The Challenge of ADHD and Bipolar

Bipolar disorder and attention-deficit hyperactivity disorder (ADHD) have overlapping clinical symptoms. Both disorders are associated with impulsive decision making, physical hyperactivity, mood reactivity, difficulty with sustained focus, among other symptoms.

The challenge of distinguishing between two conditions with similar presentations can cause delays in treatment, inaccurate diagnosis, adverse reactions to treatment, and needless suffering.

Approaches to treatment are quite different for the two conditions, which highlights the importance of accurate diagnosis.

In addition to overlapping symptoms, both conditions have significant variability in clinical presentation (bipolar includes bipolar 1 and 2, mixed mood symptoms, hypomania, mania, depression; and ADHD includes presentations with primarily inattentiveness or hyperactivity or both) and clinicians may be called upon to diagnose these conditions anywhere between early childhood and adulthood.

Adding to the difficulties, adult ADHD is often missed during clinical evaluation.

Finally, a significant number of people may have both conditions. In studies, almost 60% of children with ADHD also have a mood disorder (although not necessarily a bipolar disorder). And nearly 10% of bipolar patients are found to also have ADHD.

If both conditions are present, bipolar symptoms should be treated first. ADHD symptoms tend not to respond well to treatment unless bipolar symptoms are well treated.

Symptoms that overlap in both bipolar and ADHD include distractibility, impulsivity, increased talkativeness, increased motor activity, physical restlessness, and disinhibited social behavior. However, mood dysregulation in bipolar disorder is more likely to be episodic and cyclic in nature.

Family history is more significant for mood disorders in bipolar disorder, and inattention and distractibility predominates in family history for ADHD patients.

Patients with bipolar disorder experience less need for sleep compared to variable and less disruptive sleep in ADHD.

Psychosis, euphoria and grandiosity, when present, is predominantly seen in bipolar disorder.

Treatment of ADHD and Comorbid Bipolar Disorder

  • Treat bipolar symptoms first and if ADHD symptoms persist, titrate ADHD medications carefully.
  • It may be safe to use stimulants if bipolar symptoms respond well to a mood-stabilizing agent.
  • Stimulant use requires ongoing monitoring as it may destabilize the mood disorder.

A good practice is that when attention and impulsivity issues are the prominent symptoms in someone with bipolar disorder, a thorough assessment for ADHD is warranted, no matter what the age of the individual.

The reverse is equally true. In patients with known ADHD, presence of repeated and chronic mood dysregulation should prompt a full investigation for the absence or presence of a mood disorder.

Suspicion for the presence of bipolar disorder is further elevated when there is presence of a first degree family relative with bipolar disorder, and onset of mood symptoms occurred early in life.

Similarly, episodic aggressive behavior with episodic mood liability, particularly when combined with psychotic features (presence of delusions/hallucinations during mood episode) with decreased need for sleep coinciding with maintenance of high energy is consistent with bipolar disorders.


Dilsaver SC, et al. “Occult mood disorders in 104 consecutively presenting children referred for the treatment of attention-deficit/hyperactivity disorder disorder in a community mental health clinic.” J Clin Psychiatry. 2003; 64(10):1170–1176; 1274–1276.

Nierenberg AA, et al. “Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants.” Biol Psychiatry. 2005; 57(11):1467-73.
Robertson HA, et al. “No evidence of attentional deficits in stabilized bipolar youth relative to unipolar and control comparators.” Bipolar Disord. 2003; 5(5):330–339

Duffy A, et al. “The nature of the association between childhood ADHD and the developmen of bipolar disorder: preview of prospective high-risk studies.” Am J Psychiatry. 2012; 69 (1): 1247-55.

McIntyre RS, et al. A 3-week, randomized, placebo-controlled trial of asenapine in the treatment of acute mania in bipolar mania and mixed states. Bipolar Disord. 2012; 11(7):673-86.

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Adult ADHD