Working adeptly to diagnose and treat adult ADHD

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Behavioral Health

Working adeptly to diagnose and treat adult ADHD

J Fam Pract. 2020 April;69(3):145-149

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References

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Lisdexamfetamine (Vyvanse) is a pro-drug that requires first-pass metabolism for conversion to an active drug. This may reduce risk of overdose or misuse. Adverse effects of stimulants include decreased appetite, irritability, tics, and cardiac toxicity.¹⁶ Proper titration of dose over successive visits is essential as providers often must balance efficacy, appetite, and sleep.

Nonstimulant therapies are options for patients who cannot tolerate stimulants or are at high risk for misuse. Atomoxetine, a norepinephrine reuptake inhibitor, has qualities that may resemble antidepressants in its 2- to 4-week time lapse before taking effect. Alpha-2 agonists clonidine and guanfacine are approved by the US Food and Drug Administration in their extended release forms for adjunct therapy with stimulants. Pharmacologic therapies are listed in TABLE 2.¹⁶

Nonpharmacologic modalities for adult ADHD include psychoeducation, cognitive behavioral therapy, and work environment modification. While coordination with schools is recognized as an essential aspect of the care of ADHD in children, team care in the treatment of adults with ADHD is often forgotten. Referral for occupational or educational support, written materials on study habits and organizational skills, and the use of memory tools can be very helpful. Modifications in physical environment and time constraints in both work and school settings can enhance productivity in adults with ADHD. Attention to sleep scheduling and sleep hygiene can also improve attention and concentration throughout the day.

CASE

The clinical impression of ADHD-I was confirmed by Ms. L’s score on the ASRS. She was prescribed a long-acting formulation of methylphenidate, starting at a dose of 27 mg/d in the morning and eventually titrated to 54 mg/d. She received psychoeducation in ADHD and learned strategies to reduce distractions in her school and home study environments.

Misuse may be especially common on college campuses, where nonprescribed stimulants may be used recreationally, or as study aids.

She engaged with the education specialists at her school, who helped her discuss testing and assignment modifications with her professors. She began to develop a time-management strategy to complete her assignments; these included reduced evening caffeine intake and improved sleep hygiene. Over time, Ms. L was able to maintain attention for the more extended homework tasks assigned in college. She was also able to enjoy a similar level of success that she had achieved in high school.

CORRESPONDENCE
Jay Brieler, MD, Family and Community Medicine, Saint Louis University School of Medicine, 6420 Clayton Road, Room 2234, St. Louis MO 63117; jay.brieler@health.slu.edu.