tbh & tdah comorbidity of attention deficit hyperactivity disorder with early- and late-onset bip

7/30/2019 TBH & TDAH Comorbidity of Attention Deficit Hyperactivity Disorder With Early- And Late-Onset Bip

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466 Am J Psychiatry 157:3, March 2000

BRIEF REPORTS

Comorbidity of Attention Deficit Hyperactivity Disorder With Early- and Late-Onset Bipolar Disorder

Gary

S.

Sachs,

M.D.,

Claudia

F.

Baldassano,

M.D.,

Christine J. Truman, B.A., and Constance Guille, B.A.

Objective: The relationship between attention deficit hyperactivity disorder (ADHD) andearlier age at onset of affective illness was examined in probands with a history of bipolar

disorder. Method: The authors assessed 56 adult bipolar subjects. Those with a history ofchildhood ADHD (N=8) were age and sex matched with bipolar subjects without a historyof childhood ADHD (N=8). Results: The age at onset of the first affective episode was

lower for the subjects with bipolar disorder and a history of childhood ADHD (mean=12.1years, SD=4.6) than for those without a history of childhood ADHD (mean=20.0 years, SD=

11.3). Conclusions: ADHD in children of bipolar probands might identify children at high-

est risk for development of bipolar disorder.

(Am J Psychiatry 2000; 157:466468)

The relationship between attention deficit hyperac-tivity disorder (AD H D ) and b ipolar disorder is unclear.Studies examining the rates of ADHD in bipolar pa-tients consistently show higher than expected rates.Tab le 1 lists studies (16) examining t he rates of co-morbidity for ADHD and bipolar disorder. The meth-ods used in these studies varied, and the comorbidity

rates ranged from 9% to 94%.Four testable hypotheses might explain the high

rates of comorbidity of mania and ADHD: 1) comor-bidity is a chance phenomenon, 2) comorbidity is anartifact of overlapping criteria, 3) comorbidity is dueto a common diathesis that leaves patients vulnerableto separate illnesses, 4) symptoms of ADHD that pre-cede the onset of bipolar disorder represent a prepu-bertal expression of illness antecedent to the develop-ment of a full aff ective episode.

Wozniak et a l. (5) found that amo ng 262 children re-ferred to a pediatric psychopharmacology clinic, 94%of t he children meeting the criteria for mania also metthe criteria for ADH D .

Studies suggest th at the relationship is unlikely to beaccounted for by symptom overlap or diagnostic un-certainty. Fristad et al. (7) reported that items assess-ing classic manic symptoms (e.g., elevated mood ,

increased sexual interest, pressured speech, racingthoughts) from the Young Mania Rating Scale effec-tively discriminated between mania a nd ADH D in tw ogroups of adolescents.

If childhood ADHD is an expression of the early on-set o f a ffective illness, the age at onset of b ipolar illnessshould be earlier in subjects w ith comorbid ADH D

than in subjects w ithout ADH D.

METHOD

The Massachusetts General Hospital Bipolar M ood D isorder Pro-gram enrolled 120 patients with bipolar disorder into a naturalisticstudy from 1992 to 1994. C onsenting participants in the natura listicstudy w ere assessed by b linded research psychia trists using a versionof the Structured Clinical Interview for DSM-III-R (8). Childhoodpsychopathology was assessed by using sections from the Schedulefor Affective Disorders and Schizophrenia for School-Age Chil-drenEpidemiologic Version (K-SAD S-E) (9) and th e D iagno stic In-terview for Children and AdolescentsRevised (10).

The subjects were classified as having late-onset bipolar disorderor early-onset bipolar disorder on the basis of age at onset of the firstepisode of depression, mania, or hypomania. Designation of early-onset bipolar disorder required consensus on the occurrence of thefirst af fective episode before age 19 years, an d lat e-onset bipola r dis-order was defined as occurrence of the first affective episode afterthe 19th birthday.

For study purposes, the study group (N=56) w as first divided intotwo subgroups according to whether the K-SADS-E interview indi-cated a history o f ADH D. For comparison purposes, the eight sub-jects with bipolar disorder and a history of childhood ADHD werethen age and sex mat ched w ith eight bipolar subjects w ithout a his-tory of childhood ADHD .

Statistical methods included paired t tests using the Statview sta-tistical program for Macintosh.

Received May 5, 1997; revisions received July 24, 1998, and May5 and Aug. 4, 1999; accepted Sept. 10, 1999. From the Clinical Psy-chopharmacology Unit, Massachusetts General Hospital; and theHarvard Bipolar Research Program and Department of Psychiatry,Harvard Medical School, Boston. Address reprint requests to Dr.Sachs, Massachusetts General Hospital, WACC 812, 15 ParkmanSt., Boston, MA 02114; [email protected] (e-mail).


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Am J Psychiatry 157:3, March 2000 467

BRIEF REPORTS

RESULTS

Each of the two groups of subjects with bipolar

disorder (with and without a history of childhoodADH D ) consisted of seven subjects w ith bipolar type Iand one with bipolar type II disorder. At the time ofevaluation, the groups did not differ significantly inage (history of childhood ADH D: mean= 38.0 years,SD=5.3; subjects without childhood ADHD: mean=37.7, SD = 6.7) (unpaired t test, t= 0.08, d f= 14, p= 0.94).

The mean age at onset of the first affective episodewas significantly lower for the subjects with a historyof childhood ADHD (mean=12.1 years, SD=4.6) thanfor the subjects w ithout childhood ADH D (mean= 20.0years, SD=11.3) (paired t test, t=3.57, df=7, p


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tbh & tdah comorbidity of attention deficit hyperactivity disorder with early- and late-onset bip

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