Special Considerations in Diagnosing and Treating ADHD

Part 3: Adults

 

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This is the third in a 3-part Psychiatry Weekly CME series on special considerations in diagnosing and treating ADHD. Parts 1 and 2 focused on the preschool-age population, and the child and adolescent population, respectively.

Accreditation Statement

This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation

The Mount Sinai School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure Policy Statement

It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

This activity has been peer reviewed and approved by Eric Hollander, MD, Professor of Psychiatry and Chair at Mount Sinai School of Medicine. Review Date: May 31, 2007

Statement of Need

6%–9% of children are estimated to have ADHD, and 65%–85% of children with ADHD continue to meet at least some criteria for ADHD and present with significant impairment as adults. Of the estimated 4%–5% of adults with ADHD, only 20% are ever diagnosed. Recognition in this patient population is complicated by the dominance of inattentive symptoms (which are less likely to draw notice than hyperactive symptoms). Diagnosis is complicated both by the difficulty of obtaining reliable information on symptoms from early childhood, and the high prevalence of comorbidities.

Common comorbidities include substance abuse, mood disorders, and anxiety disorders, all of which significantly impact a patient’s quality of life and can contribute to the overall impairment of adults with ADHD, who earn less money, experience more difficulty at work, and change jobs more often than adults without ADHD. Psychosocial and pharmacologic treatment are both used, and the latter is predominantly stimulants, though one non-stimulant medication has been FDA approved for this patient population.

An important educational need exists to refine the diagnostic and treatment strategies of clinicians treating adult patients with ADHD. Particularly in light of the significant impairment caused by ADHD, effort must be made to increase recognition among this patient population. Clinicians must also keep abreast of emerging data on treatment efficacy.

Learning Objectives

• Describe the impact of ADHD in the adult population, and the role of comorbid disorders in diagnosis, impairment, and treatment response.
• Assess treatment options for adults with ADHD.
• Explain the difficulties in diagnosing this patient population, and be aware of diagnostic strategies designed to counter these difficulties.

Target Audience 

This activity will benefit psychiatrists, hospital staff physicians, and office-based “attending” physicians from the community.

Funding/Support

This activity is supported by an educational grant from Shire.

Faculty Disclosures

Sharon Wigal, PhD, has disclosed that she has received research support from Cephalon, Eli Lilly, McNeil, New Rivers, NIH, and Shire; has served as an advisor or consultant to Cephalon, McNeil, New Rivers, Novartis, Shire, and UCB; and has served on the speaker’s bureau for McNeil, Shire, and UCB.

Timothy Wigal, PhD, has disclosed that he has received research support from Cephalon, Eli Lilly, McNeil, New Rivers, NIH, Novartis, and Shire; has served as a consultant or advisor to McNeil, Novartis, and Shire; and has served on the speaker’s bureau of McNeil and Shire.

Peer Reviewers

Eric Hollander, MD, reports no affiliation with or financial interest in any organization that may pose a conflict of interest

Daniel Stewart, MD, PhD, reports no affiliation with or financial interest in any organization that may pose a conflict of interest.

To Receive Credit for this Activity

Read this poster, reflect on the information presented, and then complete the CME quiz found in the accompanying brochure or online (www.mssmtv.org/psychweekly). To obtain credit you should score 70% or better. The estimated time to complete this activity is 1 hour.

Release Date: July 9, 2007

Termination Date: July 9, 2009

Introduction/Prevalence

65%-85% of children with ADHD continue to meet at least some of the criteria for ADHD and present with impairment related to primary symptoms of the disorder as adults.¹ Evidence indicates that 4%-5% of adults have ADHD and that <20% of them are diagnosed.² Presentation in adults is heavily biased toward inattentive symptoms,³ which are less likely to draw notice than hyperactive or impulsive symptoms and may contribute to the under-recognition of ADHD in this patient population. Diagnosis is complicated both by the necessity of demonstrating symptom onset prior to 7 years of age and by the prevalence of comorbid psychiatric disorders in adults with ADHD; anxiety disorders and substance abuse are particularly prevalent in this population.⁴ Identifying comorbid disorders in ADHD is particularly important as they can interfere with diagnosis and complicate treatment. Symptoms of ADHD can severely impact an adult’s life; the disorder is implicated in more frequent job changes, more martial discord, and decreased quality of life.

