TREATMENT STRATEGIES

Failure to effectively manage ADHD can hinder overall health and quality of life1,2

As this chronic condition persists, it continues to negatively impact many domains of patient well-being1,2

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ON THIS PAGE: CONSEQUENCES OF NONTREATMENT•STIMULANT MEDICATIONS IN ADULT ADHD

Consequences of Nontreatment

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ADHD in adults is a chronic disorder that requires a consistent treatment approach2

It is important for patients to recognize that the demands of adult life at home and at work necessitate consistent control of ADHD symptoms.2 If ADHD is left untreated, adults can experience reduced emotional, social, and vocational functioning throughout the day, in areas such as2,3:

  • Morning routine (getting ready for work and/or kids ready for school)
  • Driving safely to office
  • Finishing work accurately and on time
  • Helping kids with homework
  • Interacting with significant other/partner
  • Planning next day’s activities
  • Going to bed on time

ADHD is a “24/7” disorder4

Adults with ADHD may be curious about “drug holidays” during times when they feel they need less coverage of symptoms, such as during the weekends or while on vacation.4

However, given that untreated ADHD can lead to use of substances, motor vehicle crashes, and impaired social function, adults who take drug holidays may be at greater risk for negative outcomes.4,5

  • There is an increased consensus that drug holidays are unnecessary and that the consistent use of ADHD medication can aid in developing healthy habits of planning and self-discipline4

Pharmacologic and nonpharmacologic options are both important in the adult ADHD treatment plan2,6-8

The risks and benefits of treatment strategies must be weighed carefully in adult patients2

Stimulant Medications in Adult ADHD

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Psychostimulants, as a class, have the most well-established and robust efficacy profile and are often used first in the treatment of adult ADHD2,9

  • A large, cross-sectional study of adults newly diagnosed with ADHD found that stimulants were the clear first-line agents, prescribed in 93% of patients who were started on medications9

Stimulants contain the molecules methylphenidate or amphetamine, which work on the central nervous system to improve attention and reduce hyperactivity10,11

  • Stimulants approved for adult ADHD are highly effective in treating the disorder, and have consistently demonstrated positive short- and long-term effects on core symptoms, as well as on daily functioning2,12
  • Stimulants also improve vigilance, cognition, reaction time, and short-term memory13
  • Treatment with stimulants may improve quality of life in adults with ADHD14
Icon: Controlled Stimulant

Despite clear therapeutic benefits, certain features of stimulants limit their usage among adult ADHD populations:

  • End-of-dose effects: Short-acting formulations may produce a rebound effect where behavioral symptoms recur in the late afternoon or evening13; this may be especially troubling for adult patients who are juggling around-the-clock home- and work-life responsibilities2
    • Research also points to a tolerance phenomenon with stimulants, which could result in undertreatment and a greater burden of dose adjustments15
  • Side effects: Patients who take stimulants may experience a range of common adverse effects—including elevated heart rate, anorexia, weight loss, insomnia, abdominal pain, and headache—which may all impact adherence13
  • Triggering of psychiatric symptoms: Stimulants can be destabilizing and can trigger (hypo)manic symptoms, as well as anxiety; they should therefore be used more cautiously in patients with underlying psychiatric conditions12,16
  • Risk for abuse/diversion:
    • All stimulant medications have the potential for abuse, and are therefore classified as Schedule II2
    • Patients with ADHD have been shown to divert and misuse stimulant medications significantly more frequently than non-ADHD patients taking other classes of psychotropics17
    • Prescribers should be aware that stimulants are often diverted for their purported cognitive-enhancing benefits, particularly in academic (college or university) settings12
Icon: Noncontrolled Nonstimulant

Nonstimulant medication options

Noncontrolled medications/nonstimulants are also available in the treatment of adult ADHD.18

  • Outside of stimulants and one nonstimulant medication currently approved for adult ADHD, treatment options remain limited. While there are several different drug classes used in clinical practice, none of them are specifically indicated for adult ADHD.12,13,19

Nonpharmacologic treatment of adult ADHD

There are multiple successful nonpharmacologic treatment strategies for adult ADHD. As with medication management, a nonpharmacologic treatment approach should be tailored to each patient.2,8

Behavioral therapies

  • Cognitive behavioral therapy (CBT): CBT combines higher-level organization and planning, behavior skills training, and cognitive restructuring. Studies in adults suggest that CBT can have treatment effects on ADHD symptoms, mood, and overall functioning—particularly in the area of inattention.2,20
  • Mindfulness-based cognitive therapy (MBCT): MBCT is an emerging psychosocial intervention in which individuals learn to focus on their thoughts and feelings in real time, allowing for a more conscious choice of behavior.20 For adults with ADHD, MBCT may help cultivate a “mental filter” through which impulsivity and inattentiveness are diminished.20

ADHD coaching

ADHD coaches are specialized mental health counselors who help clients develop the skills and strategies they need to achieve their personal goals and reach their full potential.

