ADHD And Bipolar Disorder: How Often They Occur Together & Treatment Options For Both

ADHD is a disorder that affects behavior and attention, with 3–6% of the adult population in the United States affected by it.¹ Bipolar disorder, on the other hand, is characterized by shifts between manic and depressive episodes, affecting around 3% of the adult population.²

While these are very different conditions, they share many of the same symptoms. This can lead to health care professionals mistaking one condition for the other and offering an incorrect diagnosis and treatment to a patient. However, it's also possible for someone to have both ADHD and bipolar disorder at the same time.

Understanding the difference between ADHD and bipolar disorder and how they coexist can bring clarity to the diagnosis and treatment process and ensure you are getting the right care.

Can bipolar co-occur with ADHD?

While it doesn't always happen, it's possible to have both bipolar disorder and ADHD at the same time. This is called comorbidity when two or more disorders occur in one patient at the same time. The comorbidity of ADHD and bipolar disorder is common enough that doctors should carefully evaluate patients diagnosed with one of these conditions for the other one. This can help improve treatment outcomes. It can also assist the patient in developing healthy coping strategies for the symptoms of both.

The two conditions have several symptoms in common, including:

• Unstable moods

• Feelings of restlessness

• Being very talkative at times

• Impatience with activities

• Bursts of energy 

• Difficulty concentrating on tasks

Because of these overlapping symptoms, it can sometimes be difficult for health care professionals to distinguish between the two disorders when trying to make a diagnosis. However, there are important differences. ADHD is a lifelong condition, and parents and teachers will often notice symptoms beginning in childhood. Many people get an ADHD diagnosis when they are around the age of 12 or earlier when the symptoms start to negatively impact performance in school.

Bipolar disorder is much more likely to develop after adolescence, with the average age of diagnosis for bipolar disorder being 25.³ While it's possible for both teens and children to have bipolar disorder, it's rare.

How common is ADHD with bipolar?

It's relatively common for patients to have both ADHD and bipolar disorder. In fact, one in 13 patients with ADHD also had bipolar disorder, while one in six patients with bipolar disorder also had ADHD.⁴

While there is clearly a link between the two conditions, the reasons for the increased likelihood of comorbidity of ADHD and bipolar disorder are unclear. While no one knows what that link is or what might cause someone to develop both conditions, genetic factors may be responsible for the high comorbidity rates.⁵ However, environmental factors may also be at play. 

Do manic episodes come with ADHD?

Manic episodes are a symptom of bipolar disorder, but they are not considered an indication of ADHD. However, people with ADHD can have manic-like bursts of energy or hyperactivity. They might fidget in their seat, be unable to sit still for long periods, and not focus on their tasks. ADHD energy is more consistent, happening on a day-to-day, consistent basis. The energy may disappear and reappear suddenly, depending on external circumstances.

These bursts of ADHD energy are different from the manic episodes associated with bipolar disorder, though. People who experience bursts of energy from a bipolar-related manic episode often talk more than usual, sleep less than normal, and have a feeling of being powerful or destined for greatness. This mania may last for weeks or even months but will eventually give way to a period of depression.

The shift from a feeling of mania to one of depression may often happen independently from external circumstances. That means those with bipolar disorder can make the shift from manic to depressive even if there is no triggering event in their life.

Without long-term observation, it can be difficult to distinguish the differences between the two. This is a contributing factor for misdiagnosis and why health care professionals need to get a thorough patient history before making a diagnosis.  

How is ADHD with bipolar diagnosed?

It can take time to get a diagnosis of ADHD or bipolar disorder. It may take even longer to get a diagnosis for both. Because the two conditions share so many similarities, a health care professional will need to take time to do a thorough evaluation and patient history. They may also want to test for other underlying health conditions that may be causing the symptoms.

To diagnose ADHD or bipolar disorder, a health care professional follows the Diagnostic and Statistical Manual (DSM-5) set by the American Psychiatric Association. This is the standard for diagnosis used by doctors across the United States to ensure consistent diagnosis and treatment of these and other conditions.

Some of the diagnostic criteria for ADHD include:

• Trouble organizing tasks

• Not following through on instructions

• Easily distracted often

• Fidgets in their seat or leave their seat often

• Talks excessively and often interrupt others

While some of the diagnostic criteria for bipolar disorder include:

• Manic episodes with elevated mood and increased energy that last for at least seven days

• Decreased need for sleep, increased talkativeness, and racing thoughts during the manic episode

• Mania gives way to a depressive episode where you experience symptoms most of the day, nearly every day

• Loss of interest in hobbies, weight loss or weight gain, or feelings of worthlessness during a depressive episode

While there are many similarities between the two disorders, the distinct differences can help health care professionals identify and diagnose whether your symptoms are due to ADHD, bipolar disorder, or both.

