Evidence-Based Reviews

Stimulants for adult bipolar disorder?

Current Psychiatry. 2008 November;7(11):33-45

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Administration. Start stimulants only when bipolar illness is well-stabilized, especially regarding manic symptoms. We highly caution against using stimulants in patients with manic or hypomanic symptoms, including mixed states. We recommend not using stimulants in patients with:

clinically significant insomnia or sleep fragmentation
active suicidal ideation or psychotic symptoms, particularly if associated with manic symptoms.

Clinical Point

See patients every other week (at least initially) to assess for the emergence of stimulant-related adverse effects

The evidence does not clarify how well patients with bipolar disorder tolerate stimulants and what subtypes or phenotypes—bipolar I, bipolar II, not otherwise specified, rapid cycling, etc.—are associated with a better or worse clinical outcome. Therefore, when starting stimulants, use the minimum available dose of whatever stimulant you select and titrate slowly. Always use stimulants with a mood stabilizer, which may attenuate stimulants’ undesirable effects on mood and behavior.^26,27

Schedule frequent office visits when prescribing stimulants. At least initially, see patients every other week to assess for the emergence of adverse events.

Table 4

6 recommendations when using stimulants in bipolar disorder

Carefully assess patient’s symptoms	Manic symptoms vs ADHD; medical conditions such as thyroid disorders, diabetes, or sleep apnea
Review possible iatrogenic causes of symptoms	Somnolence, decreased energy/fatigue, sedation, difficulty with concentration/focus
Engage patient in the therapeutic process	Discuss risks and benefits; monitor mood with life charts; enlist help of family, significant others when appropriate
Use caution in clinical scenarios that may herald adverse response to stimulants	Manic/hypomanic symptoms; sleep disturbances; psychosis; history of substance abuse
Administer stimulants with caution	Start low and go slow; always use stimulants in conjunction with a mood-stabilizing agent; be aware of possible interactions with patient’s other medications; schedule more frequent visits when starting stimulants
Monitor for adverse events associated with stimulant administration	Manic symptoms, changes in cycling patterns, sleep disturbances, substance abuse
ADHD: attention-deficit/hyperactivity disorder

Related resources

The Texas Medication Algorithm Project. Texas Department of State Health Services. www.dshs.state.tx.us/mhprograms/tmapover.shtm.
The Cochrane Collaboration. www.cochrane.org.

Drug brand names

Amphetamine and dextroamphetamine • Adderall
Aripiprazole • Abilify
Bupropion • Wellbutrin
Carbamazepine • Tegretol
Citalopram • Celexa
Clozapine • Clozaril
Dexmethylphenidate • Focalin
Dextroamphetamine • Dexedrine, DextroStat
Diazepam • Valium
Divalproex sodium • Depakote
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluvoxamine • Luvox
Gabapentin • Neurontin
Lamotrigine • Lamictal
Lisdexamfetamine • Vyvanse
Lithium • various
Methylphenidate • Ritalin, Concerta, others
Modafinil • Provigil
Nefazodone • Serzone
Olanzapine • Zyprexa
Paroxetine • Paxil
Quetiapine • Seroquel
Sertraline • Zoloft
Triazolam • Halcion
Valproic acid • Depakene
Venlafaxine • Effexor

Disclosures

Dr. Gonzalez reports no financial relationship with any company whose products are mentioned in the article or with manufacturers of competing products. He is a recipient of a T32 Ruth L. Kirschstein National Research Service Awards training fellowship sponsored by the National Institutes of Health.

Dr. Suppes receives grants/research support from Abbott Laboratories, AstraZeneca, GlaxoSmithKline, JDS Pharmaceuticals, Janssen Pharmaceutica, National Institute of Mental Health, Novartis, Pfizer Inc., and the Stanley Medical Research Institute.