ADHD in Adults: Pearls for the Non-Psychiatrist Diane C. Reis, MD, MPH IU Health Arnett dreis@iuhealth.org 1/29/2018

Disclosures I have no relevant financial conflicts of interest to disclose. I have not participated in any industry-sponsored events. 1/29/2018

ADHD in Adults DSM V criteria Brief history and “high yield” points Differential diagnosis and common co-morbidities Who to manage, who to refer? Management Sample cases

ADHD Basics Well studied and well established diagnosis with clear neurobiological basis Significant genetic component, heritability of approximately 75% Dysregulation of dopamine and prefrontal cortex (attention, inhibition, decision-making, response inhibition, working memory, vigilance) Boys > girls (2:1-9:1) Comorbidities are common

ADHD: Brain & Environment at Odds 1/29/2018

ADHD Diagnosis 5-8% of school aged children meet criteria 60-85% of these continue to do so in adolescence 60% meet criteria into adulthood Approx 2.5% of adults meet criteria for ADHD First degree relative confers RR of 2x-8x Hyperactivity often wanes but inattention and impulsivity persist (and impair function)

ADHD in the DSM V - Inattention 5 or more for >6 months: Fails to give attention to detail or makes careless mistakes Difficulty sustaining attention in tasks or play Does not listen when spoken to directly Does not follow through on instructions, fails to finish work/chores/duties (loses focus, distracted) Trouble organizing tasks & activities Avoids/dislikes tasks that require sustained mental effort Often loses things necessary for tasks or activities Easily distracted (including by unrelated thoughts) Often forgetful in daily activities (calls, bills, appointments)

ADHD in the DSM V – Hyperactivity/Impulsivity 5 or more for >6 months: Fidgets, taps, squirms frequently Leaves seat or situations when remaining seated is expected Runs or climbs or feels restless when not appropriate Unable to play or engage in leisure activities quietly “On the go”, unable/uncomfortable being still for extended period (restaurants, meetings) Often talks excessively Blurts out answer before question is complete Trouble waiting his or her turn Interrupts or intrudes on others (conversations, tasks)

ADHD in the DSM V In addition, following must be true: Several symptoms present by age 12 (note, does not have to be diagnosed by age 12) Several symptoms present in 2+ settings Clear evidence of impaired function Not better explained by another mental disorder

ADHD Diagnosis: High-yield Details Impairment in social or interpersonal relationships (inattention or impulsivity) Severity of workplace impairment (has lost multiple jobs or failed/failing out of school) Willing to offer collateral (parent, significant other, manager/boss) History of neuropsych testing, IEP or other school accommodations Symptom onset during childhood (even if impairment was sub-clinical) Goals, expectations, and experiences with treatment

ADHD Diagnosis: High-yield Details Impairment in social or interpersonal relationships (inattention or impulsivity) Patients (including those with ill intent) are aware of the school/work impact of ADHD Fewer are aware of the impact of ADHD on other functional domains History often includes failed significant personal relationships Patient may present at behest of spouse

ADHD Diagnosis: High-yield Details Severity of workplace impairment May have lost or be on the brink of losing job May show pattern of dropping or failing out of school repeatedly Threat of demotion or job loss may be the proximal cause for patient presenting to clinic

ADHD Diagnosis: High-yield Details Willing to offer collateral Can be parent, spouse, boss, current or former teacher, etc. Can provide information on performance and relationships History of neuropsych testing, IEP or other school accommodations Symptom onset during childhood (even if impairment was sub-clinical)

ADHD Diagnosis: High-yield Details Goals, expectations, and experiences with treatment “Helps me stay up and study late.” “My wife is going to divorce me if I don’t get back on medication.” “I feel kind of flat or sleepy but I do a lot better at work.” “I tried one of my son’s and I felt great!” “I’m really unmotivated unless I take my Adderall.”

The ASRS: A Useful Screening Tool

ADHD Differential Diagnosis Many psychiatric (and life!) conditions include difficulty with attention, concentration or decision-making Depression, mania, anxiety (accompanied by other symptoms) Transient stress, loss, or grief (course and duration of symptoms) Dementias (onset and insight) Substance abuse or withdrawal (tox screen, history) Malingering (this is not a disease, this is a behavior)

ADHD: Detecting Malingering “I took a friend’s Adderall and I was, like, super energetic and motivated.” A good clinician will not be right 100% of the time (nor will neuropsych testing) Obtain collateral information Check a urine drug screen Clarify expectations and experiences streetrx.com: $3.33 for 10 mg Adderall Lost prescriptions, lost weight, early refills Note: ADHD increases risk of substance abuse but stimulant treatment has not been shown to do so!

