Evidence-Based Reviews

Adult ADHD: Pharmacologic treatment in the DSM-5 era

Current Psychiatry. 2016 October;15(10):18-25

Revised diagnostic criteria reflect greater recognition of disease impact beyond childhood

References

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49. Bymaster FP, Katner JS, Nelson DL, et al. Atomoxetine increases extracellular levels of norepinephrine and dopamine in prefrontal cortex of rat: a potential mechanism for efficacy in attention deficit/hyperactivity disorder. Neuropsychopharmacology. 2002;27(5):699-711.
50. Adler LA, Liebowitz M, Kronenberger W, et al. Atomoxetine treatment in adults with attention-deficit/hyperactivity disorder and comorbid social anxiety disorder. Depress Anxiety. 2009;26(3):212-221.
51. Clemow DB. Suboptimal dosing of Strattera (atomoxetine) for ADHD patients. Postgrad Med. 2014;126(5):196-198.
52. Camporeale A, Porsdal V, De Bruyckere K, et al. Safety and tolerability of atomoxetine in treatment of attention deficit hyperactivity disorder in adult patients: an integrated analysis of 15 clinical trials. J Psychopharmacol. 2015;29(1):3-14.
53. Young JL, Sarkis E, Qiao M, et al. Once-daily treatment with atomoxetine in adults with attention-deficit/hyperactivity disorder: a 24-week, randomized, double-blind, placebo-controlled trial. Clin Neuropharmacol. 2011;34(2):51-60.
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55. Faraone SV, Glatt SJ. A comparison of the efficacy of medications for adult attention-deficit/hyperactivity disorder using meta-analysis of effect sizes. J Clin Psychiatry. 2010;71(6):754-763.
56. Ring BJ, Gillespie JS, Eckstein JA, et al. Identification of the human cytochromes P450 responsible for atomoxetine metabolism. Drug Metab Dispos. 2002;30(3):319-323.
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Attention-deficit/hyperactivity disorder (ADHD) is common; it affects 5% to 7% of children^1,2 and 4% to 5% of all adults.^3,4 Pediatric ADHD often persists into adulthood, as 65% of individuals diagnosed as children retain impairing symptoms by age 25.⁴

The prevalence of ADHD in childhood is 2 to 3 times greater among boys than girls, but more comparable between the sexes in adulthood.² Symptoms could be more easily overlooked in women because of the greater prominence of hyperactivity and impulsivity-type symptoms in men.⁵

Untreated ADHD is associated with significant costs. Adults with ADHD have increased unemployment rates, poor work performance, and comparatively lower educational performance.^6,7 Compared with non-ADHD adults, those with ADHD have:

more traffic violations and accidents and a higher rate of criminal convictions and incarcerations^8,9
a mortality rate almost 2 times higher, with the greatest differences seen in deaths by suicide and accidents.^10,11

Adults with ADHD also are more likely to have a comorbid psychiatric disorder—in particular, substance use¹¹—and often are in treatment for other mental or substance use disorders. Among adults who meet diagnostic criteria for ADHD, approximately only 10% are receiving treatment for ADHD symptoms.^3,12

Changes in DSM-5

Revisions within DSM-5 simplify ADHD’s diagnosis—and make it more difficult to ignore in

adults (Table 1).¹³ For example, DSM-IV¹⁴ required symptoms to be present by age 7, but DSM-5 raises the age to 12. Additionally, fewer ADHD symptoms are now required for the diagnosis in adults. DSM-IV required 6 of 9 symptoms in the areas of inattention or hyperactivity/impulsivity, whereas DSM-5 requires only 5 symptoms in either category.

DSM-5 also provides examples of behaviors more commonly found in adults, such as “feelings of restlessness,” compared with DSM-IV’s “often runs about or climbs excessively in situations in which it is inappropriate.” Finally, ADHD now may be diagnosed in a person with an autism spectrum disorder who meets diagnostic criteria for both disorders.^13,14

Identifying ADHD in adults

ADHD diagnosis in adults is made through careful clinical interviewing. For example, ask about what factors motivated an individual to seek evaluation for ADHD. Often, patients present after a change in responsibility at work or at home, such as a promotion or birth/adoption of a new child.

Consider incorporating a brief screen for adult ADHD in all new outpatient evaluations (Table 2).¹⁵ Screen for other psychiatric disorders as well; comorbidity with ADHD is high, and hyperactivity and inattention symptoms may result from anxiety, depression, or substance use.

Screen for learning disorders, which can present with ADHD symptoms (such as poor concentration) when the individual attempts difficult tasks. Evaluate for risk factors associated with ADHD medications, such as a history of cardiac problems, hypertension, or tachycardia. A family history of ADHD is found in approximately 80% of cases.^16,17 Determine the presence of ADHD symptoms in childhood. A careful review of the educational history often reveals long-term underachievement and struggles in school. Patients may report a chronic history of poor attention or feelings of restlessness in school. Sometimes problems do not become apparent until high school or college; some individuals, especially those with high intelligence, compensate for deficits and show fewer overt symptoms of impairment until later in their education.¹⁸Occupational history also may be revealing:

How are they performing at work?
Have they changed jobs multiple times in a short period?
Do they have difficulty organizing tasks?

Subtle ADHD signs include time of arrival to appointments (eg, late or extremely early), missing data on intake paperwork, and a history of losing keys or phones.

Neuropsychological testing. Some clinicians routinely include neuropsychological testing in an adult ADHD evaluation, but these studies have shown inconsistent cognitive deficits in people with ADHD.^19,20 No distinct psychometric cognitive test or profile is diagnostic of ADHD or its subtypes.²¹

Treatment and follow-up care

Four general categories of medications are used to treat ADHD in children and adults:

stimulant, noradrenergic, α₂ adrenergic agonist, and antidepressants (Table 3). Stimulants are associated with the highest treatment response rates in adult ADHD. Amphetamine and methylphenidate products are associated with a response rate >80%, with a large effect size of 0.99 for short-acting agents and 0.95 for long-acting agents.²² Other medications are useful options for patients intolerant to stimulants’ side effects.

After starting a patient on medication, at each follow-up appointment ask about new cardiac symptoms or diagnoses, new family history of cardiac problems, or new medications. Measure pulse and blood pressure every 1 to 3 months. Measure vital signs more frequently during titration and weaning periods.²³

Adult ADHD: Pharmacologic treatment in the DSM-5 era

References

Changes in DSM-5

Identifying ADHD in adults

Treatment and follow-up care

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