ADHD in Adults

In ADHD, Anxiety, Brain studies, School Psychology on Thursday, 13 September 2012 at 05:58

Unmasking ADHD in Adults

David W. Goodman, MD


Adult ADHD

During the past decade, awareness has grown that ADHD is not limited to children and adolescents. Rather, ADHD is now recognized as a chronic neuropsychiatric disorder that persists into adulthood in up to 65% of children with ADHD.[1-3] Data from the National Comorbidity Survey Replication (NCSR) estimate that 4.4% of adults in the United States have ADHD, although as many as 75% have never been diagnosed and 90% remain untreated.[4,5] The many similarities in symptoms and impairments seen in ADHD and mood and anxiety disorders likely account for many of the misdiagnoses.[6] In addition, the rate of comorbidity in ADHD with mood and anxiety disorders, sleep disorders, and substance use disorders is high and further complicates accurate diagnosis.[5]

Current criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) were originally developed and validated for children.[7] Diagnostic criteria require an onset of symptoms before age 7 years; the presence of at least 6 of 9 possible symptoms in 1 or both of the 2 diagnostic clusters of inattentiveness and hyperactivity; and impairment in 2 or more settings (such as home, school, and work).[7] Many similarities exist in the presentations of childhood and adult ADHD; however, adults are more likely to present with symptoms of inattention than hyperactivity.[8] But the presence of childhood symptoms is necessary for a diagnosis of ADHD in an adult.

Clinicians can use several screening tools to help in the ADHD diagnostic process; however, high scores on these tools must be interpreted within a clinical context following a clinical interview. For example, a high score on the ASRS may suggest ADHD[9,10] but may also be the result of acute anxiety, acute depression, or active substance abuse. Patients who take online screeners and self-diagnose ADHD present their symptoms and “diagnosis” to their clinicians in a descriptive rather than a diagnostic context, not understanding how other possible psychiatric disorders may lead to high screening scores. As a result, their self-diagnoses are typically inaccurate.

The clinical interview includes a comprehensive patient history that covers all major psychiatric disorders. The clinician reviews the presenting symptoms in a diagnostic evaluation, inquiring about other possible psychiatric disorders that the patient may not include in the description of symptoms. Through this process, the clinician can rule out primary mood or anxiety disorders (among others), and also ascertain a longitudinal course of symptoms originating during childhood to confirm a diagnosis of ADHD. An accurate account of childhood symptoms of ADHD improves if corroborative historical information can be obtained from an outside informant (for example, a parent). This historical information can be obtained by having a parent complete a childhood ADHD symptom rating scale that can be returned to the PCP. The use of an outside informant also conveys to the patient that third-party information will be used to establish an accurate diagnosis, a disincentive to those who simply seek a prescription for stimulants.


The cognitive and affective symptoms of ADHD can be similar to those of other psychiatric disorders, most notably mood and anxiety disorders. However, specific distinguishing characteristics can assist with the differential diagnosis. In this case, despite reporting current symptoms that might be consistent with ADHD, the notable absence of ADHD symptoms during Ms Jones’s childhood and adolescence precludes a diagnosis of ADHD. A more accurate diagnosis is generalized anxiety disorder (GAD), which is characterized by excessive anxiety and worry that is difficult to control and is associated with at least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance, which cause clinically significant distress or functional impairments.[7] Significant chronic anxiety exacerbated by an acute, stressful event can produce cognitive symptoms that appear similar to ADHD. Remember: patients use psychological terms descriptively, not diagnostically.

A survey of 400 primary care physicians highlighted the challenges clinicians face when diagnosing ADHD in adults.[11] Approximately two-thirds of the participating respondents referred adults with possible ADHD to specialists for diagnosis and treatment, whereas they felt more competent and confident when diagnosing depression or GAD. Surveys find that only 2% of PCPs refer patients to specialists for the diagnosis and management of depression; for GAD, only 3% refer out.[11,12]

