Pearls:

Pharmaceutical first-line treatment is stimulants: amphetamines and methylphenidate. Long-acting agents are preferred due to less abuse potential and more controlled release of the drug but are generally more expensive.

Though the diagnosis of ADHD is clinical and an extensive workup is generally not warranted, many common things can mimic ADHD. These include sleep deprivation, anxiety, depression, medications (ie: anticonvulsants, antihistamines), caffeine and other recreational drugs.

Adult ADHD Self-Reporting Scale (ASRS) is a nice screening tool to do with patients.

Adult ADHD is diagnosed based on the DSM V criteria which looks at 9 different symptoms. Additionally, the symptoms must be impairing (loss of job, relationship discord), pervasive (present in multiple domains) and lifelong (general onset before age of 12).

Heidi’s clinical scenario: 29 year-old guy, Brian, comes into her office saying he thinks he has ADHD. He has extreme difficulty focusing on things at work and at home, to the extent he has lost a job and has faced marital discord. No matter how much effort he puts into finishing a task, he has a hard time finishing it.

What are the diagnostic criteria for ADHD? The DSM (Diagnostic Statistical Manual) is the main reference in psychiatry to diagnose many psychiatric illnesses. The DSM V criteria for diagnosis has 9 criteria divided into 3 sections (technically you need five out of nine but you should consider severity and duration of symptoms):

Attention-related:

Easy distractibility



Inability to sustain attention



Inability to listen

Task-related

Starting task



Sustaining task



Completing task

“Bumbling” symptoms

Problems remembering appointments/obligations



Misplacing or difficulty finding items



Making careless mistakes

These symptoms are accompanied by impairment (ie: losing job, marital discord)

What about hyperactivity? May be seen less in the adult patients compared to pediatrics but can also present as irritability.

What screening tools are out there? Adult ADHD Self-Reporting Scale (ASRS questionnaire), 18 questions.

You may consider watching them fill out the questions and if they are able to easily complete it, lean away from the diagnosis.

Supplement to a fuller conversation with the patient.

Other important considerations: ADHD is pervasive and lifelong. Symptoms should be present for at least 6 months and present before age 12. It is not focal to one particular thing so you should see it in personal life, work, school, etc.

There is some newer literature to suggest adult onset ADHD may be possible but more research is needed.

What else can mimic ADHD? Sleep deprivation (common in today’s society), anxiety, depression, learning disorders, thyroid or liver problems, lead toxicity and substances (recreational, nicotine, caffeine, anti-histamines, anticonvulsants). No routine screening labs are necessary but you might consider thyroid studies and a CBC at a minimum.

Treatment?

Lifestyle and non-pharmaceutical: sleep, low-glycemic index diet, ongoing and continuous behavioral coaching (ie: to-do lists), therapy

Medications:

Stimulants (methylphenidates, amphetamines) are first-line, no study shows a difference between the two major classes. Amphetamines may have more side effects and interfere with the P450 system; however, some patients will respond to one better than the other.

Methylphenidate (ie: Concerta), short-/long-acting available



Dexmethylphenidate (ie: Focalin), short-/long-acting available



Amphetamines:



1. Mixed salts (Adderall): cheap, long-acting





D-isomer – thought to have most effects of controlling hyperactivity and inattention







L-isomer – not much activity and more side effects





2. Dextroamphetamines (Dexedrine): D-isomer mixed salt that became a popular drug of abuse (Andy Warhol’s favorite!) in the 1970’s but is actually quite effective with no more abuse potential than Adderall. Short and long-acting forms available.





3. Lisdexamfetamine (Vyvanse): D-isomer mixed salt, long-acting. Only activated in the gut so cannot be crushed or snorted for abuse. Expensive ($280-380 per month).



Long-acting preferred over short-acting in adults because stable release of medication leads to less withdrawal, once a day dosing, and less abuse risks. Short-acting is cheaper and you have more control over the timing of medication coverage.

Side effects: adrenergic fight or flight symptoms – elevated BP, tachycardia, anorexia, abdominal pain, sexual dysfunction, insomnia, jitteriness

Pearl: Patients may say they prefer short-acting because they have that “being on a drug feeling” but long-acting is just as effective.

Titrating dose: Evaluating the patient in-person to evaluate plateauing (no improvement in symptoms with last dose increase) and side effects. If either of those things, would consider switching classes.

Can you have people on two different classes? Maybe. Our interviewer has never done it but you may consider adding a short-acting onto a long-acting at the end of the day.

Other options that are not quite as effective:

Bupropion – 50% reduction in ADHD symptoms, may be used in mild cases. Good for those with co-morbid depression and smoking.



Atomoxetine (Straterra) – takes longer time to become effective and doesn’t seem to work very well, may increase diastolic blood pressure.



Tricyclic antidepressants – may help with comorbid anxiety but not as well tolerated.



Alpha-agonists – data shows effect in children with hyperactivity, last-line

How do you manage the risks of drug abuse with stimulants?

Approach your patient with positive intent, assuming they are being truthful unless something tells you otherwise

Controlled substance agreements are an options

Online state-based drug monitoring tools

If concerned about a patient, consider meds with decreased abuse potential (Vyvanse) or non-stimulant medications

How about the college students that want to use it to help them study for exams?