Improving the Recognition and Management of ADHD in Adults · Describe the presentation of...

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Provided by Integrity Continuing Education, Inc.Supported by an educational grant from Shire.

Improving the Recognition and Management of ADHD in Adults

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Faculty Affiliation

Oren Mason, MDAssistant Professor

College of Human MedicineMichigan State UniversityGrand Rapids, Michigan

Physician/OwnerAttention MD

Grand Rapids, Michigan

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Faculty Disclosures

▪ Royalty: Lulu Press

▪ Consultant: Sunovion Pharmaceuticals, Inc.

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Learning Objectives

▪ Describe the presentation of attention-deficit/ hyperactivity disorder (ADHD) in adults, as well as currently accepted diagnostic criteria and patient characteristics that are closely associated with the disorder

▪ Outline a therapeutic approach for the management of ADHD in adult patients

▪ Identify psychiatric comorbidities that are frequently associated with ADHD and describe an approach to management

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ADHD in Adults

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Overview

8.1

4.1

1.7

Lifetimeprevalence

12-monthprevalence

12-monthprevalenceclassified as

"severe"

US

Ad

ult

Po

pu

lati

on

(%

)

▪ Neurological disorder characterized by frequent and sometimes severe levels of inattention, impulsivity, and hyperactivity

▪ Traditionally viewed as emerging during childhood and usually resolved by young adulthood, but now understood to persist well into adulthood

▪ Strongly associated with poor outcomes related to social function, education, criminality, alcohol use, substance use/abuse, and occupational status

Available at: https://www.nimh.nih.gov/health/statistics/prevalence/attention-deficit-hyperactivity-disorder-among-adults.shtml

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Productivity Losses Associated with Adult ADHD

*P < .05 Of Abs, Official Absences; STD, short-term disability; Tot Abs, Total Absences (unofficial + official absences); Total Days equals sum of total absences, short-term disability, and worker compensation; Unof Abs, Unofficial Absences; WC, worker compensation.

Secnik et al. Pharmacoeconomics. 2005;23(1):93-102.

12.29

4.33

16.63

4.93

21.47

43.03

12.81

1.13

13.95

2.82

12.66

29.34

0

5

10

15

20

25

30

35

40

45

Of Abs Unof Abs* Tot Abs* STD WC Total Days*

Day

s

Individuals with ADHD

Matched Controls

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Increased Healthcare Utilization Among Adults with ADHD

Service % ADHD % Control P Value

Outpatient services

Psychiatrist 27.53 2.22 <.01

Psychologist 16.03 1.38 <.01

Outpatient GP 57.77 51.20 <.01

Mental health facility 0.09 0 .16

Mental health/chemistry department facility 1.33 0.27 <.01

Inpatient services

Emergency room 14.34 10.26 <.01

Inpatient admission 6.71 4.09 <.01

Frequency – number of admissions

0 93.29 95.91 <.01

1 5.24 3.55 —

2 1.02 0.40 —

3+ 0.45 0.14 —

Secnik et al. Pharmacoeconomics. 2005;23(1):93-102. GP, general practitioner.

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Untreated ADHD and the Risk for Substance Use Disorder

*6 study meta-analysis; †97% stimulants; ‡stimulantsCI, confidence interval

Reviewed in: Upadhyaya HP. Prim Care Companion J Clin Psychiatry 2008;10(3):211-221.

Study Population Follow-up Risk for SUD

Biederman et al. 1999

Medicated (N=56)Nonmedicated (N=19)Controls (N=137)

4-year, throughadolescence

Medicated patients at reduced risk

Adjusted OR=0.15 (95% CI=0.04 to 0.6)

Wilenset al. 2003

Medicated† (N=674)Nonmedicated (N=360)

Into adolescence & adulthood*

~2-fold reduced risk in medicated subjects

Pooled estimate OR=1.9

(95% CI=1.1 to 3.6)

Barkley et al. 2003

Medicated‡ (N=9)Nonmedicated (N=21)

>13-year into adulthood

Stimulant use and drug use in adulthood was

not associatedP>.05

Katusicet al. 2005

Medicated‡ (N=295)Nonmedicated (N=84)

