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 Table of Contents  
Year : 2019  |  Volume : 40  |  Issue : 3  |  Page : 155-161

Effect of adult attention-deficit hyperactivity on disability and quality of life of bipolar patients

Department of Psychiatry, College of Medicine, Zagazig, Egypt

Date of Submission05-Sep-2019
Date of Acceptance18-Sep-2019
Date of Web Publication19-Nov-2019

Correspondence Address:
MD Shimaa I Amin
MSc Psychiatry. 30 Abo Bakr Elsedeek,Vellal Elgamaa, Department of Psychiatry, College of Medicine, Zagazig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejpsy.ejpsy_30_19

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Background Attention-deficit hyperactivity disorder (ADHD) is a common psychiatric disease, usually first diagnosed during childhood or adolescence. A significant portion (∼50–65%) of ADHD symptoms persist into adulthood. Adult ADHD and bipolar disorder (BD) are common comorbid psychiatric conditions. Comorbidity between BD and adult ADHD has been reported in both ADHD and BD cases.
Aim To determine the effect of comorbid adult ADHD on disability and quality of life of patients with bipolar disorder.
Patients and methods This is a cross-sectional study that was done at the Psychiatric Department in the Zagazig University Hospitals, Sharkia Governorate, Egypt, during the period from May to November, 2017. One hundred and two euthymic patients with Diagnostic and statistical manual of mental disorders, 4th ed. − text revision diagnosis of BD I were selected by simple random probability sampling from the patients with bipolar disorder who came for follow-up and to receive their medications from psychiatric outpatient clinic.
Results The mean age of the participants ranged from 18 to 40 years, and 51% were female. Patients with bipolar disorder with adult ADHD had more disability in work, social life, and family life than patients with pure bipolar disorder. Moreover, patients with bipolar disorder without adult ADHD had significant better quality of life in all domains as reflected by higher scores in WHO quality-of-life scale than patients with adult ADHD.
Conclusion Adult ADHD is a frequent comorbid disorder in patients with BD. Adult ADHD comorbidity negatively affects functioning and quality of life of patients with BD.

Keywords: Attention-deficit hyperactivity disorder, bipolar disorder, disability and quality of life

How to cite this article:
Fouad AA, Fouad HA, Amin SI. Effect of adult attention-deficit hyperactivity on disability and quality of life of bipolar patients. Egypt J Psychiatr 2019;40:155-61

How to cite this URL:
Fouad AA, Fouad HA, Amin SI. Effect of adult attention-deficit hyperactivity on disability and quality of life of bipolar patients. Egypt J Psychiatr [serial online] 2019 [cited 2024 Mar 1];40:155-61. Available from: https://new.ejpsy.eg.net//text.asp?2019/40/3/155/271304

  Introduction Top

Attention-deficit hyperactivity disorder (ADHD) is an early-onset neurodevelopmental disorder characterized by developmentally inappropriate symptoms in inattention, hyperactivity, and impulsivity (American Psychiatric Association, 2013) that affects 5% of childhood population (Polanczyk et al., 2007) and persists into adulthood in up to 50% of the cases (Ramos-Quiroga et al., 2006; Torres et al., 2017).

Bipolar disorder (BD) is a common, complex, and recurrent severe mental health condition with progressive social and cognitive function disturbances and comorbid medical problems. It is characterized by mania or hypomania with overactivity, disinhibited behavior, and elation, interspersed with episodes of depression characterized by profound loss of motivation and interest (Miller, 2016).

The first reports on ADHD in adults can be traced to the middle 70s when investigators at the University of Utah, led by Paul Wender, started to develop the Utah Criteria for the diagnosis of ADHD based on the study of adults (Wood et al., 1976). Since then, accumulating data have noted that a significant proportion of children affected by the disorder continue to present ADHD symptoms and associated impairment during adulthood (Barkley, 2009; Biederman et al., 2011).

Adult ADHD and BD are commonly comorbid psychiatric conditions (Wang et al., 2017). Comorbidity between BD and adult ADHD has been reported in both ADHD (Klassen et al., 2010) and BD cases (Song et al., 2015).

The reported rates of comorbid BD and adult ADHD are extremely variable, ranging from 5.1 to 47.1% (McGough et al., 2005) for BD in ADHD and 9.5 to 21.2% (McIntyre et al., 2010; Kumar and Varambally, 2017) for ADHD in BD cohorts.

Other clinical studies showed that comorbidity rates of adult ADHD in patients with bipolar disorder range from 5 to 23% (Ryden et al., 2009).

