3/2019

Bipolar disorder and ADHD can occur together. In younger kids, those who have bipolar disorder almost always also meet criteria for ADHD. That means one has to look “underneath” ADHD to see if bipolar disorder is there also. That’s the most important idea on this page.

Next idea: treatment differs. If bipolarity is also part of the picture — which can be extremely difficult to determine — then routine treatment for ADHD is not sufficient. Indeed it may be harmful.

Last idea: relax, a little. The diagnostic issues roll out one at a time. Usually you don’t have to take them on all at once.

Bipolar, ADHD, or both? Simple solutions.

You don’t have to agonize about this, even though the distinctions are very difficult — because the treatments are few, and the order in which to try them is often fairly clear.

Diagnose and treat ADHD first

ADHD has rating scales that are generally accepted. You don’t have to guess. The scales aren’t perfect, but they’re pretty good.  Meaning: if the scale says “no, not ADHD” you can’t write off that possible diagnosis. Likewise, if the scale says “yes, ADHD” that’s not a firm diagnosis either, just a strong endorsement of the idea.

Since one can grow out of ADHD, and since the treatments are usually thought less risky than those for “bipolar”, okay fine: start by looking for ADHD. If ADHD is probable, then unless bipolarity is also obvious, go ahead and treat the ADHD. If things get better, great!

Unless bipolar is prominent, as well as ADHD

What makes bipolar stick out, underneath ADHD?

  1. Cyclicity: symptoms come and go. Maybe never really gone, but it’s highly variable.
  2. Family history: if someone in the family has a mood problem, especially a complicated one, keep considering bipolarity (as well as ADHD).
  3. Sleep: ADHD doesn’t mess with sleep, too much. Bipolarity does, big time: difficulty falling asleep (“my mind won’t shut off”), staying asleep, and waking up too early (or at times, intermittently, profound difficulty waking up).
  4. Mood is also an issue: not just moody (after all, we’re talking about adolescence here, yah?), but major swings in mood and energy. If “depression” is also present, especially in phases, bipolarity is much more likely.
  5. Anxiety is severe, and wasn’t there before. Wait, bipolarity is associated with anxiety? Yep. In kids, anxiety plus ADHD increases the chance of bipolar disorder showing up by a huge percentage. Anxiety has many causes; bipolarity is one of them (see Mixed States).
  6. Getting worse on ADHD treatment. More aggressive, more irritable, more sleep disturbance, more agitation; more “racing thoughts”, which can show up as distractibility and inability to concentrate (looks like ADHD, right? But it got worse instead of better on the ADHD treatment)

If you’re not sure, treat the ADHD first. But keep an eye out for worsening. And if things don’t get better, wonder some more, especially if several of the above are present!

Bipolar treatments are not so scary

If bipolar and ADHD are present, mood specialists generally agree: treat the bipolar first. That doesn’t mean going straight to the big guns (the so-called antipsychotics, a scary term all by itself.). Learn about non-medication approaches, including lamotrigine, and very-low-dose lithium. See my Treatment page: all of these are starting points unless bipolar disorder is obvious and severe.

Common bipolar-ADHD questions

A. Can stimulants make bipolar disorder worse? 

Yes, unless a mood stabilizer is already underway. In that case, stimulants inducing manic symptoms is remarkably uncommon (reference).

B. Can bipolar treatments help with ADHD? 

Yes. Indeed, many patients’ ADHD symptoms will disappear or become very manageable when their bipolar symptoms are controlled. This is the basis of the usual treatment mantra: “treat the bipolar first”. If ADHD symptoms are still present, after a mood stabilizer regimen is working (no cycling of mood or energy), then consider a stimulant.