Treatment of Adult ADHD: Expect the Unexpected Grand Rounds Cairns Hospital March 14 2014 Rigo Van Meer

Video interviews In the original presentation video interviews with patients were presented. For privacy reasons these video’s are not on the internet and are left out of this downloadable version of the presentation

Warning for students My experiences and the opinions I have formed on the basis of those experiences differ on many counts from commonly accepted notions about adult ADHD and the use of stimulant treatment.

Goal Make doctors and (mental) health workers more aware of adult adhd Make them consider adhd as a possibility and treat it Sharpen clinical acumen in diagnosing adhd Give an impression of treatment results

Attention Deficit / Hyperactivity Disorder in Adults Diminished capacity to concentrate & focus Impulsivity In children “hyperactivity”. In adults feeling stressed / on edge most of the time From trivial to very severe Highly genetic Problems in the frontal lobe High co-morbidity with other psychiatric disorders Not depression OR adhd but AND Not Bipolar OR adhd but AND Etc. etc.

Epidemiology adult ADHD General population: 4% Psychiatric population: 10% to 20% Males in jail: 45% Tourette syndrome: 65% Methamphetamine users: 40% Personality disorder M/F=2 (in practice 3 to 4) Patients with Acquired Brain Injury can have very similar symptoms 6

Comorbidity 78% of cases has comorbidity Depression 20-30% BPAD 8% Anxiety disorders Substance abuse 25-45% Personality Disorders: Antisocial, Borderline 25% 7

Simple Adult ADHD “a uni student with concentration problems” (from: ADDults with ADHD (NSW) Inc)

Complex Adult ADHD Difficult psychiatric presentations (ED, Clinic) Unclear psychiatric diagnosis, personality disorder High psychosocial stress Unemployed Is stressed/ on edge Unhappy / depressed / anxiety No direction in life, going nowhere Fed up with the way his/her life goes Anger issues Heavy alcohol use Heavy marijuana use Speed/ methamphetamine use Offending Jail

Psycho stimulants Short acting (3 to 4 hours) Long acting (24 hours) Methylphenidate (Ritalin) Dexamphetamine Long acting (24 hours) Methylphenidate ER (Concerta, Ritalin LA) Mixed amphetamine salts: Adderall (not in Australia) Dexamphetamine precursor: Vyvanse (new in Australia) Atomoxetine (Strattera, non stimulant) Not Addictive Do not make you “high” Performance improvement in non-adhd subjects doubtful Keep you awake 10

General effects of stimulant treatment in ADHD Stimulants have a QUALITATIVELY DIFFERENT effect on people with adhd then on others Stimulants in adhd CALM DOWN The effect is large and often dramatic The effect is almost immediate Stimulants in non-adhd persons DO NOTHING apart from keeping you awake

Common opinion: Stimulants hinder your sleep butt… in many patients with adhd sleep actually improves as long as the stimulants are not taken late in the afternoon

Common opinion Stimulants diminish appetite and cause weight loss butt.. Many patients report some nausea and loss of appetite in the first days of treatment, while in the long run their appetite improves and they start to eat more regular

Common opinion: Stimulants cause psychosis and can’t be used in patients with a psychotic illness but… Some patients report that they can cope better with their psychotic symptoms when on stimulants

Common opinion: Stimulants have little or no influence on the use of alcohol but.. patients report a dramatic decrease in the urge to drink alcohol and in the actual use of alcohol

How to diagnose? Think of it Look for it 16

Red flags in psychiatric patients Difficult patient Many problems/symptoms Diagnosed with: Bipolar disorder, depression, anxiety Antisocial personality disorder Borderline personality disorder Alcohol abuse Substance abuse Anger issues Little effect of anti-depressants, anti-psychotics Quetiapine sometimes helps (sleep, relaxation) Always ask: If you have ever tried speed / ice / methamphetamine / Ritalin / dexamphetamine What effect did it have on you?

Nobody gets addicted to Ritalin or dexamphetamine Not Addictive Nobody gets addicted to Ritalin or dexamphetamine On the contrary, it costs parents effort to keep their children on their medication and almost all of them have stopped by the age of 21. Patients often forget to take their meds (ever heard of a cigarette addict who forgets to smoke his/her cigarettes?) No tendency of dose increase No craving There is no withdrawal on stopping (although some have a “come down” when the medication works out at the end of the day, especially on Ritalin) Ever diagnosed and treated a patient with Ritalin or Dexamphetamine addiction?

What patients say I get things done now My mind is much clearer I don’t procrastinate any more I think more positive I feel motivated I hardly drink alcohol anymore I’m not depressed anymore I got my life back 19 37

Messages ADHD is a common and serious psychiatric disorder that can severely mess up the patients life (and that of others) Comorbidity is the rule A trial of Ritalin or Dexamphetamine is easy, short and safe Often spectacular therapeutic results Please treat 20

Adult ADHD lessons learned 1 I found reading about adult adhd treatment for complex adhd particularly unhelpful. Many general statements and warnings, little practical guidance. Guidelines, even from the Queensland Government, contain errors and misconceptions. Dose of Ritalin 10mg or Dexamphetamine 5mg is between 2 and 15 tablets daily, with an average of 6 to 8. Under-dosing gives many problems, as patients will use the dose they need, and run out of their tablets too soon. Once the right dose is found, patients do not want to increase the dose. Dexamphetamine has fewer side effects and is felt as “softer” than Ritalin. Dexamphetamine is therefore in general the better medication Stimulant treatment: As a rule reduces the urge to drink alcohol or to smoke dope. Often will improve sleep dramatically. Often has a general improvement in mood -> anti depressants can be stopped. Makes patients more motivated and think more positive

Adult ADHD lessons learned 2 Patients with adhd who seek treatment are often treated negatively and condescending by doctors and pharmacists. Patient with adhd who seek treatment are sometimes branded as “drug seeking”. When they try another doctor they are “doctor shopping”. Many patients with adhd use marijuana or alcohol to dampen their constant feeling of stress and unrest. Dexamphetamine and methylphenidate are not addictive. Patients who do not have adhd find these drugs in general unpleasant. Illegal use of amphetamines is often self medication for adhd. Proper treatment of adhd decreases crime and keeps people out of jail (and out of ED). Drug and alcohol abuse are not a contra-indication for treatment, but an indication

ADHD in adults can be from trivial to very severe Severe cases can be compounded by depression, anxiety, angriness and aggression, social deterioration, loss of meaning in life, illegal drug use and incarceration. Treatment of severe cases often gives spectacularly positive results that are life changing. These successful treatments are in my experience one of the very rewarding things a psychiatrist can do in his profession.

Actively diagnosing and treating adult ADHD will: Increase quality of life of ADHD patients and families Convert some long term psychiatric treatment failures into successes And will contribute to… Decrease alcohol abuse and consequences of alcohol abuse Decrease use of marijuana Decrease use of methamphetamine and speed Keep people out of jail Keep people out of hospital