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Once identified, adult ADHD may be managed effectively with drugs, psychosocial therapy, experts suggest

Wednesday, December 12 2007 | Comments

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What's This? Identifying adults with attention-deficit/hyperactivity disorder can be difficult, largely due to popular misconceptions about the illness, but once diagnosed, ADHD can be effectively managed with pharmacologic and nonpharmacologic therapy, according to a pair of experts in the field.

Many adults with ADHD may be initially hesitant to believe that their inattention or inability to focus on a given task is caused by a verifiable mental illness with neurological causes, according to Dr. David Baron, chair of the department of psychiatry at Temple University School of Medicine.

"This is not something that pharmaceutical companies made up so they can sell some more stimulant or nonstimulant medications," Dr. Baron said. ADHD is also not "psychic acne," which patients will just grow out of as they leave adolescence, he continued. Rather, it is a chronic illness with defined symptoms and what appears to be a substantially heritable genotype.

The DSM-IV can be a valuable tool in identifying adult patients with ADHD, but physicians should also look for signs of a lifetime of impairment, Dr. Baron noted. For instance, children with ADHD who were underachievers in school are characterized in adulthood by repeated job failure or underemployment; likewise, adolescents or teens with ADHD who experiment with drugs are likely to progress to drug dependence as adults.

Once adults with ADHD have been identified, it is the job of the physician to develop a treatment strategy to address the individual patient's needs, which often include pharmacotherapy, according to Dr. Allan Chrisman, the medical director of Duke School of Medicine's ADHD program.

When developing the treatment strategy, physicians should consider functional and developmental targets, such as work and family life, and also recognize any unique aspects of the patient's life that may affect treatment decisions, such as work or athletic schedules that may require concentration late into the evening or a shift work schedule that changes frequently, Dr. Chrisman noted. To accommodate these schedules, some patients may require longer-acting drugs or repeat dosing to maintain therapeutic effects throughout the day, he added.

"We have unequal potency in the stimulants, but we have equal efficacy," Dr. Chrisman said. "It doesn't make too much difference the fact that one drug appears to have a greater potency than another. It's the patient's response to that particular dose of that medication that you're looking to accomplish, so you shouldn't let [potency] distract you ...."

Specific drugs approved by the Food and Drug Administration for treating adults with ADHD include the stimulants methylphenidate and dexmethylphenidate, as well as the selective norepinephrine reuptake inhibitor atomoxetine, which can be used to treat patients in whom stimulant therapy may be inappropriate, Dr. Chrisman noted.

Additionally, potential treatments that have not yet been approved by the FDA for use in adults include lisdexamfetamine dimesylate, a prodrug that is inactive until metabolized to reduce the risk of diversion or abuse, as well as several long-acting formulations of methylphenidate and the methylphenidate transdermal system.

There are also a number of unorthodox drugs that may one day play a role in the treatment of adults with ADHD, including antihypertensive agents, amino acids, modafinil, and cholinergic agents. Tricyclic antidepressants, bupropion, and monoamine oxidase inhibitors may also have efficacy in treating adults with ADHD, although the data are far from complete. None of these agents is approved by the FDA to treat adults with ADHD.

"Even with ... a good response [to pharmacotherapy], it's very common that I have adults say 'I need something more,'" Dr. Chrisman said. Whereas parents can provide context for a child's improvement in ADHD symptoms, there is no natural equivalent for adults with ADHD, he added.

For this reason, it can be important for these patients to also undergo psychosocial treatments, such as cognitive behavioral therapy, to help translate symptom improvement into real-world, life-improving results, Dr. Chrisman concluded.

This information concerns uses that have not been approved by the FDA.

By Hunter Kaller

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