Expert: Ivan Goldberg, M.D. - 11/11/2009

Question
Hi Dr. Goldberg,  
I have an 11 year old son who has been treated for ADHD since he was 5 with Concerta.  He was diagnosed ADHD and ODD at 4.  I noticed him becoming more and more depressed just before he turned 10 and had a complete neuropsych. evaluation done that confirmed that.  his psychiatrist started him on a low dose of Zoloft in Nov. of last year and this triggered rage and suicidal behaviors. His psychiatrist diagnosed him as bipolar from the drug induced mania.  We have been using many, many different drugs ever since.  The anger and suicidal thoughts are gone but now he is not able to pay attention in school, complete work, hand in homework, etc.  He is oppositional and irritable, but he always was.  This type of behavior was much less when he was taking his more attentional medication.  in fact teachers haven't reported these behaviors at school in years with proper dosing of his Concerta. He is currently taking 15 mg. of dextro-amphetamine and 1500 mg of lithium and 1000 mg Depakote per day.

Is he truly bipolar, drug induced bipolar or just attentional and oppositional?  (Although I know you cannot diagnose from this short paragraph!)  

Answer
Hi, Jane . . .

As you point out in your last paragraph, there is no way that I can make a diagnosis based on the sort of information you provide. But, I can comment on some of the considerations that would be involved in establishing the correct diagnosis.

The first thing to be remembered is that ADD/ADHD, bipolarity, OCD, and behavioral problems are often comorbid . . . that is a technical way of saying that they often coexist. So the problem is not trying to establish which one is the correct diagnosis, but rather which of those, and possibly other diagnoses might be applicable.

According to the strict "official" diagnostic criteria found in the DSM-IV, antidepressant-induced mania is not to be considered when trying to make a diagnosis of bipolar disorder. According to me and many other psychiatrists, antidepressant-induced mania is probably the most sensitive indicator of some disorder sin the bipolar spectrum. [You might Google the term "bipolar spectrum" and read about it.] One of the most important considerations in making a psychiatric diagnosis is the family history of psychiatric disorders. An antidepressant-induced manic episode in someone with many relatives who seem to have diagnoses in the bipolar spectrum would be taken as more indicative of true bipolarity than such an episode in someone with a family history free of any bipolar relatives.

Another problem is that many people who turn out to have bipolar disorder appear to have ADD/ADHD when younger and only show their bipolarity as they get older.

I do not understand the switch from Cencerta to dextroamphetamine. If Concerta was successful in reducing attentional symptoms, why was it replaced by dextroamphetamine?

Best regards . . .

Ivan
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