Hostname: page-component-586b7cd67f-t7czq Total loading time: 0 Render date: 2024-11-25T19:21:38.176Z Has data issue: false hasContentIssue false
  • English
  • Français

The Complexity of ADHD: Diagnosis and Treatment of the Adult Patient With Comorbidities

Published online by Cambridge University Press:  07 November 2014

Jeffrey H. Newcorn ,
Margaret Weiss  and
Mark A. Stein
Jeffrey H. Newcorn
Affiliation:
Jeffrey H. Newcorn, MD, is a consultant/advisor to and receives honoraria from Cortex, Eli Lilly, Lupin, McNeil, Novartis, Pfizer, and Shire.
Margaret Weiss
Affiliation:
Mark A. Stein, PhD, receives research support from Cephalon, Eli Lilly, McNeil, and Novartis; and receives honoraria and compensation for service on the advisory boards of Cortex, McNeil, Novartis, Pfizer, and Shire.
Mark A. Stein
Affiliation:
Margaret Weiss, MD, PhD, is a consultant and/or advisor to, and has received or receives honoraria, consulting fees, or research support from Cephalon, Circa Dia, Eli Lilly, Janssen, Novartis, Purdue, and Shire.
Get access Rights & Permissions [Opens in a new window]

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is an impairing but usually treatable condition. Popular culture propagates the myth that ADHD recedes with age; this is not the case. Although it is common, <20% of adults with ADHD are diagnosed or treated. Adults with ADHD show significant comorbidities with depressive disorders, anxiety disorders, substance use, oppositional defiant disorder, personality disorders, sleep problems, and learning disabilities. However, symptoms that result from ADHD, such as mood symptoms or lability, are often mistaken for comorbid disorders. Comorbidity with ADHD impacts treatment compliance, treatment response, and patient insight. Insufficient data on the interaction between ADHD and comorbidities impedes proper diagnosis and treatment. Better clinical tools for assessing these conditions are needed. Food and Drug Administration-approved pharmacologic treatments for adult ADHD include stimulants, dexmethylphenidate, and the nonstimulant atomoxetine. Effect sizes of approved medicines at approved doses are half those seen in children. Adults may also need longer duration of medication effects than children. Short-acting stimulants are likely to result in poorer adherence and have a higher risk for diversion or abuse. Risk of abuse is a major concern; stimulant treatments are controlled substances, and children with ADHD show increased risk of substance abuse. Psychosocial interventions may be beneficial in treating both ADHD and comorbidities.

In this expert roundtable supplement, Margaret Weiss, MD, PhD, presents a comprehensive overview of complications surrounding differential diagnosis in adults with ADHD. Next, Mark A. Stein, PhD, reviews evaluation, comorbidity, and development of a treatment plan in this population. Finally, Jeffrey H. Newcorn, MD, provides a discussion on the pharmacologic options available for adults with ADHD, considering dosages specific to adults and common comorbidities.

