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 A question from reader, MH:

What is the typical drug regimen for a 23 year old woman with both ADHD and  bipolar?”

Dr. Jerry’s Comments:

Treatment of Bipolar II:

It is very important to stabilize the mood in a patient with Bipolar II.  The most common drugs available to do this are:

        Lithium, Depakote, Tegretol(not common), Abilify, Geodon, Risperdal, Seroquel, Zyprexa, Lamictal, Trileptal, Topamax, and others.

Some people with severe Bipolar Disorder require 2 or even 3 of these drugs to stabilize their mood.  Most need these drugs all of their life.

After the mood is stabilized, if it remains persistently down or depressed, it may be necessary to add an antidepressant, such as Prozac, Zoloft, Paxil, Lexapro, Citalopram, Effexor, or Cymbalta.

Treatment of ADHD

It is not always necessary to treat Adult ADD with medication.  It depends on their degree or inattention or lack of focus, and also on whether it is significantly affecting them in their work or family life.

If medication is required, it is typically one of these drugs:

•  Non-Stimulant:     Strattera
• Stimulant:   Ritalin-Based–Ritalin LA, Concerta, Focalin, Metadate CD, Daytrana patch
•                   Amphetamine Salt-Based:   Adderall, Vyvanse
• Others(2nd Line and not as effective) :  Modafanil, Tenex, Clonidine(mostly children)  

Note that medication alone is usually not as effective as combining the medications with another treatment modality, such as coaching, counseling, biofeedback, and others.  

I hope this has been helpful.

Helping You To Be the Best Person You Can Be

Dr. Jerry 

United Press International reports a US Study which suggests that many adults diagnosed with bipolar disorder or an anxiety disorder may have undiagnosed ADHD. 

Using large managed care databases in the US, 2.5 % of adults initially diagnosed with a depressive disorder or an anxiety disorder were later diagnosed with ADHD within a year.

We know from the National Comorbidity Survey the following:

• 32 % of those with depression also have ADHD
• 21.2 % of those with Bipolar Disorder also have ADHD
• 9.5 % of those with an anxiety disorder also have ADHD.

This would suggest that the ADHD is often going unnoticed in these adults with various psychiatric diagnoses.

Dr. Jerry’s comments:  In children and adults with ADHD, about 1/2 the time there is some other comorbid (= associated) disease.  This is often missed.  The result:  Often the prescribed treatment doesn’t work or doesn’t work very well. 

Often times if a patient isn’t responding to the prescribed treatment, there may be a missed comorbid condition.  After finding this and treating it, the patient tends to improve much more rapidly.

See the page on website:  “Associated conditions”

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From the October Issue of Archives of Pediatrics and Adolescent Medicine(one of the JAMA/Archives journals) comes the following information. Children diagnosed with ADHD use more health services in the 2 years before and the 2 years after they are diagnosed than do non-ADHD Children.  The study was done in Oakland, Calif area by G. Thomas Ray, M.B.A.

He compared 3122 kids with ADHD with 15,899 control kids(matched for age, sex, area of the country, calender dates,  but without ADHD). He matched about 6 non-ADHD with 1 ADHD .

Average age of diagnosis was 6.7 yrs.

Kids with ADHD medical costs were higher by the following amounts:

•  2 years before diagnosis = $488 higher cost than non-ADHD kids
• 1 year before diagnosis = $678 higher cost than non-ADHD kids
• 1 year after diagnosis = $1,328 higher cost than non-ADHD kids
• 2 years after diagnosis = $1,040 higher cost than non-ADHD kids

Dr. Jerry’s Comments:

Most times the 1st visit for an evaluation for ADD/ADHD is prompted by poor school performance–often both academically and behaviorally. Many times a crisis–such as school failure, pending failure or severe behavioral problems, resulting in alternative school placement, suspension, expulsion, or trouble with the law–is what prompts the evaluation.

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On September 29, 2006, out of Los Angeles, NBC 4 posted an article stating that if your child has behavior issues during the day, it could be from large tonsils affecting nighttime sleep.

They cited an example of a 12 y/o boy whose behavior got a lot better after tonsillectomy.

