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Kevin Leehey M.D. Child, Adolescent, and Adult Psychiatry Board Certified 520-296-4280 leeheymd.com

Differentiating and Treating Bipolar Disorder and ADHD July 27, 2007 Kevin Leehey M.D.

Differentiating and Treating Bipolar Disorder and ADHD The current # 1 controversy in Child and Adolescent Psychiatry is how to diagnose and treat Bipolar Disorder in youth; especially before puberty.

Differentiating and Treating Bipolar Disorder and ADHD Why does it matter so much?

Bipolar Disorder (BD) BD is frequently a disabling chronic and recurrent life long disorder with a worrisome prognosis. BD medications are “big guns” with variable benefit and side effects. Early onset BD may have worse prognosis. Hard to get health and other insurance. Employment, military, police, and professional licenses are often problems. Genetics and family planning. Stigma

Why does Mania matter so much? The presence of Mania (or Hypomania) changes the diagnosis to Bipolar I or II (with few exceptions) for life.

DSM IV-TR Mania Dx requires 3 Sx of 7 if  elevated mood for 7d, 4 if only irritable mood 1) Inflated self esteem or grandiosity 2) Decreased need for sleep 3) More talkative than usual; pressured speech 4) Flight of ideas or subjective feeling that thoughts are racing 5) Distractibility 6) Increase in goal directed activity 7) Excessive involvement in pleasurable activities with a high potential for painful consequences

ADHD Diagnostic Criteria  Six (or more) of the symptoms of inattention have persisted for at least six-months to a degree that is maladaptive and inconsistent with developmental level Or six (or more) of the symptoms of hyperactivity-impulsivity have persisted for at least six-months to a degree that is maladaptive and inconsistent with developmental level Present before the age of seven.

Inattention : Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) Often has difficulty organizing tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort (such as schoolwork or homework) Often loses things necessary for tasks or activities (ie: toys, school assignments, pencils, books, or tools) Is often easily distracted by extraneous stimuli Is often forgetful in daily activities

Hyperactivity:     Impulsivity: Often fidgets with hands or feet and squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) Often has difficulty playing or engaging in leisure activities quietly Is often “on the go” or often acts as if “driven by a motor Often talks excessively Often blurts out answers before questions have been completed Often has difficulty awaiting his/her turn Often interrupts or intrudes on others (eg: butts into conversations or games)

Differentiating and Treating Bipolar Disorder and ADHD The DSM IV criteria for ADHD and the Manic and Hypomanic phases of Bipolar Disorder overlap thereby making it easier for an ADHD youth to be diagnosed BD; and vice versa.

DSM IV-TR Mania dx requires 3 Sx of 7 if  elevated mood for 7d; 4 if only irritable mood 1) Inflated self esteem or grandiosity 2) Decreased need for sleep 3) More talkative than usual or pressure to keep talking          (“often talks excessively”) 4) Flight of ideas or subjective feeling that thoughts are racing 5) Distractibility 6) Increase in goal directed activity 7) Excessive involvement in pleasurable activities with a high potential for painful consequences

Sources of Controversy Overlapping signs and symptoms Overlapping Diagnostic Criteria Patient sampling errors in research Redefining the syndrome of BD in youth especially pre puberty Youth with both ADHD and BD Youth with ADHD who later develop BD “ADHD” Youth who turn out to have only BD Arguments about the coming DSM V

BP in kids redefined Broad Phenotype, eg, Bipolar  NOS Chronic continuous irritable, anger, or sad Not episodic Often Mixed (simultaneous manic and depressive) signs and symptoms Ultra Rapid Cycling - even multi per day Neither 5d (Hypomania) nor 7d (Mania) nor 14 day (Major Depression) durations required Only 25% have Bipolar as adults ! “Affective storms”, rage, extreme reactivity Hyperarousal, extreme agitation, volatility, intrusiveness, restlessness, lability

Bipolar Disorder Initial presentation in youth is most often Major Depression, not Mania or Hypomania.

Narrow Phenotype Criteria DSM IV-TR  tightly followed “A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least…”

Intermediate Phenotype Criteria BD Same as DSM IV-TR except 5 and 7 day periods not required, 1-3 days enough.  Elevated, expansive not required; irritable is enough.

