How Methylphenidate Might Be Safe in Patients with Both Bipolar Disorder and Attention Deficit/Hyperactivity Disorder

Summary and Comment |
October 5, 2016

How Methylphenidate Might Be Safe in Patients with Both Bipolar Disorder and Attention Deficit/Hyperactivity Disorder

  1. Joel Yager, MD

Prior administration of mood stabilizers may protect these patients from switches to mania, according to an analysis of Swedish registry data.

  1. Joel Yager, MD

Although attention-deficit/hyperactivity disorder (ADHD) has been reported in up to 20% of patients with bipolar disorder, many clinicians are reluctant to treat these patients with stimulants for fear of inducing switches to mania. Research into this topic has been limited. Using data from Swedish national registries, investigators identified patients over age 18 diagnosed with bipolar disorder who received a prescription for initiating methylphenidate between 2005 and 2013 after being presumably stimulant-free for ≥9 months. Mood stabilizers (lithium, anticonvulsants, antipsychotics) were prescribed to 1103 individuals, whereas 718 received no mood stabilizers. Mania was examined in periods on and off methylphenidate.

Mood stabilizer treatment was associated with significantly lower risks for treatment-emergent mania in the first 3 months after starting methylphenidate (hazard ratio [HR], 0.5). Investigators inferred additional cases of treatment-emergent mania by identifying new dispensations of mania-suitable doses of mood stabilizers. When the two mania groups were combined, the relative risks for mania were much higher with methylphenidate monotherapy and much lower with combination treatment (HRs: 0–3 months after starting methylphenidate, 7.7 and 0.6; 3–6 months, 9.7 and 0.9). No interactions between antidepressants and methylphenidate were found regarding risk for mania.

Comment

Presumably, patients not dispensed mood stabilizers prior to methylphenidate were judged to be clinically stable and not then in need of such medications. Although previous studies suggest that stimulants improve ADHD symptoms in bipolar disorder patients, these investigators could not address methylphenidate's effectiveness for ameliorating either ADHD or bipolar depression. Although limited by some diagnostic uncertainties (e.g., regarding childhood- versus adult-onset ADHD), this study's findings should at least reassure clinicians that administering methylphenidate to patients with bipolar disorder who are mood stabilized is unlikely to provoke treatment-emergent mania.

Editor Disclosures at Time of Publication

  • Disclosures for Joel Yager, MD at time of publication Editorial boards Bulletin of the Menninger Clinic; Eating Disorders Review (Editor-in-Chief Emeritus); International Journal of Eating Disorders; UpToDate; FOCUS: The Journal of Lifelong Learning in Psychiatry

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