ADHD

ADHD and bipolar disorder together: which one gets treated first

When they coexist, the order matters: mood gets stabilised first. And there is a concrete clinical reason for it.

By Dra. Daniela Málaga·September 21, 2026·7 min read

You were told you have ADHD and you have been on treatment for a while. Or you were told you have bipolar disorder and, on top of that, you have always struggled to concentrate. At some point the uncomfortable question comes up: if it turns out I have both, what happens to what I am already taking?

It is a reasonable question and it has an answer. It is not the same question asked by someone who does not yet know which of the two they have, which is a different conversation. This one is for when there is already at least one diagnosis on the table.

How common is having ADHD and bipolar disorder together?

Considerably more common than intuition suggests. Around 17% of adults with bipolar disorder also have ADHD. Looking the other way round, which is usually the direction that matters to someone who already has an ADHD diagnosis: among people with ADHD in two national registries, in Norway and Sweden, bipolar disorder appeared in about 9% of men and between 13.5% and 18% of women.

Worth keeping in proportion: that means the large majority of people with ADHD do not have bipolar disorder. And that when ADHD is there it rarely comes alone, although what accompanies it is usually something else: around 70% of adults with ADHD also have another mental health condition, most often anxiety or a depressive condition.

When they do coexist, the picture tends to be more complicated than bipolar disorder alone: it starts earlier and comes with more anxiety and more substance use. That comes from a family study in a community sample in the United States.

And an honest caveat, because certainty here is lower than it looks: the fact that they resemble each other so much does not prove they share the same root. That same family study found no cross-transmission between the two, and its authors consider that part of the overlap may be an artefact of how we diagnose. It is an open debate.

If you have ADHD and bipolar disorder, which is treated first?

The Canadian and international guideline recommends treating mood symptoms first, with mood stabilisers or atypical antipsychotics, and only then considering treatment for ADHD. If you are not sure whether what you take falls into that category, ask your doctor or pharmacist: do not work it out on your own.

The reason is not procedural, it is clinical: unstabilised bipolar disorder produces mood swings, impulsivity, hyperactivity and inattention. In other words, it looks like ADHD. While mood is making noise, there is no way to tell how much of what you see is ADHD and how much is untreated bipolar disorder.

In fact, once mood is stabilised, some people might no longer meet the criteria for ADHD. It is worth not reading that backwards: in many others ADHD is still there after stabilising, and then it gets treated. It is not that one diagnosis erases the other, but that you have to see which one remains once mood stops making noise.

The risk figure, with its fine print

There is one study that gets quoted a lot in this conversation, and that is frightening if told halfway. As reported by the European consensus and a later review, in a Swedish registry of 2,307 adults who already had a bipolar diagnosis, receiving methylphenidate without a mood stabiliser was associated with a 6.7 times higher risk of manic switch, concentrated in the first three months after starting the medication. Among those taking it alongside a mood stabiliser, the risk did not rise: it fell. And something that figure does not say, worth being clear about: it describes what happened when the medication was started. If you have been on your treatment for years without any of this appearing, it is not your situation it is measuring.

Now the fine print, which is what changes how it reads. All participants had bipolar disorder already recognised, so what separated the two groups was not getting the diagnosis right: it was whether or not they were on a mood stabiliser. And it is worth knowing where it comes from: the earliest work on the topic reported a stronger association, which later studies, this registry among them, have tempered.

That is why the conclusion of the European consensus is not to avoid treatment, but the opposite: it recommends treating ADHD with stimulants in people with bipolar disorder, as long as they are also on a mood stabiliser.

And the other half is worth saying, because an article that only talks about risks leaves a false impression: adult ADHD does have treatments with evidence behind them. A review of 113 trials with 14,887 adults found that stimulants and atomoxetine were the only interventions with evidence of reducing core symptoms in the short term. The same authors warn that this improvement did not extend to other outcomes, such as quality of life, and that the long-term effect is under-researched.

If you are taking something right now
None of the above is a recommendation for anyone, and least of all a reason to stop something. Do not start, change or stop any treatment on your own, whether it is a stimulant, an antidepressant or a mood stabiliser: stopping abruptly can trigger a relapse, withdrawal symptoms or a rebound of whatever was being controlled.
If something is not adding up, that is a conversation with your doctor, and you can ask for an appointment before your next scheduled one. If what you have are thoughts of harming yourself, several days sleeping very little without feeling tired, or a sense of losing contact with reality, do not wait for that appointment: call 113, option 5, which is free and staffed 24 hours, or 106 (SAMU) in an emergency. These lines are staffed in Spanish. If you need support in English, go to your nearest emergency department.

Why bipolar disorder takes so long to be recognised

This part explains why many people arrive at the conversation above years late.

Many people with bipolar disorder do not receive the correct diagnosis until up to ten years after symptoms begin, and along the way they tend to receive between one and four different diagnoses. Those ten years are a ceiling, not the average: in a meta-analysis, around six years pass between the onset of the disorder and the point at which treatment begins, based on studies carried out mostly in high-income countries, with no Peruvian data.

