Evidence-Based Reviews

Adult ADHD: Less hyperactivity, but lingering inattention and distress

Current Psychiatry. 2002 October;1(10):34-43

References

1. Gadrow KD, Weiss M. Attention-deficit/hyperactivity disorder in adults: beyond controversy. Arch Gen Psychiatry 2001;58(8):784-5.

2. Ernst M, Zametkin AJ, Matochik JA, Jons PH, Cohen RM. DOPA decarboxylase activity in attention deficit hyperactivity disorder adults. A [fluorine-18]fluorodopa positron emission tomographic study. J Neurosci 1998;18(15):5901-7.

3. Spencer T, Wilens T, Biederman J, Faraone SV, Ablon JS, Lapey K. A double-blind, crossover comparison of methylphenidate and placebo in adults with childhood-onset attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1995;52:434-43.

4. Spencer T, Biederman J, Wilens T, et al. Efficacy of a mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 2001;58(8):775-82.

5. Swanson J, Wigal S, Greenhill L, et al. Objective and subjective measures of the pharmacodynamic effects of Adderall in the treatment of children with ADHD in a controlled laboratory classroom setting. Psychopharmacol Bull 1998;34(1):55-60.

6. Wilens TE, Biederman J, Spencer TJ, et al. Controlled trial of high doses of pemoline for adults with attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 1999;19(3):257-64.

7. Wilens TE, Biederman J, Mick E, Spencer TJ. A systematic assessment of tricyclic antidepressants in the treatment of adult attention-deficit hyperactivity disorder. J Nerv Ment Dis 1995;183(1):48-50.

8. Findling RL, Schwartz MA, Flannery DJ, Manos MJ. Venlafaxine in adults with attention-deficit/hyperactivity disorder: an open clinical trial. J Clin Psychiatry 1996;57(5):184-9.

9. Wender PH, Reimherr FW. Bupropion treatment of attention-deficit hyperactivity disorder in adults. Am J Psychiatry 1990;147(8):1018-20.

10. Wilens TE, Spencer TJ, et al. A controlled clinical trial of bupropion for attention deficit hyperactivity disorder in adults. Am J Psychiatry 2001;158(2):282-8.

11. Grabowski J, Roache JD, Schmitz JM, Rhoades H, et al. Replacement medication for cocaine dependence: methylphenidate. J Clin Psychopharmacol 1997;17(6):485-8.

12. Levin FR, Evans SM, McDowell DM, Kleber HD. Methylphenidate treatment for cocaine abusers with adult attention-deficit/hyperactivity disorder: a pilot study. J Clin Psychiatry 1998;59(6):300-5.

13. Biederman J, Wilens T, Mick E, Spencer T, Faraone SV. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104(2):e20.-

14. Zametkin AJ, Nordahl TE, Gross M, et al. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. N Engl J Med 1990;323(20):1361-6.

15. Spencer T, Biederman J, Wilens T. Effectiveness and tolerability of atomoxetine in adults with attention deficit hyperactivity disorder. Am J Psychiatry 1998;155(5):693-5.

16. Noven Pharmaceuticals. The Science of Noven. Research and development. Transdermal technology. Available at: http://www.noven.com/research.htm.

Patients often function better when their home and work environments are thoughtfully organized, with a designated work/study space and regularly scheduled times for meals, sleep, and exercise. An ADHD coach may facilitate such structure and discipline (Box 2).

New agents in the pipeline

Efforts are being made to increase awareness of adult ADHD and to improve its treatment. For example, the National Institute of Mental Health is funding research on adult ADHD and displays on its Web site a PET scan of an adult brain with ADHD (see “Related resources”).¹⁴ Several medications also are being developed to treat ADHD.

Atomoxetine, a nonstimulant medication awaiting FDA approval for adult ADHD, is a selective norepinephrine reuptake inhibitor. In a double-blind, placebo-controlled, crossover study of adults with well-characterized ADHD, 11 of 21 patients improved with use of atomoxetine, compared with 2 of 21 who improved with use of a placebo. The average dosage of 76 mg/d was well-tolerated.¹⁵ The 52% response rate is similar to the 54% average improvement rate reported for methylphenidate in previous studies of adult ADHD.

In clinical trials, atomoxetine was given bid. Insomnia was not a side effect, so bid dosing does not interfere with sleep. Approximately 10 to 15% of patients experienced weight loss as a side effect.

Other treatment options under development include:

a transdermal system for delivery of methylphenidate¹⁶
a novel nicotinic analogue
glutamate AMPA receptor modulation
omega-3 fatty acids.

Related resources

Hallowell EM, Ratey JJ. Driven to distraction: Recognizing and coping with attention deficit disorder from childhood through adulthood. New York: Simon and Schuster; Reprint edition 1995.
Solanto MV, Arnstein AFT, Castellanos FX, eds. Stimulant drugs and ADHD: Basic and clinical neuroscience. New York: Oxford University Press; 2001.
Weiss M, Trokenberg-Hechtman L, Weiss G. ADHD in adulthood: A guide to current theory, diagnosis, and treatment. Baltimore: Johns Hopkins University Press; 1999.
National Institute of Mental Health. http://www.nimh.nih.gov

Drug brand names

Atomoxetine • (investigational)
Bupropion • Wellbutrin
Desipramine • Norpramin
Dextroamphetamine • Dexedrine, Dextrostat
Methamphetamine • Desoxyn
Methylphenidate • Focalin, Ritalin
Methylphenidate SR • Concerta, Metadate CD, Metadate ER, Methylin ER, Ritalin SR
Mixed salts of amphetamine • Adderall, Adderall XR
Modafinil • Provigil
Pemoline • Cylert
Venlafaxine • Effexor

Disclosure

The author reports that he serves as a consultant to Eli Lilly and Company and is on the speaker’s bureaus of Wyeth Pharmaceuticals and AstraZeneca.