17.2 years into adulthood (mean)

Substance abuse in 20% of medicated vs

27% of nonmedicated

Adjusted OR=0.6 (95% CI=0.3 to 1.0)

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Clinician Confidence in the Diagnosis and Treatment of Adult ADHD*

0

10

20

30

40

50

60

70

80

90

100

Not Confident SomewhatConfident

ExtremelyConfident

SomewhatConfident +ExtremelyConfident

Pe

rcen

tage

of

Re

spo

nd

en

ts

Primary care physiciansPsychiatrists

0

10

20

30

40

50

60

70

80

90

100

Not Confident SomewhatConfident

ExtremelyConfident

SomewhatConfident +ExtremelyConfident

Pe

rcen

tage

of

Re

spo

nd

en

ts

Primary care physiciansPsychiatrists

Diagnosis in Adults with ADHD† Treatment in Adults with ADHD†

Goodman DW. Prim Care Companion CNS Disord. 2012;14(4):PCC.

*Differences between primary care physicians and psychiatrists are significant at P < .001 for diagnosis and treatment of ADHD.†Primary care physicians: n = 1,145; psychiatrists: n = 600.

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Undertreatment of ADHD in Adults

Faraone et al. Am J Psychiatry. 2006;163:1720–1729.

0

20

40

60

80

100

120

140

Subthreshold ADHD (N=41) Late-Onset ADHD (N=79) Full ADHD (N=127)

Life

tim

e T

reat

me

nt

for

AD

HD

Counseling Counseling and Pharmacotherapy Pharmacology None

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Recognition and Diagnosis

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Case Evaluation #1: 18-year-old Female

▪ First-year college student

▪ Generally high functioning, in good academic standing, involved in multiple extracurricular activities

▪ Feels overwhelmed by too many commitments, tends to procrastinate, has become increasingly forgetful of appointments and course assignments

▪ Reports that her grades have started to decline

▪ Speaks very quickly and abruptly, loses her train of thought when speaking, appears to be having difficulty sitting still in her chair

▪ When queried, she reveals that she has always had to work really hard to keep up and takes longer to complete tasks than any of her peers

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▪ What aspects of the patient’s clinical presentation might lead you to suspect that she has ADHD?

▪ What other conditions would you consider? (eg, mania)

▪ What additional questions would you pose?

▪ What criteria would you use to make a diagnosis?

Case Evaluation 1: Discussion

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Common Dysfunctional Behavior Patterns in Adult ADHD

Adapted from Rostain AL, Ramsay JL: Adults with ADHD? Try medication and psychotherapy. Curr Psychiatry. 2006;5:13-27; Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/attention-deficit-hyperactivity-disorder-in-adults/.

Behavior Description Short-term Gain/Long-term Loss

Anticipatory avoidance

• Magnification of difficulty of a pending task with doubts about the ability to complete it

• Rationalizations to justify procrastination

• Defers short-term stress but creates a self-fulfilling prophecy

• Task looms ahead and can seem overwhelming when facing a deadline

Brinkmanship• Waiting until the last moment to

complete a task, often when facing an impending deadline

• Deadline-associated stress can be focusing, but leaves little room for error and can yield suboptimal results

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Common Dysfunctional Behavior Patterns in Adult ADHD (Cont’d)

Adapted from Rostain AL, Ramsay JL: Adults with ADHD? Try medication and psychotherapy. Curr Psychiatry. 2006;5:13-27; Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/attention-deficit-hyperactivity-disorder-in-adults/.

Behavior Description Short-term Gain/Long-term Loss

Pseudoefficiency

• Completing several low-priority, manageable tasks (eg, checking e-mail)

• Avoiding high-priority tasks (eg, work projects)

• Creates sense of productivity by reducing a to-do list

• Defers more difficult projects

Juggling

• Taking on new, exciting projects

• Feeling busy without completing projects

• Becoming motivated to start a novel project is easier than completing an ongoing one

• Usually results in many incomplete projects

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Overview of DSM-5 Criteria for ADHD in Adults

▪ Presence of ≥ 5 symptoms of inattention and/or hyperactivity-impulsivity:

– Prior to 12 years of age

– For ≥ 6 months to a degree inconsistent with developmental level

– In ≥ 2 settings

▪ Clear evidence that symptoms interfere with, or reduce the quality of social, academic, or occupational functioning

▪ Not occurring exclusively during the course of schizophrenia or other psychotic disorder, and not better explained by another mental disorder

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5™); 2013.

DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

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DSM-5: Symptoms of Inattention

Lack of attention to details/careless errors

Difficulty sustaining attention

Does not seem to listen

Does not follow through on instructions

Difficulty organizing tasks and activities

Avoids sustained mental efforts

Loses and misplaces objects

Easily distracted

Forgetful in daily activities

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5™);2013.

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DSM-5: Symptoms of Hyperactivity-Impulsivity

Fidgetiness (head or feet)/squirms in seat

Leaves seat frequently

Running about/feeling restless

Excessively loud or noisy

Always “on the go”

Talks excessively

Blurts out answers

Difficulty waiting his/her turn

Tends to act without thinking


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Relative Frequency of ADHD Symptoms in Adults

Wilens TE, et al. J Clin Psychiatry. 2009;70(11):1557-62.

Difficu

ltyp

laying q

uie

tly

Difficu

lty rem

ainin

g seate

d

Ru

ns/clim

bs e

xcessive

ly

Talks exce

ssively

Drive

n b

y a mo

tor

Difficu

lty waitin

g turn

Fidge

ts

Inte

rrup

tso

r intru

de

s

Blu

rts ou

t answ

ers

Care

less/slo

pp

y

Lose

s thin

gs

Forge

tful in

daily activitie

s

Do

esn

’t listen

Difficu

lty organ

izing tasks/activitie

s

Difficu

lty follo

win

g instru

ction

s

Difficu

lty with

sustain

ed

me

ntal e

ffort

Difficu

lty sustain

ing atte

ntio

n

Easily distracte

d

100

90

80

70

60

50

40

30

20

Pe

rce

nt

of

Sub

ject

s

Hyperactive/ImpulsiveSymptoms

InattentiveSymptoms

N = 107

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After ruling out other conditions, you diagnose the patient with ADHD.

▪ Do you have enough information to classify this patient’s ADHD?

– Importance of acquiring a full clinical history

– Corroborating with a third party

▪ What further questions would you pose?

▪ How can classification inform management goals and treatment for adults with ADHD?


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DSM-5: ADHD Subtypes

CombinedPredominantly

inattentive

Predominantly hyperactive-

impulsive


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DSM-5: ADHD Severity

▪ Mild

– Few symptoms beyond the required number for diagnosis

– Minor impairment in social, school, or work settings

▪ Moderate

– Symptoms or functional impairment between “mild” and “severe”

▪ Severe

– Many symptoms beyond the required number for diagnosis

– Several symptoms are particularly severe

– Marked impairment in social, school, or work settings


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▪ What type of validated tools are available to aid in your evaluation? Which would you choose to employ?

– WHO Screener: brief, free resource, easily completed in the waiting room, and can be used to guide patient interview


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ADHD Rating Scales

ACDS ADHD Clinical Diagnostic Scale for Adults

ASRS Adult ADHD Self-Report Scale

BADDS Brown Attention-Deficit Disorder Symptom Assessment Scale for Adults

ADHD-RS-IV ADHD Rating Scale IV with Adult Prompts

BCS Barkley Current Symptom Scale

CSS Current Symptom Scale

WRAADDS Wender-Reimherr Adult Attention Deficit Disorder Scale

CAARS-S-S Conners' Adult ADHD Rating Scales Short Version Self-Report

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WHO Adult ADHD Self-Report Scale Screener

Check the box that best described how you have felt and conducted yourself over the past 6 months. Please give the completed questionnaire to your health care professional during your next appointment to discuss the results.1. How often do you have trouble wrapping up the final details of a

project once the challenging parts have been done?2. How often do you have difficult getting things in order when you

have to do a task that requires organization?3. How often do you have problems remembering appointments or

obligations?4. When you have a task that requires a lot of thought, how often

do you avoid or delay getting started?5. How often do you fidget or squirm with your hands or feet when

you have to sit down for a long time?6. How often do you feel overly active and compelled to do things,

as if you were driven by a motor?

