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

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

3. 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

4. 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

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

6. 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)

7. 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)

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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.”

15. The ASRS: A Useful Screening Tool

16. 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)

17. 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!

18. 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)

19. 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

20. 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

21. 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

22. 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 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

23. 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 mg q7d
70 mg
*BID dosing: AM and early PM
*TID dosing: AM, early PM, late PM

24. 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”)

25. 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

26. 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

27. 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)

28. 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

29. 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?

30. 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

31. 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?

32. 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!

33. 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

34. Questions?