Factors influencing course and outcome include general cognitive ability, severity of ADHD, causal factors (genes and environment), brain maturation and development, and the presence of co-occurring mental health and neurodevelopmental disorders (Faraone et al., 2015). Protective factors, such as exercise, might also have an important role (Rommel et al., 2013).

  Patients and methods Top


One hundred and two euthymic patients (50 males and 52 females) diagnosed with bipolar I disorder according to a Diagnostic and statistical manual of mental disorders, 4th ed. − text revision (DSM-IV-TR) were included in the study. Patients did not show any manic or depressive symptoms at the time of the assessment (Young Mania Rating Scale score <7 and Hamilton Depression Rating Scale <8) and were recruited from the psychiatry outpatient clinic during their regular follow-up.

Inclusion criteria

The included patients were of both sexes, with age ranged from 18- to 40-year old to avoid a retrospective ADHD diagnosis time that was potentially too long to minimize recall bias, and were willing to participate in the study.

Exclusion criteria

The following were the exclusion criteria: current depressive or manic symptoms, current psychotic disorders, clinically significant medical condition that might have a psychiatric manifestation, diagnosis of intellectual disability, and unwillingness or inability to comply with assessment.


  1. Collection of sociodemographic and clinical data of patients was done by a semistructured

    questionnaire specifically developed for this study and employed to obtain sociodemographic

    information of patients and clinical characteristics of the disorder.
  2. Screening for ADHD was done as follows:
    1. Adult ADHD self-rating scale (ASRS, version 1.1) symptom checklist was used for ADHD screening based on DSM-IV-TR criteria for adult ADHD. This instrument was intended to assess ADHD by means of 18 items exploring the symptoms reported during the previous 6 months, based on the DSM-IV-TR criteria (Kessleret al., 2005). Obtaining at least four out of first six items can be considered suggestive for a current ADHD.
    2. Wender-Utah Rating Scale (WURS) which used to screen for ADHD during childhood. WURS is a 25-item self-administered instrument, retrospectively measures ADHD-relevant childhood behaviors and symptoms. It is a measure with quinary Likert-type scale including choices from 0 to 4 (0 = none, 4 = severe). The cut-off score for a positive screening of childhood ADHD was established at 46 or higher. This cut-off score correctly identifies 86% of patients with ADHD, 99% of normal subjects and 81% of depressed subjects (Wardet al., 1993). The Arabic version used in this study was translated and validated through previous research conducted by (Abdelkarimet al., 2015). It was found that the concomitant use of WUR in addition to ASRS considerably improved the reliability to detect ADHD subjects thus suggesting that in psychiatric populations the use of both scales give better results (Daigreet al., 2014).
    3. Additionally, clinical assessment was conducted with each patient who was positive in both ASRS and WURS to confirm the diagnosis of ADHD on the basis of the DSM-IV criteria.
  3. Assessment for disability and quality of life using the following:
    1. The Sheehan disability scale (Sheehan, 1983) was applied to patients to assess the level of disability.
    2. WHO quality-of-life scale − BREF was applied to evaluate the quality of life (Eseret al., 1999).

After the clinical assessment, participants were divided into two groups:
  1. BD with adult ADHD group (BD+ADHD), which included 22 patients who had positive screening test result at ASRS and fulfilled the DSM-IV-TR criteria for ADHD by clinical diagnostic interview.
  2. BD without adult ADHD group (BD), which included 80 patients who screened negative in ASRS. This group was subdivided into two groups:
  3. Only childhood ADHD group (BD+CDHD), which included 16 patients who had positive screening (score of ≥46) at WURS.
  4. Pure BD, which included 64 patients who had a negative screening at both the ASRS and the WURS scales.

Administrative design:
  1. Approval was obtained from the Intuitional Review Board (IRB) and Department of Psychiatry, Zagazig University.
  2. A written consent was taken from the study subjects.

Statistical analysis

Epidemiological and clinical variables were compared in patients with and without current ADHD. Data collected were analyzed using the statistical program for social sciences 11.0.1 software (SPSS, 2017) by a professional statistician. The results were considered significant when the probability of error is less than 5% (P=0.01). The following tests were done: paired t test for independent variables and χ2 test for percentages.

