Evidence-Based Reviews

ADHD in adults: Matching therapies with patients’ needs

Current Psychiatry. 2008 September;7(9):51-62

References

1. Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med 2005;35:245-56.

2. Faraone SV, Biederman J, Spencer TJ, Aleardi M. Comparing the efficacy of medications for ADHD using meta-analysis. MedGenMed 2006;8(4):4.-

3. Greenhill L, Pliszka S, Dulcan M, et al. Summary of the practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry 2001;40(11):1352-5.

4. Faraone SV, Spencer T, Aleardi M, et al. Meta-analysis of the efficacy of methylphenidate for treating adult attention-deficit/hyperactivity disorder. J Clin Psychopharmacol 2004;24:24-9.

5. Adler LA, Spencer TJ, Williams DW, et al. Long-term, open-label safety and efficacy of atomoxetine in adults with ADHD: final report of a 4-year study. J Atten Disord Epub 2008 April 30.

6. Nissen SE. ADHD drugs and cardiovascular risk. N Engl J Med 2006;354:1445-8.

7. American Academy of Pediatrics/American Heart Association clarification of statement on cardiovascular evaluation and monitoring of children and adolescents with heart disease receiving medications for ADHD May 16, 2008. Available at: http://www.aap.org/pressroom/aap-ahastatement.htm. Accessed August 14, 2008.

8. 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(9):829-35.

9. Biederman J, Mick E, Surman C, et al. Comparative acute efficacy and tolerability of OROS and immediate release formulations of methylphenidate in the treatment of adults with attention-deficit/hyperactivity disorder. BMC Psychiatry 2007;7:49.-

10. Mick E, Spencer TJ, Surman C, et al. Randomized single-blind substitution study of methylphenidate in ADHD adults receiving immediate-release methylphenidate. NR357. Poster presented at: Annual Meeting of the American Psychiatric Association; May 19-24, 2007; San Diego, CA.

11. Capone N, McDonnel T. Medication persistence among agents used to treat attention-deficit/hyperactivity disorder, diabetes, and elevated serum cholesterol. NR 639. Poster presented at: Annual Meeting of the American Psychiatric Association; May 20-25, 2006; Toronto, Ontario, Canada.

12. Adler L, Morrill M, Reingold B. d-methylphenidate augmentation of extended-release stimulant therapy in ADHD. NR 619. Poster presented at: Annual Meeting of the American Psychiatric Association; May 20-25, 2006; Toronto, Ontario, Canada.

13. Adler L, Reingold LS, Morrill MS, Wilens TE. Combination pharmacotherapy for adult ADHD. Curr Psychiatry Rep 2006;8:409-15.

14. Biederman J, Monuteaux MC, Spencer T, et al. Stimulant therapy and risk for subsequent substance use disorders in male adults with ADHD: a naturalistic controlled 10-year follow-up study. Am J Psychiatry 2008;165:597-603.

15. Faraone SV, Wilens TE. Effect of stimulant medications for attention-deficit/hyperactivity disorder on later substance use and the potential for stimulant misuse, abuse, and diversion. J Clin Psychiatry 2007;68(suppl 11):15-22.

16. Wilens TE, Adler LA, Weiss MD, et al. Atomoxetine treatment of adults with ADHD and comorbid alcohol use disorders. Drug Alcohol Depend 2008;96:145-54.

Mr. Z does not meet DSM-IV-TR criteria for major depressive disorder or alcohol abuse/dependence. His depressed mood appears to be linked to his marked ADHD symptoms. Mr. Z agrees to a new treatment plan that includes starting atomoxetine at 25 mg to allow for flexible titration and psychotherapy to monitor his mood and achieve sobriety.

ADHD and substance abuse

Clinical judgment determines whether an adult with ADHD and a history of substance use disorders may safely benefit from treatment with a stimulant. The relationship between ADHD and substance use disorders is of clinical concern, but ADHD medications have not been shown to increase risk for later substance use disorders in children.¹⁴ Conversely, effective ADHD treatment appears to reduce later cigarette and substance use.¹⁵

Consider using a nonstimulant-class medication in adults with ADHD and active substance use disorders. In a 12-week, double-blind, controlled trial, atomoxetine improved ADHD symptoms significantly more than placebo in adults meeting DS-MIV-TR criteria for comorbid alcohol use disorders. After 4 to 30 days of alcohol abstinence, 72 patients were randomly assigned to atomoxetine, 25 to 100 mg/d (mean final dose 90 mg/d), and 75 patients to placebo. Although estimated times to initial relapse to heavy drinking did not differ:

atomoxetine-treated subjects had 26% fewer cumulative heavy drinking days than placebo-treated subjects (P=0.023)
the difference in cumulative heavy drinking days between the atomoxetine and placebo groups became statistically significant after 55 days of treatment.¹⁶

Related resources

World Health Organization Adult Self-Report Scale (ASRS) 18-item instrument and 6-item screener. www.med.nyu.edu/psych/psychiatrist/adhd.html.
Volkow ND, Swanson JM. Does childhood treatment of ADHD with stimulant medication affect substance abuse in adulthood? Am J Psychiatry 2008;165:553-5.
Adler LA, Spencer TJ, Levine LR, et al. Functional outcomes in the treatment of adults with ADHD. J Atten Disord 2008; 11:720-7.

Drug brand names

Atomoxetine • Strattera
Bupropion • Wellbutrin
Extended-release mixed amphetamine • Adderall XR
Extended duration OROS methylphenidate • Concerta
Extended-release dexmethylphenidate • Focalin XR
Lisdexamfetamine • Vyvanse
Modafinil • Provigil

Disclosure

Dr. Hammerness has received research support from and is on the speakers bureau for Shire Pharmaceuticals. He has received support for CME activities and talks from Shire Pharmaceuticals, Ortho-McNeil, and Abbott Laboratories.

Dr. Surman receives research support and/or is a speaker for Abbott Laboratories, Cephalon, Eli Lilly and Company, Janssen, Ortho-McNeil, Merck, New River Pharmaceuticals, Novartis, Pfizer Inc., Shire Pharmaceuticals, and Takeda Pharmaceutical Company.

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

Acknowledgement

Clinical research assistant Katherine Miller, BA, contributed to the literature review for this article and assisted in preparing the manuscript.