Diagnosing and Treating Adult ADHD and Comorbid Conditions

Abstract

Many adults with attention-deficit/hyperactivity disorder (ADHD) were never diagnosed as children. The impairment caused by untreated ADHD can complicate, or even lead to, other psychiatric conditions. Accurate diagnosis and efficacious treatment of ADHD in adults, which may include pharmacologic and nonpharmacologic interventions, is vital to improve their functioning. When a patient has ADHD and a co-occurring condition, the clinician should usually treat the most impairing condition first.
(J Clin Psychiatry 2008;69[11]:e31)

Based on the ACADEMIC HIGHLIGHTS “ADHD and Comorbid Disorders in Adults.” 
This activity was supported by an educational grant from Eli Lilly and Company.

Case Vignette

Ms. R is a 45-year-old married woman with 2 teenaged children. She has a history of chronic mild depression and has been undergoing sporadic psychotherapy for 25 years, which she restarted after her mother’s death 2 years ago. She reports having little family support without her mother. Over the years, her chronic symptoms of depression and early insomnia have not responded to brief trials of low-dose selective serotonin reuptake inhibitors (SSRIs). She has experienced no other vegetative symptoms of depression or an episode of major depression or mania. Her current psychotherapist has noted that Ms. R has difficulty with organization and attention, which dates back to her elementary school years. He suspects attention-deficit/hyperactivity disorder (ADHD) and has referred her to you.

What is the best first step in evaluating Ms. R?

a. Corroborate the patient’s history with family members and/or available records and evaluate current ADHD symptoms and impairments
b. Evaluate her for sluggish cognitive tempo
c. Evaluate her for bipolar disorder
d. Evaluate her for substance use disorder (SUD)

Lesson

The correct answer is a. Corroborate the patient’s history with family members and/or available records.

The prevalence of adult ADHD in the United States is about 4%.¹ Only about 10% of adults with this disorder are treated specifically for ADHD.² Although ADHD usually begins in childhood, it may not be diagnosed until adulthood. General symptoms of adult ADHD include inattention, distractibility, impulsivity, difficulty in initiating and completing tasks, not listening to others, misplacing items, and forgetfulness. Compared with children, adults with ADHD are not often frankly hyperactive. Experts have proposed diagnostic criteria^3-5 for ADHD in adults that may be helpful to clinicians working with these patients.

Assessment^1,2 of ADHD in adults includes obtaining patient reports of current and childhood functioning, corroboration of patient reports (if available), obtaining evidence of a chronic course of illness, defining impairment relative to an average-functioning person, using rating scales for adult ADHD, and ruling out any conditions that would explain the symptoms and impairment, such as low IQ, learning disabilities, and mood or anxiety disorders.

For more information, please see the ACADEMIC HIGHLIGHTS “ADHD and Comorbid Disorders in Adults.” 

1. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006;163:716–723
2.  Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry 2007;190:402–409
3. Barkley RA, Murphy KR, Fischer M. ADHD in Adults: What the Science Says. New York, NY: Guilford Press; 2008
4. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York, NY: Guilford Press; 2005
5. Adler L, Cohen J. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North America 2004;27:187–201

Case follow-up

Ms. R’s symptoms fit the symptom profile of ADHD in adults. Her procrastination and poor listening have been consistently noted in her reviews at work, and her husband complains that she is messy and does not complete projects around the house. Her father corroborates that she was inattentive in school as a child and exhibited signs of hyperactivity, often being described as “not living up to her potential.” While Ms. R does not exhibit signs of frank hyperactivity as an adult, she does report restlessness and difficulty waiting, which is exemplified in her extreme avoidance of long check-out lines at grocery and department stores. Her symptoms have increased since her mother’s death, and Ms. R reports that her mother was usually the person to support her and help to keep her organized and on task. She has no history of SUD or active medical problems, and her electrocardiogram results are normal. Her mother had major depressive disorder, and a niece has ADHD.

You diagnose Ms. R with ADHD, inattentive subtype, and dysthymia. The ADHD preceded the dysthymia in the patient’s developmental course and is likely to be causing more impairment than the dysthymia. A national survey1 reported that mood disorders occurred in 38% of respondents with ADHD.

1. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006;163:716–723

For reflection

How often have you diagnosed adults with ADHD and comorbid or secondary disorders in your practice?

Which of the following would be the best treatment strategy to try first with Ms. R?

a. Resume SSRI treatment at a higher dose than before
b. Start treatment with a stimulant or nonstimulant to treat the ADHD
c. Recommend that psychotherapy be continued as the sole treatment for ADHD
d. Resume low-dose SSRI and start stimulant or nonstimulant treatment

Evidence

The correct answer is b. Start treatment with a stimulant or nonstimulant to treat the ADHD.

Because ADHD is the primary disorder, resolution of these symptoms may lead to resolution of depressive symptoms. Antidepressant medication should not be resumed until the ADHD is successfully managed. If ADHD improvement does not improve dysthymia, certain SSRIs could be added.¹

For adult ADHD, the stimulants methylphenidate and mixed amphetamine salts have shown efficacy in immediate-release^2,3 and extended-release4,5 formulations. The prodrug stimulant lisdexamfetamine dimesylate and the nonstimulant atomoxetine have also shown efficacy in adults with ADHD.^6,7 Possible side effects for both classes of medication include dry mouth, insomnia, and decreased appetite. However, stimulants may be abused, and both types of medication carry cardiovascular warnings.