Type
Research Article
Information
CNS Spectrums , Volume 12 , Issue S12 , 2007 , pp. 1 - 16
Copyright
Copyright © Cambridge University Press 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Faraone, SV, Biederman, J. Adult ADHD NOS: Is it a valid diosrder? Poster presented at: the American Psychiatric Association Annual Meeting; May 2005; Atlanta, Georgia.Google Scholar
2.Canadian Attention Deficit Disorder Resource Alliance. Canadian Practice Guidelines for ADHD. Toronto, Ontario: McCleery McCann; 2006.Google Scholar
3.Kessler, RC, Adler, L, Barkley, R, et al.The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–723.CrossRefGoogle ScholarPubMed
4.Biederman, J, Faraone, SV, Spencer, T, et al.Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(12):1792–1798.Google ScholarPubMed
5.Wilens, TE, Kwon, A, Tanguay, S, et al.Characteristics of adults with attention deficit hyperactivity disorder plus substance use disorder: the role of psychiatric comorbidity. Am J Addict. 2005;14(4):319–327.CrossRefGoogle ScholarPubMed
6.Shekim, WO, Asarnow, RF, Hess, E, Zaucha, K, Wheeler, N. A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state. Compr Psychiatry. 1996;31:416–425.CrossRefGoogle Scholar
7.Altfas, JR. Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. BMC Psychiatry. 2002;2:9.CrossRefGoogle ScholarPubMed
8.Downey, KK, Pomerleau, CS, Pomerleau, OF. Personality differences related to smoking and adult attention deficit hyperactivity disorder. J Subst Abuse. 1996;8(1):129–135.CrossRefGoogle ScholarPubMed
9.Barkley, RA, Murphy, KR. Comorbid psychiatric disorders in adults with ADHD. The ADHD Report. 2007;15(2):1–7.Google Scholar
10.Tillman, R, Geller, B. Controlled study of switching from attention-deficit/hyperactivity disorder to a prepubertal and early adolescent bipolar I disorder phenotype during 6-year prospective follow-up: rate, risk, and predictors. Dev Psychopathol. 2006;18(4):1037–1053.CrossRefGoogle ScholarPubMed
11.Adler, LA, Florence, M. Scattered Minds. New York, NY: Putnam; 2006.Google Scholar
12.Hinshaw, SP, Carte, ET, Fan, C, Jassy, JS, Owens, EB. Neuropsychological functioning of girls with attention-deficit/hyperactivity disorder followed prospectively into adolescence: evidence for continuing deficits? Neuropsychology. 2007;21(2):263–273.CrossRefGoogle ScholarPubMed
13.Flory, K, Milich, R, Lynam, DR, Leukefeld, C, Clayton, R. Relation between childhood disruptive behavior disorders and substance use and dependence symptoms in young adulthood: individuals with symptoms of attention-deficit/hyperactivity disorder and conduct disorder are uniquely at risk. Psychol Addict Behav. 2003;17(2):151–158.CrossRefGoogle ScholarPubMed
14.Philipsen, A. Differential diagnosis and comorbidity of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults. Eur Arch Psychiatry Clin Neurosci. 2006;256(Suppl 1):i42–i46.CrossRefGoogle ScholarPubMed
15.Spencer, TJ, Biederman, J, Mick, E. Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. J Pediatr Psychol. 2007;32(6):631–642.CrossRefGoogle ScholarPubMed
16.Weiss, M, Hechtman, L. A randomized double-blind trial of paroxetine and/or dextroamphetamine and problem-focused therapy for attention-deficit/hyperactivity disorder in adults. J Clin Psychiatry. 2006;67(4):611–619.CrossRefGoogle ScholarPubMed
17.First, MB, Spitzer, RL, Gibbon, M, Williams JBW. SCID-I, Clinician Version. Washington, DC: American Psychiatric Press; 1997.Google Scholar
18.Biederman, J, Monuteaux, MC, Mick, E, et al.Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med. 2006;36(2):167–179.CrossRefGoogle ScholarPubMed
19.Gadow, K, Sprafkin, J, Weiss, M. Manual for the Adult Self Report Inventory and Adult Symptom Inventory. Stony Brook, New York: Checkmate Plus; 2004.Google Scholar
1.Hallowell, EM, Ratey, JJ. Driven to Distraction. New York: Pantheon Books; 1994.Google Scholar
2.Klein, R, Mannuzza, S. Long-term outcome of hyperactive children: a review. J Am Acad Child Adolesc Psychiatry. 1991;30:383–387.CrossRefGoogle ScholarPubMed
3.Rostain, AL. Treating comorbid ADHD in adults: mixed results in recent clinical trials. Curr Psychiatry Rep. 2006;8(5):391–392.CrossRefGoogle ScholarPubMed
4.Safren, SA, Otto, MW, et al.Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther. 2005;43(7):831–842.CrossRefGoogle ScholarPubMed
5.Barkley, RA, Anastopoulos, AD, et al.Adolescents with ADHD: patterns of behavioral adjustment, academic functioning, and treatment utilization. J Am Acad Child Adolesc Psychiatry. 1991;30(5):752–761.Google ScholarPubMed
6.Biederman, J, Wilens, TE, et al.Diagnosis and treatment of adults with attention-deficit/hyperactivity disorder. CNS Spectr. 2007;12(4 Suppl 6):1–15.Google Scholar
