Samuel R. Weber, MD Physician Lead, Logan Psychiatry Intermountain Health Budge Clinic Logan, Utah
Anne-Marie Duchemin, MD Professor Adjunct Department of Psychiatry and Behavioral Health The Ohio State University College of Medicine Columbus, Ohio
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Once a patient is deemed to be a candidate for stimulants, clinicians need to choose between methylphenidate or amphetamine/dextroamphetamine formulations. Table 6 lists medications that are commonly prescribed to treat ADHD; unless otherwise noted, these are FDA-approved for this indication. As a general rule, for adults, long-acting stimulant formulations are preferred over short-acting formulations.28 Immediate-release stimulants are more prone to misuse or diversion compared to extended-release medications.29 Longer-acting formulations may also provide better full-day symptom control.48
In contrast to many other psychiatric medications, it may be beneficial to encourage periodically taking breaks or “medication holidays” from stimulants. Planned medication holidays for adults can involve intentionally not taking the medication over the weekend when the patient is not involved in work or school responsibilities. Such breaks have been shown to reduce adverse effects of stimulants (such as appetite suppression and insomnia) without significantly increasing ADHD symptoms.49 Short breaks can also help prevent medication tolerance and the subsequent need to increase doses.50 Medication holidays provide an opportunity to verify the ongoing benefits of the medication. It is advisable to periodically assess whether there is a continued need for stimulant treatment.51 If patients do not tolerate stimulants or have other contraindications, nonstimulants should be considered.
Lastly, no psychiatric patient should be treated with medication alone, and nonpharmacologic approaches should be incorporated as needed. Clear instructions, visual aids, nonverbal cues, frequent breaks to stand and stretch, schedules, normalizing failure as part of growth, and identifying triggers for emotional reactivity may help patients with ADHD.52 In a study of the academic performance of 92 college students taking medication for ADHD and 146 control students, treatment with stimulants alone did not eliminate the academic achievement deficit of those individuals with ADHD.53 Good study habits (even without stimulants) appeared more important in overcoming the achievement disparity of students with ADHD.53 Providing psychoeducation and training in concrete organization and planning skills have shown benefit.54 Practice of skills on a daily basis appears to be especially beneficial.55
Bottom Line
A sensible approach to diagnosing attention-deficit/hyperactivity disorder (ADHD) in adults includes ruling out other disorders that may present similar to ADHD, taking an appropriate developmental history, obtaining collateral information, and assessing for functional impairment. Sensible treatment involves ruling out comorbidities that stimulants could worsen, selecting extended-release stimulants, incorporating medication holidays, and using nonpharmacologic interventions.
Related Resources
National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management. https://www.nice.org.uk/guidance/ng87
