ADULT ADHDdiagnoses and Medication Treatment

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ADULT ADHD-diagnoses and Medication Treatment
www.adhdclinicjeeva.com
DR SHABEER JEEVA SPECIALIST PSYCHIATRIST
MELROSE ARCH 684 1621

DD
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CADDRA 2006

• CADDRA 2006 RecommendationsCanadian ADHD
  Resource AllianceCAP-GUIDELINES

• Handouts-medication-CADDRA
• Slides /notes/movies repeat
• Rating scales- ADULT ADHD
• Website-www.adhdclinicjeeva.com
• Talk on drug treatment only
• Drug names generic used
• Adhd/add interchangebly used

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DENIS THE MENACE
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ADULT ADHD IN SOUTH AFRICA

• Psychiatrists,GPs, psychologists,teachers,spouses,
  parents,
• PROBLEM---- - MISDIAGNOSES AND RESISTENCE TO
  TREAT WITH DRUGS
• ADHD-diagnoses esp.inattentive type
• -girls gtboys,-later or not diagnosed
• 60-70 child adhd go onto adulthood
• predicament
• -compensation-substance abuse,work
  exercise,success
• -84 of adult adhd has Co-morbidity-antisocial
  personality, bipolar, -depression,anxiety,substanc
  e abuse
• -therefore Rx polypharmacy
• Problems
• 1.adultexistence/different symptoms
• 3.Co-morbidity vs Simple Adult adhd
• 2.Stuck on IR Ritalin usage
• -Fear of long-acting stimulants

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ATTENTION DEFICIT HYPERACTIVITY DISORDER-ADULT

• INATTENTION IMPULSIVITY
• (Distractible) (Act before thinking)
• A.D.H.D.
• )
• 
  Hyperactivity
• 
  -(optional
• TYPES
• 1.INATTENTIVE-TYPE-
  girlsgtboys-------worse -inattentive
• 2.HYPERACTIVE-IMPULSIVE boysgtgirls---------improv
  e
• 3.COMBINED TYPE
  -boysgt.girls--------inattentive

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Age-Dependent Decline of ADHD Symptoms


6

Inattention
Syndromatic Criteria
5
Impulsivity
4

Mean No. Symptoms
Functional Impairments
3
Hyperactivity
2
1
b 0.25 (0.35, 0.15)
0
lt6
6-8
9-11
12-14
15-17
18-20
Age (y)
Biederman J et al. Am J Psychiatry. 2000157
816-818.
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Inattention Drives Presentationof ADHD in Adults
90
N149
Plt.05
45
Affected
Hyperactive/ Impulsive
Inattentive
Endorsed Symptom Clusters
Millstein R et al. J Atten Disord. 19972159-166.
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CO-MORBIDITY
1.reading 2.writing/spelling 3.math,etc
1.inattention 2.Impulsivity 3.hyperactivity
S.L.D
ADHD
50
C.D.
O.D.D.
50
1.lying 2.stealing,firesetting 3.drugs,alcohol,pro
stitution
70
See next
ADHD ADULT90 C0-MORBID
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ADHD and Comorbid Disorders in Children

• Oppositional defiant disorder (ODD)
• Negativistic, Hostile, and defiant pattern of
  behavior
• Often loses temper
• Often argues with adults
• Often actively defies or refuses to comply with
  requests or rules of adults
• Often deliberately annoys people
• Often blames others for his/her mistakes or
  behavior
• Often touchy or easily annoyed by others
• Often angry and resentful
• Often spiteful or vindictive

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Symptoms of Hyperactivity Often Manifest
Differently in Adults
Hyperactivity often changes to inner restlessness

• DSM-IV Symptom Domain
• Squirms and fidgets
• Cant stay seated
• Runs/climbs excessively
• Cant play/work quietly
• On the go/driven by motor
• Talks excessively

• Common Adult Manifestation
• Workaholic
• Overscheduled/ overwhelmed
• Self-selects a very active job
• Constant activity leading to family tension
• Talks excessively

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Symptoms of Impulsivity Often Manifest
Differently in Adults
Impulsivity in adulthood often carries more
serious consequences

• DSM-IV Symptom Domain
• Blurts out answers
• Cant wait turn
• Intrudes/interrupts others

• Common Adult Manifestation
• Low frustration tolerance
• Losing temper
• Quitting jobs
• Ending relationships
• Driving too fast
• Addictive personality

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Symptoms of Inattention Often Manifest
Differently in Adults

