Attention deficit hyperactivity disorder in adults

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

ADHD without concomitant mood, anxiety, or substance use disorder

1st line – psychoeducation + stimulant therapy ± psychological therapy

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1st line –

psychoeducation + stimulant therapy ± psychological therapy

Psychoeducation, if available, is a recommended first step following diagnosis according to treatment guidelines.[3] Structured psychoeducation programmes offer information about attention deficit hyperactivity disorder (ADHD) as well as support to patients and their families, and may include aspects of cognitive behavioural therapy (CBT). There is preliminary evidence to suggest structured psychoeducation programmes may increase psychological well-being, improve relationship quality, and increase knowledge of ADHD.[101][102]

Pharmacological treatment is typically considered when symptoms are still causing a significant impairment after environmental modifications have been implemented and reviewed.[4] First-line treatment is usually with a stimulant medication (e.g., lisdexamfetamine, methylphenidate).[3][4][103][104][105]

The dose of stimulants needs to be titrated. Dose should always be started low and increased gradually according to response. Consider switching from lisdexamfetamine to methylphenidate (or from methylphenidate to lisdexamfetamine) if a person has had a 6-week trial of the initial drug at an adequate dose, but has not derived enough benefit in terms of reduced ADHD symptoms and associated impairment.[4]

Extended-release methylphenidate is reported to provide better symptom control than immediate- or sustained-release formulations. However, a Cochrane review found 'very low' certainty of evidence to support symptom improvement with extended-release methylphenidate versus placebo in adults with ADHD.[112]

It is suggested that amfetamines are better tolerated in adults than methylphenidate.[33][104]

Consider dexamfetamine for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.[4][Evidence B]

The FDA has noted concerns about nonmedical use of prescribed stimulants, particularly with respect to patients sharing their prescribed stimulants with family members and peers.[109] Prevention of misuse involves offering anticipatory guidance and close monitoring, including educational materials and monitoring frequency of prescription requests.

A careful cardiac history, including family history of sudden death or arrhythmia, symptoms including syncope and dyspnoea with exertion, should be obtained. In cases where there are symptoms of concern or a history of such symptoms, an ECG and/or a cardiology consultation should be obtained prior to starting a stimulant.[4]

Stimulants are associated with adverse effects such as sleep problems and decreased appetite, and ongoing monitoring is warranted.[104]

Prescribers should note that there are differences in long-acting formulations of methylphenidate in terms of dosing frequency, administration with food, amount and timing of the modified release component, and overall clinical effect. It is important to follow specific dosage recommendations for each formulation and to use caution if switching from one to another long-acting preparation of methylphenidate, including a careful discussion with the patient. Follow specific prescribing guidance relevant to your location of practice; for example, there may be a recommendation to prescribe long-acting formulations of methylphenidate by specifying the brand name or by using the generic drug name and name of the manufacturer.[113]

Psychosis has been associated with stimulants. In one study of adolescents and young adults (13 to 25 years old) who started taking prescription stimulants for ADHD, amfetamines were associated with a greater risk of new-onset psychosis than methylphenidate.[110] One population-based cohort study found no evidence that methylphenidate increases the risk of psychotic events in adolescents and young adults with ADHD.[111]

Use of stimulant medication should last for as long as there is clinical benefit. It should be stopped when side effects appear to outweigh benefits.

Psychological therapy (e.g., CBT) should be available as an adjunct to pharmacotherapy in all clinical adult ADHD settings.[3][116]

Non-pharmacological treatment alone may be considered in particular circumstances; for example, for those who have made an informed choice not to have medication, those with difficulty adhering to medication, and those who have found medication to be ineffective or who cannot tolerate it.[4]

Primary options

methylphenidate: consult product literature for guidance on dose

lisdexamfetamine: 30-70 mg orally once daily in the morning

Secondary options

dexamfetamine: 5-60 mg/day orally given in 2-4 divided doses

2nd line – atomoxetine ± psychological therapy

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2nd line –

atomoxetine ± psychological therapy

Atomoxetine is a selective noradrenaline-reuptake inhibitor. It may be considered for patients who are unable to tolerate stimulant medication, and/or for those whose symptoms have not responded to two adequate trials of stimulant medication, having considered alternative preparations and adequate doses.[4]

Treatment over several weeks may be needed to evaluate efficacy for reduction of attentional and other cognitive symptoms.

Dose should always be started low and increased gradually according to response.

Medication should be stopped if side effects appear to outweigh benefits. Atomoxetine may not be well tolerated in adults with attention deficit hyperactivity disorder (ADHD), a meta-analysis showed a 40% greater discontinuation rate compared with placebo.[33]

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

Primary options

atomoxetine: 40-120 mg/day orally given in 1-2 divided doses

3rd line – alternative experimental treatments including antidepressants and antipsychotic medication ± psychological therapy

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3rd line –

alternative experimental treatments including antidepressants and antipsychotic medication ± psychological therapy

The following treatments should only be initiated under specialist guidance (e.g., from a tertiary attention deficit hyperactivity disorder [ADHD] service).[4] Additional experimental and adjunct treatments may be useful, including bupropion for core symptoms, venlafaxine, and risperidone (an atypical antipsychotic often used for aggressive behaviour).[107] [ ]

Bupropion is an antidepressant with dopaminergic effects. Treatment over several weeks may be needed to evaluate efficacy for reduction of attentional and other cognitive symptoms. Bupropion is contraindicated in patients with seizure disorders or conditions that increase the risk of seizure disorders, and in patients with anorexia/bulimia.