ADHD and Comorbidity

ADHD affects approximately 9 to 10 million adults in the United States (4.4% of the adult population). This makes ADHD in adults the second most prevalent psychiatric disorder after major depressive disorder (MDD), which reportedly affects 6.6% of the US population, and more prevalent than GAD (3%), bipolar disorder (2%), and schizophrenia (1%).[5] Adults with ADHD have a higher percentage of comorbidities than their peers without ADHD.[5] Among the most prevalent psychiatric comorbidities in patients with ADHD are anxiety disorders, mood disorders, and substance use disorders (SUD).[13] Many adults with ADHD present with symptoms of anxiety, MDD, or both. Further, high levels of stress may mimic the symptoms of ADHD.[13] Consequently, the high prevalence rate of ADHD in the adult population makes it essential for clinicians to include ADHD as part of the differential diagnosis in any mental health evaluation or whenever patients present with depression or anxiety.

Data from the NCSR suggest that up to 75% of adults with ADHD were not diagnosed during childhood.[5] Many adults play down a possible diagnosis of ADHD because they do not recall being hyperactive in childhood or because they have not been previously diagnosed with the disorder. Other adults will dismiss the diagnosis because they appear to be functioning well and are successful in their chosen fields, even though they have symptoms such as restlessness, low self-esteem, or poor time-management skills.[14] Exceptionally intelligent individuals or adults who had predominantly inattentive ADHD as children may not have had observable impairments during childhood because disruptive behavior was absent; however, symptoms may surface as demands increase with greater school and work responsibilities.[15] Similarly, clinicians may overlook ADHD among high-functioning patients, not realizing the need to look past a patient’s success to explore whether the patient might have developed strategies to compensate for ADHD-related deficiencies and is working hard to compensate.

PCPs who rely on the accuracy of a psychiatric diagnosis of adult ADHD from mental health clinicians may not serve their patients well. Data from the NCSR indicate that 37% of women and 53% of men later diagnosed with ADHD were currently taking or had been in treatment for other mental disorders or SUDs in the previous year, in contrast to 25% who had been treated for ADHD.[5] From these data, Kessler and colleagues concluded that adult ADHD is often misdiagnosed by mental health providers.[5] Before prescribing medication, the PCP should review the psychiatric presentation and history with the patient to ensure agreement on the diagnosis. Premature prescription of stimulants for ADHD will only cloud the diagnosis, as adults with ADHD, as well as people in general, may report improvements in mood, cognition, and energy when taking stimulants, which does not confirm a diagnosis of ADHD. In addition, undetected psychiatric disorders may worsen in the presence of stimulants prescribed for ADHD.

Strict adherence to the DSM-IV-TR diagnostic criteria might lead to substantial underdiagnosis of ADHD, as these criteria were originally developed for young boys and may not reflect ADHD symptoms in adults.[16] Clinicians may need to examine whether the patient is advancing appropriately in his or her career or has become a workaholic to compensate for disorganization, procrastination, and sloppy errors.[17] Recent research highlights that adults with ADHD often underestimate the degree of ADHD-related impairments.[18] ADHD that persists into adulthood has been associated with many adverse life experiences or outcomes, including divorce, substance abuse, motor vehicle infractions, academic and occupational underachievement, and brushes with the law.[5,16,19-24] Research suggests that although the number of symptoms may decline along the lifespan, the severity of the impairments does not.[25]

Among the numerous medical conditions that may be associated with cognitive symptoms similar to those of ADHD are thyroid disorders, sleep apnea, hypoglycemia, and lead poisoning.[13] The prevalence of psychiatric comorbidity associated with ADHD is high, with 1 large study reporting that 87% of adults with ADHD had at least 1 comorbid psychiatric diagnosis and 56% had at least 2 comorbid psychiatric disorders.[25] Common comorbidities in ADHD include GAD (which occurs in 25% to 43% of the adult population with ADHD), MDD (16% to 31%), bipolar disorder (up to 47%), and SUD (21% to 53%).[26-28]

