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How to Treat Adult ADHD

The Carlat Psychiatry Report, Volume 15, Number 1, January 2017
https://www.thecarlatreport.com/newsletter-issue/tcprv15n1/

From The Carlat Psychiatry Report, January 2017, Adult ADHD

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: ADHD | Free Articles | Practice Tools and Tips

Print Friendly, PDF & Email

Aashish R. Parikh, MD

Staff psychiatrist, Veterans Affairs North Texas Health Care System. Assistant professor, University of Texas Medical School at Southwestern

Dr. Parikh has disclosed that he has been a speaker for Sunovion. Dr. Carlat has reviewed this article and has found no evidence of bias in this educational activity.

Over the past decade, it’s become apparent that ADHD does not suddenly end when children grow up, and that the disorder often continues into adulthood. Since 2011, I have run a clinic specializing in adult ADHD. ADHD is relatively common in adults, with conservative estimates of a 4%–5% prevalence in the adult population, equal in men and women (http://tinyurl.com/grgb5j9). However, only about 10% of adults with ADHD are receiving treatment for their condition (Kessler RC et al, Am J Psychiatry 2006;163(4):716–723).

Assessment
Before doing an ADHD assessment, keep in mind that most ADHD symptoms are nonspecific and can be present in many other psychiatric disorders—or even present in people without any disorder at all. I suggest a number of useful questions to ask patients below, but note that positive answers to any of them cannot “make” the diagnosis; instead, they are clues that may (or may not) prompt a suspicion of ADHD.

When patients come into my clinic, the first thing I do is to assess their motivation. It takes significant time and energy to see a psychiatrist, especially given the shortage of practitioners and the long waits usually required. So I will ask, “Why are you coming in for an ADHD evaluation at this age? Why now? Have there been any major changes in your life recently?” Frequently, there’s a precipitating factor that prompts a patient to seek treatment, such as a promotion, increased work responsibilities or educational demands, the birth or adoption of a child, or a new marriage.

If a patient comes in and says, “I have poor attention,” I ask how long the problem has been going on. For my patients with ADHD, the most common answer is “my whole life.” Many of them have teary eyes when answering this question.

I’ll dig into patients’ education—for example, I’ll ask, “Was school a struggle for you?” They will often say yes, or they might say their problems didn’t surface until college, in which case I ask, “How long did it take you to get your degree?” Patients may say it took them many years and multiple attempts to attain it.

I like to ask about patients’ daily home life. For example, I’ll ask, “What does your bedroom closet look like?” and many will simply laugh, because it is so disorganized. I’ll also ask, “How often do you lose important things, like cell phones or keys?” and often patients will show me that they have these items tied to their waists, saying, “This is what I have to do to not lose them.”

I additionally ask about feelings of restlessness. The way I phrase this is not just, “Are you unable to sit still?” but rather, “Do you have an urge to constantly be on the go? What is it like to sit in a meeting? Are you able to stand in line at a coffee shop?” Given the growing data that ADHD may increase the risk of mortality (Barbaresi WJ et al, Pediatrics 2013;131(4):637–644), especially due to motor vehicle accidents, I will ask patients about the number of near misses they’ve had while driving.

After these initial questions, I will more systematically go through the formal list of ADHD symptoms. I don’t simply read off a list for patients to answer out loud—instead, I have them fill out the ADHD Rating Scale IV With Adult Prompts (ADHD-RS-IV) in the waiting room. Then I go through the items with them during the interview, clarifying and asking patients to expand on select answers.

After the ADHD questions, I will do a psychiatric review of systems, because mood, anxiety, and trauma-related disorders are common in patients with ADHD.

If a patient describes symptoms of depression, it may be hard to tell whether the poor concentration is due to depression or due to ADHD. I find it helpful in these situations to ask about self-esteem. If most of the patient’s depressive symptoms are related to statements like, “I feel down on myself” or, “I feel like a failure,” I am more likely to consider ADHD, because ADHD often leads to poor self-esteem due to an inability to function well (Cook J et al, Atten Defic Hyperact Disord 2014;6(4):249–268. doi:10.1007/s12402-014-0133-2. Epub 2014 Mar 26). Anecdotally, I’ve found poor self-esteem to be more common in my female ADHD patients than my male ADHD patients.

