July 1, 1996
Psychiatric Times.
No. 7
ADHD in Adults
Paul H. Wender, M.D.
Dr. Wender serves as distinguished professor of psychiatry and director of psychiatric research at the University of Utah School of Medicine. He has written more than 50 journal articles and six books, the latest of which are The Hyperactive Child, Adolescent and Adult; Understanding Depression; and Attention-Deficit Hyperactivity/Disorder in Adults.
Practical Comments
The stimulant drugs are the treatments of choice, but they have one serious shortcoming: their brief duration of action, which necessitates multiple daily doses. Their advantages are that-unlike many psychoactive drugs-they have an immediate (30 to 45 minutes) onset of action and that methylphenidate and the amphetamines rarely produce idiosyncratic reactions. We have seen only rare tolerance develop to methylphenidate or d-amphetamine. The usual dose of methyl-phenidate is 10 to 15 mg administered every two, two and one-half, or three hours with a total daily dose of 40 to 90 mg. The long-acting formulation, Ritalin-SR, is available in only one dosage size, and many patients report that the formulation does not provide symptom suppression on once-a-day dosing as claimed by the manufacturer. The dose range for d-amphetamine is 5 to 15 mg administered every three to four hours, with a total daily dose of 20 to 45 mg. Dexedrine (dextroamphetamine) is available in an ostensibly long-acting formulation, Dexedrine spansules, but many patients report that this formulation does not provide symptom suppression for the claimed six to eight hours. Methamphetamine is available as a long-acting formulation, Desoxyn gradumets, which do indeed last eight to 10 hours, but they are extremely expensive; the total daily dose is the same as for d-amphetamine, 20 to 45 mg per day. Methylphenidate and the amphetamines seem to be equally effective; however, an individual patient may do better on one than the other, and if the response is not complete, the other stimulant drug should be tried. In all patients, pulse and blood pressure may increase and so they should be monitored; it is best to take measurement at the same time (usually about one hour) after drug administration. Pemoline is administered in a dosage range of 75 to 150 mg per day, usually in one dose, although some patients require bid dosing. Repeated liver function tests must be obtained (for an undetermined period of time) as hepatic toxicity occurs in a small fraction of patients receiving this drug. Pemolineýs chief appeal is that it is relatively long-acting and is a Schedule IV drug. However, it appears that patients do not respond to pemoline as frequently or as well as they do to methylphenidate or the amphetamines. The open studies of the efficacy of bupropion and selegiline were favorable, and these agents should be systematically evaluated because compared to the stimulants they are relatively long-acting and do not carry the abuse stigma. Management of the patient involves more than adequate drug therapy. Having made the diagnosis, I help patients to recognize the ADHD aspects of their current symptoms and behavior, and, as our relationship develops and my knowledge becomes more extensive, of the role ADHD personality characteristics have played in their life history, including academic and vocational experience, friendships, sexual relationships and functioning as a spouse and as a parent. ADHD symptomatology may be intimately woven into all these aspects of life; and it takes patients much time-during continuing treatment-to identify and understand ADHD contributions to their life story. In my education of patients I help them to see that because they have had ADHD their entire lives, they may have developed techniques for dealing with their symptoms that are no longer adaptive after the ADHD symptoms have remitted. These symptoms may resolve spontaneously or they may require psychotherapeutic intervention. Supportive problem-directed reality therapy (administered by persons sometimes referred to as "coaches") can help with these problems. Obviously, having ADHD does not prevent one from having other psychological problems and these may be more apparent and therapeutically accessible when the symptoms of ADHD have remitted. Couple therapy, with direct behavioral prescriptions and proscriptions, may be useful. ADHD is a life-long disorder and the duration of drug treatment may have to be life-long. Amphetamines have been used since 1937, and no long-term toxicities have been reported. However, both methylphenidate and d-amphetamine increase heart rate and blood pressure, which must be carefully monitored in all patients. Their use may require adjuvant therapy to control heart rate and blood pressure. Whether such drugs interfere with the therapeutic action of the stimulants remains to be demonstrated.
Conclusion
ADHD in adults is a common, genetically transmitted disorder, probably mediated by decreased brain dopaminergic functioning. It is usually undiagnosed but fairly easily diagnosed. At least 60 percent of patients experience a substantial, and in many instances a dramatic, response to drug treatment; and such drug treatment can make ADHD patients amenable to a number of psychotherapeutic
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