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 covered a wide variety of psychiatric issues and industry updates, from complementary and alternative approaches in the COVID-19 era to mental health’s most toxic myth. Here are some highlights from the week.

COVID-19 and Mental Health: Global Consequences and CAM Approaches

As the virus that causes COVID-19 illness (SARS-CoV-2) continues to mutate, we continue to see high rates of COVID-19 illness with concomitant neuropsychiatric symptoms including depressed mood, anxiety, posttraumatic stress disorder (PTSD), and other mental health problems. Medical and psychiatric comorbidity are expected to have serious long-term consequences for global public health and mental health.

Although there is no evidence that natural supplements or other complementary and alternative medicine (CAM) interventions prevent or treat medical illnesses caused by SARS-CoV-2, preliminary findings suggest that select supplements and other CAM approaches may have beneficial effects on mental health problems associated with the pandemic. 

Prior Authorizations and (Micro)managed Care

During my first year working at a community mental health center (CMHC) in New Hampshire, there was a moratorium on prior authorizations for patients with state Medicaid insurance. This was due to strong advocacy efforts with state legislature by one of my psychiatrist colleagues at the CMHC, and other dedicated stakeholders. This was great… until it ended.

My nurse practitioner program prepared well me for many facets of patient care, but an area that was not addressed was the concept of prior authorizations and the potential challenges faced by insurance formularies. My first experiences left me thinking, 

What do you mean I went through all of this training to select the best possible medication for my patient, and now I am being told I cannot prescribe that? 

The idea of someone who has never met or assessed the patient making these judgment calls is difficult to sit with, especially when medications that have proven to be efficacious for a patient when nothing else has are no longer covered or the coverage is declined. 

Examining the Increasing Number of Adult Women With ADHD

“So many adult patients—women—come in and are being newly diagnosed with ADHD [attention-deficit/hyperactivity disorder] for the first time,” Pamela Wall, PhD, PMHNP, FAANP, told attendees of the American Psychiatric Nurse Association 36th Annual Conference. The goals for the session were to explain the reason for this phenomenon and to share some of the unique issues associated with ADHD in adult women.

Implicit bias was a top reason for missing the diagnosis earlier in women, Wall explained, as she conducted a mini-experiment with attendees. After asking attendees to visualize a child who is hyperactive, Wall surveyed the group to see what gender they saw; most of the audience pictured a boy. 

The biggest and most deeply destructive myth of mental health is the twisted notion that there is a group of people called the “mentally ill” who are somehow different and separate from the rest of us. “We,” the majority composed of “normal” people, are not like them, the mentally ill. They are different from the rest of us, worthy of pity and curiosity. But since we are good, sympathetic people, we all want to help “those people” who suffer from such illnesses out of the goodness of our hearts.

What is wrong with all of this? The delusional idea that we are separate in any way from the mentally ill. In fact, there is no 

 because the people who deal with mental illness are 

. All of us. Literally all of us deal with mental illness. Every single one of us does. How can this be true? Because massive, carefully performed studies tell us that half of our population experiences some form of mental illness over the course of their lives. Fifty percent of us experience mental illness directly. And what about the other 50% of us? The other 50% have the experience of seeing someone we love suffer from mental illness. Whether it is a friend, a family member, or a close coworker, every single one of us loves someone who experiences mental illness. All of us are affected by mental illness, directly or indirectly. There is no 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

From complementary and alternative approaches in the COVID-19 era to mental health’s most toxic myth, here are highlights from the week in Psychiatric Times.

The Week in Review: October 24-28

We’re going to talk about novel treatments for ADHD. First thing we’d like to discuss are the benefits and limitations of recently approved FDA therapies with novel drug-delivery systems. Pro drugs, devices, single-pulse sustained-release medications, patches, tablets, and suspensions. What do you all think about this wide array of therapies that the FDA has approved in the last few years?

: It’s great. Like I mentioned earlier, I use every single one, more or less, of the various formulations of stimulants. Any advancement is going to be a one that I welcome. And especially as a chemistry major in college, that’s what lets me really investigate the pharmacokinetics of these different formulations. And they are just so much better, recently. Like I said, an extended release from just 10, 15, 20 years ago is very primitive, compared to what’s coming out today. A lot of clinicians, when they hear that, oh, another extended-release amphetamine, another extended-release methylphenidate, it is very different. It’s like having a V-6 engine in 1969, versus a V-6 in 2022. You’re going to have a lot better parameters for this newer engine than you did for the old one.