ADHD has been found to increase rates of suicide attempts (Dalsgaars S et al, Lancet 2015;385(9983):2190–2196), probably in part because people with ADHD are impulsive, and some suicide attempts are impulsive acts (Chronis-Tuscano A et al, Arch Gen Psychiatry 2010;67(10):1044–1051). The key point is to ask about suicidal ideation in all patients you are screening for ADHD.

I make sure to take a good substance use history. I specifically ask about caffeine usage (which I don’t ordinarily do when interviewing patients without possible ADHD), and find that patients with ADHD are often using multiple energy drinks throughout the day. I ask about nicotine use, and I have observed an unusual pattern in which these patients smoke a small number of cigarettes a day, such as 4 or 6, as opposed to just saying “a half pack” or “a pack.” It’s possible they are dosing themselves with cigarettes to enhance attention.

I ask about family history, because ADHD is highly heritable: “Have any of your family members been diagnosed with ADHD?” To further clarify, I ask, “Whom do you suspect has problems with attention in your family?” In terms of past psychiatric history, I’ve found that patients with possible ADHD have had poor responses to multiple antidepressants and antianxiety meds.

When I get a patient’s medical history, I spend extra time on cardiac history to screen for preexisting cardiovascular disease. I’ll ask, “Have you ever been told that there is anything wrong with your heart? Have you had fainting spells, severe chest pains, or palpitations so severe that you had to go to the emergency room?” I try to ascertain whether there is a history of sudden cardiac death in the patient’s family, which can be difficult with some patients. My highest-yield question is, “Has anyone in your family younger than 35 passed away for an unknown reason?”

If a patient has a history of documented cardiac disease, before I prescribe a stimulant, I send a prepared letter to the patient’s cardiologist, which essentially asks, “In your opinion, do you think it is reasonably safe to use stimulants in your patient?” Most of the time, the cardiologist will approve. Only a few conditions are absolute contraindications to prescribing stimulants: cardiomyopathy, prolonged QT interval, short QT interval, Brugada syndrome, Wolff-Parkinson-White syndrome, and Marfan syndrome.

Research has not demonstrated an increased risk of serious cardiovascular events in healthy young and middle-aged adults receiving stimulant medications for ADHD (Habel et al, JAMA 2011;306(24):2673–2683). A baseline EKG is not required before starting a stimulant if there is no personal or family history of cardiac disease.

ADHD is a clinical diagnosis based on a clinical assessment and history. Neuropsychological testing has not been found beneficial for diagnosing adult ADHD. In my experience, unnecessary neuropsychological testing often serves as a barrier to treatment, because of the time-consuming process of making an appointment and receiving a report. Nor is there any utility to be found in the many device-based “diagnostic tests,” such as the TOVA, CPT, quantitative EEG, and SPECT scans.

Medication treatment
Before I start any medication, I run a patient’s name through my state’s prescription drug monitoring program (PDMP). After querying the system, it can be quite obvious that someone is doctor-shopping in order to get stimulants, and I will confront patients with this information; they will need to seek specialized substance abuse treatment before I will treat them. But PDMPs are useful for other reasons, too. For example, when patients can’t remember all the medications they’ve been prescribed, a search of the PDMP can be helpful; however, note that only scheduled medications will be listed.

There are two main categories of drug treatment for ADHD: stimulants and non-stimulants. Stimulants have a much larger effect size than non-stimulants, in the range of 0.9 for stimulants as opposed to 0.45 for non-stimulants such as atomoxetine (Arnold LE, J Atten Disord 2000;3(4):200–211). For this reason, I encourage most patients to start with stimulants. If they are reluctant, I will say that they are the gold-standard treatment for ADHD, that we’ve been using them since the 1940s, and that they are safe at the prescribed dosages.

Among stimulants, there are essentially two main choices: amphetamine vs. methylphenidate preparations. Although studies have not shown any difference in efficacy between the two classes, my clinical impression is that amphetamines are somewhat more effective for adults, and for that reason about 90% of my adult ADHD patients are on one of the amphetamines.

My first choice is generic Adderall IR (mixed amphetamine salts, immediate release) because it is effective, very well tolerated, and cheap. I set a target dose of 0.5 mg per kilogram of body weight, and I prescribe it twice daily, to be taken morning and noon. For the first week I have patients take 0.25 mg/kg, increasing to the target dose of 0.5 mg/kg in the second week. Methylphenidate is less potent, and its target dose is about 1 mg/kg.