  Results Top

Demographic data

Overall, 72.7% of patients with bipolar disorder with comorbid adult ADHD were males and 27.3% were females, with male : female ratio of nearly 2.5 : 1. Most patients with bipolar disorder with comorbid adult ADHD (90.9%) were educated for less than 12 years of education compared with only 67.5% of patients without adult ADHD, and this difference is statistically significant. There was a statistically significant difference between patients with comorbid adult ADHD and patients without ADHD regarding marital status and occupation, as patients with adult ADHD were more frequently unmarried and not working ([Table 1]).
Table 1 Demographic data of the studied group

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Frequency of adult ADHD in patients with bipolar disorder was 21.6%, whereas the frequency of childhood ADHD which did not persist into adulthood was 15.7% ([Table 2]).
Table 2 Frequency of adult attention-deficit hyperactivity disorder, bipolar disorder without adult attention-deficit hyperactivity disorder, childhood-only attention-deficit hyperactivity disorder, and pure bipolar disorder among the studied group

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Patients with comorbid adult and childhood ADHD had more significant disability in work, social life, and family life than patients with bipolar disorder without ADHD ([Table 3] and [Table 4]).
Table 3 Disability as reflected by Sheehan disability scale scores among patients with and without adult attention-deficit hyperactivity disorder

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Table 4 Comparison between patients with pure bipolar disorder, patients with adult attention-deficit hyperactivity disorder and patients with childhood-only attention-deficit hyperactivity disorder regarding disability

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Quality of life

Patients with bipolar disorder without comorbid ADHD had better quality of life than patients with comorbid adult and childhood ADHD ([Table 5], [Table 6]).
Table 5 Quality of life as reflected by WHO quality-of-life scale scores of patients with and without adult attention-deficit hyperactivity disorder

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Table 6 Comparison between patients with pure bipolar disorder, patients with adult attention-deficit hyperactivity disorder and patients with childhood attention-deficit hyperactivity disorder regarding quality of life

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  Discussion Top

In this study, 102 euthymic patients with bipolar disorder were screened for presence of adult ADHD. Sociodemographic data, clinical data, other comorbid disorders, disability, and quality of life were assessed in patients with bipolar disorder with adult ADHD and compared with patients without adult ADHD to determine the effect of presence of adult ADHD in clinical characteristics and outcomes of BD.

Frequency of attention-deficit hyperactivity disorder ([Table 2])

In the current study, 22 (21.6%) patients with bipolar disorder had adult ADHD. Moreover, 15.7% of the patients had childhood ADHD that did not persist into adulthood, whereas 62.7% of patients had pure BD without ADHD. These frequencies of ADHD were in line with previous studies. The frequency of adult ADHD varied across the studies: 23.3% (Karaahmet et al., 2013), 21.7% (Perroud et al., 2014), 19.8% (Perugi et al., 2013), 17.6% (McIntyre et al., 2010), 16.4% (Ryden et al., 2009), 16.3% (Tamam et al., 2008), and 10.5% (Torres et al., 2015).

The thorough methodology used to diagnose a concurrent ADHD with BD in previous studies may be a reason for this variance of prevalence of ADHD among the studies.

Regarding disability ([Table 3] and [Table 4])

Clinical research has widely demonstrated that BD may present functional impairment at some point or permanently during the course of the illness (Bonnín et al., 2014). However, in ADHD, the research on functioning is a relatively immature area, especially in adult populations, and even fewer in patients with comorbid BD+ADHD (Torres et al., 2017).

Regarding disability, patients with comorbid adult and childhood ADHD had more disability in work, social life, and family life than patients with bipolar disorder without ADHD. This finding is in consistent with previous reports (Nierenberg et al., 2005; Biederman and Faraone, 2006; Garcia et al., 2012).

Nierenberg et al. (2005) showed that patients with bipolar disorder with adult ADHD presented poorer functioning evaluated by means of the Global Assessment of Functioning compared with patients with bipolar disorder without ADHD.

Koc and Kesebir (2014) found that global functioning of patients with pure BD was higher than patients with comorbid ADHD, which indicates that the presence of ADHD comorbidity affects functioning negatively.

Increased numbers of episodes and severity, which are caused by the presence of comorbid ADHD, with presence of other comorbidities may cause deterioration in functioning in BD cases (Sanchez-Moreno et al., 2009).

Peurgi et al. (2013) found that patients with BD with and without ADHD had similar impairment in global, work, and social functioning, whereas ADHD-positive patients were significantly more impaired in familial adjustment than ADHD-negative patients. Wang et al. (2017) reported that severity of the comorbid BD and ADHD was associated with poor family environment, such as lower socioeconomic state, poor familial emotional support, and low satisfaction with familial relationships. Because this study used a cross-sectional design, it could not determine any causal relationship between increased comorbidity and poor family environment. One explanation is that poor socio-environmental factors might lead to higher rates of this comorbidity. Another is that experiencing the comorbid condition might cause people to regard their socio-environmental state as poor. A third is that psychiatric problems in family members might worsen people’s socio-environmental status (Wang et al., 2017).

