Adult ADHD: Treatment of a Grown-up Disorder

Edward M. DeSimone II, RPh, PhD, FAPhA; Kellie Busby, PharmD Candidate

US Pharmacist. 2014;39(1):52-57.

Abstract and Introduction

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is often thought of as a disorder of childhood, but approximately one-half of individuals who exhibit ADHD early in life will go on to have persistent symptoms into adulthood. These symptoms generally differ in presentation from the typical presentation of a school-aged child with hyperactivity and academic difficulties. Further complicating the picture is the fact that co-occurring psychiatric disorders that were not apparent during an individual's younger years can present in later adolescence. Therefore, the diagnosis and treatment of symptomatic patients can change over time, requiring some similar and some unique approaches to therapeutically managing ADHD in adults.

Introduction

Attention-deficit/hyperactivity disorder (ADHD; also called attention-deficit disorder) is a neurobehavioral condition that causes impairments in concentration, impulsivity, and cognitive processing. As with many psychiatric conditions, the diagnosis of ADHD relies on subjective observations. Attempts to pinpoint the neuropathology of ADHD are ongoing. It was formerly believed that ADHD was a disorder of childhood that resolved with age. It was not until the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition–Revised, in 1987 that the existence of ADHD in adults was recognized, provoking the question of how patients with childhood ADHD differ from those who continue to have symptoms beyond adolescence.^[1] Although this question has not been completely answered, current research has been able to increase understanding of ADHD and how to best manage the unique symptomology of the adult patient.

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Abstract and Introduction
Diagnosis
Pathophysiology
Genetics and Environment
Epidemiology
Co-occurring Conditions and Differential Diagnoses
Treatment
Pharmacist Involvement
References

Table 1. Criteria for Diagnosing ADHD in Adults ^a
Category A: Inattention
Often: Does not pay close attention to details or makes careless mistakes in schoolwork, work, or other activities Has trouble keeping attention on tasks or play activities Does not seem to listen when spoken to directly Does not follow through on instructions and fails to finish schoolwork, chores, or workplace duties (not due to oppositional behavior or failure to understand instructions) Has trouble organizing activities Avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period (e.g., schoolwork, homework) Loses items needed for tasks and activities (e.g., toys, assignments, pencils, books, tools) Is easily distracted Is forgetful in daily activities
Category B: Hyperactivity/Impulsivity
Hyperactivity
Often: Fidgets with hands/feet or squirms in seat when sitting still expected Gets up from seat when remaining in seat expected Runs about/climbs excessively when and where inappropriate (adolescents or adults may feel very restless) Has trouble playing or doing leisure activities quietly "On the go" or acts as if "motor-driven" Talks excessively
Impulsivity
Often: Blurts out answer before question finished Has trouble waiting his/her turn Interrupts or intrudes on others (e.g., butts into games or conversations)

^a≥5 of category A or B symptoms present for ≥6 months to a point inappropriate for developmental level. Some symptoms causing impairment present at age ≤12 years. Some impairment from symptoms present in ≥2 settings (e.g., school/work, home). Clear evidence of clinically significant impairment in social, school, or work functioning. Symptoms do not occur only during the course of PDD, schizophrenia, or other psychotic disorder, and symptoms are not better accounted for by another mental disorder (e.g., MD, AD, DD, PD).
AD: anxiety disorder; ADHD: attention-deficit hyperactivity disorder; DD: dissociative disorder; MD: mood disorder; PD: personality disorder; PDD: pervasive developmental disorder. Source: Reference 2.

Table 2. Marketed Formulations of ADHD Drugs
Drug	Dosing	Common AEs	Comments
Methylphenidates		Insomnia, anorexia, high blood pressure, dysphoria, dry mouth, headache, acute psychosis, irritability	Caution with cardiovascular risk factors
Methylphenidate IR	10–60 mg/day
Methylphenidate SR	10–60 mg/day
Methylphenidate ER	10–60 mg/day
Amphetamines
Amphetamine/dexamphetamine IR	5–40 mg/day
Amphetamine/dexamphetamine XR	5–40 mg/day
Dextroamphetamine	5–40 mg/day
Methamphetamine	5–40 mg/day
Lisdexamfetamine	30–70 mg/day
Atomoxetine	40–100 mg/day	GI distress, high blood pressure, headache, sleep disturbances	Poor response rate, delayed onset
TCAs
Imipramine	100–300 mg/day	Sedation, dry mouth, constipation, urinary retention, ECG changes	Delayed onset
Nortriptyline	50–150 mg/day		Delayed onset
Bupropion	150–300 mg/day	Irritability, reduced seizure threshold, insomnia	May increase anxiety

ADHD: attention-deficit/hyperactivity disorder; AE: adverse effect; ER: extended-release; GI: gastrointestinal; IR: immediate-release; SR: sustained-release; TCA: tricyclic antidepressant; XR: extended-release.
Source: Reference 18.

Table 3. Resources for Patients and Health Professionals
Organization	Contact Information
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)	www.chadd.org
Attention Deficit Disorder Association (ADDA)	www.add.org
National Alliance on Mental Illness (NAMI)	www.nami.org
Substance Abuse and Mental Health	http://samhsa.gov
Services Administration (SAMHSA)
College of Psychiatric and Neurologic Pharmacists (CPNP)	ww.cpnp.org