Working adeptly to diagnose and treat adult ADHD

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Behavioral Health

Working adeptly to diagnose and treat adult ADHD

J Fam Pract. 2020 April;69(3):145-149

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References

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In the primary care setting, an assessment for ADHD should, at minimum, involve a review of the patient’s academic and work history, assessment of psychiatric comorbidities and substance use history, and administration of appropriate rating scales. When evaluating adults, these tools include the Adult ADHD Self-Report Scale (ASRS)^11,12 screening tool and the Diagnostic Interview for ADHD in adults (DIVA-5).^13,14 If possible, obtain scale assessments not only from the patient but from family members or other observers who can provide information about the patient in childhood/adolescence and present day.

In an integrated care setting, consider involving a behavioral health consultant for a more comprehensive evaluation of educational, employment, driving, and relationship histories. Historical record review may include report cards from elementary school through high school, standardized test scores, psycho-educational and individual education plan reports, and medical records. Having a snapshot of the patient as a younger child, adolescent, and young adult can help to identify overall patterns of academic underachievement and reveal gaps between potential and overall achievement and performance. Pursue a more thorough evaluation in cases where other comorbid psychiatric disorders are present or when the patient is unfamiliar to you.

TWO GROUPS OF TREATMENT OPTIONS

The treatment of ADHD in adults (and children) can be broadly divided into pharmacologic and nonpharmacologic modalities.

Stimulants are first-line pharmacologic treatment for ADHD in patients with low risk for misuse. Stimulants improve cognitive function, decrease impulsivity, and increase alertness.¹⁵ However, these effects are not exclusive to those with ADHD, and response does not aid in diagnosis. No stimulant is preferred over another, although individuals may respond better to 1 specific agent than to others. Be aware that stimulants may be diverted; patients at increased risk include those with comorbid substance use or mood disorders. Misuse may be especially common on college campuses, where nonprescribed stimulants may be used as study aids or recreationally.

Up to 20% of patients with bipolar illness also have ADHD.

Stimulants come in a variety of formulations that differ primarily in their time profile or mode of delivery. Some preparations (eg, Ritalin LA and Adderall XR) contain a mixture of immediate-release and extended-release mechanisms and therefore have bimodal peaks. Others (eg, Concerta) use an osmotic system to approximate a steadier flow of drug delivery. However, as these drugs have entered the generic market, time response between products is much less predictable. Individual differences in metabolism may also alter duration of action.

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