Dr. Robert Chervin, a sleep specialist, conducted a sleep study on 22 kids with ADHD, who were already scheduled to have their tonsils removed. The article did not indicate the results of the sleep studies, but stated that 11 of the 22 had an improvement in behavior, so that they no longer met the criteria for ADHD.

In that small group, 50% of the kids had a marked improvement in behavior.

This small report, of course, does not prove that Tonsillectomy is a treatment or cure for ADHD. In general, there are strict criteria for Tonsillectomy, as it is not 100% safe, and there can be serious complications, including death.

Dr. Jerry’s Comments 

Until more studies are done, I would suggest the following:

• If your child has behavioral issues at school and snores heavily at night, mention this to your doctor and consider a sleep study.
• If sleep study is positive, then see an ENT(Ear,Nose & Throat) Dr. to see if he/she feels that a tonsillectomy might be helpful.
• If your child has behavior problems, and needs a tonsillectomy for some other reason, it would be very interesting to see if behavior improves after tonsillectomy.
• If it does improve and remains improved over the long-run, you could report this to your Dr. and maybe be another case study,

I would advise against seeking out an ENT Dr. who would take your child’s tonsils out to see if it would help his/her behavior.

Helping you Be The Best Person You Can Be,

Dr. Jerry Is Online

An article on the site FoodConsumer.org presents the results of a study of 4000 U.S. kids ages 4 - 15 looking at the relationship between 1) ADHD and mother smoking during pregnancy and 2) ADHD and the exposure to lead shortly after birth.

Mothers were simply asked if they smoked during pregnancy and this was then compared with the number of diagnoses of ADD/ADHD in their kids.

Actual blood levels of lead were measured in the 4000 kids and these lead levels were compared between ADHD kids and non-ADHD kids.

The following results were obtained:

Children exposed to pre-natal(before birth) tobacco smoke were 2 1/2 times more likely to have ADHD than those who were not exposed to the smoke.

Children with blood lead levels more than 2 micrograms/dl were 4 times as likely to have ADHD than those kids whose blood lead was less than 0.8 micrograms/dl.

Note than the current “acceptable” level of lead in the blood is 10 micrograms/dl. The question arises as to whether the current acceptable level is really “acceptable”.

In recent years there has been a lot of research as to the cause of ADHD. One study by the National Academy of Sciences in 2000 estimated that toxic chemicals cause as much as 3 % of all developmental and neurological disorders in US kids.

Several outside researchers praised the above paper, stating “that the paper once again invites suspicion that low-level lead exposure” is in fact associated with ADHD.

However, Dr. Helen Binns, a researcher at Children’s Memorial Hospital in Chicago, agreed that the study was a thorough analysis, but it did not offer conclusive proof that lead exposure caused ADHD. She stated that the higher lead levels in kids with ADHD may be because the ADHD kids were more likely to eat old paint chips or inhale leaded paint dust just because of their hyperactivity.

Dr. Jerry’s Comments:

Certainly smoking while you are pregnant is a very bad thing for a number of reasons. It should definitely be avoided.Young children need to be monitored carefully to avoid as many toxic exposures as possible, including peeling paint exposure and lead based paint dust.I don’t feel there is enough evidence to definitely indict the lead level as a big culprit in ADHD. We do know that high lead levels definitely result in behavioral problems.

Dr. Jerry

It was originally thought that kids with ADD/ADHD had suffered some sort of injury before birth or at birth. The original name for the disorder was Minimal Brain Dysfunction.

There was, of course, never any proof of this “minimal injury” as being the cause of ADD. We now know that birth injury has nothing to do with ADD or ADHD.

It appears that heredity is a very large factor in the development of ADD/ADHD. This was determined by observation and by twin studies. Identical twins, raised by separate families from birth, have a very high chance of both having ADHD if either twin has it.

Rather than being determined by a single gene, ADHD requires changes in several genes.

A lot of research is currently in progress to further determine the exact cause of ADHD. In addition to heredity, researchers are looking at neurophysiology and environment as possible causes.

As new research develops, it will be discussed in our Blog and Forum. Also additional articles will be developed, as more information becomes available.

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