Who to manage in primary care Clear diagnosis No psychiatric co-morbidities OR co-morbidities are well controlled No history of serious substance misuse (particularly no meth/uppers) Stable regimen or only minor adjustment (e.g. addition of PM dose when a patient goes from part time to full time work)

A side note on marijuana… Evidence: marijuana use impedes the clinical benefit of psychostimulant treatment Struggles with motivation and productivity are common amongst regular users of marijuana, especially heavy users (you didn’t need me to tell you that)… Very rare use is likely not a significant contributor to ADHD symptoms or treatment failure 1/29/2018

Who to refer or seek assistance Significant substance misuse History muddled (note: if clearly malingering, I don’t need to see them) Co-morbidities are complex (e.g. bipolar disorder) or poorly controlled Pregnant or nursing Age >50-55

ADHD Management Stimulants are first line, have strongest evidence, and have good efficacy in most cases (and it can be fun!). Methylphenidate preparations Amphetamine salts Consider duration of effect Consider patient’s daily schedule

Methylphenidate Medications Drug Onset Duration Dosing Max Dose Ritalin 30 min 3-5 hours 5-10 mg bid-tid, incr by 5-10 mg q7d 60 mg Focalin 4-5 hours 2.5 mg bid-tid, incr by 2.5 mg q7d 20 mg Ritalin LA 30-45 min 6-9 hours 20 mg qAM, incr by 10 mg q7d, biphasic release Focalin XR 8-12 hours 10 mg qAM, incr by 10 mg q7d 40 mg Metadate CD 8-10 hours 20 mg qAM, incr by 10-20 mg q7d Concerta* 10-12 hours 18-36 mg qAM, incr by 18 mg q7d *write “OROS only” on Rx 75 mg Daytrana 2 hours 9-12 hours 10 mg patch, incr to next size q7d 30 mg/9h

Amphetamine Salt Medications Drug Onset Duration Dosing Max Dose Adderall 30 min 5-8 hours 5 mg qAM or bid, incr by 5 mg q7d 40 mg Adderall XR 2 hours 10-12 hrs 20 mg qAM, incr by 10 mg q7d 30 mg, may dose BID Vyvanse 2+ hours 10-14 hours 30 mg qAM, incr by 10-20 mg q7d 70 mg *BID dosing: AM and early PM *TID dosing: AM, early PM, late PM

Notable Side Effects in Adults Psychosis and aggression: rare, dose-related, more likely in those predisposed to psychosis Cardiovascular safety: warnings issued in 2006, newer data reassuring, worth getting/reviewing cardiac history and get EKG if positive findings; avoid if known disease Common and predictable: insomnia, anorexia, anxiety, abrupt discontinuation (“crash”)

Non-stimulant Treatment Atomoxetine (Strattera) Norepinephrine reuptake inhibitor Takes 2-4 weeks to see effect BID dosing better tolerated, no improvement in effectiveness Warnings: hepatotoxicity, increased BP and HR, class warning for SI in kids/teens Good choice if history of substance abuse, poor tolerability or response to stimulant, tic disorder, anxiety

Non-stimulant Treatment Clonidine & guanfacine Used off-label in children and adults; Kapvay & Intuniv (ext release) is FDA approved ages 6-17 More helpful for hyperactivity/impulsivity than for inattention Can be used as part of treatment combination Avoid abrupt discontinuation due to rebound HTN Limited utility in adults

Non-stimulant Treatment Bupropion Helpful for attention and motivation symptoms related to depression Mixed evidence and experience with ADHD Contraindicated in: epilepsy, anorexia/bulimia, tic disorders Will help patient quit smoking, too! If using SR (BID) formulation for any indication, please dose AM and early PM (or risk insomnia)

Non-pharmacologic Interventions ADHD coaching Mindfulness meditation Adequate sleep Exercise, especially just prior to period of work/concentration Omega-3 fatty acids (60% EPA) Driven to Distraction and Delivered from Distraction by Hallowell Smart But Stuck by Brown ADHD Effects on Marriage by Orlov

Case 1 28 year old teacher, works 7:30 to 4, on a stable dose of Adderall XR 20 mg in the morning, complains that she can’t get anything done starting around 3. She’s weeks behind on grading and lesson plans get turned in but changed last minute. What would you do next?

Case 1 Tell her “too bad, you need to find a different career” Add a 10 mg Adderall dose at 2 PM Increase morning dose to 30 mg Suggest 30 minutes of exercise after work and prior to sitting down to work on grading and lesson planning Do nothing

Case 2 28 YO teacher, on Adderall XR 20 mg in AM, does okay through school but not getting work done in evening. Smokes a joint (marijuana) 3-4x a week after work (“what would you do if you spent 8 hours a day with 35 eighth graders?”) and has for last 2 years. Has noticed a slow decline in performance in the last school year. What would you do next?

Case 2 Stop the Adderall XR and tell her she can come back when she’s sober Continue current medication and counsel her about marijuana use Add a benzo to help her manage the stress of all of those hormonal pre-teens Refer to psychiatry Ask if you can come by after work!

Case 3 A 35 YO computer repair tech comes to your office because he is about to lose his job; he does a good job on the computers but his paperwork is always behind, incomplete, and he forgets to bill for parts of what he does. He has a history of panic disorder that has been stable for the last 3 years on 100 mg a day of sertraline. He endorses occasional marijuana use in college but none in the last 10 years. He is married with two kids and notes that his wife is going to be furious if he loses another job. What do you want to know next? What diagnoses would you consider? 1/29/2018

Questions?