Add the number of checkmarks that appear in the darkly shaded areas. Four or more checkmarks indicate that your symptoms may be consistent with adult ADHD. It may be beneficial for you to talk with your health care provider about an evaluation.

Source: “Adult ADHD SELF-REPORT SCALE – V1.1 (ASRS-V1.1) SCREENER,” FROM WHO COMPOSITE INTERNATIONAL DIAGNOSTIC INTERVIEW, © WORLD HEALTH ORGANIZATION.

Bilkey T, et al. Scientific American Mind. 2014;25:64-69.

Nev

er

Rar

ely

Som

etim

es

Oft

en

Ve

ry O

fte

n

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Treatment Strategies

28

You diagnose the patient as having ADHD (combined presentation and moderate severity).

▪ What is your initial treatment approach?

▪ How do you go about choosing a first-line therapy for a newly diagnosed patient such as this one?


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Approaches to the Treatment of ADHD in Adults

*Form of psychosocial therapy using cognitive-behavioral principles

Weisler RH and Childress AC. Prim Care Companion CNS Disord. 2011;13(6). pii: PCC.

Nonpharmacologic

• Cognitive-behavioral therapy (CBT)

• Metacognitive therapy• Dialectical behavioral

therapy (DBT)-based psychotherapy

Pharmacologic

• Psychostimulants• Nonstimulants

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FDA-Approved Pharmacologic Treatments

Class Agents Mechanism of Action

Psychostimulants

• Methylphenidate

• Dexmethylphenidate

• Mixed amphetamine salts

• Lisdexamfetamine

• Increase availability of synaptic dopamine

Nonstimulant• Atomoxetine • Specifically inhibits

norepinephrine reuptake

FDA, US Food and Drug Administration.

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Considerations for Choice of Pharmacotherapy

▪ Stimulant vs nonstimulant

– Risk for abuse/misuse

▪ Short-acting* vs long-acting

– Required duration of symptom control

– Patient preference

– Risk for nonadherence

– Risk for abuse/misuse

*Short-acting stimulants are not currently approved for adult ADHD

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Osmotic-Release Oral System (OROS) Methylphenidate

AISRS, Adult ADHD Investigator System Symptom Report Scale; IR, immediate release; MPH, methylphenidate; TID, 3 times per day.Spencer et al. J Atten Disord. 2011;15(4):286-294.

Me

an A

ISR

SSc

ore

0 1 2 3 4 5 6

Week

24

20

16

12

8

4

0

IR-MPH (TID)

OROS-MPH

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Lisdexamfetamine Treatment Improves Executive Function Among Adults with ADHD

Me

an (

SD)

BR

IEF-

A G

EC T

-Sco

re

Lisdexamfetamine PlaceboDimesylate

≥100

90

80

70

60

50

40

≤30

Means at Baseline and End Point* Change From Baseline

Baseline Week 10/end point/early termination

Ch

ange

Fro

m B

ase

line

,LS

Me

an (

SE)

BR

IEF-

A G

EC T

-Sco

re

Lisdexamfetamine PlaceboDimesylate

0

–10

–20

–30†

Mean (SD) self-reported BRIEF-A GEC T-score at baseline and week 10/end point/early termination, and Change from baseline LS mean (SE) self-reported BRIEF-A GEC T-score at week 10/end point/early termination.*Shaded area represents range of T-scores considered to represent clinically significant impairments.†P < .0001.GEC, Global Executive Composite; LS, least squares; SD, standard deviation; SE, standard error.

Adler et al. J Clin Psychiatry. 2013;74(7):694-702.