• Common Adult Manifestation
• Difficulty sustaining attention
• Meetings, reading, paperwork
• Paralyzing procrastination
• Slow, inefficient
• Poor time management
• Disorganized
• Poor financial management

• DSM-IV Symptom Domain
• Difficulty sustaining attention
• Doesnt listen
• No follow-through
• Cant organize
• Loses important things
• Easily distractible, forgetful

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ADHD in childhood as adults

• Many adults who had ADHD in childhood continue to
  have16
• Stuttering, speech and language disorders
• Anxiety disorders
• Restlessness
• High impulsivity (e.g. more car accidents, move
  house more often)
• Interpersonal problems and sexual problems (many
  divorced or separated)
• Higher rates of antisocial personality disorders
  (e.g. conduct disorder)
• Substance abuse (particularly with co-existing
  conduct and antisocial disorders)

1 Seidman LJ et al. Biol Psychiatry
199844260268 2 Biederman J et al. Am J
Psychiatry 199315017921798 3 Gittelman R et
al. Arch Gen Psychiatry 198542937947 4 Weiss
G et al. J Am Acad Child Psychiatry
198524(2)211220 5 Elia J et al. N Engl J Med
1999340(10)780788 6 Reviewed in Mannuzza S
Klein RG. Child Adolesc Psychiatr Clinics N Am
20009(3)711726.
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Famous People with Attention Deficit and
Learning Disorders

• Albert Einstein
• Thomas Edison
• Gen. George Patton
• John F. Kennedy
• Bruce Jenner
• Eddie Rickenbacker
• Harry Belafonte
• Walt Disney
• Steve McQueen
• George C. Scott
• Tom Smothers
• Suzanne Somers
• Jules Verne
• Magic Johnson
• Carl Lewis

• Nelson Rockefeller
• Sylvester Stallone
• Cher
• Gen. Westmoreland
• Charles Schwab
• Danny Glover
• John Lennon
• Greg Louganis
• Winston Churchill
• Henry Ford
• Robert Kennedy
• George Bernard Shaw
• Beethoven
• Hans Christian Anderson

• Leonardo da Vinci
• Whoppi Goldberg
• Tom Cruise
• Henry Winkler
• F. Galileo
• Mozart Scott Fitzgerald
• Robin Williams
• Louis Pasteur
• Werner von Braun
• Dwight D. Eisenhower
• Lindsay Wagner
• Alexander Graham Bell
• Woodrow Wilson

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Prevalence and Genetics of ADHD

• 6-8 of children 3-5 of adults
• Male-Female 61, 31, 11
• All levels of IQ
• All levels of socioeconomic status
• Family genetic transmission 0.91
• Inheritance not specific to subtype

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Twin Studies Show ADHD Is a Genetic Disorder
Height
Asthma
Schizophrenia
Breast cancer
Hudziak, 2000
Nadder, 1998
Levy, 1997
Sherman, 1997
Silberg, 1996
Gjone, 1996
Thapar, 1995
Schmitz, 1995
Edelbrock, 1992
Gillis, 1992
Goodman, 1989
Willerman, 1973
Average genetic contribution of ADHD based on
twin studies
ADHD Mean
Faraone. J Am Acad Child Adolesc Psychiatry.
2000391455-1457. Hemminki. Mutat Res.
20012511-21.Palmer. Eur Resp J.
200117696-702.
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Clinical Presentation

• Multiple mental health consultations
• Multiple jobs
• Stormy relationships
• Trouble with authority figuresarrest record
• Family history of bipolar disorder,substance
  abuse, or Tourette syndrome
• Family history of ADHD
• Performance and mood determinedby interest and
  challenge

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Office Presentation

• Patients with ADHD

• Are forgetful or airheads
• Miss appointments or arrive late
• Lose prescriptions
• Do not carry out instructions or the treatment
  plan
• Are hypertalkative
• Are passionate or have emotional storms
  triggered by events

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Comorbid Psychiatric Disturbances Are Common in
Adults With ADHD
Antisocial Disorder (10) Major Depressive
Disorder (35) Bipolar Disorder (15) Anxiety
Disorders (40) Substance Abuse Disorders (50)
Shekim WO et al. Compr Psychiatry.
199031416-425. Biederman J et al. Am J
Psychiatry. 19931501792-1798.
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TARGET SYMPTOMS--MAIN

• 1 Problems concentrating
• 2 Impulsiveness
• 3.Anger control
• 4.Anxiety
• 5.Depression
• 6.Not meeting ones potential
• 7.Poor organizational skills
• 8.Learning problems
• 9.Procrastination
• 10.Other