Why so long? Because what shows up first, for years, is depression. In a British study comparing 2,366 people who later received a bipolar diagnosis with more than forty-seven thousand controls, records of depression appeared long before the diagnosis.

And there is a very concrete reason why that information never reaches the consulting room. In an internet survey of 457 adults with self-reported bipolar disorder in Japan, 34% of those who had experienced manic symptoms before diagnosis did not mention them to their doctor, and the most frequent reason was not considering them an illness. It makes sense: a stretch in which you get more done, sleep less and feel good is not experienced as a symptom. It is experienced as a good run.

That is why the guideline asks clinicians to routinely ask about previous manic or hypomanic episodes in anyone consulting for depression. And it is why, if you are going to see someone about low mood, it is worth also mentioning the stretches when you felt sped up, needed less sleep or were doing more than usual, even if at the time they seemed like good ones.

There is an underlying reason not to let it drift: a longer time with untreated bipolar disorder is associated with a higher likelihood of suicide attempts. Reaching the right diagnosis is not an administrative detail. And if you are having thoughts of harming yourself right now, do not wait for an appointment: call 113, option 5 or 106.

What to bring to the appointment

If you are going to raise this conversation with your doctor, three things change the quality of the answer you get:

A written timeline of your good and bad stretches, with approximate dates and what was going on in your life then.
Someone who has known you for years, because periods of elevated mood are usually remembered better by the people around you than by yourself.
The list of what you have taken and what happened with each: what helped, what did not, and whether a stretch of euphoria or speeding up ever appeared after starting an antidepressant.

That last point deserves separate attention. The international guideline lists several features that raise the suspicion of bipolar disorder in someone with depression: episodes that began before the age of 25, that are brief and highly recurrent, a family history, and irritability or manic symptoms appearing after starting an antidepressant. None of those features settles anything on its own, but together they change the conversation.

And if you cannot afford a private appointment, this is not assessed only there: the Ministry of Health runs community mental health centres across the country, alongside the mental health services of hospitals and primary care posts.

If you have a diagnosis and suspect there is something else, or you have just been given a second one and do not know what happens to what you were already taking, an assessment that sorts out both is the place to start. In my practice in Miraflores (Lima) and by video consultation I assess adult ADHD and bipolar disorder with an evidence-based approach. I see patients in Spanish and English and provide receipts for insurance reimbursement.

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Frequently asked questions

Can you have ADHD and bipolar disorder at the same time?
Yes, and more often than it seems. Around 17% of adults with bipolar disorder also have ADHD. Looking the other way round, among people with ADHD in two national registries, in Norway and Sweden, bipolar disorder appeared in about 9% of men and between 13.5% and 18% of women. It is not a rare exception, and it is one of the reasons an assessment has to look at both possibilities rather than settling for the first one that fits.

If I have both, which one gets treated first?
The Canadian and international guideline recommends treating mood symptoms first with mood stabilisers or atypical antipsychotics, and only then considering treatment for ADHD. The reason is clinical: unstabilised bipolar disorder produces mood swings, impulsivity, hyperactivity and inattention, so it looks like ADHD and hides whatever is underneath. In fact, some people might no longer meet the criteria for ADHD once mood is stabilised. In many others ADHD is still there, and then it is treated.

I take a stimulant and I have just been told I also have bipolar disorder. Do I have to stop it?
That decision belongs to your doctor, and it is worth raising soon, but do not make it on your own. What the available data show, in people who already had a bipolar diagnosis, is that methylphenidate taken without a mood stabiliser was associated with more manic episodes, mostly in the first three months; among those taking it alongside a mood stabiliser, the risk did not rise. The European consensus recommends treating ADHD with stimulants in people with bipolar disorder, as long as they are also on a mood stabiliser. Stopping abruptly can trigger a relapse or withdrawal symptoms, so the thing to do is talk about it, not cut it.

Why does bipolar disorder take so many years to be recognised?
Because what shows up first, for years, is depression. In a British study comparing more than two thousand people who later received the diagnosis with more than forty-seven thousand controls, records of depression appeared long before. And there is a practical reason behind it: in a survey of adults with bipolar disorder in Japan, 34% of those who had experienced manic symptoms before diagnosis did not mention them to their doctor, mostly because they did not consider them an illness. Periods of elation are rarely experienced as a problem, so they do not get reported.

I have had my diagnosis for years and my treatment works. Does this affect me?
No. This article is not about revisiting treatments that are going well. It is for two specific situations: when a second diagnosis appears and what you are already taking has to be reordered, and when something about the picture never quite fitted. If your treatment works and your diagnosis explains what happens to you, nothing you read here contradicts it.

This article is for information only and does not replace an individual medical evaluation. Do not start, change or stop any treatment without consulting your doctor.