Presentation and Impact

Male children are far more likely to be diagnosed with ADHD than female children; by late adolescence and adulthood the ratio has shrunk from 3:1 to 1:1.^6,7 This may be due to the predominance of hyperactivity in male children with ADHD and the diminution of hyperactive symptoms across individuals with ADHD as they age (hyperactive symptoms are generally easier to spot than inattentive symptoms). ADHD may manifest differently in females than males, but more research is needed to clarify gender-related issues in diagnosis, treatment, and the impact of ADHD symptoms on life events. Adult males with ADHD earn less money, experience more difficulty at work, and change jobs more often than adult males without ADHD.⁸ Adults diagnosed with ADHD also have, on average, fewer years of education and are less likely to be professionally employed.⁹

Other studies have indicated that patients with substance use disorders and ADHD are more prone to social maladjustment, lower levels of work-related achievement, and higher rates of separation and divorce than are patients with substance use disorders without comorbid ADHD.^10,11 There is also evidence that adults with ADHD are more likely to report psychological maladjustment and to have more speeding violations than adults without ADHD.¹² Adults with ADHD also report less satisfaction in the workplace and in life in general.¹³

Adults with ADHD may have developed effective coping skills over the years, but they tend to have difficulty with time management, sleeping, motivation, and tolerating frustration. They are also prone to talking too much and/or too fast at work and in social situations. They are likely to seek help when managing the demands of work and/or home life become overwhelming.^14-16

Comorbidity

Comorbid disorders are common in adults with ADHD. Anxiety disorders, substance abuse disorders, and mood disorders are all highly prevalent comorbidities in this patient population, and there is also a significant incidence of antisocial disorder.

Substance Use Disorders

Substance use disorders tend to manifest in adolescence or early adulthood and affect 15%-20% of adults in the US.²⁰ There is significant bi-directional overlap between ADHD and substance-use disorders; 40%-50% of adults with ADHD present with comorbid substance abuse, and 15%-25% of adults with substance use disorders present with comorbid ADHD. Marijuana is the most common substance abused by adults with ADHD, although alcohol abuse is also common.²¹

Substance use disorders have a significant impact on the long-term course of ADHD; not only are patients with ADHD and comorbid substance abuse more likely to have another psychiatric disorder, but patients with ADHD and comorbid substance abuse have been found to have an earlier onset of symptoms, longer course and greater severity of disease, and more relapses.­ ADHD has also been linked with increased risk of cigarette use and increased difficulty in quitting smoking.²¹ The latter may be due in part to nicotine’s reducing ADHD symptoms.²² Early treatment with stimulants may decrease the risk for later development of substance use disorders, particularly when adolescents maintain pharmacotherapy.²³ First-line treatment for adults with ADHD and recently resolved substance abuse may include atomoxetine or strongly noradrenergic TCAs, due to their lack of a dopaminergic effect, and stimulants with decreased liability for abuse.²⁴

Depression

Up to 50% of adults with ADHD will experience at least one depressive episode during their lifetime,²⁵ with up to 35% suffering from major depression.²⁶ There is evidence that patients with comorbid ADHD and depression respond well to antidepressants but do not respond as well to treatments for ADHD as do patients with ADHD without comorbid depression.²⁷ Thus, clinicians may consider attempting to treat the depression before prescribing stimulants in patients with comorbid ADHD and depression.²⁸ If treating both disorders simultaneously, MAOIs must not be prescribed with stimulants due to the possibility of hypertensive crisis.²⁹ Overall, practitioners must exercise caution when prescribing stimulants and TCAs in combination due to the product labeling contraindication, although research suggests the combination is generally safe.³⁰

Bipolar Disorder

Approximately 10%-15% of adults with ADHD co-present with bipolar disorder, and males are more likely than females to present with both disorders. The disorders are further linked in that the onset of mood disorder in patients with comorbid ADHD and bipolar disorder predates the onset of mood disorder in patients without ADHD by an average of 5 years. Comorbid ADHD and bipolar disorder have also been linked to increased severity of bipolar disorder.³¹

Other Comorbid Disorders

Comorbid anxiety disorder is highly prevalent in adults with ADHD, but evidence of the interaction of anxiety with ADHD is unclear. There is some indication that adults with comorbid ADHD and an anxiety disorder have more pronounced attentional deficits.³¹ In addition, studies have shown that ADHD in adults is strongly associated with sleep disturbance,³² but it is not clear whether actual sleep disorders are linked with adult ADHD. Poor sleep patterns contribute to a worsening of ADHD symptoms in adults, and stimulant treatment has been shown to improve overall sleep.³³ Personality disorders co-present in 10%-15% of adults with ADHD, and children with ADHD are far more likely to have an antisocial personality disorder as an adult.³⁴

