Q:  Tenex and Other Meds Helpful in ADHD?

I have noticed many of your viewers have an issue with ADHD as well. How do you feel about adding in a drug such as Tenex? This may help with their cognitive problems while perhaps dealing with high blood pressure that they may have as part of their anxiety. Perhaps propranolol could fill this roll as well. On the same topic I have read that Pramipexole increases the metabolism in certain regions of  the left hemisphere while not increasing it in the Amygdala. I have noticed when I take stimulants that the positives are outweighed when the oversensitive Amygdala gets into the picture. In fact I think this kickstart to the Amygdala is what starts the cycling(kindling). I also wonder whether Levetiracetam  might have a roll to play here. thanks    michael



Dear Michael -- 
You are right, ADHD and bipolar disorder overlap a great deal. In general, as you have seen, mood experts recommend treating the bipolar first and then treating any remaining ADHD symptoms. Importantly, there is a non-medication approach to ADHD (although so far it has only been tested in conjunction with stimulant treatment). It is described in the manual for patients, entitled Mastering Your ADHD.

But if a medication is to be used, to address ADHD symptoms in people with bipolar disorder, which should be used? So far, experience is largely limited to the use of conventional stimulants and their long-acting counterparts (methylphenidate/Ritalin; amphetamines/Dexedrine;Concerta, Metadate, etc.). Some evidence supports using Wellbutrin, which used to be rather concerning to me until recent data suggested that the risk of "switching", i.e. inducing manic symptoms, is appears to be considerably lower with this medication than with other antidepressants. I still worry about that. Therefore I also worry about using atomoxetine (Strattera) in this role. 

In general, however, I think experience and what little research we have is beginning to suggest that stimulant medications do not propose a large risk -- at least in the short run -- of worsening bipolar disorder. We still know too little to be very confident about this conclusion, in my opinion.

As for other medications for ADHD, such as guanfacine (Tenex), we know even less. One could reason that a medication for blood pressure might be less likely to be destabilizing than an amphetamine or amphetamine-like compound; that certainly seems reasonable. But to my knowledge, we have no evidence for propanolol as a treatment for ADHD.

The other medications you name have been around a relatively short while. So nearly any comment is largely speculation. In general, as you may gather, my inclination is to assume that medications present a risk until this has been countered by a fairly lengthy period of clinical experience. As a result, I am a "late adopter". Thank you for sharing your thoughts, as you are pioneering and your experience may be valuable for others.

Dr. Phelps