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EXECUTIVE FUNCTIONS

• 1 Relationship with self----self-esteem
• 2 Relationship with loved ones
• 3 Relationship with authority figures
• 4 Time management
• 5 Organizational skills
• 6 Financial management

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ADHD in childhood as adults

• Many adults who had ADHD in childhood continue to
  have16
• Stuttering, speech and language disorders
• Anxiety disorders
• Restlessness
• High impulsivity (e.g. more car accidents, move
  house more often)
• Interpersonal problems and sexual problems (many
  divorced or separated)
• Higher rates of antisocial personality disorders
  (e.g. conduct disorder)
• Substance abuse (particularly with co-existing
  conduct and antisocial disorders)

1 Seidman LJ et al. Biol Psychiatry
199844260268 2 Biederman J et al. Am J
Psychiatry 199315017921798 3 Gittelman R et
al. Arch Gen Psychiatry 198542937947 4 Weiss
G et al. J Am Acad Child Psychiatry
198524(2)211220 5 Elia J et al. N Engl J Med
1999340(10)780788 6 Reviewed in Mannuzza S
Klein RG. Child Adolesc Psychiatr Clinics N Am
20009(3)711726.
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Sound of Music
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ADHD Clinical Presentation Adulthood

• Inattention/concentration problems
• Disorganized, fails to plan ahead
• Forgetful, loses things
• Difficulty in initiating and finishing projects
  or tasks
• Shifts activities prematurely
• Misjudges available time
• May have job instability and marital difficulties

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Sexual Behavior

• Longitudinal follow-up at young adulthood of a
  cohort of children (ongoing Milwaukee follow-up
  study) with ADHD compared to controls
• Sexual intercourse at earlier age (15 vs 16
  years)
• More sexual partners (19 vs 7)
• More pregnancies (38 vs 4)
• More sexually transmitted diseases (17 vs 4)
• Tested for HIV (54 vs 21)

Barkley. ADHD A Handbook for Diagnosis and
Treatment. New York Guilford Press 1998209.
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Chaotic Personal Family Routines

• Trouble organizing and maintaining home
• Poor housekeeping
• Poor financial management
• Impulsive, little oversight
• Poor health consciousness/habits
• Poor diet
• Little or no exercise
• Smoking, drinking
• Riskier sexual lifestyle
• disease/more partners/unwanted pregnancies

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Poor Interpersonal Skills

• Trouble making friends
• Marital problems
• Impulsive comments
• Quick to anger
• Verbally abusive
• Poor follow-through
• Perceived as immature
• Failure to appreciate others needs
• Poor listening
• Trouble sustaining friends

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Diagnosis of ADHD in Adults DSM-IV Symptoms of
Hyperactivity/Impulsivity
Adults with ADHD very often1

• Are unable to stay seated
• Fidget
• Move excessively (internal restlessness)
• Are on the go
• Talk excessively
• Blurt out answers
• Have difficulty waiting turns (impatience)
• Interrupt or intrude
• Set up rigid schedules
• Pursue areas of interest with extreme zeal
• Seek careers/situations with controllable stimuli
• Make use of organizational tools
• Impose own time outs during stimulus overload
  situations (take walks/disappear)

Efforts toward compensation are an important
diagnostic indication

1American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. 4th ed,
text rev. 2000.
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ADHD Motor Vehicle Driving

• In computer stimulated driving tests, ADHD
  drivers had more
• Citations for speeding
• Crashes
• Scrapes
• Erratic steering
• On checks of official driving records the ADHD
  group had more
• Citations for speeding
• License suspensions
• Crashes (including more causing bodily injury)

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ADHD Impact on Family

• Divorce
• Marital discord
• Marital dissatisfaction
• Parenting difficulties

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Mrs. Doubtfire
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FROG TO PRINCESS
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Holistic Interventions

• The medications are there to facilitate the other
  interventions
• Behavioral
• Psychological
• School- Educational
• Social

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Treatment at different ages

• a) Age 1-6-------------------------watch
• b) Age 712------------stimulants/straterra
• c) Age 13----18---stimulants/straterra-- ??anti
  depressants
• d) Age 18yrs-----antidepressants
• stimulants/straterra
• -

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ADHD Treatment Algorithm
Pliszka et al. J Am Acad Child Adolesc Psychiatry
200645642-657.
37
ADHD Anxiety
Pliszka et al. J Am Acad Child Adolesc Psychiatry
200645642-657.
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ADHD Depression
Pliszka et al. J Am Acad Child Adolesc Psychiatry
200645642-657.
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ADHD Aggression
Partial or non-response aggression
Pliszka et al. J Am Acad Child Adolesc Psychiatry
200645642-657.
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Medical Treatment Algorithm for ADHD