Differentiating ADHD and Other Psychiatric Disorders

Clinicians often mistake adult ADHD symptoms as manifestations of other psychiatric disorders, especially anxiety, MDD, or bipolar disorder.[29] It is especially important that clinicians attend to the context of the symptoms: when they originated, how long they have persisted, and whether aggravating or alleviating factors exist. Clinicians also need to determine whether the symptoms might be a function of stress or another condition, such as a sleep disorder. Patient misinterpretation of the symptoms may be more prevalent among adults who were not diagnosed with ADHD during childhood, and some adults may be surprised that they did not “outgrow” their childhood ADHD. Other adults may not recall being diagnosed with ADHD during childhood, suggesting that the absence of a self-report of an ADHD diagnosis may not accurately reflect the absence of childhood ADHD.[30] Misdiagnosis and subsequent inappropriate treatment may help to resolve some secondary symptoms (anxiety and minor depression) but will not resolve the core symptoms of inattentiveness, impulsivity, and hyperactivity.

ADHD is historically a disorder of childhood; as such, diagnosis requires evidence of symptoms occurring during childhood. Adults typically present with fewer overt symptoms and different manifestations of hyperactivity, inattention, and impulsivity than children (Table 1).[31] Whereas hyperactive children cannot sit still and are fidgety, adults may feel restless, have difficulty relaxing, and show impatience. Childhood manifestations of inattention include daydreaming, poor reading comprehension, and working slowly; adult manifestations include procrastination, disorganization, forgetfulness, and missing or showing up late for appointments. Making careless mistakes is common among patients of all ages with ADHD. Impulsive symptoms during childhood include blurting out answers, interrupting others, and having temper outbursts; adults will also manifest with temper outbursts and verbal impulsivity, as well as impulsive spending, starting but not necessarily finishing multiple projects, and moving from job to job.[31]

Table 1.

ADHD Symptom Evolution from Childhood to Adulthood

Childhood Adulthood
  Difficulty sustaining attention (meetings, reading, paperwork)
Failure to pay attention to details Makes careless errors
Appears not to listen Easily distracted/forgetful
Lacks follow-through Poor concentration
Cannot organize Difficulty finishing tasks
Loses important items Disorganized/misplaces items
Squirming/fidgeting Inefficiencies at work
Cannot stay seated Internal restlessness
Cannot wait his/her turn Difficulty sitting through meetings
Runs/climbs excessively Works more than one job
Cannot play/work quietly Works long hours
“On the go”/seems “driven by a motor” Self-selects very active jobs
Talks excessively Overwhelmed
Talks excessively
Blurts out answers Impulsive job changes
Cannot wait in line Drives too fast
Intrudes/interrupts others Interrupts others
Easily frustrated

The Question of Early Symptoms

A particularly challenging component in diagnosing adult ADHD is obtaining sufficient retrospective information to confirm the presence of ADHD symptoms during childhood. Patients may not remember having ADHD-related symptoms before age 7 (a diagnostic criterion for pediatric ADHD in the DSM-IV-TR), although they may identify problems in late grade school or early middle school that continued throughout high school. A recent study compared 4 groups of adults: those who met all criteria for childhood-onset ADHD; those who met all criteria except the age-at-onset criterion (late-onset ADHD); those with subthreshold ADHD who did not meet full symptom criteria; and those without ADHD.[32] Substantial similarities existed between the adults who met the age-at-onset criterion and those with late-onset ADHD, leading these and other investigators to conclude that the current age-at-onset criterion of 7 years is too stringent and to suggest extending the criterion to age 12 in the next iteration of the DSM.[32,33]

Many adults who were not diagnosed during childhood have developed compensatory mechanisms enabling them to function, albeit less than optimally. Clinicians could ask to speak with the patient’s parents or other family members who may be able to provide insights into the patient’s childhood symptomatology. Similarly, current family members, a spouse, and friends might report clinically relevant ADHD symptoms that have been observed for a long time. While an adult might recognize restlessness as a possible ADHD symptom and admit to receiving numerous driving citations, others might note that the patient overreacts, has difficulty staying with tasks, is easily frustrated, or has held numerous jobs.