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Safety and Tolerability of Lisdexamfetamine

Adverse Event* LDX (n=79) N (%) PBO (n=80) N (%)

Any event 62 (78.5) 47 (58.8)

Decreased appetite 26 (32.9) 5 (6.3)

Dry mouth 25 (31.6) 6 (7.5)

Headache 20 (25.3) 2 (2.5)

Feeling jittery 10 (12.7) 0 (0.0)

Insomnia 10 (12.7) 3 (3.8)

Initial insomnia 8 (10.1) 5 (6.3)

Irritability 8 (10.1) 3 (3.8)

Weight decreased 8 (10.1) 0 (0.0)

Diarrhea 6 (7.6) 2 (2.5)

Fatigue 6 (7.6) 3 (3.8)

Hyperhidrosis 5 (6.3) 0 (0.0)

Upper respiratory tract infection 5 (6.3) 1 (1.3)

Anorexia 4 (5.1) 0 (0.0)

Heart rate increased 4 (5.1) 2 (2.5)

Libido decreased 4 (5.1) 0 (0.0)

Nasopharyngitis 4 (5.1) 4 (5.0)

Nausea 2 (2.5) 5 (6.3)

*Preferred Terminology, Medical Dictionary for Regulatory Activities.LDX, lisdexamfetamine dimesilate; PBO, placebo

Adler et al. J Clin Psychiatry. 2013;74(7):694-702.

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Extended-Release Mixed Amphetamine Salts

Weisler R, et al. CNS Drugs. 2017;31:685–697.

AD

HD

-RS-

AP

To

tal S

core

, Me

an ±

SD

Baseline 1 2 3 4Treatment Week

50

40

30

20

10

0

Placebo (n=86)12.5 mg/day SHP465 MAS (n=89)37.5 mg/day SHP465 MAS (n=88)

CG

I-I S

core

, Me

an ±

SD

1 2 3 4Treatment Week

5

4

3

2

1

0

*

* †

†

Placebo (n=86)12.5 mg/day SHP465 MAS (n=89)37.5 mg/day SHP465 MAS (n=88)

ADHD-RS-AP, Attention-Deficit/Hyperactivity Disorder Rating Scale with Adult Prompts; CGI-I, Clinical Global Impressions-Improvement; MAS, mixed amphetamine salts; MMRM, mixed-effects model for repeated measures.

*P < .001;†P < .001

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Atomoxetine Treatment Is Associated with Improved Executive Function in Young Adults with ADHD

*N includes all randomized patients who also had a BRIEF-A baseline score and a postbaseline score at Visit 4 (Week 5) and/or Visit 6 (Week 12), as applicable.

Adler LA, et al. PLoS One. 2014; 9(8):e104175.

Week Treatment N* LS Mean Change ± SE Difference P Value 95% CI

5

Atomoxetine 157 –18.02 ± 1.69 –7.11 .002 –11.49 to –2.73

Placebo 166 –10.91 ± 1.67

12

Atomoxetine 115 –22.53 ± 2.07 –7.78 .005 –13.19 to –2.36

Placebo 128 –14.75 ± 2.00

BRIEF-A Mean Change from Baseline to Postbaseline Visitors for All Randomized Patients –Repeated Measures Analysis for Global Executive Composite Scores

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Increased Response to Atomoxetine Over 6 Months of Treatment

Wietecha et al. CNS Neurosci Ther. 2016;22:546–557.

CAARS AISRS

LS M

ean

Sco

re C

han

ge

0 1 2 4 6 to 8 10 to 12 14 to 16 20 to 22 24 to 26Weeks

0

–5

–10

–15

–20

PLAATX

*

*

† † † † †† LS

Me

an S

core

Ch

ange

0 1 2 4 6 to 8 10 to 12 14 to 16 20 to 22 24 to 26Weeks

0

–5

–10

–15

–20

†

*

*

PLAATX

† † ††

*(A) P ≤ .006 atomoxetine vs placebo; (B) P ≤ .012 atomoxetine vs placebo. †P < .0001 atomoxetine vs placebo. ATX, atomoxetine; PLA, placebo.

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Atomoxetine Treatment: Onset and Resolution of AEs

AEs, adverse events.

Upadhyaya et al. 2016. Postgrad Med. 2016;127:677-685.