CHADD training and support for adults

Children and Adults with Attention Hyperactivity Disorder (CHADD) offers free, online courses specifically for adults with ADHD on subjects such as diagnosis and treatment, as well as practical strategies on meeting financial goals and time management.

Virtual ADHD support groups

Support groups that meet virtually can help adults connect with peers to share their ADHD struggles and successes. The Attention Deficit Disorder Association (ADDA) offers an array of online groups and programs for adult patients with specific support needs.

Treating Comorbid Complex ADHD: Part 1

Dr. Jain, an adult, child, and adolescent psychiatrist, discusses the treatment of comorbid complex ADHD in part 1 of this two-part series.

Hello, dear colleagues. It’s a true pleasure to be able to talk to you today. My name is Rakesh Jain and I’m an adult, child, and adolescent psychiatrist and a proud member of Team ADHD. Team ADHD is an educational initiative, with the main goal of creating and deepening discussion of issues of treating, educating about, and managing ADHD.

Today, I’ll address the issue of comorbidities in ADHD. Comorbidities are common in ADHD, with the most common comorbidities being oppositional defiant disorder, conduct disorder, anxiety disorders, major depressive disorder, and substance abuse disorders. As you will undoubtedly note, the pattern of comorbidities changes significantly over the course of a lifetime. In particular, depressive and substance use disorders increase in prevalence in adolescent and adult patients with ADHD.1-2

The American Academy of Pediatrics specifically includes the assessment of comorbidities in their ADHD diagnostic guidelines. Step 1 is to determine the presence of ADHD-specific symptoms; step 2 is to rule out any alternative causes of these symptoms; and step 3 is to evaluate for the presence of any comorbid disorder or disorders.3

Let’s talk about the evolving thinking regarding treatment of ADHD and its comorbidities. The older treatment paradigm was to treat any and all comorbidities first, then wait it out, and only then treat ADHD. The new paradigm suggests treating all disorders at the same time. Emerging evidence strongly supports the wisdom of taking this approach, which is to respect and treat both ADHD and all its comorbidities with equal attention.4,5

Let’s turn our attention to 1 specific comorbidity of ADHD, major depression. Having comorbid complex ADHD confers an unusually high risk of treatment resistance to antidepressants. In fact, the numbers are strikingly high, with more than a two-times higher risk of treatment resistance for patients with ADHD and major depression compared to major depression alone. That’s the bad news. The good news is that treating ADHD may reduce the risk of antidepressant resistance in this population.6

In addition, treating ADHD may reduce the risk of these comorbidities, as well as moderate negative outcomes in patients with comorbid conditions. You will notice that treating ADHD reduces the risk of substance abuse by 31%, the 3-year risk of recurrence of depression by 43%, the risk of substance abuse recurrences by 61%, and the risk of motor vehicle accidents by approximately 40%. All of these data persuade us to consider treating both ADHD and all of its potential comorbidities.7-10

Let’s shift gears and examine another issue. Treatment must address the time outside of school and work, too. As these two 24-hour clocks demonstrate, the lives of children, adolescents, and adults with ADHD are not limited to finite times during the day, but they extend to include the entire day. We clinicians must respect this 24-hour clock that all patients live by, whether these patients have comorbidities or not.4,11

With that, I thank you very much for your attention, and on behalf of Team ADHD, I appreciate you being part of this educational initiative.

REFERENCES: 1.Turgay A, Ansari R. Major depression with ADHD: in children and adolescents. Psychiatry (Edgmont). 2006;3(4)20-32. 2. Kollins SH. ADHD, substance use disorders, and psychostimulant treatment: current literature and treatment guidelines. J Atten Disord. 2008;12(2):115- 125. 3. American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007-1022. 4. Mattingly GW, Anderson RH. Optimizing outcomes in ADHD treatment: from clinical targets to novel delivery systems. CNS Spectr. 2016;21:45-59. 5. Faraone SV, et al. Attention- deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1:1-23. 6. Chen MH, et al. Attention-deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: a nationwide longitudinal study. Eur Neuropsychopharmacol. 2016;26(11):1760- 1767. 7. Chang Z, et al. Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry. 2014;55(8);878- 885. 8. Chang Z, et al. Medication for attention- deficit/hyperactivity disorder and risk for depression: a nationwide longitudinal cohort study. Biol Psychiatry. 2016;80(12);916-922. 9. Bihlar Muld B, et al. Long-term outcomes of pharmacologically treated versus non- treated adults with ADHD and substance use disorder: a naturalistic study. J Subst Abuse Treat. 2015;51:82-90. 10. Chang Z, et al. Association between medication use for attention-deficit/ hyperactivity disorder and risk of motor vehicle crashes. JAMA Psychiatry. 2017;74(6):597-603. 11. Jain R, et al. Addressing diagnosis and treatment gaps in adults with attention- deficit/hyperactivity disorder. Prim Care Companion CNS Disord. 2017;19(5):17nr02153.