No standard for the screening of adults for ADHD currently exists. Among the tools that clinicians can use to help in the diagnostic process are the 18-item World Health Organization’s (WHO) ASRS, which can be freely downloaded from the Internet[34]; the Conners’ Adult ADHD Rating Scale (CAARS); the Brown Attention Deficit Disorder Scale (BADDS); the Wender Utah Rating Scale; and the Wender-Reimherr Adult Attention Deficit Disorder Scale. A recent factor analysis determined that many of these scales are in strong agreement with one another, suggesting that clinicians can choose whichever scale is the most pragmatic, cost efficient, and least time-consuming to use.[35] Patients who screen positive on these assessments should then undergo a full diagnostic evaluation, including a clinical interview that assesses current and lifetime symptoms, a thorough developmental history, and behavioral assessments to identify any functional impairments and symptoms.[31]

Treatment of ADHD in Adults

As yet, no formal guidelines have been developed for the treatment of adult ADHD in the United States. However, guidelines for the treatment of ADHD in children and adolescents, as well as international guidelines for the treatment of adult ADHD, offer recommendations that can be extrapolated to US adults. Considerable concordance exists among the guidelines established by the Canadian ADHD Resource Alliance (CADDRA),[17] the American Academy of Child and Adolescent Psychiatry (AACAP), the National Institutes of Health (NIH), and the British Association for Psychopharmacology on Childhood ADHD.[36] The National Institute for Health and Clinical Excellence (NICE) guidelines address both childhood and adult ADHD.[37] The European Network Adult ADHD consensus statement on the diagnosis and treatment of adult ADHD notes the substantial negative and far-reaching consequences of non-treatment of ADHD.[38] These guidelines recommend a multimodal approach to the treatment of ADHD in adults, beginning with psychoeducation about ADHD and pharmacotherapy for ADHD and any comorbid disorders. Recognizing that pharmacotherapy is often insufficient to address all the problems associated with adult ADHD, the guidelines recommend various symptom-specific coaching programs and cognitive behavior therapy to teach problem solving, coping, and time management skills.[38] Similar multimodal treatment recommendations have been proposed by CADDRA.[17]

Available pharmacologic treatments include short-acting and long-acting stimulant and nonstimulant medications. Psychostimulants, including amphetamines and methylphenidates, are recommended as first-line therapy for both children and adults across all sets of US and international guidelines. Currently, only long-acting agents have been approved for the treatment of ADHD in adults in the United States. Despite this, research suggests that 46% of adults diagnosed with ADHD are prescribed off-label, short-acting stimulants.[39]

Approximately 95% of children who were diagnosed with ADHD during childhood and treated with stimulants do not persist with their medication into adulthood,[40] perhaps because clinicians and patients continue to believe that ADHD is a disorder of childhood. Stimulant medications have been shown to effectively address many of the symptoms of ADHD, including poor attention span, restlessness, short-term memory, and hyperactivity. Some patients may respond preferentially to either amphetamine or methylphenidate compounds, and a small percentage of patients do not respond to stimulants at all.[41,42] Side effects are dose-dependent and can include insomnia, nausea, loss of appetite and weight loss, irritability, mood changes, and clinically nonsignificant increases in heart rate and blood pressure in the majority of patients.[43,44,45] However, clinical practice dictates monitoring vital signs to detect any clinically significant changes that may need to be addressed. A baseline check of vital signs also allows for the detection of undiagnosed hypertension that would require treatment before consideration of stimulant medication. Treatment should be initiated at a low dose and titrated based on symptom reduction and side effects. The dose response in adults is variable; clinicians should not expect that higher doses are needed because the patient is an adult or overweight.

US Food and Drug Administration (FDA)-approved nonstimulants in the ADHD armamentarium include atomoxetine, extended-release (XR) guanfacine, and extended-release (ER) clonidine. Only atomoxetine is currently approved for use in adults, while guanfacine XR and clonidine ER have been approved for use in children and adolescents up to age 18. Other agents that are used off-label include bupropion, tricyclic antidepressants (especially desipramine), and modafinil. The onset of action for atomoxetine is slower than for stimulants, taking to a few weeks to attain the maximum treatment effect. The lack of an abuse potential with nonstimulants may be particularly attractive for use in patients who have SUDs, are at risk for substance abuse, or are potential diverters or sellers of illicit substances.

