Attention deficit hyperactivity disorder in adults

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

Treatment often follows a multimodal approach, incorporating elements of psychoeducation, medication, and psychological therapy; for example, cognitive behavioral therapy (CBT).[3] Treatment recommendations for adult attention deficit hyperactivity disorder (ADHD) may differ between healthcare settings; for example, in some locations, such as the UK, either pharmacotherapy or psychological therapy may be offered in isolation.[80] Pharmacologic treatment is typically initiated in secondary care, although primary care physicians may be responsible for continuation of treatment under shared care arrangements, including monitoring for adverse effects.

Availability of medications varies worldwide; in some locations, pharmacologic treatment options may be very limited.

Psychoeducation

Psychoeducation, if available, is a recommended first step following diagnosis according to treatment guidelines.[3] Structured psychoeducation programs offer information about ADHD as well as support to patients and their families, and may include aspects of cognitive behavioral therapy. There is preliminary evidence to suggest structured psychoeducation programs may increase psychological well-being, improve relationship quality and increase knowledge of ADHD.[103][104]

Environmental modifications (changes made to the physical environment in order to minimize the impact of ADHD on day-to-day life) may also help. Specific modifications are determined via an individual assessment of needs, but they may include changes to seating arrangements, changes to lighting and noise, reducing distractions and optimizing the working or educational environments to have shorter periods of focus with movement breaks.[80]

ADHD without concomitant mood disorder or anxiety

Medication; general approach

Pharmacologic treatment may typically be considered when symptoms are still causing a significant impairment after environmental modifications have been implemented and reviewed.[80] First-line treatment is typically with a stimulant medication; for example:[3][80][105][106][107]

Lisdexamfetamine
Methylphenidate

Dextroamphetamine may also be considered for some patients; for example, those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer-effect profile.[80]

Second-line treatment (for patients not responding to at least two separate trials of stimulants) is typically with:[80][108]

Atomoxetine (a selective norepinephrine-reuptake inhibitor without stimulant properties)

Further-line and/or adjunctive options with a less clear evidence base, and which should be initiated under specialist guidance only, include:[2][109] [ ]

An antidepressant (e.g., bupropion or venlafaxine)
An atypical antipsychotic (e.g., risperidone) as an adjunctive treatment if there is significant aggression and/or irritability

The dose of both stimulant and nonstimulant preparations needs to be titrated. Dose should always be started low and increased gradually according to response. Treatment response can be monitored by use of a symptom rating scale such as the Adult ADHD Investigator Symptom Rating Scale or the World Health Organization Adult ADHD Self-Report Scale.[90][110] Adult ADHD Self-Report Scale (ASRS-v1.1) symptom checklist - 18 item Opens in new window Adult ADHD Self-Report Scale (ASRS-v1.1) Screener - 6 item Opens in new window Regular (e.g., weekly) review is recommended.[80] Use of medication should last for as long as there is clinical benefit. If benefit is obtained with either nonstimulant or stimulant treatment, the prescribed agent can be continued for several months, with subsequent evaluations weighing the need for ongoing treatment.[107]

First-line pharmacologic options: stimulants

Stimulants are controlled drugs in some locations. 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. In response, the FDA has mandated updates to product warnings and other information to ensure consistency of prescribing information across all stimulants.[111] Prevention of misuse involves offering anticipatory guidance and close monitoring, including educational materials and monitoring frequency of prescription requests. (See Amphetamine and methamphetamine use disorder)

Given the sympathomimetic properties of stimulants, when considering stimulant treatment, obtain a careful cardiac history, including:[80]

Family history of sudden death or arrhythmia
Symptoms of syncope and dyspnea with exertion

In cases where there are cardiac symptoms of concern or a history of such symptoms, obtain an ECG and/or a cardiology consultation prior to starting a stimulant.[80] Stimulants are also associated with adverse effects such as sleep problems and decreased appetite, and ongoing monitoring is warranted.[106]

Psychosis has been associated with stimulants. In one study of adolescents and young adults (13-25 years old) who started taking prescription stimulants for ADHD, amphetamines were associated with a greater risk of new-onset psychosis than methylphenidate.[112] One population-based cohort study found no evidence that methylphenidate increases the risk of psychotic events in adolescents and young adults with ADHD.[113]

Where adult ADHD symptoms persist without comorbid symptoms, a trial with lisdexamfetamine or methylphenidate is recommended as first-line pharmacologic treatment according to both the UK and European treatment guidelines.[3][80][Evidence B] 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.[80] It is suggested that amphetamines are better tolerated in adults than methylphenidate, and that they are associated with the best risk: benefit ratio of all the treatment options for adult ADHD.[32][106] Consider dextroamphetamine for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile.[80][Evidence B]

Of the commonly used stimulants for treating ADHD in adults, a number of different formulations, delivery systems, and pharmacokinetic profiles are available. 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.[114]

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.[115]

Further-line pharmacologic options; nonstimulants and alternative experimental treatments

If a trial of stimulant medication does not provide benefit or is not well tolerated, change to an alternative formulation. If this is also unsuccessful, the next step would usually be to try atomoxetine.[3][116] Atomoxetine may not be well tolerated in adults with ADHD, a meta-analysis showed a 40% greater discontinuation rate compared with placebo.[32] Treatment over several weeks may be needed to evaluate efficacy for reduction of attentional and other cognitive symptoms.

