Elsevier

Biological Psychiatry

Volume 57, Issue 11, 1 June 2005, Pages 1467-1473
Biological Psychiatry

Original article
Clinical and Diagnostic Implications of Lifetime Attention-Deficit/Hyperactivity Disorder Comorbidity in Adults with Bipolar Disorder: Data from the First 1000 STEP-BD Participants

Presented in part at the National Institute of Mental Health (NIMH) Pediatric Bipolar Conference, Washington, DC, March 21–22, 2003.
https://doi.org/10.1016/j.biopsych.2005.01.036Get rights and content

Background

Systematic studies of children and adolescents with a diagnosis of bipolar disorder show that rates of attention-deficit/hyperactivity disorder (ADHD) range from 60% to 90%, but the prevalence and implications of ADHD in adults with bipolar disorder are less clear.

Methods

The first consecutive 1000 adults with bipolar disorder enrolled in the National Institute of Mental Health’s Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were assessed for lifetime ADHD. The retrospective course of bipolar disorder, current mood state, and prevalence of other comorbid psychiatric diagnoses were compared for the groups with and without lifetime comorbid ADHD.

Results

The overall lifetime prevalence of comorbid ADHD in this large cohort of bipolar patients was 9.5% (95% confidence interval 7.6%–11.4%); 14.7% of male patients and 5.8% of female patients with bipolar disorder had lifetime ADHD. Patients with bipolar disorder and ADHD had the onset of their mood disorder approximately 5 years earlier. After adjusting for age of onset, those with ADHD comorbidity had shorter periods of wellness and were more frequently depressed. We found that patients with bipolar disorder comorbid with ADHD had a greater number of other comorbid psychiatric diagnoses compared with those without comorbid ADHD, with substantially higher rates of several anxiety disorders and alcohol and substance abuse and dependence.

Conclusions

Lifetime ADHD is a frequent comorbid condition in adults with bipolar disorder, associated with a worse course of bipolar disorder and greater burden of other psychiatric comorbid conditions. Studies are needed that focus on the efficacy and safety of treating ADHD comorbid with bipolar disorder.

Section snippets

Methods and Materials

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is a multicenter National Institute of Mental Health-funded project designed to evaluate the longitudinal outcome of patients with bipolar disorder. The overall study combines a large, prospective, naturalistic study and a series of randomized controlled trials, which share a battery of common assessments (Sachs and Thase 2000). To enter STEP-BD, patients are required to be at least 15 years of age and to meet DSM-IV

Demographic and Diagnostic Characteristics

Participants in this study are the first consecutive 1000 participants in STEP-BD. Of the original 1000 patients, 81 were excluded from these analyses because of incomplete diagnostic data, resulting in a sample size of 919. Demographic and clinical characteristics are presented in Table 1. For the entire group, 41.6% were male, 92.6% were Caucasian, and the mean (SD) age at the time of evaluation was 40.58 (12.83) years. The proportions of the group diagnosed as bipolar I, II, and “other” were

Discussion

We found evidence of lifetime comorbid ADHD in approximately 9.5% (95% confidence interval 8%–11%) of our sample of 919 treatment-seeking adults with bipolar disorder, with 54 of 87 (62.1%) of those with lifetime ADHD meeting current criteria. An important gender difference exists, with 14.7% of male patients and 5.8% of female patients with comorbid lifetime ADHD. Consistent with previous studies that documented ADHD almost exclusively among patients with early-onset bipolar disorder, there

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      Comorbidity between attention-deficit hyperactivity disorder (ADHD) and major mood disorders, such as major depressive disorder (MDD) and bipolar disorder (BD), has been well-established in both clinical and community-based studies of adults and children (Angold et al., 1999; Blackman et al., 2005; Kalaydjian and Merikangas, 2008; Karaahmet et al., 2013; Klassen et al., 2010; Larson et al., 2011; Ostrander et al., 2006). In clinical samples, rates of ADHD among adults with BD range from 9.5 to 30% (Bernardi et al., 2010; Karaahmet et al., 2013; McIntyre et al., 2010; Nierenberg et al., 2005; Perroud et al., 2014; Perugi et al., 2013; Rydén et al., 2009; Sentissi et al., 2008; Tamam et al., 2008; Wingo and Ghaemi, 2007), and rates of BD range from 5 to 47% among adults with ADHD (Faraone, 2006; McGough et al., 2005; Wilens et al., 2009; Wingo and Ghaemi, 2007). Strong associations between ADHD and BD in community samples of adults (Bernardi et al., 2012; Kessler et al., 2006; Merikangas et al., 2011, 2010) suggest that this comorbidity is not merely an artifact of the increased severity that characterizes clinical samples (Berkson, 2014; Merikangas et al., 2009).

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