Atomoxetine is a selective inhibitor of the presynaptic norepinephrine transporter. It has been associated with slightly increased diastolic blood pressure and heart rate, and patients with milder forms of autonomic impairment should be monitored if given this agent.[46] In addition, atomoxetine is predominantly metabolized by the cytochrome P450 2D6 (CYP2D6) isoenzyme, necessitating caution for patients who take medication that inhibits CYP2D6, including fluoxetine, paroxetine, and bupropion.[13] Guanfacine is a direct agonist of the α-2a subtype of norepinephrine receptors. Guanfacine XR can be used as monotherapy or adjunctive therapy with a long-acting psychostimulant.[47,48] Clonidine ER is an α-2a-adrenergic receptor agonist that is considered a second-line agent in the treatment of ADHD, but it may be particularly useful for patients with ADHD and comorbid Tourette syndrome or other tic disorders. As yet, the α-2a agonists have not been studied sufficiently in adults either as monotherapy or as adjunctive treatment in combination with stimulants. Because of the effects of these agents on blood pressure and pulse, monitoring vital signs is recommended, and caution is needed in adults who are being treated for hypertension with other medications.

Monitoring Effects and Side Effects After Initial Treatment

Routine clinical monitoring is necessary throughout the duration of treatment.[13] It is important to meet with the patient on a more frequent basis after medication has been initiated to review tolerability and efficacy and to adjust the dosage (or the medication) as necessary; this typically requires follow-up every 2 to 3 weeks and availability by phone if the patient encounters problems with the medication or dosage. Patients engaged in psychotherapy or skills training will likely be seen on a more frequent, often weekly or biweekly, basis. Once stabilized on an effective and well-tolerated dosage of medication, patients can be seen every 2 to 3 months to monitor the need for dosage adjustments based on tolerability and residual symptoms. Clinicians should assess ADHD symptoms, medication side effects, medication adherence, and comorbid medical/psychiatric conditions at each visit. Similarly, clinicians should monitor caffeine and nicotine intake, as these will further elevate blood pressure and heart rate for all patients on ADHD pharmacotherapies. Although not a common problem, patients with a low body mass index (BMI) should be monitored for suppressed appetite leading to weight loss. Regular assessment of medication utility as measured by daily functional performance should be part of routine monitoring. In the process, you can discuss the continued benefit of medication with the patient. On occasion, a patient may wish to stop the medication to reassess its benefit, and the physician should provide support and oversight in this process. A follow-up reassessment when the patient is off the medication can clarify the re-emergence of ADHD symptoms and impact on daily productivity.

One means for monitoring symptom reduction is through the periodic use of symptom checklists, such as the patient-rated 18-item ASRS. The ASRS is an easy and preferred tool to use because it is standardized, validated, nonproprietary, and readily available on the Internet. It can be administered at baseline and then intermittently, especially with changes to medication dosage, to complement the clinical interview. Patients and their clinicians can get a sense of ADHD symptom improvement with treatment or an increase in symptoms if treatment is suspended or stopped. Patients may forget their ratings of baseline symptoms and find the change in symptom ratings helpful to verify treatment benefit. Although symptom reduction is desirable, the true measure of treatment benefit is the improvement in daily function, such as the ability to initiate and complete more tasks, sustain attention, be less distractible in conversations and meetings, finish tasks on time, reduce careless oversights and errors, and have better, more patient social interactions.

Stimulants, Nonstimulants, and Cardiovascular Risk in Adults

Stimulants are associated with mild elevations in both blood pressure and pulse. It is recommended that patients receiving stimulants have blood pressure and heart rate checked at baseline and regularly throughout treatment.[49] A retrospective database analysis in the United Kingdom found no additional risk of sudden death associated with either stimulants or atomoxetine in children and adolescents 2 to 21 years of age with ADHD.[50] Another retrospective study of adults with new ADHD treatments found that preexisting cardiovascular conditions appeared more likely to reduce prescribing of stimulant treatment in younger vs older patients but did not appear to influence initiation of atomoxetine therapy.[51] In this cohort of 8752 patients, 41% with 1 or more preexisting cardiovascular conditions were prescribed stimulants.[51] Small studies have demonstrated that adults being treated for primary essential hypertension can be safely treated with mixed amphetamine salts[52,53] and methylphenidate.[54] However, stimulant medications for ADHD should not be initiated until the patient is normotensive with a stable antihypertensive medication dose.