Ms. R began taking stimulant medication, and, after appropriate titration, many of her ADHD symptoms improved (which her husband corroborated). She also became mostly euthymic. However, she still had trouble prioritizing and planning, so psychotherapy was recommended to target these issues. Nonpharmacologic therapies can be an important part of a treatment plan for adults with ADHD, especially in patients who are only partially responsive to pharmacologic treatment.⁸

For more information, please see the ACADEMIC HIGHLIGHTS “ADHD and Comorbid Disorders in Adults.” 

1. Findling RL. Open-label treatment of comorbid depression and attentional disorders with co-administration of serotonin reuptake inhibitors and psychostimulants in children, adolescents, and adults: a case series. J Child Adolesc Psychoparmacol 1996;6:165–175
2. Spencer TJ, Biederman J, Wilens T. A large, double-blind, randomized clinical trial of methylphenidate in the treatment of adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2005;57:456–463
3. Spencer T, Biederman J, Wilens T, et al. Efficacy of a mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2001;58:775–782
4. Biederman J, Mick E, Surman C, et al. A randomized, placebo-controlled trial of OROS methylphenidate in adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2006;59:829–835. Correction 2007;61:1402
5. Weisler RH, Biederman J, Spencer TJ, et al. Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 2006;11:625–639
6. Adler LA, Goodman DW, Kollins SH, et al. Double-blind, placebo-controlled study of the efficacy and safety of lisdexamfetamine demesylate in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry 2008;69:1364–1373
7. Michelson D, Adler L, Spencer T, et al. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 2003;53:112–120
8. Safren SA, Otto MW, Sprich S, et al. Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther 2005;43:831–842

Drug Names

atomoxetine (Strattera)
lisdexamfetamine (Vyvanse)
methylphenidate extended release (Ritalin LA, Concerta, and others)
methylphenidate immediate release (Ritalin and others)
mixed amphetamine salts extended release (Adderall XR)
mixed amphetamine salts immediate release (Adderall and others)

CME Background Information

Lenard A. Adler, MD
Departments of Psychiatry and Child and Adolescent Psychiatry, New York University School of Medicine, New York

This activity was supported by an educational grant from Eli Lilly and Company.

Objective

After completing this educational activity, you should be able to:
• Create an individualized treatment plan for adults with ADHD and comorbid psychiatric disorders

Financial Disclosure

The faculty for this CME activity and the CME Institute staff were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure is as follows:
Dr. Adler has received grant/research support from Abbott, Cortex, Bristol-Myers Squibb, Merck, Novartis, Pfizer, Shire, Eli Lilly, Ortho-McNeil/Janssen/Johnson & Johnson, New River Pharmaceuticals, Cephalon, and the National Institute on Drug Abuse; is a member of the speakers bureaus for Eli Lilly and Shire; is a member of the advisory boards and is a consultant for Abbott, Cortex, Novartis, Pfizer, Shire, Eli Lilly, Ortho-McNeil/Janssen/Johnson & Johnson, New River Pharmaceuticals, Cephalon, Merck, Organon, Sanofi-Aventis, and Psychogenics; and has received royalty payments from New York University for license of adult ADHD scales and training materials.

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release, Review, and Expiration Dates

This Case and Comment was published in September 2008 and is eligible for AMA PRA Category 1 Credit through September 30, 2011. The latest review of this material was September 2008.
To obtain credit for this activity, study the material and complete the CME Posttest and Evaluation.

Statement of Need and Purpose

Attention-deficit/hyperactivity disorder (ADHD) is a common condition that affects children and adults in the United States. Although ADHD is often thought of as a disorder primarily affecting children and adolescents, the incidence of this condition in adults is growing in recognition. Individuals with ADHD have a high rate of comorbid psychiatric disorders, making ADHD difficult to diagnose and treat. Although pharmacotherapy is the standard treatment for ADHD, evidence suggests that stimulant treatment is less effective than nonstimulants in patients with comorbid ADHD and anxiety. Physicians need more information on diagnosing ADHD and the risks and benefits of prescribing medication in adults with ADHD and comorbid disorders. This activity was designed to meet the needs of participants in CME activities provided by the CME Institute of Physicians Postgraduate Press, Inc., who have requested information on ADHD in adults.

Disclosure of Off-Label Usage

Dr. Adler has determined that, to the best of his knowledge, mixed amphetamine salts immediate release and methylphenidate immediate release are not approved by the U.S. Food and Drug Administration for the treatment of adult attention-deficit/hyperactivity disorder.

Review Process

The entire faculty of the series discussed the content at a peer-review planning session, the Chair reviewed the activity for accuracy and fair balance, and a member of the External CME Advisory Board reviewed the activity to determine whether the material is evidence-based and objective.

Acknowledgment

This Case and Comment was based on the planning teleconference series “ADHD and Comorbid Disorders in Adults,” which was held in January and February 2008, and from the core material. This activity was independently developed by the CME Institute of Physicians Postgraduate Press, Inc., pursuant to an educational grant from Eli Lilly and Company. The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher or the commercial supporter.