0

20

40

60

80

100

1 2 3

Pe

rce

nta

ge o

f P

atie

nts

wit

h E

ven

t (%

)

Month of Onset

Nausea

Headache

Dry mouth

Decreased appetite

Fatigue

0 50 100 150 200 250 300 350 400Days to Event Resolution

Pe

rce

nta

ge o

f U

nre

solv

ed

Eve

nts

(%

) 100

80

60

40

20

0

Nausea

Headache

Dry mouth

Decreased appetite

Fatigue

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▪ Would you also recommend nonpharmacologic intervention for the patient? If so, what type?

▪ How strong is the evidence in support of nonpharmacologic therapies for the treatment of ADHD?


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Effect of CBT on ADHD Symptoms and Global Function

ADHD (BCS/CSS)

GLOBAL FUNCTION (CGI)

CBT, cognitive behavior therapy.

Jensen CM, et al. Atten Defic Hyperact Disord. 2016;8(1):3-11.

Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

Emilsson 2011 15.7 8.7 15 25 8.5 17 50.1% -1.05 (-1.80, -0.31)

Safren 2005 14.8 8.7 16 23.9 9.9 15 49.9% -0.95 (-1.70, -0.20)

Total (95% CI) 31 32 100.0% -1.00 (-1.53, -0.48)

Heterogeneity: Tau2 = 0.00; CHI2 = 0.04; df = 1 (P = .85); I2 = 0%

Test for overall effect: Z = 3.72 (P = .0002)

-4 -2 0 2 4

Favors (experimental) Favors (control)



Emilsson 2011 3 0.8 8 4.1 0.9 13 36.5% -1.22 (-2.19, -0.25)

Safren 2005 3.3 0.8 16 4.1 1.1 15 63.5% -0.81 (-1.55, -0.08)

Total (95% CI) 24 28 100.0% -0.96 (-1.55, -0.38)



-4 -2 0 2 4


41

Effect of CBT vs Standard Treatment on Symptoms of Depression and Anxiety

DEPRESSION

ANXIETY



Emilsson 2011 5 5.8 15 15.4 9.3 17 47.4% -1.29 (-2.06, -0.52)

Safren 2005 7.6 4.3 16 12.4 7.7 15 52.6% -0.76 (-1.49, -0.02)

Total (95% CI) 31 32 100.0% -1.01 (-1.54, -0.48)



-4 -2 0 2 4




Safren 2005 3.7 3.5 16 7.2 4.9 15 49.2% -0.81 (-1.54, -0.07)

SaEmilsson 2011 7.3 5.9 15 12.8 7.5 17 50.8% -0.79 (-1.51, -0.06)

Total (95% CI) 31 32 100.0% -0.80 (-1.31, -0.28)



-4 -2 0 2 4


Jensen CM, et al. Atten Defic Hyperact Disord. 2016;8(1):3-11.

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Psychiatric Comorbidities of ADHD

43

▪ Presents to his PCP for symptoms of depression

▪ History of mild depression during his early 20s with excessive alcohol consumption (not currently an issue)

▪ Diagnosed at the age of 8 with ADHD and treated with methylphenidate until the age of 14

▪ Reports being recently laid off from his job as a research associate during a company-wide reorganization. Adds that his last 2 performance reviews were mediocre and “would have been let go soon anyway.”

▪ Further questioning reveals employer feedback suggesting a lack of ability to carefully follow directions and track multiple ongoing projects, as required for his position

Case Evaluation #2: 32-Year-Old Male

PCP, primary care physician.

44

▪ What additional questions would you ask the patient to further assess the nature of his symptoms?

▪ How do you discern whether the patient’s symptoms and behavioral patterns are primarily due to ADHD or to depression?

– Patient interview

– Third party account

– Is trouble with concentration worse than usual?

▪ What are your management goals for this patient?

▪ Would you refer this patient to a psychiatrist?

Case Evaluation #2: Discussion

45

Comorbidities of ADHD in Adults

*P ≤ .05; **P ≤ .0001

Hodgkins P et al. Primary Care Companion to CNS Disorders. 2011;13(2):PCC.