For patients who do not respond adequately to the above treatments, seek advice from a tertiary ADHD service.[80]

The following treatments should only be initiated under specialist guidance.[80] The atypical antipsychotic risperidone may be offered in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages, or irritability. Physicians should be vigilant for potential serious side effects of antipsychotics.[117] Additional experimental and adjunct treatments may be useful, including bupropion for core symptoms, and venlafaxine.[109] [ ] 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.

Psychological therapy

Nonpharmacologic treatment alone may be considered for some adults with ADHD; for example, 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.[80]

As an adjunct to medication, it is recommended that psychological therapy be available in all clinical adult ADHD settings as a viable treatment option.[3][118] There is evidence that cognitive-behavioral-based treatments may be beneficial for treating adults with ADHD in the short term both in terms of core symptoms and associated symptoms such as depression and anxiety.[32][119][120][121] One review found that reductions in core symptoms of ADHD were fairly consistent when cognitive behavioral therapy (CBT) was used in addition to pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list.[121] Alternative psychological therapies include dialectic behavior therapy and metacognitive therapy.[122][123] There is insufficient evidence for meditation-based therapies.[124][125] Occupational therapy focusing on organization skills, enhancing social interaction/awareness, stress management techniques and sensory regulation can be helpful although further evidence is required to assess the effectiveness of different interventions.[126]

ADHD with suspected or confirmed 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][127]

Expert opinion (from a European Consensus statement) recommends that drug or alcohol use problems should be stabilized 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 stabilization 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 nonstimulant medications, as well as behavioral therapies, for addressing ADHD symptoms. The key is to carefully assess the potential benefits and risks of medication for each patient, taking into account their unique circumstances.[127]

ASAM advises to consider the prescription of psychostimulant medications when their benefits outweigh the risks, but also consider the use of nonstimulant medications as an alternative, and to consider behavioral approaches for all patients.[127] Stimulant medication can be used with caution in this group.[81][128] 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 medications, 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 minimize the risk of medication 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 prioritizing patient safety and adopting a balanced, patient-centered strategy that takes into account the intricate relationship between substance use disorder and ADHD.[81][127] 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.[127]

There is no evidence to suggest that stimulant treatment for ADHD precipitates the onset of substance use disorder in adults without previous substance use disorder.[129] Conversely, there is evidence from one Danish registry study suggesting that treatment of ADHD (with methylphenidate) may result in reduced substance use disorder symptomatology.[130] There is also a suggestion that higher doses of methylphenidate and some amphetamine preparations demonstrate better effects on both ADHD and substance use symptoms compared to lower dosages.[131][132][133]

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 coexisting substance use disorder; however, they are likely to be less effective against symptoms of ADHD than long-acting stimulant medications.[127] Further research is needed to examine multimodal treatment strategies addressing comorbid ADHD and substance use disorder.[83]

ADHD with concomitant mood disorder (depression, bipolar disorder) or anxiety

Medication

It is important to identify all comorbidities before treatment is initiated for ADHD, in order to establish the best order of treatment.[3] Mood and anxiety disorders can occur with adult ADHD and when they do, the treatment becomes more complicated.[2] The symptoms of the comorbid disorders can have a spill-over effect into the ADHD symptoms, so inattentiveness, impulsivity, and hyperactivity can appear worse than they would be in the absence of comorbidity. Treating the comorbid condition(s) first may help lessen the symptomatology attributed to ADHD.

In addition, since common side effects of stimulant treatment may include mania, weight loss, and insomnia, once stimulant treatment is begun it may be difficult to assess whether such symptoms are stimulant side effects or are the symptoms of untreated, comorbid conditions. When treating the comorbidities first, the least potentially harmful drugs are used first.

For patients presenting with symptoms of a mental health disorder such as depressive, bipolar, or anxiety disorder, in addition to adult ADHD symptomatology, the first step is typically to provide treatment for the non-ADHD condition(s). Psychological therapy participation may be initiated concurrently, based on assessment of the severity of the ADHD symptomatology and patient preference. Mood symptoms may necessitate treatment with antidepressants and/or mood-stabilizing agents, while anxiety symptoms can benefit from treatment with anxiolytics, antidepressants and occasionally benzodiazepines. The goal is to reduce the severity of the non-ADHD symptoms, which may lead to significant lessening of reported attentional and cognitive deficits that would have otherwise been attributed to ADHD. Patients with depression who are prescribed a selective serotonin-reuptake inhibitor (SSRI) should be informed about the possibility of increased risk of suicidality associated with SSRI use. (See Depression in adults, Generalized anxiety disorder)

If careful evaluation does reveal the persistence of ADHD symptoms, despite adequate treatment of the mood/anxiety disorders, consideration of medication treatment aimed at reduction of the persisting ADHD symptoms is indicated.

This treatment may require significant expertise with psychopharmacologic agents for those patients requiring multiple medications for non-ADHD symptom stability. Patients with mood (depression and bipolar disorder) and/or anxiety disorders may require a regimen that includes antidepressant medication.

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 (methylphenidate or amphetamine salt preparation) treatment is not contraindicated with concurrent antidepressant or mood-stabilizer 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.[80] (See Bipolar disorder in adults)

Psychological therapy for comorbidities

There is evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression, anxiety, and antisocial behavior.[119][134][135]

Studies into the role of nonpharmacologic interventions for ADHD and comorbid substance use disorder are limited. In the absence of clear evidence, expert consensus recommends that clinicians should consider therapy with a focus on overlapping symptoms as part of a multimodal treatment approach including psychotherapy and medication.[81]

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