12.5 mg) caused him to become totally sleepless, more irritable, nonfunctional in school and at home, and profoundly oppositional. Subsequently, off all medications, he had periods of inappropriate euphoria, hypersexuality, and decreased sleep need (4 hours less than the standard for his age). His best behavior so far has come in response to therapeutic levels of lithium. Presently, he appears to have both a bipolar and an ADHD disorder.

When his mother, our patient, was initially asked about manic criteria, she clearly said she had never had a manic experience. The mother met criteria for ADHD as determined by the Wender Utah Rating Scale³ and the Barkley Semistructured ADHD Interview for Adults.⁴ She also met full DSM-IV criteria for ADHD from clinical history, having a lifelong history of inattention, careless mistakes, distractibility, poor follow-through, poor organization, regularly losing things, constantly being forgetful in her daily activities, being fidgety, and talking slightly excessively. The patient was also diagnosed at this point with major depression (Beck Depression Inventory [BDI] score of 30), with a significant anxiety component (Beck Anxiety Inventory [BAI] score of 51). She was placed on 30 mg of paroxetine, which caused a significant decrease in her depression. She was also placed on clonazepam, with a decrease in her anxiety. Indeed, on the paroxetine, her score on the Inventory to Diagnose Depression (IDD) became normal (10), and her anxiety fell to a mere 4 on the BAI on clonazepam 0.125 mg in the morning and 0.25 mg at bedtime. Yet she remained forgetful, scattered, and troubled with procrastination. Her distractibility was still significant.

She was treated with low-dose dextroamphetamine for comorbid ADHD, with eventual increase to 15 mg in the morning and 12.5 mg at noon. These doses, she felt, caused her to be focused during the first 2 weeks. Then she became more “energized” and was “in a daze,” her dressing deteriorated, and she had tremendous amounts of energy for housecleaning.

She continued to meet full criteria for bipolar-manic disorder for 2 weeks despite taking no dextroamphetamine or paroxetine. After 2 weeks out of town, she returned to treatment and was started on valproic acid sprinkles; 500 mg/day gave her a blood level of 72 units. Her symptoms remitted.

A month later the patient became depressed. She received regular bupropion 75 mg in the morning, 75 mg at noon, and 150 mg at bedtime. This dose completely ameliorated her depression and did not cause recurrence of her manic symptoms in the presence of valproic acid.

At this point, she recalled times before her clear manic episode and any psychiatric treatment in which she had periods of “a week or weeks” in which she felt “increased energy” and had a “mild” decrease in sleep, felt “unusually good about herself” and “slightly high,” would be “a bit more talkative,” would have “more distractibility than is typical” for her, and would have an increase in “stupid mistakes.” Her recall of these feelings illustrates that sometimes patients recall a manic history after a more dramatic and severe manic episode.

Over 9 months, the patient had a stable mood. However, the therapist, patient, and patient's husband reported only “adequate” functioning. She did not meet DSM-IV criteria for mania, depression, or an anxiety disorder, but she did meet full criteria for ADHD.

She was placed on dextroamphetamine 5 mg in the morning, 5 mg at noon, and 2.5 mg in the late afternoon. She initially talked about having some increase in insomnia with the dextroamphetamine, but she habituated to it after a week. Indeed, her third dose was increased to 5 mg because she felt irritable from withdrawal after 7 days on the medication. That drug increased the patient's productivity strikingly. She was able to accomplish much more, but not in a way that was felt to be abnormal by her husband, mental health workers, or her family. She was cognitively sharper, with better impulse control and less distractibility. On the Brown ADD Scale (Adult Version),⁵ she showed a striking decrease from many high 2 and 3 scores to virtually all 0's and some 1's; that is, she significantly improved. This status has continued for approximately two years, with the patient experiencing no depression and no symptoms of ADHD. She, her husband, her therapist, and we feel that the success of the treatment has been striking and profound.

Our treatment of this patient by beginning with a mood stabilizer, adding an antidepressant, and finally adding slowly a very low dose of stimulant seems the best route in such cases. Unfortunately, it took many months to uncover or clarify comorbidities, get a more accurate history, and finally adjust the medications to treat all facets of her comorbidity.