Key Takeaways

  • Undertreated ADHD can have significant negative consequences for adults1,2,3,5
  • Stimulants are currently considered first-line therapy in the treatment of adult ADHD, but their use may be limited by their tolerability profile and risk for diversion2,12,13,21
  • Nonstimulant options may be better tolerated, though their efficacy is less established12,13
  • Nonpharmacologic treatment options are also important to consider2

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Resources  

REFERENCES

  1. Ginsberg Y, Quintero J, Anand E, Casillas M, Upadhyaya HP. Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. Prim Care Companion CNS Disord. 2014;16(3): PCC.13r01600. doi: 10.4088/PCC.13r01600.
  2. Jain R, Jain S, Montano B. Addressing diagnosis and treatment gaps in adults with attention-deficit/hyperactivity disorder. Prim Care Companion CNS Disord. 2017;19(5):17nr02153. doi: 10.4088/PCC.17nr02153.
  3. Fields SA, Johnson WM, Hassig MB. Adult ADHD: addressing a unique set of challenges. J Fam Pract. 2017;66(2):68-74.
  4. Faraone SV, Spener TJ, Montano CB, Biederman J. Attention-deficit/hyperactivity disorder in adults—a survey of current practice in psychiatry and primary care. Arch Intern Med. 2004;164:1221-1226.
  5. Franke B, Michelini G, Asherson P, et al. Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. Eur Neuropsychopharmacol. 2018;28;1059-1088.
  6. Buoli M, Serati M, Cahn W. Alternative pharmacological strategies for adult ADHD treatment: a systematic review. Expert Rev Neurother. 2016;16:131-44.
  7. Geffen J, Forster K. Treatment of adult ADHD: a clinical perspective. Ther Adv Psycopharmacology. 2018;8(1):25-32.
  8. De Crescenzo F, Cortese S, Adamo N, Janiri L. Pharmacological and non-pharmacological treatment of adults with ADHD: a meta-review. Evid Based Mental Health. 2017;20(1):4-11.
  9. Piñeiro-Dieguez B, Balanzá-Martínez V, García-García P, et al. Psychiatric comorbidity at the time of diagnosis in adults with ADHD. J Atten Disord. 2014;20:1066-1075.
  10. Briars L, Todd T. A review of pharmacological management of attention-deficit/hyperactivity disorder. J Pediatr Pharmacol Ther. 2016;21(3):192-206.
  11. Felt BT, Biermann B, Christner JG, Kochhar P, Harrison RV. Diagnosis and management of ADHD in children. Am Fam Physician. 2014;90(7):456-464.
  12. Volkow ND, Swanson JM. Adult attention-deficit disorder. N Engl J Med. 2013;369(20):1935-1944.
  13. Kolar D, Keller A, Golfinopoulos M, Cumyn L, Syer C, Hechtman L. Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. 2008;4(2):389-403.
  14. Agarwal R, Goldenberg M, Perry R, et al. The quality of life of adults with attention deficit hyperactivity disorder: a systematic review. Innov Clin Neurosci. 2012;9:10–21.
  15. Yanofski J. The dopamine dilemma—part II. Could stimulants cause tolerance, dependence, and paradoxical decompensation? Innov Clin Neurosci. 2011;8(1):47-53.
  16. Perugi G, Pallucchini A, Rizzato S, Pinzone V, De Rossi P. Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD). Exp Opinion Pharmacother. 2019;20(12):1457-1470.
  17. Bukstein O. Substance abuse in patients with attention-deficit/hyperactivity disorder. Medscape J Med. 2008;10(1):24.
  18. Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry. 2019;56:14-34.
  19. Wilens TE, Spencer TJ, Biederman J, et al. A controlled clinical trial of bupropion for attention deficit hyperactivity disorder in adults. Am J Psychiatry. 2001;158: 282–288.
  20. Gallagher R, Feder MA. Adult ADHD: psychosocial treatment components and efficacy status. Psychiatr Ann. 2018;48(7):333-337.
  21. Carpentier P-J, Levin FR. Pharmacological treatment of ADHD in addicted patients: what does the literature tell us? Harv Rev Psychiatry. 2017;25(2):50-64.

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