Diagnosis

Numerous obstacles beset diagnosis of ADHD in adults. The DSM-IV criteria are geared toward school-age children, yet ADHD persists into adolescence and adulthood and may not be diagnosed until the adult years.³⁵ Further, diagnosis of ADHD in adults requires marshalling evidence that the symptoms began before the age of 7 years old. Self-reports are flawed; aside from obvious difficulties centered around recalling symptoms that occurred many years ago,³⁶ adults have been shown to deny symptoms that are verified by others.³⁷ Difficulty with diagnosis of ADHD in adults is further compounded by the fact that hyperactive symptoms, which are generally the easiest symptoms to observe in an interview setting, usually decline with age. Unlike children, most adults with ADHD have the freedom to avoid overly structured situations, and a strong base of support at home or at work can make it difficult to identify substantial impairment in multiple settings. Finally, the high rate of symptom overlap between comorbid psychiatric disorders in adults with ADHD impedes diagnosis. Impulsivity, for example, is a defining symptom of both bipolar disorder and ADHD, while poor concentration is common in both depression and ADHD.

In order to address the difficulties of retrospectively identifying childhood symptoms, researchers at the University of Utah School of Medicine Department of Psychiatry have developed a set of criteria for diagnosing ADHD in adults.³⁸ The Utah Criteria eschew specific cataloguing of childhood symptoms, focusing instead on recollection of problem areas that may be more easily recalled by the patient or a parent or former teacher (eg, behavior problems in school). The Utah Criteria may result in a more inclusionary diagnosis than strictly following the DSM-IV criteria, and this could, in turn, result in identifying patients who would benefit from treatment despite not meeting formal diagnostic criteria.³⁹

Recently, investigators at the University of California, Irvine, Child Development Center have developed a method of more effectively diagnosing ADHD in adults. Called “QUEST,’ the method is geared toward identifying the problematic behaviors in adults with age-appropriate probes combined with a logical, careful approach.

1. Query about three current problems that are most debilitating: This open-ended query both establishes therapeutic rapport and allows the clinician to identify possible comorbid conditions.
2. Uncover history: This step involves integration of the patient’s medical history and self-report of symptoms. The patient’s reliability can also be assessed in this step. Alternative strategies for eliciting information may be formulated as needed.
3. Evaluate symptom by symptom: In this step, the clinician must carefully examine each symptoms, making certain to distinguish between impairing symptoms and behaviors.
4. Setting pervasiveness is judged: DSM-IV criteria require significant impairment in at least two settings—in this stage, clinicians gauge the severity of impairments in different settings, taking into account the effect of social support on the patient’s level of functioning.
5. Test for comorbidities: Before diagnosing ADHD, the clinician must eliminate possible alternative explanations of the patient’s impairments. When other possible disorders are identified, the clinician must determine whether they are primary or comorbid with ADHD.

Management

Management of adult ADHD should involve both psychosocial and pharmacologic treatment. Counseling and patient education is recommended,³⁹ and evidence suggests that cognitive behavioral therapy in conjunction with pharmacotherapy outperforms pharmacotherapy alone.⁴¹

Atomoxetine was the first medication approved by the FDA for treating adults with ADHD, and it currently is the only non-stimulant medication with this labeled indication. Atomoxetine, a selective norepinephrine reuptake inhibitor, shows limited clinical efficacy in adults, but a number of studies indicate it has promise particularly for some patients.^42,43

The FOCUS (Formal Observation of Concerta versus Strattera) study, published in 2005, indicated that, while both methylphenidate and atomoxetine are effective treatments for ADHD, methylphenidate is associated with significantly greater symptom improvement.⁴⁴ Because atomoxetine is not a Schedule II medication, practitioners may be more inclined to prescribe it for patients with a history of substance abuse or tic disorders.45,46 However, atomoxetine use produces a number of side effects including dry mouth, insomnia, nausea, and erectile difficulty.^45,46 Blood pressure should also be monitored in patients taking this medication.⁴⁷

Psychostimulants are first-line treatments for ADHD due to their established efficacy and safety. Methylphenidate (MPH) has been shown to be effective in adults⁴⁸ and is now available in an FDA-approved extended-release formulation. Amphetamines are similarly effective as MPH, and are often prescribed as a second-line treatment when MPH is not well-tolerated or does not lead to optimal efficacy.⁴⁹ D-methylphenidate functions similarly to MPH, but only half the dose size is required and it may have an altered side-effect profile.⁵⁰ Adverse events most commonly observed with stimulant treatment are headache, abdominal pain, jitteriness, decreased appetite, delayed sleep onset, social withdrawal, and loss of appetite, and dry mouth has been reported in adults in particular.⁵¹

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