para>Mood disorders, generalized anxiety disorders, and substance abuse can also coexist with adult ADHD; treating both the ADHD and comorbid conditions will improve the patient's prognosis.
TREATMENT
- Most of the research and medication trials have been performed in children.
- There is increasing evidence that stimulants and nonstimulants used in children are also effective in adults (5)[A].
ALERT
Because stimulant medication may induce dependency, substance abuse, and diversion, it is necessary to do pill counts, screen urine for drugs, monitor behavior, and query prescription databases. Misuse of amphetamines may cause sudden death and serious cardiovascular adverse events.
GENERAL MEASURES
When prescribing stimulant medications for adults with ADHD, watch for misuse, abuse, and diversion of prescription medications. When substance abuse is not present, stimulants are 1st-line treatment for ADHD and highly efficacious. There are multiple formulations of stimulants, and patients may require trials of different dosages, formulations, and medications before an optimal response in symptoms and functions is achieved.
MEDICATION
- Psychotropic medications play a large part in the treatment of ADHD symptoms. Medications should be titrated slowly to effective dose to avoid side effects.
- Stimulants are more effective than antidepressants or nonstimulants, but up to 30% discontinue medications because of side effects.
- Stimulants can be divided into two different classes: Methylphenidate and amphetamine come in both short-acting and long-acting preparations.
- Antidepressants studied for ADHD include bupropion, which has been shown to have a medium effect compared with stimulants (6)[A].
First Line
- Stimulants: methylphenidate (Concerta, Ritalin), dexmethylphenidate (Focalin), dextroamphetamine/amphetamine (Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine (Vyvanse)
- Nonstimulants: Atomoxetine (Strattera) has been shown effective in adults with ADHD when compared to placebo (7)[B]. It may be given as a single dose or split dose and has low abuse potential, making it a better choice over a stimulant medication for patients with substance abuse history. Onset of effect may take up to 4 weeks. Atomoxetine may require dose adjustments with strong inhibitors of cytochrome P2D6 (e.g., Paxil or Prozac). Also, there are rare cases of liver damage associated with these medications. Monitor for increased suicidal thinking.
- Antidepressants: best used for those at high risk or with history of substance abuse disorder
- Bupropion (Wellbutrin) is an antidepressant effective in adults with ADHD symptoms (6)[A].
ISSUES FOR REFERRAL
Patients with comorbid conditions may need referral for diagnosis and treatment. Consider cardiology consult for patients with known cardiac issues who may require stimulant treatment. Consider referral to obstetrician experienced in high-risk pregnancies when treating pregnant women with ADHD.
ADDITIONAL THERAPIES
Cognitive-behavioral therapy can be useful in conjunction with medication to help patient modify and cope with symptoms.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Vitamin-Mineral supplementation is an area of active research that holds promise for improved ADHD treatment (8)[A].
ONGOING CARE
Transfer from pediatric to adult care must be closely coordinated to avoid hiatus in treatment.
FOLLOW-UP RECOMMENDATIONS
- Close follow-up of medication as dose is titrated.
- Continue to monitor for medication side effects.
- Repeat screening checklists to quantify benefit of interventions as needed.
- Reinforce behavioral change (e.g., self-initiated through cognitive-behavioral therapy), which is essential goal of long-term management.
REFERENCES
11 Doshi JA, Hodgkins P, Kahle J, et al. Economic impact of childhood and adult attention-deficit/hyperactivity disorder in the United States. J Am Acad Child Adolesc Psychiatry. 2012;51(10):990.e2-1002.e2.22 Simon V, Czobor P, B ¡lint S, et al: Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194(3):204-211.33 Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723.44 Gatt JM, Burton KL, Williams LM, et al. Specific and common genes implicated across major mental disorders: a review of meta-analysis studies. J Psychiatr Res. 2015;60:1-13.55 Castells X, Ramos-Quiroga JA, Bosch R, et al. Amphetamines for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2011;(6):CD007813.66 Verbeeck W, Tuinier S, Bekkering GE. Antidepressants in the treatment of adult attention-deficit hyperactivity disorder: a systematic review. Adv Ther. 2009;26(2):170-184.77 Asherson P, Bushe C, Saylor K, et al. Efficacy of atomoxetine in adults with attention deficit hyperactivity disorder: an integrated analysis of the complete database of multicenter placebo-controlled trials. J Psychopharmacol. 2014;28(9):837-846.88 Rucklidge JJ, Frampton CM, Gorman B, et al. Vitamin-mineral treatment of attention-deficit hyperactivity disorder in adults: double-blind randomised placebo-controlled trial. Br J Psychiatry. 2014;204:306-315.
ADDITIONAL READING
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Mongia M, Hechtman L. Cognitive behavior therapy for adults with attention-deficit/hyperactivity disorder: a review of recent randomized controlled trials. Curr Psychiatry Rep. 2012;14(5):561-567.
- Post RE, Kurlansik SL. Diagnosis and management of adult attention-deficit/hyperactivity disorder. Am Fam Physician. 2012;85(9):890-896.
CODES
ICD10
- F90.9 Attention-deficit hyperactivity disorder, unspecified type
- F90.1 Attn-defct hyperactivity disorder, predom hyperactive type
- F90.0 Attn-defct hyperactivity disorder, predom inattentive type
- F90.2 Attention-deficit hyperactivity disorder, combined type
- F90.8 Attention-deficit hyperactivity disorder, other type
ICD9
- 314.01 Attention deficit disorder with hyperactivity
SNOMED
- 444613000 Adult attention deficit hyperactivity disorder (disorder)
- 7461003 Attention deficit hyperactivity disorder, predominantly hyperactive impulsive type
- 35253001 attention deficit hyperactivity disorder, predominantly inattentive type (disorder)
- 31177006 Attention deficit hyperactivity disorder, combined type (disorder)
CLINICAL PEARLS
- Adult ADHD results in inattention, easy distractability, hyperactivity, and impulsive behavior; it is associated with low self-esteem, problematic interpersonal relationships, and difficulty meeting academic and job expectations.
- Psychotropic medications plus cognitive-behavioral treatments are the cornerstone of management.
- Substance abuse is a common comorbidity; recommend use of nonstimulant medication in those at high risk