7.Schubiner, H. Substance abuse in patients with attention-deficit hyperactivity disorder: therapeutic implications. CNS Drugs. 2005;19(8):643–655.CrossRefGoogle ScholarPubMed
1.Weisler, RH, Biederman, J, Spencer, TJ, et al.Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr. 2006;11:625–639.CrossRefGoogle ScholarPubMed
2.Spencer, TJ, Adler, LA, McGough, JJ, et al.Efficacy and safety of dexmethylphenidate extended-release capsules in adults with attention-deficit/hyperactivity disorder. Biol Psychiatry. 2007;61(12):1380–1387.CrossRefGoogle ScholarPubMed
3.Spencer, T, Biederman, J, Wilens, T, et al.A large, double-blind, randomized clinical trial of methylphenidate in the treatment of adults with attention-deficit/hyperactivity disorder. Biol Psychiatry. 2005;57(5):456–463.CrossRefGoogle ScholarPubMed
4.Wilens, TE, Haight, BR, Horrigan, JP, et al.Bupropion XL in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled study. Biol Psychiatry. 2005;57(7):793–801.CrossRefGoogle ScholarPubMed
5.Taylor, FB, Russo, J. Comparing guanfacine and dextroamphetamine for the treatment of adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol. 2001;21(2):223–228.CrossRefGoogle ScholarPubMed
6.Turner, DC, Clark, L, Dowson, J, et al.Modafinil improves cognition and response inhibition in adult attention-deficit/hyperactivity disorder. Biol Psychiatry. 2004;55(10):1031–1040.CrossRefGoogle ScholarPubMed
7.Taylor, FB, Russo, J. Efficacy of modafinil compared to dextroamphetamine for the treatment of attention deficit hyperactivity disorder in adults. J Child Adolesc Psychopharmacol. 2000;10(4):311–320.CrossRefGoogle ScholarPubMed
8.Barkley, RA, ed. Attention-deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: The Guilford Press; 1998:594–597.Google Scholar
9.Biederman, J, Mick, E, Surman, C, et al.A randomized, placebo-controlled trial of OROS methylphenidate in adults with attention-deficit/hyperactivity disorder. Biol Psychiatry. 2006;59:829–835.CrossRefGoogle ScholarPubMed
10.Wilens, TE, McBurnett, K, Bukstein, O, et al.Multisite controlled study of OROS methylphenidate in the treatment of adolescents with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2006;160(1):82–90.CrossRefGoogle ScholarPubMed
11.Wolraich, ML, Greenhill, LL, Pelham, W, et al.Randomized, controlled trial of OROS methylphenidate once a day in children with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108(4):883–892.CrossRefGoogle Scholar
12.Robinson, MR, Keating, GM. Dexmethylphenidate extended release in attention-deficit hyperactivity disorder. Drugs. 2006;66:661–668.CrossRefGoogle ScholarPubMed
13.Strattera, TM [package insert]. Indianapolis, IN: Eli Lilly and Company; 2002.Google Scholar
14.Michelson, D, Adler, L, Spencer, T, et al.Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry. 2003;53(2):112–120.CrossRefGoogle ScholarPubMed
15.Adler, LA, Spencer, TJ, Milton, DR, Moore, RJ, Michelson, D. Long-term, open-label study of the safety and efficacy of atomoxetine in adults with attention-deficit/hyperactivity disorder: an interim analysis. J Clin Psychiatry. 2005;66(3):294–299.CrossRefGoogle ScholarPubMed
16.Schubiner, H, Saules, KK, Arfken, CL, et al.Double-blind placebo-controlled trial of methylphenidate in the treatment of adult ADHD patients with comorbid cocaine dependence. Exp Clin Psychopharmacol. 2002;10(3):286–294.CrossRefGoogle ScholarPubMed
17.Riggs, PD, Hall, SK, Mikulich-Gebertson, SK, et al.A randomized controlled trial of pemoline for attention-deficit/hyperactivity disorder in substance-abusing adolescents. J Am Acad Child Adolesc Psychiatry. 2004;43(4):420–429.CrossRefGoogle ScholarPubMed
18.Gasior, M, Bergman, J, Kallman, MJ, Paronis, CA. Evaluation of the reinforcing effects of monoamine reuptake inhibitors under a concurrent schedule of food and i.v. drug delivery in rhesus monkeys. Neuropsychopharmacology. 2005;30(4):758–764.CrossRefGoogle Scholar
19.Jasinski, DR, Krishnan, S. Abuse liability of intravenous L-lysine-damphetamine (LDX). Presented at: The 68th Annual Meeting of the College on Problems of Drug Dependence; June 2006; Scottsdale, Arizona.Google Scholar
20.Abikoff, H, McGough, J, Vitiello, B, et al.Sequential pharmacotherapy for children with comorbid attention-deficit/hyperactivity and anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2005;44(5):418–427.CrossRefGoogle ScholarPubMed
21.Geller, D, Donnelly, C, Lopez, F, et al.Atomoxetine treatment for pediatric patients with attention-deficit/hyperactivity disorder with comorbid anxiety disorder. J Am Acad Child Adolesc Psychiatry. In Press.Google Scholar