Evidence-Based Reviews

Adult with ADHD? Try medication + psychotherapy

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References

Atomoxetine has a long duration of action (>12 hours) but a more gradual onset (4 to 6 weeks) than that of stimulants. Approximately 60% of patients respond to atomoxetine, though effect sizes are less than those of stimulants. We have found atomoxetine works well for patients who:

  • do not tolerate or are uncomfortable with taking stimulants
  • are highly anxious
  • report emotional dysregulation as a major target symptom.

To reduce risk of common side effects (nausea, GI upset, headache, sedation, reduced sex drive), we start with low dosages (such as 25 mg bid) and increase weekly by 25 mg to a target of 80 to 100 mg/d.

Treating complicated ADHD

Bupropion or tricyclic antidepressants are reasonable options for ADHD with depression. Atomoxetine, a tricyclic, or a stimulant plus a selective serotonin reuptake inhibitor (SSRI) can provide good symptom relief for adults with ADHD and comorbid anxiety and/or depression.

Bupropion. Approximately 50% of adults with ADHD respond to bupropion,23,24 with a treatment effect size of 0.6. Bupropion’s efficacy in smoking cessation adds value for those trying to quit.

We usually start extended-release bupropion at 150 mg/d and increase after 2 weeks to 300 mg/d if response is suboptimal. Headache, dry mouth, insomnia, and nausea are the most common adverse effects. Agitation or irritability is sometimes serious enough to warrant stopping bupropion.

Combining medications. Using SSRIs with stimulants can help adults with ADHD and comorbid anxiety or depression. Any SSRI can be safely combined with stimulants, though we tend to pick:

  • more-sedating agents such as paroxetine or sertraline when patients report difficulty with insomnia or overactivation
  • less-sedating compounds such as fluoxetine or citalopram when patients complain of being too tired or underactive.

When patients taking SSRIs seek help for ADHD, adding a stimulant usually reduces inattention, distractibility, impulsivity, and/or subjective feelings of restlessness. We prescribe usual dosages because stimulants and SSRIs do not interact. We have not seen serious side effects, but some patients report feeling oversedated.

Tricyclics. We use tricyclics when a stimulant/SSRI combination does not relieve symptoms satisfactorily or a patient complains of side effects. We usually have good results with desipramine or imipramine, 150 to 300 mg/d, or nortriptyline, 50 to 150 mg/d. Spencer et al have reported a response rate of 68% with nortriptyline or desipramine in a retrospective chart review25 and a prospective placebo-controlled trial26 of adults with ADHD.

Case continued: Closer to dream job

After 6 months of combined treatment, Mr. B reports much-improved ADHD symptoms, with minimal stimulant-related side effects. He has made some realistic plans for computer programming school and is taking preliminary courses. Keeping a schedule book has reduced his tardiness and tendency to procrastinate.

He is more comfortable in the classroom and better able to challenge self-critical thinking. When routine difficulties arise, he is using more-adaptive coping strategies. To maintain gains achieved in therapy, he chooses to continue periodic CBT booster sessions.

Long-term treatment

Even with medication and CBT, patients may require referral for organizational coaching, academic counseling, school or workplace accommodations, vocational counseling, cognitive remediation, group therapy, or social skills classes. You can help them obtain quality adjunctive care by collaborating with professionals who offer these services.

No studies have examined long-term care of adults with ADHD. In our experience, ongoing medication and intermittent therapy can sustain symptom control and coping skills for years. Most patients are initially skeptical about staying on medication, but after they experience the benefits most seem willing to continue as long as the medication helps.

Most of our patients sustain changes in thinking, feeling, and behaving that they learn through BT. They may seek additional sessions to meet a challenge, such as a new job or starting a family.

Related resources

Books

  • Kolberg J, Nadeau K. ADD-friendly ways to organize your life. New York: Brunner-Routledge; 2002.
  • Hallowell EM, Ratey JJ. Driven to distraction. New York: Touchstone; 1994.
  • Hallowell E, Ratey J. Delivered from distraction. New York: Ballantine Books; 2005.

Organizations

  • Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on AD/HD. www.chadd.org.
  • Attention Deficit Disorder Association (ADDA). Resources and membership organization for adults with ADHD. www.add.org.

Drug brand names

  • Amphetamine • Adderall, Dexedrine
  • Atomoxetine • Strattera
  • Bupropion • Wellbutrin
  • Desipramine • Norpramin
  • Imipramine • Tofranil
  • Methylphenidate • Concerta, Focalin, Metadate, Ritalin
  • Nortriptyline • Aventyl, Pamelor

Disclosures

Dr. Rostain is a consultant to Shire Pharamaceuticals Group and a speaker for Eli Lilly & Co. and Ortho-McNeil Pharmaceutical

Dr. Ramsay reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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