Questions

Can ADHD medications worsen bipolar disorder?

By Charles Li, MD

December 15, 2022

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Studies have linked ADHD medication with manic episodes in individuals with Bipolar Disorder.

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As a result, the FDA has placed a warning on Adderall, Ritalin, and Strattera regarding risks in patients with Bipolar Disorder.

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With proper supervision and treatment of Bipolar Disorder, much of this risk can be mitigated.

ADHD is typically treated with a stimulant medication or atomoxetine, a non-stimulant.

Each of these medications has been linked to specific risks in patients who have bipolar disorder.

With stimulants, doctors are primarily concerned with causing manic episodes in patients with bipolar disorder.

The FDA has placed a warning label on Adderall, alerting clinicians to the risk of causing manic episodes in bipolar patients.

This risk is concerning enough that the warning recommends screening patients with depressive symptoms to see if they have Bipolar Disorder that they may not be aware of yet.

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Particular care should be taken in using stimulants to treat ADHD patients with comorbid bipolar disorder because of concern for possible induction of mixed/manic episode in such patients. Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.

Adderall XR Label

A manic episode is one of the key defining features of Bipolar Disorder. It’s characterized by an elevated or irritable mood and goal-directed behavior for at least one week, nearly every day:

A manic episode is a distinct period where one experiences an abnormally elevated or irritable mood and goal-directed behavior, for at least one week, nearly every day.

What is mania?

Ritalin and the risk of mania

One study estimated that an individual with bipolar disorder who takes Ritalin for ADHD has a nearly 7-fold greater risk of mania, if taken alone.

This finding tells us that Ritalin can cause mania in individuals with ADHD.

The same study also found that when Ritalin was given with a mood stabilizer, individuals had a slightly lower risk of mania than before treatment, suggesting that Ritalin can be safely administered as long as it was given with a mood stabilizer.

Adderall and mania risk

A separate study below showed that Adderall did not increase mania risk or symptoms in children with bipolar disorder if given along with a mood stabilizer. This finding is consistent with the Ritalin study above.

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For the 30 subjects who entered the placebo-controlled crossover trial, mixed amphetamine salts was significantly more effective than placebo for ADHD symptoms. No significant side effects or worsening of manic symptoms was observed...Pediatric patients with bipolar disorder and concurrent ADHD can be safely and effectively treated with mixed amphetamine salts after their manic symptoms are stabilized with divalproex sodium.

Scheffer et al, 2005

Like Ritalin, Adderall can be a treatment option for ADHD in Bipolar Disorder.

In fact, some experts recommend using it as a potential treatment for Bipolar Disorder symptoms if other medications don't work, though this view remains controversial:

Perugi et al. Current Psychiatry Reports, 2017

"Several international guidelines indicate stimulants, including methylphenidate (MPH), amphetamines and derivatives, modafinil, and armodafinil among the second-third-line choices for bipolar depression...In spite of these preliminary observations, the use of stimulants in bipolar patients is still controversial. Potential of misuse and abuse and mood destabilization with induction of (hypo)manic switches, mixed states, and rapid cycling are the concerns most frequently reported."

Strattera and Bipolar Disorder

Strattera is an SNRI commonly prescribed for ADHD. It comes in a capsule with doses ranging from 10mg to 100mg. It can increase the risk of suicidal ideation in children and adolescents. The side effects of Strattera include nausea, fatigue, constipation, decreased appetite, and sleep dysfunction.

Strattera is a non-stimulant medication used for ADHD. While it has a different mechanism of action than Ritalin or Adderall, some data suggest that it may worsen Bipolar Disorder symptoms as well.

There have been several cases of hypomania reported as a result of Strattera in patients with bipolar disorder:

Kumar et al, Indian J Psychol Med

"Here, we report induction of hypomania by atomoxetine when used for the treatment of comorbid ADHD in a BD patient while on prophylactic treatment with mood stabilizers. This report indicates that atomoxetine carries the risk of induction of (hypo) mania even in stabilized BD patients. Clinicians should closely monitor such patients for (hypo) mania symptoms."

Perugi et al, 2015. Expert Opin Pharmacother

ATX may be effective in the treatment of ADHD symptoms in BD patients, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers.

While these case reports don’t tell us how frequent or how strong the link between Strattera and hypomania might be, they do alert us to potential risks that should be weighed with the benefits of Strattera in individuals who may have Bipolar Disorder:

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In general, particular care should be taken in treating ADHD in patients with comorbid bipolar disorder because of concern for possible induction of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with STRATTERA, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.

Strattera Prescribing Information