75% of patients present to a clinician with depressive symptoms. 

Presenting symptoms include anhedonia, lack of energy, feeling tired, low mood. 

Symptoms of mania include reduced need for sleep, racing thoughts, talkative, and restless. 

Common features: anger, lack of attention, anxious, agitated. 

treatment for bipolar depression include quetiapine and cariprazine.

many medications to treat bipolar mania. 

Establishing a diagnosis of adult ADHD can be challenging. ADHD has a genetic link and adults may inquire if their children are diagnosed. In addition, many false positive cases of late-onset ADHD may be attributable to nonimpairing cognitive fluctuations.   care must be made to avoid overdiagnosing and inappropriately treating. As their are no reliable diagnosing tools, and clinicians rely on self reported questionnaires, the concerns regarding malingered symptoms are high.   College students may be particularly prone to overreport to obtain academic accommodations and or stimulant medication.  clinicians need to be astute to those students that report high on the various screening scales, yet managed to achieve.  there is also the need to differentiate poor attention form other disorders that present with concentration issues. these include anxiety disorders, PTSD, depression, bipolar disorder, or other cognitive disorders.   In addition a clinician also needs to screen for any underlying sleep disorder that may impair concentration or any other medical issue as well as a substance use disorder. Two studies of adult-onset ADHD concluded that 95% of cases were better explained by other cases. 

Concerns about overprescribing stimulants include risk of addition, and interactions with other medications.  Stimulants also increase the risk of anxiety, psychosis, irritability, insomnia, and trigger manic like behaviors. Stimulants can raise blood pressure and heart rate with potential  cardiovascular events like arrthymias and strokes.

There are only 2 stimulant medications available. this is either methylphenidate or amphetamine.  These 2 medications however are prescribed in various ways, from long acting to short immediate release.   There are prodrugs for each, which require an enzyme to release the active compound.  Other delivery symptoms include one based on osmotic release through the gut, different formulations with coated beads to delay release,  patch, oral disintegrating tabs, liquids, and a preparation that is taken the night before and released in the am. 

There are 2 non stimulant medications that work on norepinephrine reuptake blocking and two preparations that work on the alpha receptor. 

There are several medications also used off label which have shown some promise in improving concentration. These include bupropion, modafinil, and armodafinil. 

NO psychiatric patient with ADHD should be treated with medication alone. Behavioral tools in addition, are essential for optimum treatment.