Managing Expectations and Individualizing Treatment for Adults With ADHD: An Expert Interview With Richard H. Weisler, MD

May 09, 2008

Editor's Note

Attention deficit-hyperactivity disorder occurs in adults as well as children, but engaging adults in treatment and ensuring adherence to therapy present specific challenges. As medication options broaden, more people may benefit from treatment for ADHD, but comorbidity and other life circumstances must be taken into account for each patient. To review the latest clinical thinking in this field, Medscape's Randall F. White, MD, spoke with Richard H. Weisler, MD. Dr. Weisler, a busy clinician and researcher, is adjunct professor of psychiatry at the University of North Carolina at Chapel Hill, and adjunct associate professor of psychiatry at Duke University Medical Center in Durham, North Carolina.

Medscape: Although attention deficit-hyperactivity disorder (ADHD) is considered a disorder of childhood, some manifestations persist into adulthood in at least half the cases. ADHD prevalence among US adults is estimated at 4.4%, which is a lot of people.[1] In your opinion, who should get treatment, and who in fact is actually getting treatment?

Dr. Weisler: In Kessler's survey, which found the 4.4% prevalence of ADHD among people age 18 to 44 years, only 10.9% were actually getting any treatment during the preceding year.[1] Yet some in the general public worry that ADHD may be overdiagnosed. When you look at the diagnostic criteria, they require impairment in multiple areas, such as school or work, and also in relationships or at home.[2] If significant impairment exists in these areas, I believe that treatment is indicated. Many people have a little forgetfulness or inattentiveness, but if it doesn't cause problems, it does not require treatment.

Medscape: In your opinion, who are the 10.9% of adults with ADHD receiving treatment, and why are they getting treatment whereas the others are not?

Dr. Weisler: Some selection bias exists related to resources that people have, such as insurance coverage and maybe access to care in some regions. Certain places have a shortage of mental health professionals, and although primary care physicians may be comfortable in making a diagnosis of major depression or generalized anxiety disorder, almost half feel uncomfortable making a diagnosis of adult ADHD. They likely will refer the person to a psychiatrist for evaluation, if possible.[3]

Medscape: Once the diagnosis is established and a decision is made to proceed with treatment, how should the clinician and patient arrive at the treatment goals? And what's the best way to monitor progress?

Dr. Weisler: As far as treatment goals, in my opinion it's very useful to track target symptoms, even if you don't want to use a rating scale such as the ADHD-RS, the Wender Utah Rating Scale, or the Conners scale. Specific targets could be, for example: Is the patient better organized and better able to focus on tasks? Is the patient listening to people more carefully? Is he less forgetful? Does she intrude less in conversations? Can the patient more readily complete tasks? Most patients will identify several symptoms that to them are important.

Medscape: Some of the manifestations you mentioned would best be determined by another observer, such as a spouse or a partner.

Dr. Weisler: In my practice and often in my research as well, I contact family members and speak to significant others, roommates, and friends to learn if they see it the same way as the patient. Many times they do, but sometimes amazing disparities occur; patients tend, if anything, to minimize the symptoms. Patients have lived with it all their lives. By definition, you would expect some manifestations in childhood, probably before age 7 and certainly before age 12. If a person has somehow managed for 15, 20, or 30 years, he or she thinks that's just the way it is.

Medscape: In people with ADHD, comorbidity is common and may include anxiety, depression, and substance use disorders.[1] Should comorbid conditions be treated first?

Dr. Weisler: It depends on what the comorbid condition is. In someone with bipolar disorder and comorbid ADHD, I think it would be a mistake to treat the ADHD first. I'd work to get the affective illness under control, and the same would apply to major depression.

With an anxiety disorder, particularly if it's very symptomatic, I would also treat that initially and then address whatever ADHD symptoms remain.

Substance use disorders are tricky; I think that the clinician should, if at all possible, strive to have the patient attain abstinence. But at times, you may have to treat the ADHD to allow the patient enough stability to go forward. In those cases, I prefer to use medications that have little or no liability for abuse if possible. With treated ADHD, many patients will have less likelihood for substance abuse because they will have fewer tendencies to self-medicate.

Medscape: In a 2007 study by Safren and colleagues,[4] they examined self-reported treatment adherence in adults with ADHD, and they did not find that adherence seemed to correlate with the presence of anxiety or depression. But they found that adults with poor adherence, defined as fewer than 80% of medication doses taken, had greater severity of ADHD symptoms. This presents clinicians with a conundrum: the more impaired patients are the ones who are less likely to take their medication. What's the solution?

Dr. Weisler: I think there's a lot of truth to that; we also see poor adherence in severely impaired patients with schizophrenia or bipolar disorder. Forgetfulness and inattentiveness clearly increase in those situations, and motivation goes down. Highly impaired ADHD patients tend to be more impulsive, and some have a comorbid conduct disorder.

