Since I occasionally work in a hospital, I often run across patients with Bipolar Disorder that are also prescribed Adderall for Attention Deficit Hyperactivity Disorder (ADHD). Many patients I encounter are unaware that Adderall is highly prone to induce mania and that it is dangerous to take if you have Bipolar Disorder.
1. Adderall Induces Mania
Adderall works by increasing the amount of dopamine in your brain. We also now know that dopamine levels are highly increased during mania. The brain then adapts to the elevated dopamine levels during mania by decreasing the number and sensitivity of the dopamine receptors, which is know as down regulation.
Later, when the mania is over, the dopamine levels come back down to normal. The dopamine receptors are then not activated enough by the lower, normal amount of dopamine. The low activation of dopamine receptors causes the severe depression of Bipolar Disorder.
2. Adderall is Similar to Methamphetamine
This pattern of highly elevated dopamine that causes down regulation of the dopamine receptors and then inadequate dopamine signaling when the dopamine levels return to normal is also what happens in methamphetamine intoxication. That is why methamphetamine causes people to not sleep, feel grandiose and be hyperactive for a few days until they crash and become severely depressed, similar to the cycle of mania and depression.
Adderall is also a mixture of four types of amphetamine. The difference between Adderall and methamphetamine is that the body can break down Adderall in 6 to 8 hours, but methamphetamine has a methyl group chemically attached to the amphetamine molecule, which the body has a hard time breaking down.
The methyl group is the only chemical difference between Adderall and methamphetamine. They work both work exactly the same way. The only other difference is that Adderall is typically prescribed in the 10 to 40 milligram range per day, while people who use methamphetamine tend to use hundreds to thousands of milligrams a day.
3. ADHD is Over Diagnosed in Bipolar Disorder
It is normal to have “ADHD” symptoms during mania because mania causes inattention, impulsivity and hyperactivity. The difference between mania and ADHD is that mania comes and goes, but ADHD is constantly present every single day. So if you have Bipolar Disorder and your “ADHD” comes and goes, you don’t have ADHD. You are just cycling and having mania or hypomania.
Interestingly, Adderall decreases hyperactivity, impulsivity and inattention regardless of cause, from ADHD to brain injuries to sleep deprivation to even mania. I have personally seen manic people get Adderall and then calm down from it. The only problem is that their mania is worse that night after the Adderall wears off. Just because Adderall improves your hyperactivity and impulsivity, that doesn’t mean you have ADHD if you also have Bipolar Disorder.
4. There are Better Treatments for Bipolar Depression than Adderall
Some patients with Bipolar Disorder tell me they only take the Adderall from October through February and don’t need it the rest of the year. October through February has the shortest days of the year with the least amount of sunlight. Bipolar Disorder often has a seasonal pattern where people are severely depressed with increased need for sleep and low energy during fall and winter months, but then tend to be manic during the spring and summer.
Adderall is highly “effective” for treating depressive episodes in Bipolar Disorder. The only problem is that it shoots you of the depression into a manic episode, not back to normal. People who only take Adderall during the fall and winter are just treating their seasonal depression while putting themselves at risk for mania and worsened depression when they stop the Adderall.
There are much safer ways to treat seasonal depression in Bipolar Disorder. Lithium is still the safest and most effective medication for treating the depressive phase of Bipolar Disorder, including seasonal depression. Light therapy is another safe and effective way to treat seasonal depression in Bipolar Disorder.
5. Adderall May Permanently Worsen Bipolar Disorder
As a child psychiatrist, I can personally attest to seeing dozens of cases over the years where children with subtle forms of Bipolar Disorder were misdiagnosed with ADHD and started on Adderall. The Adderall tended to induce much more severe forms of mania than the children had ever experienced before. The disturbing part is that even after the Adderall was stopped and the mania was successfully treated, many of the children continued to have much more severe manic and depressive episodes than they had before the Adderall.
Even though psychiatrists are well aware that giving Adderall by itself without a mood stabilizer to someone with Bipolar Disorder is dangerous, many psychiatrists still think that it is fine to combine the Adderall with a mood stabilizer or an antipsychotic. The problem is that no research has been done on that question because it is unethical to give patents a medication just to see if it will permanently worsen their condition.
Given that Adderall seems to permanently worsen Bipolar Disorder when given by itself, I think it is unethical to give Adderall with other medications until the research can be done to prove that it is safe. Just because a patient doesn’t seem to get manic from Adderall due to mood stabilizers and antipsychotics, does not prove that it is safe. The Bipolar Disorder could still be quietly worsening.
6. Adderall Makes You Use Higher Doses of Other Medications
Even if you can balance the Adderall with the mood stabilizers and antipsychotics (its kind of like standing on the brake and the gas of your car at the same time), you a probably having to use higher doses of mood stabilizers and antipsychotics to do it. Mood stabilizers and antipsychotics have severe side effects and toxicities, especially at higher doses. All kinds of side effects from nausea to sedation to severe weight gain to stiffness and restlessness could be avoided with lower doses of mood stabilizers and antipsychotic.
The bottom line is that in almost ever circumstance, patients with Bipolar Disorder would be better off not being on Adderall provided they are on appropriate mood stabilizers and antipsychotics and have access to light therapy during the winter. Even though I am taking a strong stance against Adderall in Bipolar Disorder, I am still interested in your thoughts and comments, which you can leave below.