Magazine article Clinical Psychiatry News

Stimulant Use in ADHD, Bipolar Discouraged: Expert in Mood Disorders Cites Evidence Showing That Amphetamines Might Worsen Both Illnesses

Magazine article Clinical Psychiatry News

Stimulant Use in ADHD, Bipolar Discouraged: Expert in Mood Disorders Cites Evidence Showing That Amphetamines Might Worsen Both Illnesses

Article excerpt

CHICAGO -- Dr. Nassir Ghaemi is a bit of a maverick. The well-published author and director of the mood disorders and psychopharmacology programs at Tufts Medical Center in Boston likes to step off the well-worn CME lecture track and challenge his audience with the words of ancient philosophers, artists, and economists.

At the annual meeting of the American Academy of Clinical Psychiatrists, he pushed those in attendance even further, asking them to reconsider the widely held view that stimulant treatment is relatively safe in attention-deficit/ hyperactivity disorder (ADHD) and bipolar disorder.

Dr. Ghaemi contends that children and adults who are diagnosed with ADHD in the United States are automatically given amphetamines, and that there is a routine presumption that long-term treatment with these agents is warranted. He said he believes amphetamines should only be used as a last resort and primarily for short-term treatment in ADHD. In bipolar disorder, he takes the stance that amphetamines should be used even more sparingly--if at all.

The cornerstone of Dr. Ghaemi's arguments lies in emerging evidence that amphetamines might actually worsen ADHD and bipolar disorder.

Some of the first glimmers of this came nearly a decade ago from two retrospective pediatric studies showing a correlation between stimulants and mania. In 42 children with bipolar disorder and ADHD, the mean age of onset of ADHD was 5.5 years, mean length of stimulant use 6.9 years, and onset of manic symptoms 7.1 years (J. Am. Acad. Child Adolesc. Psychiatry 2000;39:713-20).

In 34 adolescents hospitalized with mania, patients with stimulant use before the onset of bipolar disorder had an earlier age at onset of the disease than those without prior stimulant exposure (10.7 vs. 13.9 years). Additionally, adolescents treated with at least two stimulants had a younger age at onset than those treated with one stimulant (Bipolar Disord. 2001;3:53-7).

"It's all association, correlational, observational; it's not definitive, it's not causative, but there's room for suspicion that amphetamines might be causing mania in these children," said Dr. Ghaemi, also a professor of psychiatry at Tufts University who completed a research fellowship in psychopharmacology at Massachusetts General Hospital.

He went on to highlight additional data on treatment-emergent mania. In a brief open study in 14 depressed adults with a DSM-IV diagnosis of bipolar illness treated with methylphenidate added to a mood stabilizer regimen, 3 patients (21%) stopped methylphenidate because of anxiety, agitation, or hypomania (Bipolar Disord. 2000;2:56-9).

A case review of 82 children (mean age 10.6 years) with bipolar disorder not receiving mood stabilizers reported treatment-emergent mania in 20% of 40 children on stimulants--6 of 28 children on methylphenidate and 2 of 12 on amphetamines. The mean time to mania onset was 12.5 days from start of treatment (J. Affect. Disord. 2004:82:149-58).

By themselves, these data are not that alarming, given that antidepressants in the observational setting are associated with roughly a 20% mania switch rate, Dr. Ghaemi said. In the case review, however, long-term harmful effects were observed, including more mood episodes, suicidality, and hospitalization. …

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