Dose should always be started low and increased gradually according to response.

If benefit is obtained with either non-stimulant or stimulant treatment, the prescribed agent can be continued for several months, with subsequent evaluations weighing the need for ongoing treatment.[105]

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

Primary options

bupropion: 100 mg orally (sustained-release) once daily in the morning, increase gradually to 200 mg twice daily, maximum 400 mg/day

venlafaxine: consult specialist for guidance on dose

risperidone: consult specialist for guidance on dose

ADHD with concomitant substance use disorder

1st line – simultaneous and integrated multimodal treatment for ADHD and substance use disorder

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1st line –

simultaneous and integrated multimodal treatment for ADHD and substance use disorder

Treating ADHD is crucial in the overall management of substance use disorder due to the interconnected nature of these conditions. Guidelines stress the importance of a holistic approach that addresses both disorders simultaneously, recognising the complex needs of individuals with co-occurring ADHD and substance use disorder.[3][125]

Expert opinion (from a European Consensus statement) recommends that drug or alcohol use problems should be stabilised first, but that they can be treated at the same time as ADHD, depending on the substance used.[3] Treatment of ADHD with pharmacotherapy without initial stabilisation of the substance use disorder does not appear to be particularly effective for treating either condition.[83] The American Society of Addiction Medicine (ASAM) advises that, despite the low certainty of evidence, there is a strong recommendation to consider both psychostimulant and non-stimulant medicines, as well as behavioural therapies, for addressing ADHD symptoms. The key is to carefully assess the potential benefits and risks of medicine for each patient, taking into account their unique circumstances.[125]

ASAM advises to consider the prescription of psychostimulant medicines when their benefits outweigh the risks, but also consider the use of non-stimulant medicines as an alternative, and to consider behavioural approaches for all patients.[125] Stimulant medicine can be used with caution in this group.[81][126] As with any clinical decision, the key is a careful risk:benefit analysis. Clinicians will need to determine whether it is reasonable to initiate or continue stimulant pharmacotherapy, taking into account individual patient factors.[81] When prescribing psychostimulant medicines, ASAM guidelines strongly recommend using extended-release formulations and implementing rigorous monitoring practices. This recommendation is based on clinical consensus among experts, even though the evidence is of low certainty. To minimise the risk of medicine misuse and ensure treatment safety and effectiveness, guidelines provide a conditional recommendation for strict monitoring measures. These include pill counts, drug testing, and frequent clinical contacts with healthcare providers. This approach underscores the importance of prioritising patient safety and adopting a balanced, patient-centered strategy that takes into account the intricate relationship between substance use disorder and ADHD.[81][125] Immediate-release stimulants should be avoided in patients with ADHD and substance use disorders.[3] Anticipatory discussion with the patient is important.[81]

Expert opinion suggests that people with stimulant use disorder who have developed tolerance for the effects of stimulants may require higher doses of prescribed stimulants to achieve clinical benefit.[125]

Note that atomoxetine and bupropion have low/no misuse potential, and, depending on the individual risk:benefit analysis, may be considered as treatments for ADHD in people with co-existing substance use disorder; however, they are likely to be less effective against symptoms of ADHD than long-acting stimulant medicines.[125] Further research is needed to examine multimodal treatment strategies addressing comorbid ADHD and substance use disorder.[83]

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

See: Amphetamine and methamphetamine use disorder (Treatment algorithm).

ADHD with depression (with or without prominent anxiety)

1st line – antidepressants + psychological therapy

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1st line –

antidepressants + psychological therapy

The aim of treatment of the mood disorder is to achieve euthymia with antidepressant treatments, unrelated to specific treatment for attention deficit hyperactivity disorder (ADHD).

In the case of suboptimal response to initial antidepressant therapy (treatment resistance), the aim of treatment is still to achieve euthymia, and ongoing ADHD-like symptoms would be seen as part of the resistant depression.[2] ADHD-like symptoms should not be specifically treated.

Specialist (psychopharmacologist) referral should be considered for complex cases.

Patients who are prescribed a selective serotonin-reuptake inhibitor (SSRI) should be informed about the possibility of increased risk of suicidality associated with SSRI use.