At this study, there was no statistical significant difference regarding disability between patients with comorbid adult ADHD and patients with comorbid childhood-only ADHD.

Regarding quality of life ([Table 5] and [Table 6])

This study found that patients with bipolar disorder without comorbid ADHD had better quality of life, which is reflected in higher scores of WHO quality-of-life scale than patients with comorbid adult and childhood ADHD. Nierenberg et al. (2005) also showed that patients with BD and ADHD had lower quality of life compared with patients without ADHD.

Koc and Kesebir (2014) found that patients with pure BD had higher scores in all domains of life quality (social, physical health, environmental, and psychological) than patients with comorbid ADHD. These findings suggested that ADHD comorbidity negatively affects quality of life in patients with BD.

At this study, it was found that the group of patients with bipolar disorder with childhood-only ADHD had poorer quality of life than patients with pure BD, but they did not differed significantly from those patients with adult ADHD.

  Conclusion Top

  1. Adult ADHD is a frequent comorbid disorder in patients with BD.
    1. Comorbid adult ADHD in patients with BD is associated with earlier age of onset, longer duration of illness, more mood episodes, more frequent psychotic features during mood episodes, noncompliance to medications, more times of hospitalization, and more suicidal attempts.
    2. Adult ADHD comorbidity negatively affect functioning and quality of life of patients with BD.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Abdelkarim A, Salama H, Ibrahim S, Abou El Magd O (2015). The prevalence and characteristics of attention-deficit hyperactivity disorder among a sample of Egyptian substance-dependent inpatients. Egyptian J Psychiatry 36:9–13.  Back to cited text no. 1
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association Publishing.  Back to cited text no. 2
Barkley RA. (2009). Challenges in diagnosing adults with ADHD. J Clin Psychiatry 69:e36.  Back to cited text no. 3
Biederman J, Faraone SV (2006). The effects of attention-deficit/hyperactivity disorder on employment and household income. MedGenMed 8:12.  Back to cited text no. 4
Biederman J, Petty CR, Clarke A, Lomedico A, Faraone SV (2011). Predictors of persistent ADHD: an 11-year follow-up study. J Psychiatr Res 45:150–155.  Back to cited text no. 5
Bonnín CM, Torrent C, Goikolea JM, Reinares M, Solé B, Valentí M et al. (2014). The impact of repeated manic episodes and executive dysfunction on work adjustment in bipolar disorder. Eur Arch Psychiatry Clin Neurosci 264:247–254.  Back to cited text no. 6
Daigre C, Roncero C, Rodrigueuez-Cintas L, Ortega L, Ligon S, Fuentes S et al. (2014). Screening in alcohol-dependent patients using the Wender-Utah rating scale and the adult ADHD self-report scale. J Atten Disord.  Back to cited text no. 7
Eser E, Fidaner H, Fidaner C (1999). Measuring life quality, WHO QOL-100 vs WHOQOOL-BREF. J Psychiatry Psychol Psychopharmacol 7:23–40.  Back to cited text no. 8
Faraone SV, Asherson P, Banaschewski T (2015). Attention-deficit/hyperectivity disorder. Nat Rev Dis Primers 2015: 1:15020.  Back to cited text no. 9
Garcia CR, Bau CH, Silva KL, Callegari-Jacques SM, Salgado CA, Fischer AG et al. (2012). The burdened life of adults with ADHD: impairment beyond comorbidity. Eur Psychiatry 27:309–313.  Back to cited text no. 10
Karaahmet E, Konuk N, Dalkilic A (2013). The comorbidity of adult attention deficit/hyperactivity disorder in bipolar disorder patients. Compr Psychiatry 54:549–555.  Back to cited text no. 11
Kessler RC, Adler L, Ames M (2005). The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general popu-lation. Psychol Med 35:245–256.  Back to cited text no. 12
Klassen LJ, Katzman MA, Chokka P (2010). Adult ADHD and its comorbidities, with a focus on bipolar disorder. J Affect Dis 124:1–8.  Back to cited text no. 13
Koc I, Kesebir S (2014). The subgroup effect of adult attention deficit hyperactivity on disability and quality of life among bipolar patients. Bull Clin Psychopharmacol 24:49–54.  Back to cited text no. 14
Kumar V, Varambally S (2017). Atomoxetine induced hypomania in a patient with bipolar disorder and adult attention deficit hyperactivity disorder. Indian J Psychol Med 39:89–91.  Back to cited text no. 15
