by Leila Noghrehchi, MD
Currently many psychiatrists are struggling with the ability to take patients with newly or undiagnosed ADHD into their practices due to schedule congestion with maintenance and follow-up appointments. Many primary care providers (PCP) continue to be wary of prescribing stimulants due to concerns of misuse and cardiovascular risk.
ADHD is a psychiatric condition that is characterized by patterns of developmentally inappropriate levels of inattentiveness, restlessness, and/or impulsivity. There are three recognized subtypes in DSM-V, published by the American Psychiatric Association, which are predominantly inattentive, predominantly hyperactive, and a combined type. The inattentive subtype is more common in females, however as a whole ADHD affects men more than women at a ratio of about 2:1. The current estimate for children in the US with ADHD is between 6-8% and 55-66% of those childhood cases will persist into adulthood. About 3-6% of Americans struggle with adult ADHD, which makes up about 10 million people. ADHD can have large consequences, including social interactions, increased risky behaviors, and occupational and/or academic impairment.
Adults with ADHD suffer from executive dysfunction, memory impairments, and slower information processing speed. Emotional dysregulation also tends to be common. ADHD is the single most heritable psychiatric disease that exists, followed by autism spectrum disorder.
The etiology of ADHD is multifactorial and several factors influence this condition and how it presents. Several risk factors have been implicated in ADHD pathophysiology including genetic factors, individual factors, neurological factors, environmental factors, psychological factors, and some associated disorders.
Overall, the precise pathophysiology of ADHD is not fully understood. Dopaminergic and serotonergic pathways, located in the midbrain and hindbrain respectively, have been most recently proposed as playing a part in the pathophysiology of ADHD. The thought is that abnormal levels of dopamine and/or serotonin are produced via these pathways and contribute to symptoms of inattention, hyperactivity, and impulsivity in ADHD.
The DSM-V, outlines diagnostic criteria for making a diagnosis of ADHD in children and adults. Differential diagnoses for adult ADHD include mild cognitive impairment, depression, anxiety, mania, psychoses, substance use disorder, thyroid dysfunction, eating disorders, vitamin deficiencies, and sleep related disorders such as obstructive sleep apnea.
The gold standard for ADHD diagnosis is clinical evaluation by either a psychologist or physician who is trained to perform this type of evaluation. The AAFP recommends at least two visits for a PCP to make a diagnosis of ADHD. The first visit includes a standard mental health assessment, review of current symptoms using a validated tool, identification of comorbidities including substance use disorder, and review of physical health. The second visit is meant to review all of the gathered information and interview for corroboration of childhood symptoms. The Conners’ adult ADHD rating scale is a commonly used assessment among mental health professionals for ADHD diagnosis and maintenance. This tool contains self-report assessments and observer report assessments to gather extensive and accurate childhood history. The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed by the World Health Organization and may be useful in treatment monitoring. As a diagnostic tool the ASRS has >90% sensitivity and ~60% specificity. The AAFP Adult ADHD Toolkit contains links to several screeners and informant questionnaires such as those mentioned.
Stimulants are the first- and second-line treatment for this condition and trial of another stimulant is indicated if the first one does not work. Atomoxetine is a non-stimulant option, and there are short-term studies and a meta-analysis that suggests bupropion as an effective non-stimulant option as well. It is recommended that patients start with long-acting formulas. Of the listed major adverse effects, sleep disturbance is by far the most common. CBT-I is the recommended management for this side effect.
Evidence-based non-pharmacologic treatment options include cognitive behavioral therapy (CBT), meta-cognitive therapy, attention training techniques, and neurofeedback.
Although many patients in the primary care setting have multiple comorbidities which can lead to hesitancy about prescribing stimulants, treatment with stimulants can help in a variety of ways including reduced stress as well as improved professional performance, relationships and ability to manage other health conditions. Overall, most recent reviews on the cardiovascular effects of these drugs in healthy subjects found the stimulants to be safe to use and studies have shown that adequate adult ADHD treatment can improve mortality by anywhere from 10-15 years.
PCP follow-up is usually dictated by controlled substance practice policy versus what is necessary- there is no standard of care. The AAFP recommends 30 day follow-up after initiation of medication and monitoring every 3-6 months after. PCP follow-up appointments for adult ADHD should include evaluation of symptoms either with ASRS or general questioning, assessment of symptom control coverage, assessment of sleep and appetite, evaluation of heart rate, blood pressure, and respiratory rate, as well as cardiac screening which includes syncope, near syncope, and paroxysmal tachycardia, and finally screening for other psychiatric issues including substance use.
In May 2023, the FDA released an update on warnings to improve safe use of prescription stimulants. Recommendations for health care professionals include counseling patients on misuse, regularly assessing for nonmedical use and addiction, educating patients on proper storage, disposal of stimulants, and symptoms of overdose. Additional suggestions for health professionals in order to reduce risks of stimulant treatment include careful diagnosis, risk-benefit analysis, informed consent, avoid short acting stimulants where possible, treatment agreements, and meticulous documentation.
In summary, adult ADHD is a psychiatric condition that, when untreated, can decrease quality of life and increase morbidity. Currently stimulants remain first-line therapy although they carry risk of misuse and abuse. Overall, most recent reviews on the cardiovascular effects of these drugs in healthy subjects found stimulants to be safe to use. There is no universally agreed upon method of diagnosis or monitoring, but as a Family Medicine physician, the AAFP has published recommendations for assessment and diagnostic approach. Risk reduction methods include evaluating for contraindications, counseling on misuse/abuse, regular screening for comorbid conditions, and careful documentation and record keeping.
References
https://www.ncbi.nlm.nih.gov/books/NBK441838/
Duke Family Medicine & Community Health. (2021). Adhd in Adults: An Open Discussion on the Diagnosis and its Treatment. Virtual PrimaryCare Grand Rounds. Retrieved February 16, 2022,fromhttps://duke.zoom.us/rec/play/PRm_6V0PxJx7FQIpwjG9FIB2BVqylxfDon2yV60N7QaphNcfmMozuXGJ6wyVDAdciixj0mk_OpsT9Nt3.0YEuteeOskysDhUu?continueMode=true&_x_zm_rtaid=3qADWonrQHCWOwZHyjuFbg.1645151720626.47c2f3acd3bd76a8a8d8235ffc892824&_x_zm_rhtaid=357.
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Magnus W, Nazir S, Anilkumar AC, et al. Attention Deficit Hyperactivity Disorder. [Updated 2021 Aug 20]. In: StatPearls [Internet]. TreasureIsland (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441838/
Núñez-Jaramillo, L., Herrera-Solís, A., & Herrera-Morales, W. V. (2021). ADHD: Reviewing the Causes and Evaluating Solutions. Journal ofpersonalized medicine, 11(3), 166. https://doi.org/10.3390/jpm11030166
Dr. Noghrehchi is from Phoenix, Arizona. She completed her undergraduate degree at the University of Arizona and her medical degree at the University of Arizona College of Medicine- Tucson. Her medical interests include rural health, Tribal health, integrative medicine, gender-affirming care and public/community outreach. She enjoys Pilates, cooking, reading fiction, and taking walks outside. She chose the University of Utah because of the resident wellness, opportunity to continue rural health experiences, gender-affirming care training, and the ability to practice in a community hospital setting.
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