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option. There is evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression, anxiety, and antisocial behaviour.[117][132][133]

See Depression in adults (Treatment algorithm).

persistent ADHD-like symptoms despite euthymia on antidepressants

Consider – multi-modal treatment for ADHD

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Consider –

multi-modal treatment for ADHD

Additional treatment recommended for SOME patients in selected patient group

If patients retain persistent attention deficit hyperactivity disorder (ADHD)-like symptoms despite successful pharmacological treatment of depression, the next step is to start multi-modal treatment for ADHD as in those with ADHD without depression (see above). One difference is that risperidone is not typically used in this group.

persistent anxiety symptoms despite euthymia on antidepressants

Consider – anxiolytic therapies

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Consider –

anxiolytic therapies

Additional treatment recommended for SOME patients in selected patient group

Anxiolytic therapies include both medication and psychotherapies.

Medication treatments include antidepressants, and occasionally, benzodiazepines..

Psychotherapies include cognitive behavioural therapy, which has shown efficacy for patients with obsessive-compulsive disorder and panic disorder.[134][135] Mindfulness-based cognitive therapy may help patients with generalised anxiety disorder.[136]

Benzodiazepines pose risks of addiction, tolerance, and withdrawal, possibly including withdrawal seizures.

Patients who are prescribed a selective serotonin-reuptake inhibitor should be informed about the possibility of increased risk of suicidality associated with their use.

See Generalised anxiety disorder (Treatment algorithm).

ADHD with bipolar disorder

1st line – mood stabilisers + psychological therapy

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1st line –

mood stabilisers + psychological therapy

If the comorbid mood disorder is bipolar disorder, the aim in initial treatment is to achieve euthymia with mood-stabiliser treatments, unrelated to specific treatment for attention deficit hyperactivity disorder (ADHD).[2]

In the case of suboptimal response to initial mood-stabiliser therapy (treatment resistance), the aim of treatment is still to achieve euthymia, and ongoing ADHD-like symptoms may be seen as part of the resistant bipolar disorder.

ADHD-like symptoms should not be specifically treated.

Specialist (psychopharmacologist) referral should be considered for complex cases, where stimulant or alternative ADHD medication may be initiated.

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

See Bipolar disorder in adults (Treatment algorithm).

persistent ADHD-like symptoms despite euthymia on mood stabilisers

Consider – multi-modal treatment for ADHD

Back

Consider –

multi-modal treatment for ADHD

Additional treatment recommended for SOME patients in selected patient group

If patients retain persistent attention deficit hyperactivity disorder (ADHD)-like symptoms despite successful pharmacological treatment of bipolar disorder, the next step is to start multi-modal treatment for ADHD as in those with ADHD without bipolar disorder (see above). One difference is that risperidone is not typically used in this group.

In patients with bipolar disorder, caution is recommended with use of antidepressants and closely related agents (such as atomoxetine) due to the risk of such agents inducing mood cycling.

Stimulant medication treatment is not contraindicated with concurrent antidepressant or mood-stabiliser treatment. Stimulant use also carries risk of mood-cycling induction, so caution is recommended, particularly with use in patients with bipolar illness. Stimulants can additionally worsen anxiety and cause insomnia. Any of these effects could be detrimental to the patient with significant mood and/or anxiety symptoms, and careful, ongoing monitoring for the emergence of such medication effects is important.

UK guidance recommends that if a patient taking medication for ADHD experiences an acute psychotic or manic episode, any medication for ADHD should be stopped in the first instance, with consideration given to restarting or starting a new ADHD medication after the episode has resolved, depending on the risk:benefit analysis as guided by the individual circumstances.[4] (See Bipolar disorder in adults)

ADHD with anxiety disorder alone

1st line – anxiolytics + psychological therapy

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1st line –

anxiolytics + psychological therapy

Anxiolytic therapies for initial treatment and treatment-resistant patients can be either medication or psychotherapies.

Medication treatments include antidepressants, and occasionally, benzodiazepines.

Psychotherapies can include cognitive behavioural therapy: in particular, for obsessive-compulsive disorder and panic disorder.[134][135] Mindfulness-based cognitive therapy may help with generalised anxiety disorder.[136]

In the case of suboptimal response to initial anxiolytic therapy (treatment resistance), ongoing attention deficit hyperactivity disorder (ADHD)-like symptoms may be seen as part of the resistant anxiety disorder.[2] ADHD-like symptoms should not be specifically treated.

Specialist (psychopharmacologist) referral should be considered for complex cases.

Benzodiazepines pose risks of addiction, tolerance, and withdrawal, possibly including withdrawal seizures.

Patients who are prescribed an SSRI should be informed about the possibility of increased risk of suicidality associated with their use.

Psychological therapy should be available in all clinical adult ADHD settings as a viable treatment option.

See Generalised anxiety disorder (Treatment algorithm).

persistent ADHD-like symptoms despite controlled anxiety on anxiolytics

Consider – multi-modal treatment for ADHD

Back

Consider –

multi-modal treatment for ADHD

Additional treatment recommended for SOME patients in selected patient group

If patients retain persistent attention deficit hyperactivity disorder (ADHD)-like symptoms despite successful pharmacological treatment of anxiety, the next step is to start multi-modal treatment for ADHD as in those with ADHD without an anxiety disorder (see above).

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