Easy Pound-to-Kilogram Conversion

  1. Divide weight in pounds by 2
  2. Subtract 10% from the result

Example: Calculating Adderall dosing for a 130 lb. woman

Divide weight by 2: 130 / 2 = 65. Subtract 10% (6.5, but you can round down for simplicity): 65 – 6 = 59 kg. Use rule-of-thumb Adderall dosing of 0.5 mg/kg, and round up to 60 kg: 0.5 x 60 = 30 mg, prescribed as 15 mg twice daily.

Regular dextroamphetamine is interchangeable with Adderall, and has the same dosing. However, it’s generally more expensive than Adderall.

Extended-release formulations
Some patients do better on extended-release medications, which yield more consistent serum levels of the stimulant. Adderall XR is my usual choice because it is generic, and the same total dose can be maintained when switching from the IR to the XR version. Although theoretically the duration of action of Adderall XR is long enough for once-a-day dosing, in my experience it must still be dosed twice daily for most patients.

In general, I avoid prescribing Vyvanse (lisdexamfetamine) as a first-line treatment because it is costly and no more effective than Adderall. Its advantages include being longer-acting, often allowing once-a-day dosing, and lower abuse potential, because it requires digestion in the GI tract before it is active. I’ve seen a lot of variability in responses to Vyvanse. When I have switched patients from Adderall formulations to Vyvanse, half of my patients have said, “This is great; it’s smooth and I don’t have a crash,” but half have said, “I want to go back on my Adderall.” I speculate this has to do with variability in how efficiently the drug is activated.

There is a subset of patients for whom Vyvanse is clearly the best choice: those who have had bariatric surgery. Whereas most stimulants require an intact stomach for absorption, Vyvanse is absorbed in the small bowel, which is preserved after such operations.

If I have a patient who has responded to a methylphenidate product in the past or who requests it for some other reason, I will generally start with the immediate-release version (brand name Ritalin) and may switch to other versions, such as Focalin IR/XR or Concerta, as dictated by response and patient preference.

Stimulant side effects
In terms of side effects, I warn patients that appetite suppression is common in the beginning and that they may lose 8–10 pounds over the first several months, but that this weight loss should not persist. If appetite loss is a problem, I recommend eating before taking the medication. Insomnia can occur, but it is usually not an issue, because paradoxically sleep improves—either because of decreased bedtime ruminations, or because of symptoms wearing off due to decreased blood levels of a stimulant (“crashing”). For patients with significant insomnia, I recommend only morning dosing. If crashing becomes a problem, splitting the medication into three daily doses sometimes helps.

Irritability is a potential side effect of stimulants, but it is less common than many assume. In fact, I often see decreased irritability, since many people say the medications produce a calming effect. Irritability and increased anger are likely more common among amphetamine abusers who do not have ADHD.

One of the most common side effects of stimulants is dry mouth. Patients usually do well with oral rinses (brands include Biotene and SalivaMAX), but if they are having gingival recession, I will prescribe pilocarpine, a medication approved for xerostomia.

Non-stimulant treatments
I will prescribe a non-stimulant for patients who have failed a stimulant in the past, have responded well to a non-stimulant in the past, or have recently gone through substance abuse treatment.

My first choice is Wellbutrin (bupropion), which is equally effective as and cheaper than Strattera (atomoxetine), and has the added benefit of being an approved antidepressant. Bupropion can be used for ADHD, but many doctors do not dose it high enough. In the clinical trials for ADHD, the mean daily doses were 362 mg of bupropion SR and 393 mg of bupropion XL. I typically use the XL formulation because it is difficult for patients to remember to take the second dose of the SR. I will start at 150 mg daily for one week, then 300 mg for another week, then 450 mg. I warn patients of potential side effects like sleeplessness, decreased appetite, and jitteriness. It may take 5–6 weeks to see the full benefit.

My second choice is atomoxetine (Strattera). I start with 40 mg daily for a week, then go up to 80 mg, and if needed increase to 100 mg. The side effects are similar to antidepressants, such as insomnia, sexual dysfunction, and nausea. I will wait about 6–8 weeks before declaring a non-response.

Other potential non-stimulants are alpha 2 agonists, which I have not found effective for adults, and modafinil (Provigil), which was found effective in clinical trials for ADHD in children but not in adults.

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  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Chris Aiken, MD

Dr. Aiken is the director of the Mood Treatment Center in North Carolina, where he maintains a private practice combining medication and therapy along with evidence-based complementary and alternative treatments. He has worked as a research assistant at the NIMH and a sub-investigator on clinical trials, and conducts research on a shoestring budget out of his private practice.

Full Editorial Information

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