• Establish ADHD and relevant co-morbidities

• Is the medication indicated in your age group?
  Off label is widely done..
• Family member on a specific medication? Yes try
  again
• Do you have a drug plan? No second line
  medications
• Are you in an urgent situation for treatment? Yes
  Concerta / Ritalin L A
• Cant swallow pills? Yes Ritalin L A
• Do you have compensatory anxiety? Compensatory
  Concerta / Ritalin L A
• Primary anxiety or tics? Yes Strattera
• Need for more continuous effect past 6 pm? Yes
  Strattera

• CO-MORBIDITY---ANTISOCIAL,DEPRESSION,BIPOLAR,
• ANXIETY DIS.,SUBSTANCE-ABUSE DISORDER,AGGRESSION

• Combination Treatments
• ATX Concerta /Ritalin L A?
• Concerta /Ritalin L A I.R. prep.
• Welbutrin,SNRI.SSRI,TCA,Epilim,
• Resperidone, Provigil,clonidine

CADDRA
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Primary NeurotransmitterEffects of Adhd
medication

• NE 5-HT DA
• RITALIN
  
• Welbutrin SR ? ?
• STRATERRA ?
• SNRI-all
  
• TCAs
  
• SSRI-all ?

Richelson E. J Clin Psychiatry 199455 Suppl
A34 Stahl S. Essential Psychopharmacology, 2000
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Pharmacotherapy in Adults

• Stimulants
• Methylphenidate-Ritalin
• Long acting stimulants -Ritalin-SR.Ritalin-L.A,Con
  certa,Adderal XR
• Atomoxetine (FDA-approved in adults)-Straterra
• Antidepressants
• Bupropion-Welbutrin SR
• SSRI/SNRI
• Tricyclics
• Other
• - Mood Stabilizers Valproic Acid/Lithium
• - Atypical Antipsychotics Resperidone
• - Clonidine
• Research
• Modafinil (Provigil)

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Behavioural Half-life of New Stimulant
Medications for ADHD
MPH IR/D-AMPH MPH SR Mixed AMPH salts OROS MPH
Response
Therapeutic Effect
Hours 0 2 4
6 8 10
12
Spencer et al, 2000
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CADDRA 2006 RecommendationsCanadian ADHD
Resource AllianceCAP-GUIDELINES

• Long acting agents will be first line
• Across the lifespan but particularly for
  adolescents and adults
• Short acting agents will be considered adjuvant
  treatments in the first line
• RITALIN-IRcan and should be used freely with
  long acting agents,welbutrin, SNRI,TCA.SSRIs,

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The CONCERTA Formulation5

• Advanced OROS delivery provides an initial dose
  within 1 hour and controlled release of
  methylphenidate over 12 hours 1-4

Release of Methylphenidate from a Concerta 18-mg
tablet 5
Reference 5. Data on file, Janssen-Ortho Inc.
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Side Effects in Stimulant Studies
Side effects for the 2 molecules are similar

• Dry mouth
• Insomnia
• Appetite suppression
• Headache
• Edginess
• Cardiovascular (not clinically significant)
• BP increased 2-4 mmHg
• HR increased 2-4 bpm

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Stimulant Dosing

• No parameter predicts optimal stimulant dosage
• Not weight
• Not age
• Not sex
• Not scale scores

Each person must have a dosage titrated
according to individual need and medication
duration of action
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Does the Pharmacotherapy of ADHD Beget Later
Substance Abuse?A Meta-Analytic Review of the
Literature

• Results

Meta-analysis of the effects of stimulant
treatment on children on later substance abuse in
adolescent and young adult years shows that
stimulant pharmacotherapy for ADHD significantly
decreases the risk for subsequent SUD
Stimulants REDUCE the risk for substance abuse by
1/2
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IMPULSIVITY
IMPULSIVITY-----------------INATTENTION
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GUIDELINES

• 1.adhd simple------stimulants/straterra
• 2.tics/tourettes -anxiety------straterra
• 3.Aggressive beh.urgency---stimulants
• 4.Adhd mood dis.------welbutrin/SNRI
• 5.adhd/mood/ primary anxiety---stim.SSRI

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MEDICAL TREATMENT FOR ADHD simple-1st line

