Question-and-Answer Session

TL;DR: If a patient has bipolar disorder and presents with predominantly manic symptoms or a mixed state, a psychostimulant would not be used in that state.

Abstract: Dr. Mclntyre: In the area of bipolar disorder, if the patient is presenting to my office with a predominantly manic presentation with typical manic symptoms or a syndromal mixed state, I would not use a psychostimulant in that state. The more typical patient that clinicians encounter in the real world is a patient who presents with major depressive disorder (MDD) and various admixtures of hypomanic features, which historically has been referred to as depressive mixed states. Also, there has been the appellation "agitated depression." This is a bit more challenging. I discussed the principle of assuring that bipolar disorder is treated first and ADHD treated second, which is admittedly in some cases an arbitrary distinction. Nevertheless, there have been many situations I have encountered when patients have bipolar depression and have minimal features of the typical symptoms of hypomania, yet they have very prominent distractibility and very prominent problems with focusing themselves as well as cognitive problems. In that case, I have often found myself treating what I believed to be symptoms that would comport with ADHD as well as a major depressive episode in bipolar disorder. Granted, in that case, I am using a stimulant primarily to target some ADHD symptoms, and some may ask if there is an additional benefit in treating the depressive episode with a stimulant, which is an entirely different question. Thus, the principle of treating bipolar disorder first is very much the principle. The fine print would be that there are many cases of treating a depressed bipolar patient who is not progressing through mixed hypomania or mixed mania, where I may use a stimulant with an aim to target some of the ADHD features in this patient who is still not stable from bipolar disorder.