In 2008, in response to evidence supporting concerns that the use of stimulants for ADHD could augment the risk of serious cardiovascular events by increasing heart rate and blood pressure, the American Heart Association (AHA) recommended an electrocardiogram (ECG) before initiating treatment in children.[55] This recommendation contradicted recommendations by the AACAP and the American Academy of Pediatrics (AAP), which found that sudden cardiac death in persons taking stimulants was a rare event that could not be prevented or predicted by routine screening with ECG.[56] The AAP recommends an ECG only in those patients with the following risk factors: previously detected cardiac disease, palpitations, syncope, or seizures; a family history of sudden death in children or young adults; hypertrophic cardiomyopathy; or long QT syndrome.[56] Two recent large studies found no significant additional risk of sudden death, myocardial infarction, or stroke in children, young adults, or middle-age adults who were receiving stimulants or atomoxetine.[45,57]

Clinical trials of ADHD medications demonstrate short-term efficacy and safety; however, the majority of patients require chronic long-term treatment.[58-60] Recent studies have demonstrated the safety and efficacy of stimulants, atomoxetine, and guanfacine XR over 24-month treatment periods in children and adolescents.[61] Significant differences between stimulants regarding efficacy or risk of cardiac or cerebrovascular events are not apparent.[62] If clinicians observe any cardiovascular changes, they should determine whether these changes are directly related to the ADHD medication or might instead be related to cardiovascular risks and changes associated with normal aging — for example, weight gain as a cause of hypertension. Nevertheless, long-term studies addressing adverse events are warranted.[59]

Approaches to Improve Executive Function in Adults With ADHD

ADHD can be associated with executive function impairments that can compromise occupational functioning.[63] Executive function is broadly defined as the ability to organize, sequence, prioritize, and hold information in your memory as you consider multiple factors (working memory). Executive function can be defined behaviorally (symptoms observed by patient or others) or by specific neuropsychological measures. Most ADHD symptom checklists enumerate executive function symptoms because they are part of the ADHD symptom criteria. By this definition, all patients with ADHD have executive dysfunction. Executive function may improve with ADHD medication such that inattention, distractibility, and sustained attention improve. In this case, executive dysfunction may be an epiphenomenon of inattention, distractibility, and restlessness. Adults with ADHD may notice improvements in many of their symptoms of impulsivity, inattention, and restlessness but may still struggle with difficulties in organization, developing timelines, planning, and making and initiating decisions.

If the definition of executive function is based on abnormalities that appear on specific neuropsychological tests, then approximately one-third of ADHD patients have executive dysfunction, not 100% as the behavioral definition demands.[64] The clinical relevance of these distinctions is that patients with ADHD may have improved attention and less distractibility and restlessness but still be disorganized. If the clinician believes the disorganization is a residual ADHD symptom, the clinician may respond by increasing the dose of ADHD medication, only to find no further benefit but more side effects. These residual executive dysfunction symptoms tend not to improve with escalating medication dosing.

Results from 2 large trials indicate that adults with ADHD who experienced improvements in executive function with stimulant treatment also experienced improvements in health-related quality of life, particularly in the domains of performance and function.[65] However, a clinical trial of adults with ADHD found that the presence of executive function deficits, as assessed by standardized neuropsychological testing, did not affect clinical response to treatment with osmotic controlled-release oral delivery system (OROS) methylphenidate, and that measures of executive function were not affected by treatment response.[66] The need to better define executive function deficits so that an accurate assessment can be determined is critical; the means to minimize such impairments can be challenging.

