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Dr. Tim Wilens:
There are a lot of clinical questions about the overlap of bipolar disorder and ADHD. First of all, we know that the rates of ADHD are highest in individuals who have the onset of their bipolar disorder during childhood, and that can include both children or adolescents who have the onset of their bipolar during childhood. The rates of ADHD in those cases are up to 90%. The rates drop to about 50% of kids who have the onset of their disorder in adolescence. And if you're talking about the big group of individuals who have the onset of their bipolar disorder during young adult years, that rate drops closer to about 15%. So it's still higher than the 5% baseline rate, but it's lower.

It's important to distinguish between bipolar and ADHD. Bipolar brings with it manic symptoms, ADHD doesn't. Bipolar brings with it pretty substantial depressive symptoms, whereas ADHD may increase the rate of depression and demoralization, but nowhere near that same rate. Bipolar disorder has a lot more influence, if the environment changes, you'll see more of an effect on the mania. With ADHD, environment is important, but it's more the structure that helps the ADHD. And generally, if you see psychosis, you have to worry more about bipolar disorder than ADHD. And higher rates of symptoms, as well as comorbidity in the bipolar group, compared to the ADHD.

In terms of treatment, it's important to realize that those individuals with bipolar and ADHD will eventually require treatment for their ADHD to really meet and fulfill what is available to them in life. In considering that, it is important, based on the data we have, which is both clinical data and large registry studies, to stabilize the bipolar mood first and then introduce treatment for the ADHD. The stabilization of the bipolar can be done with second generation antipsychotics, mood stabilizers, basically follow guidelines for the treatment of bipolar disorder. And in those individuals, once stabilized, then you can introduce carefully the use of stimulant and non-stimulant medications.

Most of the data have been with stimulant medications and typically show that at lower to moderate doses of stimulants, there isn't activation of the mania, but there is improvement in the ADHD. With some of the non-stimulants, the data are lacking and there is concern about manic activation. Again, slow titration with a careful eye on the outcomes for mania.

Again, I'll end by saying that bipolar and ADHD is a common comorbid condition that really necessitates treatment for, first, the bipolar, and then after stabilization, to ADHD for individuals to really fulfill their potential.