Differentiating BD and ADHD ADHD earlier onset ADHD is continuous, not episodic DSM IV - TR (Narrow Phenotype) ADHD alone does not include psychosis ADHD alone does not include Major Depression or suicidal ideas or behavior Extreme incapacitating anxiety may indicate BD (ADHD alone doesn’t include  severe anxiety)

Differentiating BD and ADHD Grandiosity, elevated mood, racing thoughts, flight of ideas, and much increased inappropriate behavior (silly, daredevil, sexual), decreased need for sleep, all together indicate BD, not ADHD  Irritablity, rapid speech, high energy, and distractibilty often occur in both ADHD and BD - they do not differentiate. Family History is an important guide. Make the diagnosis over a period of time (unless mania)

Medications for ADHD-1 Stimulants Methylphenidate Short and extended duration Amphetamines Short and extended duration Pemoline (Cylert)

Medications for ADHD-2 Non-stimulants Atomoxetine (Stattera) Tricyclics (Imipramine, Desipramine) Buproprion (Wellbutrin) Partial alpha agonists [Guanfacine (Tenex), Clonidine]

Medications for ADHD-3 Beads/sprinkle Adderall XR, Ritalin LA, Metadate CD, Focalin XR Liquid Methylin, Amantadine (Symmetrel) Chewable Methylin Patch -  Catapres, MPH (Daytrana) Osmotic pressure release -  Concerta Compounding

Prescribing for ADHD-1 Co-morbidity: Depression, anxiety, tics, substances, bipolar, nicotine Height, weight Appetite decrease and low weight is the most common limiting stimulant side effect Class II, no “refills”, 60 days, less on base post, out of state varies, 90 day mail order Match side effects as well as good effects

Prescribing for ADHD-2 Duration Convenience Weight (height less of a concern) Tics “Meaner” Abuse of stimulants Truck driver, pilot

Treating Bipolar Disorder Mood stabilizers Antipsychotics Antidepressants, antianxiety Sleep Stimulants and nonstimulants for ADHD Psychosocial, family, psychoeducation, PCP

Principles in Treating Bipolar Disorder and ADHD If ADHD present, treat ADHD If BD present, treat BD If both present, treat both.  Usually, first stabilize the mood disorder.  Then see what’s needed. Psychosocial treatments also.  School, family, PCP, activities, psychoeducation

Treating Bipolar Disorder Few studies and no specific BD  FDA approved meds pre puberty. We use the same meds as in adolescents and adults. Monitor as adults but extra caution - labs, weight, BMI, (height), AIMS, EKG Assume kids are more sensitive to side effects, pediatric psychopharmacology

Treating Bipolar Disorder Stimulants are not contraindicated but use with caution unless also Mood Stabilizer Antidepressants are not contraindicated but use with caution unless Mood Stabilizer. Atypical Antipsychotics are fast, often help and cover multi targets. We need better medicines ! Don’t neglect developmentally informed psychosocial interventions !

Mood Stabilizers lithium valproic acid (Depakote) carbamazepine (Tegretol) oxcarbazepine (Trileptal) lamotrigine (Lamictal)

Antipsychotics risperidone (Risperdal) quetiapine (Seroquel) ariprazole (Abilify) ziprasidone (Geodon) olanzapine (Zyprexa) clozapine (Clozaril) perphenazine chlorpromazine

Case 1 John is a 7 year old 50 pound boy in his 6th week of taking 10 mg TID (am, noon and 4 pm) of mixed amphetamine salts for presumed ADHD who now shows prominent impulsive rageful aggression with 5 lb weight loss and new 2 hour sleep onset delay. What do you do?

Case  2 Cherie is an 8 year old girl dressed in excessive “jewelry”, gaudy self made purse, and tight teen “fashion” clothes her mother abhors but can’t stop. She has just begun, totally on her own, collecting cash door to door to save the rain forest. She was irritable and very down for 2 months but is now way up. She has always been moody.  Academics, peer and family relationships have suffered.  She’s skipping meals and sleeps 4 hours: “I don’t need to eat or sleep”.  Maternal aunt has BD. What do you do?

Case 3 Connor is a 16 year old in a boarding school for boys with serious substance abuse.  Even in this group he is loud, volatile, and moody.  He calmly tells you he wants off the Trileptal he was given while living at home.  His history is dramatic for athletic skill unfulfilled by consequences for drug use, drug deals, promiscuity, impulsivity, fights and property damage, and impressive risk taking. What do you do?

Case 4 Ann is a 13 year old athlete and dancer who was started on Depakote by her neurologist for seizures (no BD SSx).  In the first month she gained 5 unneeded excess lbs which upsets Ann and her mother.  Her mother, whom you know through the kids’ sports asks your help. What do you do?

Finis Kevin Leehey M.D. 1980 E. Fort Lowell Rd. Suite 150 Tucson, AZ 85719 Phone: 520-296-4280 Fax: 520-296-3835 leeheymd.com kevino@leeheymd.com