I think that 1 solution is a point you brought up earlier, which is trying to involve a significant other who can help improve adherence. Not only can you improve adherence; the more time I spend talking to families and patients about the disorder and their treatment goals, the more likely they are to comply with treatment and understand the consequences of not treating. By bringing in and educating a girlfriend, a wife, a father, or a grandparent, you create a surrogate to ask, "Are you taking your medication today?" This improves the likelihood that the patient will continue the therapy.

Using long-acting, once-a-day medications also makes a big difference. The shorter-acting drugs have effect for only 3-6 hours, and doses have to be repeated multiple times during the day. We know that multiple dosing tends to reduce adherence, especially with 3 or more doses per day. But even twice a day can be a problem for someone with significant ADHD.

Medscape: Do you know of any other studies of adults that examined adherence, especially looking at it more objectively than just by self-report?

Dr. Weisler: There was a very interesting study of medication compliance in patients with cocaine dependence.[5] In this trial, medication was dispensed using a medication event management system (MEMS) with a technology that recorded the time when people took out the pills. The investigators also had patients record in a diary when they took the medication. When they analyzed the data, they found that a sizeable number of patients who wrote that they had taken the medication as prescribed actually took out the pills just before they came to the office. So patient reports are reliable much of the time, but not always. Having family members give you feedback about how the patient is doing and whether the patient is taking the medication is helpful.

More directly relevant to ADHD is a study by Capone and colleagues[6] that examined monthly persistence on medication. They found that even after just a few months, half the people weren't taking their medication. Adherence dropped to 20% after a year or so. Unfortunately, it's not all that different from what we see with bipolar disorder, depression, or other psychiatric disorders.

An analysis I was involved in found that children and adolescents tend to take medication for ADHD during school sessions, but when summer holidays come, prescription use goes down.[7] In fact, clinicians have known for years that children and adolescents tend to decrease their use of medication during the summer. And among college-age adults, we see the same thing; they don't take the medication during school breaks or even on weekends.

Medscape: What are the consequences of patients taking medication only when they perceive the most need for it? Does it really matter?

Dr. Weisler: ADHD affects job performance and even the likelihood of maintaining gainful employment.[8] It also has an impact on relationships; people with ADHD are more likely to be separated or divorced.[9] Given impairment in multiple areas, most people without active treatment will have difficulty in work or personal relationships.

Furthermore, among all young adults, death and injury are most likely to result from automobile accidents. Barkley found that people with ADHD are more likely to have traffic violations.[10] With distractibility and impaired attention, someone may lose focus on the road because he's tuning the radio and talking to friends at the same time he's driving.

Medscape: So poor adherence could have deadly consequences.

Dr. Weisler: Yes. And then you have addiction and destructive behavior.[9] People with ADHD do things impulsively; they get into arguments or fights. They may gravitate toward smoking, drinking excessively, or using recreational drugs. So in general, steady treatment is desirable. And a bonus is that the side effect burden is reduced with regular treatment because patients often accommodate to adverse effects. Otherwise, each time they restart treatment they may have bothersome effects again.

Medscape: Aside from extended-action medications, what other pharmacologic characteristics affect treatment adherence?

Dr. Weisler: With ADHD, just as with other diseases, people will have idiosyncrasies as to what effects are unacceptable. In some people, stimulants interfere with sleep, and that's enough to turn them against medication. Yet in most cases, if they take the medication for a few weeks, their sleep cycle will normalize.

Other patients really love to eat, but some of the medications, particularly stimulants, affect appetite. For some, that's a plus and actually promotes medication adherence, but for others, it's really upsetting. So with each patient, it's important to explore what would make him or her less likely to take medication. If patients notice improvements, if they are listening better, are more organized, and more productive, the improvements are reinforcing and enhance adherence. But they often need to be told what to look for.

Medscape: What role do psychotherapy or other psychosocial interventions play in treatment of adult ADHD and promoting medication adherence?

Dr. Weisler: I think that psychotherapy can play a significant role. If you've lived with undiagnosed ADHD for many years, your self-esteem is likely to be low. You may well have some depression or be anxious in certain situations because you are worried about what people think of you. I think that cognitive therapy can make a big difference for both depression and anxiety.[11]

Patients can learn techniques that will help them cope with their limitations better.[12] Professional coaches can assist people, and simple techniques such as wearing sound-canceling headphones while they're trying to work in a noisy environment can make a difference.

In my experience, adherence is clearly improved with psychotherapy. It doesn't necessarily get people better faster, but it makes them more likely to stick with treatment, and it's another way of addressing difficult issues.


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