0.9

2.3 2.11.6

7.1

0.9

4.1

0.20.9

21.5

0.3

14.0

3.8

7.5

0.3 0.0 0.3 0.0

1.2 1.5

0.30.6

2.8

1.5 1.4

7.3

0.9

2.7

0.10.6

15.7

0.1

3.2

0.6

2.2

0.0 0.0 0.0 0.0 0.4 0.4 0.1

0

5

10

15

20

25

Pro

po

rtio

n o

f P

atie

nts

(%

)

ADHD (n = 31,752)

Non-ADHD (n = 95,256)

**** ** *

**

***

**

**

**

**

**

** * ** **** **

**

Physical Comorbidities Psychiatric Comorbidities

46

Risk for Psychiatric Comorbidities by ADHD Presentation Subtype

5.6

3.0

7.7

4.7

3.3

2.2

1.5

3.6

2.11.8

6.0

3.5

7.2

3.8

2.5

0

1

2

3

4

5

6

7

8

GeneralizedAnxiety Disorder

MajorDepression

Bipolar EffectiveDisorder

ObsessiveCompulsive

AlcoholDependence

Od

ds

Rat

io

Combined

Hyperactive-impulsive

Inattentive

Adults with ADHD, n = 17,899

Friedrichs B, et al. J Atten Disord. 2012;16:13-22.

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Impact of Adjunctive Atomoxetine Therapy in Adults with ADHD and Anxiety

BP, blood pressure; HAM-A, Hamilton Anxiety Scale.Gabriel et al. Atten Defic Hyperact Disord. 2011;3(4):319-326.

Total HAM-A 6.6 <.001

Cognitive anxiety subscale 6.7 <.001

Somatic anxiety subscale 4.8 <.001

Total Sheehan’s Disability Scale 6.3 <.001

Occupational disability 4.6 <.001

Social disability 5.6 <.001

Family and home responsibilities 4.9 <.001

Weight 1.3 <.20

Systolic BP 1.1 <.30

Diastolic BP -.10 <.92

Pulse -1.2 <.25

48

Atomoxetine in Adults with ADHD and Alcohol Use Disorder

Wilens et al. Drug Alcohol Depend. 2008;96(1-2):145-154.

Atomoxetine ADHD/SUD Study Group

Cu

mu

lati

ve H

eav

y D

rin

kin

g D

ays

0 20 40 60 80 100Follow-up Time (days)

35

30

25

20

15

10

5

0

AtomoxetinePlacebo

Event ratio = 0.737P value = .0230

49

Considerations for Optimizing ADHD Management

50

Patient Education

▪ Manage therapeutic expectations

▪ Provide information about how medications work (eg, relationship between timing of release and therapeutic effects)

▪ Emphasize the importance of adherence to therapy

▪ Address patient concerns regarding development of tolerance and long-term safety

▪ Ensure patient awareness of the potential for misuse

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Medication Adherence

▪ Mean adherence was 86.8% (SD = 14.5%) to ADHD medications in the 2 weeks prior to assessment.

▪ Level of education was not associated with adherence.

▪ Self-reported adherence to ADHD medications was negatively associated with severity of ADHD symptoms.

Adherence Level % of Patients

<80% 22%

<90% 44%

100% 26%

Safren et al. J Atten Disord. 2007.10(3):257-260.

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Summary

▪ ADHD is a disorder that affects adults as well as children, and has been found to have pervasive negative impact across multiple life domains

▪ Application of DSM-5 criteria and knowledge of characteristics closely associated with adult ADHD can facilitate diagnosis, which is complicated by heterogeneous clinical presentation and the frequent presence of psychiatric comorbidities

▪ Several pharmacotherapies have been shown to be effective for treating adult ADHD, especially when combined with disorder-oriented psychotherapy to address residual symptoms

▪ To optimize disease management, clinicians should tailor treatment based on behavioral and physiological patient characteristics, as well as provide education on the nature of ADHD and the importance of treatment adherence

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Questions and Answers

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Thank You!

Improving the Recognition and Management of ADHD in Adults · Describe the presentation of...

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