Some patients might benefit from adjunctive therapy to address executive function deficits. Research in children and adolescents suggests that the concurrent use of stimulant and nonstimulant therapies can afford significantly greater improvements in ADHD symptoms than stimulant monotherapy, although some combinations have been associated with an additive adverse effect burden and higher cost.[67;48]

Many clinicians recommend cognitive behavior therapy (CBT) or other forms of psychotherapy once the patient has been stabilized on pharmacotherapy. CBT and other interventions can help the patient address organization skills and self-efficacy that have evolved over many years of insufficient treatment for ADHD; it can help patients develop effective compensatory strategies and improve other functional impairments typically associated with ADHD.[68,69] CBT may also help the subset of patients who choose not to use medications (or for whom medications are not appropriate or intolerable), as well as the large proportion of patients who have comorbid conditions.[70] Research suggests that adding CBT may enhance the response to and benefits of pharmacologic treatments.[68]

Metacognitive therapy uses principles and methods of CBT to teach time management, organization, and planning skills, and to address depressive and anxious thoughts that undermine effective self-management. Solanto and colleagues[71] compared a 12-week course of group metacognitive therapy (N = 41) with supportive therapy (including nonspecific group support and validation, psychoeducation, and therapist attention; N = 38) in adults with ADHD. They found that metacognitive therapy provided significantly more benefit in adults with ADHD “with respect to inattention symptoms that reflect the specific functions of time management, organization, and planning.” These benefits were seen in patients who were receiving medication treatment as well as those who were not.

When appropriate, patients may also benefit from couples or family counseling or both, and life skills training or coaching. A review of studies of group and individual psychosocial treatments for adult ADHD found that various psychosocial therapies, including skills-training and psychoeducation, improved motivation and reduced residual symptoms in adults with ADHD.[72]

ADHD and Substance Use Disorders

Up to 75% of adults with ADHD have had at least one comorbid condition,[13] and 40% of adults with ADHD present with a concurrent comorbidity.[73] The high rate of comorbid psychiatric conditions — particularly anxiety disorders, mood disorders, and SUDs — can influence both diagnosis and treatment of ADHD as well as the other condition(s). A significant number of adults with ADHD have a comorbid mood disorder, and a significant proportion of adults with mood disorders have comorbid ADHD.[74] As many as 50% of adult patients with ADHD have had comorbid SUDs.[23] Consequently, clinicians should maintain a high index of suspicion for ADHD among patients with any mental health concern because of its high prevalence in these subpopulations.[75,13]

Evidence suggests that ADHD is a significant risk factor for the development of both SUDs and cigarette smoking.[76] A recent meta-analysis and meta-regression analysis suggests that nearly 1 in 4 patients with SUD met DSM criteria for comorbid ADHD,[77] and 10% to 30% of adults with ADHD have SUD.[78] Alcohol dependence is associated with higher ADHD prevalence than cocaine dependence.[77] Substance use, including cigarette smoking, begins at an earlier age among adults with ADHD,[79] and SUDs are generally more severe in patients with comorbid ADHD.[16] Moreover, SUD may manifest with self-control, attention, and behavioral symptoms similar to those seen in ADHD. The prognosis for patients with ADHD and SUD worsens with additional comorbidities. Adolescents with ADHD and comorbid major depression generally have more severe substance use at baseline and throughout treatment compared with nondepressed adolescents with ADHD and SUD.[80]

Concerns that children treated for ADHD with stimulants are at elevated risk for developing SUD have not been supported by the research. A naturalistic, controlled, 10-year follow-up study of 112 boys and men over 10 years and found no statistically significant associations between stimulant treatment and alcohol, drug, or nicotine use disorders.[81] The investigators concluded that the risk for subsequent SUD is neither increased nor decreased in individuals treated with stimulants for ADHD during childhood and adolescence.

ADHD Comorbidity

It is estimated that only 25% of adult ADHD cases are uncomplicated.[26] In addition to SUD, ADHD has a high comorbidity with mood and anxiety disorders. Data from the NCSR indicate that 9.4% of adults with MDD have ADHD, as do 22.6% of adults with dysthymia.[5] The lifetime prevalence of anxiety disorders among adult patients with ADHD is 40% to 60%.[23] ADHD has been identified in 21.2% of adults with bipolar disorder,[5] and the presence of ADHD may increase the risk of developing bipolar disorder.[17] Many patients do not have just 1 comorbid diagnosis; diagnosing patients with SUD and comorbid psychiatric disorders can be particularly challenging because of the high rate of symptom overlap.

