Adjunctive stimulant use in patients with bipolar disorder: treatment of residual depression and sedation

Background: Residual depression and medication-induced sedation remain significant problems for many patients with bipolar disorder (BD). Some evidence indicates that bipolar depression may be more responsive to dopaminergic agents, suggesting that adjunctive stimulant medication may be an effective treatment for bipolar depression as well as for medication-induced sedation. However, there are few data regarding the use of these medications in BD, likely due in part to concerns regarding potential stimulant-induced switching and stimulant abuse. Methods: In order to evaluate the effectiveness and safety of psychostimulants in BD, we retrospectively reviewed the cases of eight consecutive individuals from our clinic (five with bipolar I and three with bipolar II) who received adjunctive stimulants (either methylphenidate or amphetamine) within the last 2 years. Primary target symptoms of stimulant therapy included residual depression and medication-induced sedation. The degree of clinical change in target symptoms was estimated, and the Clinical Global Impression-BP Version scale (CGI-BP) was used to evaluate the overall severity of illness at baseline, 6 months after stimulant initiation, and at last visit. Results: The eight patients generally showed moderate clinical improvement in their target symptoms and substantial improvement of overall bipolar illness (mean change in CGI-BP overall score 2.9). There was no evidence of stimulant-induced switching or abuse. The stimulants were well tolerated. Conclusion: The present case series suggests that adjunctive stimulants may be a reasonable therapeutic option for treating residual depression and medication-induced sedation in some patients. Controlled trials are needed to assess the safety and effectiveness of stimulant augmentation in BD.