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MEDICAL TREATMENT FOR ADHD 2nd line
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MEDICAL TREATMENT FOR ADHD-3rd line agentsCADDRA
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Study of Wellbutrin SR in Adult ADHD
ADHD Clinical Global Impression
60
50
Plt.02
40
Improved at Endpoint
30
20
10
6-wk
0
Wellbutrin SR
200 mg SR bid
Wilens T et al. Am J Psychiatry. 1996.
57
WELLBUTRIN SR - summary

• The first aminoketone (NDRI) antidepressant1
• As effective as other antidepressants2,3,4
• Improved sexual functioning vs. SSRIs6,7
• Not commonly associated with weight gain8
• Not associated with sedation1,2,3,7,9,10
• Safe when used in recommended therapeutic doses12

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When to Use StratteraPatient Characteristics

• No need for urgent response in severe cases
• Pre-existing bedtime/morning problems
• New cases that are fussy eaters or pre-existing
  eating problems
• Adolescents or college students where concern is
  recreational misuse or diversion
• Prior history of drug dependence or abuse
• Comorbid tic disorders
• Comorbid anxiety
• Comorbid enuresis

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Indications for Atomoxetine

• Patients who require symptom-control during the
  day and evenings
• Patients not responsive to stimulants
• Patients with significant side effects to
  stimulants (e.g., rebound, tics)
• Patients with Tourettes Syndrome or chronic
  motor tic disorders
• Epilepsy
• Comorbid Anxiety

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More on Strattera

• Reduces ADHD, ODD, aggression
• Reduces anxiety symptoms (effect size -0.5)
• Increases in school productivity
• Improved peer social behavior
• Improved self-esteem
• Improved parent-child relations
• Improved dry nights among bed-wetters
• Better morning after behavior
• Less insomnia (7) than methylphenidate (30-50)
  Faster time to sleep onset
• No emotional blunting restriction of range

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Side Effects in Adults
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ADHD Pharmacotherapy Responsiveness
Methylphenidate
Amphetamine
Atomoxetine
Bupropion
MAOI
Clonidine
Guanfacine
100
80
60
0
40
20
Responders
Wilens, T., Spencer, T., Postered at MGH Child
Adolescent Psychopharmacology Meeting, Boston
2000 Wilens, T., CNS News, 2003
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Is It ADHD?
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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom
Checklist

• Never
• Rarely
• Sometimes
• Often
• Very Often
• Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom
  Checklist
• Please answer the questions below, rating
  yourself on each of the criteria shown using the
• scale on the right side of the page. As you
  answer each question, place an X in the box that
• best describes how you have felt and conducted
  yourself over the past 6 months. Please give
• this completed checklist to your healthcare
  professional to discuss during todays
• appointment.
• Patient Name Todays Date

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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom
Checklist

• 1. How often do you have trouble wrapping up the
  final details of a project,
• once the challenging parts have been done?
• 2. How often do you have difficulty getting
  things in order when you have to do
• a task that requires organization?
• 3. How often do you have problems remembering
  appointments or obligations?
• 4.
• 5. How often do you fidget or squirm with your
  hands or feet when you have
• to sit down for a long time?
• 6. How often do you feel overly active and
  compelled to do things, like you
• were driven by a motor?

67
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom
Checklist

• 7. How often do you make careless mistakes when
  you have to work on a boring or
• difficult project?
• 8. How often do you have difficulty keeping your
  attention when you are doing boring
• or repetitive work?
• 9. How often do you have difficulty concentrating
  on what people say to you,
• even when they are speaking to you directly?
• 10. How often do you misplace or have difficulty
  finding things at home or at work?
• 11. How often are you distracted by activity or
  noise around you?
• 12. How often do you leave your seat in meetings
  or other situations in which
• you are expected to remain seated?
• 13. How often do you feel restless or fidgety?
• 14. How often do you have difficulty unwinding
  and relaxing when you have time
• to yourself?

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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom
Checklist

• 15. How often do you find yourself talking too
  much when you are in social situations?
• 16. When youre in a conversation, how often do
  you find yourself finishing
• the sentences of the people you are talking to,
  before they can finish
• them themselves?
• 17. How often do you have difficulty waiting your
  turn in situations when
• turn taking is required?
• 18. How often do you interrupt others when they
  are busy?
• Part B
• Part A
• When you have a task that requires a lot of
  thought, how often do you avoid
• or delay getting started?

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Structuring Treatment for Adults with ADHD

• Avoid unstructured psychotherapy sessions
• Offer personalized education about ADHD and
  comorbidities
• Monitor medication compliance response
• Identify successes and problem priorities
• Help pt specify reasonable goals for change
• Monitor progress obstacles to change
• Encourage positive efforts of patients