The numerous similarities in clinical presentation among these psychiatric disorders can interfere with accurate diagnosis. For example, symptoms of both ADHD and depression may include trouble sleeping, eating, and concentrating; patients with MDD, ADHD, or GAD may be restless and fidgety. It is important to obtain a comprehensive evaluation for child and adult symptoms, including the temporal relationship between the various comorbid disorders.[82] A primary complaint of a consistent negative mood for 3 months is more suggestive of MDD than ADHD, whereas a report of persistent poor concentration and lack of motivation dating from childhood is more consistent with ADHD. Poor concentration and anhedonia following a depressive episode suggests MDD; poor concentration, depression, organizational problems, and impulsivity that are long-standing suggest ADHD.[17] The clinical presentation of MDD is not affected by comorbid ADHD.[23] Clinicians need to distinguish between a lack of motivation suggestive of ADHD, dysregulated mood and irritability that might indicate ADHD with comorbid mood disorder, and significantly low affect symptomatic of depression.[17] The psychotic symptoms present in bipolar disorder are not likely to be misdiagnosed as ADHD; patients with ADHD do not report a cyclic pattern to their symptoms.[28] Primary care physicians who suspect bipolar disorder, or a manic or hypomanic episode, may want to refer the patient to a specialist, particularly if the patient is diagnosed with comorbid ADHD.

What to Manage First?

Identifying the primary disorder can be particularly challenging in adults with ADHD, as many comorbidities have an onset in mid-to-late-adolescence and these individuals have had many years of dealing with their disorders. In patients with active substance abuse, experts recommend that SUD be considered the primary diagnosis and treated first, regardless of age; once the SUD is under control, clinicians can then reassess the patient to determine whether the presenting symptoms were caused by the SUD, comorbid ADHD, or a mood disorder.[17,38] This strategy is based on controlled studies suggesting that treatment for ADHD in patients with comorbid active SUDs has little effect on either ADHD symptoms or substance use.[83] Adults with SUD who require treatment for ADHD cannot be treated with stimulants until they are in recovery treatment, as stimulants are contraindicated for patients who are actively using addictive substances. However, in adults with comorbid SUD, ADHD can be treated with FDA-approved nonstimulants such as atomoxetine or off-label bupropion, tricyclic antidepressants, or modafinil.[84] Stimulants, preferably long-acting formulations, can be used once patients are in stable substance use remission.

In adults, severe psychiatric mood or anxiety disorders are treated before treating ADHD, whereas ADHD is typically treated prior to initiating treatment for other psychiatric disorders of mild to moderate severity. In some cases, treating ADHD will help resolve the mild or moderate symptoms of the other psychiatric disorders. Clinicians must perform an adequate screen in adult patients with ADHD suspected of comorbid depression to rule out bipolarity. It is recommended that patients with comorbid bipolar disorder and ADHD be treated with mood stabilizers or atypical antipsychotics before initiating treatment with stimulants, which can destabilize bipolar symptoms.[85] Patients with comorbid ADHD and MDD can be treated with a stimulant and an antidepressant, particularly selective serotonin reuptake inhibitors (SSRIs).[74] Stimulants can be administered with serotonin-norepinephrine reuptake inhibitors (SNRIs), but this combination needs to be closely monitored for sympathomimetic side effects.[13] However, when atomoxetine is co-administered with SSRIs, one should be mindful of potential kinetic interactions through the cytochrome P450 enzyme system.

ADHD Treatment for Patients in Stable Recovery

Guidelines support and encourage treatment of ADHD in patients with SUD.[2,17,37,38] Indeed, optimal treatment for ADHD may improve adherence to treatment for SUD. Pharmacotherapy choices for adult patients in stable recovery can follow usual adult recommendations. Stimulants are more effective than nonstimulants for adult ADHD[86]; however, stimulants may be diverted or abused. These risks are lower for long-acting stimulants approved for adult ADHD (OROS methylphenidate, dexmethylphenidate XR, mixed amphetamine salts, and lisdexamfetamine) than for the short-acting agents.[83] At this time, atomoxetine is the only nonstimulant treatment approved for adult ADHD. The nonstimulant α-2 receptor agonists guanfacine XR and clonidine ER have not been studied in adults; their use is currently off-label in this population.


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