Although we typically assign between-session homework, we expect patients to have difficulty completing it. We remain nonjudgmental and collaborative, viewing incomplete assignments as opportunities to learn about patients’ unproductive problem solving and to help them develop more-effective patterns.
Challenging maladaptive beliefs. A strong therapeutic relationship allows adults with ADHD to discuss their chronic frustrations, which often are associated with deep shame. We then shift CBT’s focus to deeper ADHD-related schemata that perpetuate dysfunctional patterns.
We work with patients to elucidate and challenge their maladaptive core beliefs and encourage new ways to view themselves and others. Allowing patients to grieve about the limitations ADHD imposes on their lives also helps to reduce chronic negative self-esteem.
Case continued: ‘less frenetic’
Mr. B achieves good results within 3 weeks of an increasing titration of stimulant medication, reporting significantly less restlessness and greater concentration without significant side effects. His wife confirms that he is less frenetic, can converse without interruptions, and is better at managing his complicated work schedule.
Which medications?
Drug therapy for adult ADHD is not as well-studied as in children and adolescents, but American Academy of Child and Adolescent Psychiatry guidelines and others15-18 recommend stimulant and nonstimulant medications. Your choice depends on the patient’s clinical profile (including risk factors and comorbid conditions), past medication use, treatment goals, preferred medication effects and dosing patterns (once-daily versus multiple times), and potential side effects. Stimulants or atomoxetine are first-line choices for adult ADHD without psychiatric comorbidity.
Stimulants work quickly and are cleared relatively rapidly from the brain without causing euphoria or dependency. They are effective (80% to 90% response rate) and well-tolerated, though long-term effects have not been studied in adults (Table 4).
Stimulants’ effect size of 0.9 is considered substantial. Effect size—a statistical method of reporting an intervention’s effect across different studies—is typically rated as:
- <0.32 very small
- 0.33 to 0.54, moderate
- >0.55, significant or very strong.
When choosing a medication, we usually try methylphenidate and amphetamine first, one after the other. We explain to the patient how stimulants work in the brain and the need for a comparative trial to determine which might work best for him or her. If the patient has tried a stimulant and found it helpful, we start with that class. Similarly, if he/she has not had good results with one type, we start with the other. Approximately one-third of our patients respond equally well to methylphenidate or amphetamine, one-third respond better to methylphenidate, and one-third respond better to amphetamine.
To determine the optimal dosage, we usually titrate up from 10 to 30 mg per dose of an immediate-release preparation. We begin with this form to help patients notice the medication’s onset and duration of action. After we find the optimal dosage, we switch to a longer-acting preparation.
Insomnia, mood instability, and euphoria are unacceptable stimulant side effects, although many patients welcome others such as appetite suppression and weight loss. Closely monitor cardiovascular effects, and review potential interactions with other medications, such as antihypertensives or bronchodilators. Because sudden death has been reported with stimulants in persons with structural cardiac lesions,19 obtain a cardiology consultation for patients with a history of heart disease.
We encourage patients to keep daily medication logs (Box), which we review at each visit and use to make dosing or medication changes. Dosing guidelines resemble those used for children and adolescents, although adults usually tolerate higher maximum dosages (such as methylphenidate, 80 to 100 mg/d).
Because of stimulants’ potential for recreational misuse and abuse, remain wary about choosing stimulants for patients with whom you lack a solid doctor-patient relationship.
Table 4
Stimulant dosages used in treating adult ADHD
| Class (brand name) | Daily dosing | Typical dosing schedule |
|---|---|---|
| Methylphenidate | ||
| Short-acting (Metadate, Ritadex, Ritalin) | Two to four times | 10 to 40 mg bid to qid |
| Intermediate-acting (Metadate SR, Ritalin SR) | Once or twice | 20 to 60 mg qd to bid |
| Extended-release (Concerta, Metadate CD, Ritalin LA) | Once or twice | 18 to 108 mg qd (Concerta) 20 to 40 mg bid (Ritalin LA, Metadate CD) |
| Dextromethylphenidate | ||
| Short-acting (Focalin) | Two to four times | 5 to 20 mg bid to qid |
| Long-acting (Focalin XR) | Once or twice | 10 to 20 mg qd or bid |
| Dextroamphetamine | ||
| Short-acting (Dexedrine) | Twice or three times | 10 to 30 mg bid or tid |
| Intermediate-acting (Dexedrine spansules) | Once or twice | 10 to 30 mg bid |
| Mixed amphetamine salts | ||
| Intermediate-acting (Adderall) | Once or twice | 10 to 30 mg bid or tid |
| Extended-release (Adderall XR) | Once or twice | 10 to 40 mg qd or bid |
Atomoxetine, a nonstimulant, norepinephrine re-uptake inhibitor, is approved for ADHD in adults.20-22 In two double-blind, controlled, randomized trials totalling 536 adults, Michaelson et al20 found significantly reduced ADHD symptoms after 10 weeks of atomoxetine treatment. Effect sizes of 0.35 and 0.40 were reported, with 10% of patients discontinuing because of side effects.