For example, because ADHD is a lifelong condition, its symptoms are typically recognized earlier in life, usually before the age of 12. Bipolar symptoms don't usually begin until after childhood, with the average age of diagnosis being 25. Children and teens can have bipolar disorder, but it's rare.

The symptoms of bipolar disorder are often episodic, coming and going over a period of time. ADHD symptoms are more consistent starting in childhood and continuing throughout your lifetime and within multiple settings.

To diagnose these conditions, your health care professional will take a thorough health history, including asking whether any relatives also had either condition, as genetics can contribute to either condition. If they determine you have ADHD, bipolar disorder, or both, they can recommend treatment that can help you manage your symptoms. 

How is ADHD with bipolar disorder treated?

Both ADHD and bipolar disorder are treatable conditions. The most common treatment method is medication, which can help you manage the symptoms associated with both.

ADHD medications commonly include:

Stimulants

These include Adderall, Dexedrine, methylphenidate, and other amphetamines. There are both slow-release and immediate-release formulas available. These medications work by stimulating the central nervous system and encouraging the production of dopamine and norepinephrine in the brain.

Non-stimulants

These may include Strattera, Clonidine ER, and Guanfacine ER. Doctors prescribe non-stimulants when patients don't react well to stimulants or want to avoid certain side effects. These medications affect the brain's neurotransmitters, but they don't stimulate the production of dopamine and norepinephrine the same way stimulants do. 

Medications for bipolar disorder can include:

Mood stabilizers

Lithium, lamotrigine, and valproic acid are some of the mood stabilizers prescribed to a person who has bipolar disorder to help reduce the frequency of mood changes.

Antipsychotic medications

Zyprexa, Seroquel, and Abilify are often prescribed along with mood stabilizers to help control symptoms associated with mania, as well as hallucinations and delusions.

Antidepressants or anti-anxiety medications

These medications help with symptoms associated with depressive episodes. This might include a desire to self-harm, feelings of worthlessness, and an inability to experience joy.

When creating a treatment plan, you and your doctor must work closely together to find a combination of medications that works best for you. There are many medication options for both disorders, which means if the initial treatment plan doesn't work, there will be other options to try.

It's important to be patient when trying to find the right combination of medications. It may take weeks or even months to start to feel the effects of some medications, especially those used to treat bipolar disorder. In the meantime, therapy or a support group may offer a way to cope with symptoms until you find a medication combination that works well for you.

Currently, there isn't a lot of research about the best methods for treating ADHD and bipolar disorder together. The best method may be to treat bipolar disorder first to treat this comorbidity.⁶ The goal is to help stabilize your mood, then add in medications to treat ADHD.

Because medication to treat ADHD is usually a stimulant, there is concern they can increase the rate of bipolar mood fluctuations.⁷ That means they could cause you to cycle through manic and depressive episodes more frequently. That can increase the risk of self-harm and suicidal ideation and impact general function and wellbeing.

Because of this, many doctors will recommend mood stabilizers first, then add in ADHD medication while monitoring symptoms closely. It's important to communicate with your health care team about any symptoms you experience while taking new medication. This can alert them to any issues so they can either adjust the medication or try an alternative. 

What are the risk factors for developing ADHD with bipolar disorder?

The reason why some people develop ADHD or bipolar disorder remains unknown. However, both conditions have genetic and environmental risk factors that make someone more likely to develop one, the other, or both.

Risk factors for developing ADHD include:

• Relatives who have also been diagnosed with ADHD

• Drug use by the mother during pregnancy

• Premature birth

• Exposure to certain environmental toxins, such as lead

Risk factors for developing bipolar disorder can include:

• Relatives who have also been diagnosed with the condition

• Stress or experience from traumatic events

• Substance abuse

People with a prior ADHD diagnosis are eleven times more likely to be diagnosed with bipolar disorder.⁸ Those previously diagnosed with ADHD and anxiety are 30 times more likely to be later diagnosed with bipolar disorder. This indicates a link between both conditions and anxiety disorders, though the cause will require further study.

The lowdown

It's possible to have both ADHD and bipolar disorder. While the cause of ADHD and bipolar disorder remains unknown, risk factors include both genetic and environmental factors.

Bipolar disorder is a mood disorder, while ADHD affects behavior and focus, but these two conditions share many of the same symptoms. Both conditions can cause mood swings, bursts of energy, impatience with tasks, and feelings of restlessness. Health care professionals must take time to correctly diagnose one, the other, or both using the DSM-5.

Treatment for ADHD with bipolar disorder typically involves medication. These medications must be carefully balanced, so they don't aggravate the symptoms of one or both conditions. While there is no set protocol for the treatment, research suggests it's best to stabilize the mood swings caused by a bipolar disorder before adding medication to treat ADHD. This can lower the risk of causing more frequent episodes of mania due to ADHD stimulants, which could put the patient at risk of self-harm.