Real-World Office Management of ADHD in Adults

3 STAGES OF OFFICE-BASED TREATMENT
Office-based treatment of adult ADHD includes 3 stages, as shown in Table 1. The first stage includes a thorough assessment of ADHD and all coexisting conditions; aggressive medication management of all the conditions present; and restoration of patient morale. The second stage includes helping pa tients learn to manage an interest-based nervous system and to disregard the importance-based techniques that they have been taught and that they have seen working for people with importance-based nervous systems. The third stage of treatment includes an assessment of the current level of skills necessary for autonomous adult functioning and the acquisition of interest-based skills.

Stage 1: Assessment, morale, medication
Assessment. First impressions are important. We recommend that psychiatrists who treat adults with ADHD make a special effort to make the office environment welcoming. Many of these patients have what has been termed rejection-sensitive dysphoria. They are excessively sensitive to the mere per ception of rejection, criticism, or ridicule. Many experience what can only be called affective storms as a result. Patients may fail to engage with a practitioner whom they perceive to be analytical, judgmental, and aloof. We encourage our staff to be welcoming and friendly, and we offer soft drinks and snacks in a relaxed and informal setting. These measures send a welcoming signal to patients.

The first step in the treatment of any person with apparent ADHD is a thorough assessment, as outlined in Table 2. In our practice, this may take as long as 3 hours. As many as 70% of patients with ADHD will have another Axis I diagnosis.² We confirm the ADHD diagnosis while looking for other potential problems, including perceptual problems, learning difficulties, and anxiety.

Obtaining a general medical history, along with a list of current medications, is essential. Glaucoma is the only absolute contraindication to stimulant use.

Ask about a female patient's menstrual status. While there has been no formal research concerning this matter, ADHD medications are likely to be less effective when estrogen levels are in the low physiologic range. When large numbers of women stopped taking hormone replacement therapy because of reports of an association with myo cardial infarction and stroke, physicians who treat adults with ADHD received complaints from many of these women that their ADHD medication had be come ineffective; when they resumed taking estrogen, the ADHD drugs began working again.

Particular attention to the cardiovas cular system and especially any fam ily history of early heart disease is essential, because of the presumed risk of cardiac complications with some ADHD medications.³ This perception of increased cardiac risk is being challenged, however. Wilens and colleagues⁴ have demonstrated that mixed amphetamine salts can be used with safety in adults with preexisting cardiac disease. The details of the cardiac evaluation are shown in Table 3.³

It is important to ask about conditions that might mimic or coexist with ADHD, such as petit mal seizures, distraction by obsessions of obsessive-compulsive disorder, bipolar disorder, or head injury. Sleep apnea is a major problem in this regard. We have seen patients with sleep apnea whose daytime behavior bears considerable resem blance to that of people with ADHD. If you suspect sleep apnea, you may need to ask a bed partner whether the patient snores in an apneic pattern.