McGough JJ, Smalley SL, Mccracken JT, Yang M, Del’homme M, Lynn DE, Loo S (2005). Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry 162:1621–1627.  Back to cited text no. 16
McIntyre RS, Kennedy SH, Soczynska JK, Nguyen HT, Bilkey TS, Woldeyohannes HO et al. (2010). Attention-deficit/hyperactivity disorder in adults with bipolar disorder or major depressive disorder: results from the international mood disorders collaborative project. Prim Care Companion J Clin Psychiatry 12:pii: PCC.09m 00861.  Back to cited text no. 17
Miller TH (2016). Bipolar disorder. Prim Care Clin Office Pract 43:269–284.  Back to cited text no. 18
Nierenberg AA, Miyahara S, Spencer T, Wisniewski SR, Otto MW, Simon N et al. (2005). Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants. Biol Psychiatry 57:1467–1473.  Back to cited text no. 19
Perroud N, Cordera P, Zimmermann J, Michalopoulos G, Bancila V, Prada P et al. (2014). Comorbidity between attention deficit hyperactivity disorder (ADHD) and bipolar disorder in a specialized mood disorders outpatient clinic. J Affect Disord 168:161–166.  Back to cited text no. 20
Perugi G, Ceraudo G, Vannucchi G, Rizzato S, Toni C, Dell’Osso L (2013). Attention deficit/hyperactivity disorder symptoms in Italian bipolar adult patients: a preliminary report. J Affect Disord 149:430–434.  Back to cited text no. 21
Polanczyk G, deLima MS, Horta BL, Biederman J, Rohde LA (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164:942–948.  Back to cited text no. 22
Ramos-Quiroga JA, Bosch-Munsó R, Castells-Cervelló X, Nogueira-Morais M, García-Gimenez E, Casas-Brugué M (2006). Attention deficit hyperactivity disorder in adults: a clinical and therapeutic characterization. Rev Neurol 42:600–606.  Back to cited text no. 23
Rommel AS, Halperin JM, Mill J, Asherson P, Kuntsi J (2013). Protection from genetic diathesis in attention-deficit/hyperactivity disorder: possible complementary roles of exercise. J Am Acad Child Adolesc Psychiatry 52:900–910.  Back to cited text no. 24
Ryden E, Thase ME, Straht D, Aberg-Wistedt A, Bejerot S, Landen M (2009). A history of childhood attention-deficit hyperactivity disorder (ADHD) impacts clinical outcome in adult bipolar patients regardless of current ADHD. Acta Psychiatr Scand 120:239–246.  Back to cited text no. 25
Sanchez-Moreno J, Martinez-Aran A, Tabares-Seisdedos R, Torrent C, Vieta E, Ayuso-Mateos JL (2009). Functioning and disability in bipolar disorder: an extensive review. Psychother Psychosom 78:285–297.  Back to cited text no. 26
Sheehan D (1983). The anxiety disease. New York: Scribner’s.  Back to cited text no. 27
Song J, Bergen SE, Kuja Halkola R, Larsson H, Landén M, Lichtenstein P (2015). Bipolar disorder and its relation to major psychiatric disorders: a family-based study in the Swedish population. Bipolar Disord 17:184–193.  Back to cited text no. 28
SPSS for Window (2017). Statistical package for social sciences, version 25.0. IBM, Armonk, NY, USA: IBM corp 2017.  Back to cited text no. 29
Tamam L, Karakus G, Ospoyraz N (2008). Comorbidity of adult attention-deficit hyperactive disorder and bipolar disorder: prevalence and clinical correlates. Eur Arch Psychiatry Clin Neurosci 258:385–394.  Back to cited text no. 30
Torres I, Gomez N, Colom F, Ramos-Quiroga JA, Goikolea JM (2015). Bipolar disorder with comorbid attention- deficit and hyperactivity disorder. Main clinical features and clues for an accurate diagnosis. Acta  Back to cited text no. 31
Torres I, Garriga M, Sole B, Bonnín CM, Corrales M, Jiménez E et al. (2017). Functional impairment in adult bipolar disorder with ADHD. J Affect Disord 227:117–125.  Back to cited text no. 32
Wang HR, Jung YE, Chung SK, Hong J, Kang NR, Kim MD, Bahk WM (2017). Prevalence and correlates of bipolar spectrum disorder comorbid with ADHD features in nonclinical young adults. J Affect Disord 207:175–180.  Back to cited text no. 33
Wood DR, Reimherr FW, Wender PH, Johnson GE (1976). Diagnosis and treatment of minimal brain dysfunction in adults: a preliminary report. Arch Gen Psychiatry 33:1453–1466.  Back to cited text no. 34


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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