Pharmacotherapy for bipolar disorder in adults with high-functioning autism

ABSTRACT

Introduction

The association between high-functioning autism (HFA) and bipolar disorder (BD) in adult subjects has been confirmed by a growing number of studies. However, identifying and treating BD in this population is a clinical challenge and requires careful assessment and adequate knowledge of both disorders.

Areas covered

This review aims to provide a clinical presentation of mood episodes in HFA individuals, and an update on the pharmacotherapy of BD in these individuals, sharing with the reader expert opinion on the current state of the art and future perspectives.

Expert opinion

BD has an atypical clinical presentation in HFA subjects with the possibility of diagnostic and therapeutic mistakes. Despite the absence of controlled studies, the available evidence indicates mood stabilizers, especially lithium, as the first treatment option. HFA subjects are particularly vulnerable to pharmacological side effects, such as extrapyramidal and catatonic symptoms with antipsychotics, or activation syndrome with antidepressants. Accordingly, initial titration of these drugs should be slow and their use should be limited in time. Among antipsychotics, dopamine receptor antagonists with combined serotonergic activity are preferable. Further research is needed to improve the diagnostic process and to delineate the effectiveness of different drugs for BD in HFA subjects.

KEYWORDS:

• Autism spectrum disorder
• high-functioning autism
• bipolar disorder
• mood stabilizers

Article highlights

• Bipolar disorder (BD) is a common comorbidity in individuals with high-functioning autism (HFA).

• HFA individuals show an atypical clinical presentation of mood episodes.

• No pharmacological treatment has been studied systematically or in controlled clinical trials.

• Mood stabilizers, particularly lithium, are the first treatment option.

• Antipsychotics with serotonergic activity are preferred for mania or aggression.

• Antidepressants should be used with caution due to the risk of behavioural activation.

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Declaration of interest

G Perugi acted as consultant to Lundbeck, Angelini, and FB-Health. He received a scholarship/research support from Lundbeck and Angelini. He is a member of the speaker/advisory board of Sanofi-Aventis, Lundbeck, FB-Health, and Angelini. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed research funding from Otsuka. Peer reviewers on this manuscript have no other relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.