Bond David J, Hadjipavlou George, Lam Raymond W, McIntyre Roger S, Beaulieu Serge, Schaffer Ayal, Weiss Margaret
Mood Disorders Centre, University of British Columbia, Vancouver, British Columbia, Canada.
Ann Clin Psychiatry. 2012 Feb;24(1):23-37.
Patients with bipolar disorder (BD) and major depressive disorder (MDD) experience adult attention-deficit/hyperactivity disorder (ADHD) at rates substantially greater than the general population. Nonetheless, ADHD frequently goes untreated in this population.
We reviewed the literature regarding the management of adult ADHD in patients with mood disorders. Because a limited number of studies have been conducted in adults, our treatment recommendations also are partly informed by research in children and adolescents with BD+ADHD or MDD+ADHD, adults with ADHD, and our clinical experience.
In individuals with mood disorders, ADHD is best diagnosed when typical symptoms persist during periods of sustained euthymia. Individuals with BD+ADHD, particularly those with bipolar I disorder (BD I), are at risk for mood destabilization with many ADHD treatments, and should be prescribed mood-stabilizing medications before initiating ADHD therapies. Bupropion is a reasonable first-line treatment for BD+ADHD, while mixed amphetamine salts and methylphenidate also may be considered in patients determined to be at low risk for manic switch. Modafinil and cognitive-behavioral therapy (CBT) are second-line choices. In patients with MDD+ADHD and moderate to severe depression, MDD should be the treatment priority, whereas in mildly depressed or euthymic patients the order may be reversed. First-line treatments for MDD+ADHD include bupropion, an antidepressant plus a long-acting stimulant, or an antidepressant plus CBT. Desipramine, nortriptyline, and venlafaxine are second-line options.
Clinicians should be vigilant in screening for comorbid ADHD in mood disorder patients. ADHD symptoms can respond to appropriately chosen treatments.
双相情感障碍（BD）和重度抑郁症（MDD）患者患成人注意力缺陷多动障碍（ADHD）的比例显著高于普通人群。尽管如此，该人群中的ADHD常常未得到治疗。
我们回顾了有关情绪障碍患者中成人ADHD管理的文献。由于针对成人进行的研究数量有限，我们的治疗建议部分也参考了BD+ADHD或MDD+ADHD儿童和青少年、ADHD成人的研究以及我们的临床经验。
在情绪障碍患者中，当典型症状在持续心境正常期间持续存在时，ADHD最易被诊断出来。BD+ADHD患者，尤其是双相I型障碍（BD I）患者，在接受许多ADHD治疗时有情绪不稳定的风险，在开始ADHD治疗前应先开具心境稳定剂。安非他酮是BD+ADHD合理的一线治疗药物，而对于确定躁狂转换风险较低的患者，也可考虑使用混合苯丙胺盐和哌甲酯。莫达非尼和认知行为疗法（CBT）是二线选择。在MDD+ADHD且有中度至重度抑郁的患者中，应优先治疗MDD，而在轻度抑郁或心境正常的患者中，顺序可能相反。MDD+ADHD的一线治疗包括安非他酮、一种抗抑郁药加一种长效兴奋剂，或一种抗抑郁药加CBT。地昔帕明、去甲替林和文拉法辛是二线选择。
临床医生在筛查情绪障碍患者的共病ADHD时应保持警惕。ADHD症状可通过适当选择的治疗得到缓解。