Andy, what’s your take-home message for these new medications? Is there one that pops out to you, that you say, “this came along, and it’s been useful in my practice?”

 It has been very exciting, and it is very confusing, with all the new medications approved. Most of the ones that have been approved over the past few years are formulations, newer formulations of stimulants. It’s either amphetamine or methylphenidate. That’s not necessarily new. It’s this increased technology that Craig’s talking about. And I completely agree. The newer ones tend to have a lot of superior delivery mechanisms. And that translates into a superior pharmacokinetic profile. We know that, for stimulants, there’s a tight relationship between PK and PD. Meaning the pharmacokinetic profile, or what it looks like in your blood, and the clinical effect or clinical efficacy. I’m very fascinated by the fact that we finally have a prodrug version of methylphenidate available, the serdexmethylphenidate. We’ve had the lisdexamfetamine amphetamine version available for a long time. A new tablet form of an extended-release amphetamine has been just recently approved, and I’m very excited about. It has superior pharmacokinetics, and it’s made by an ion exchange, a coded particle system that’s very advanced. And Craig would understand it better than me, being a chemistry major. And then, of course, there has also recently been an amphetamine patch finally approved. For many years, we’ve had a methylphenidate patch. We now have a methylphenidate and an amphetamine version of both prodrugs and of patches. And that certainly allows us to have a tremendous ability to individualize, as Craig said. It is worth taking a couple minutes to try to familiarize yourself with these different formulations. And finally, the one we’ve all alluded to, viloxazine extended release, was approved for kids in April of this year, 2022, was now approved for adults. And that’s been a significant addition. There is one in development that’s not far away, I’d like to mention. That’s called sentinaphidine, which I’ve been very involved with developing. That’s a triple reuptake inhibitor. It’s very exciting. What we need, of course, are probably some newer mechanisms that go beyond the traditional monoamines of norepinephrine and dopamine. But that’s what keeps us going.

Theresa, I’m going to turn it over to you, and ask you what you think about some of the new devices that are out there for ADHD.

: The more the merrier. Just allows us to individualize treatment options. It’s never about one thing being better than another. Not a drug, not a device. But like any good relationship, finding the right fit between the individual patient and their treatment needs. That’s my take-home message.

Absolutely. In a way, it’s a gift to the practitioner that the toolbox is full of tools that can help the patient. And we now have this trigeminal nerve stimulation that Jim McGuff published a paper on. Very good RCT, randomized control trial. Very decent effect size, close to what you would expect for stimulant medication. It needs to be shown how it works in clinical practice, but it’s something people should look at. The FDA also cleared a game for ADHD, called EndeavorRx®. And what the clinician needs to know about EndeavorRX® is that its primary outcome in the clinical trial was a neuropsychological test of attention. It did a good job separating from placebo. But in the clinical trial, although it improved ADHD symptoms a lot, it didn’t separate from placebo. And until we see that happening, we can’t recommend it as a treatment for symptoms of ADHD. But I say keep your eye on this device field. Because my expectation is, in the next 10 years, we’re going to see some creative devices coming out, that are going to be very helpful for kids with ADHD.

: Steve, there’s devices and then there’s PDTs, prescription digital therapeutics. And that game you’re talking about is a therapeutic video game that’s a prescription digital therapeutic. There are others in development. That device you mentioned from Jim McGuff’s group is interesting. And then the other area- believe it or not, TMS is also being looked at. And there are some newer protocols that appear to be even more efficient in delivering the magnetic pulses, that have some promise, as well. I agree with you. We’re going to go beyond the pills.

: I will say I’m cautiously optimistic, in that there have been devices in the past. And I have been- and used clinically. What I have found is that, although you may see initial benefits- and that was supported not just clinically but by the data of some of these in the past. The sustained benefit wasn’t there. And 6 months later, a year later. Again, cautiously optimistic. I know we’ve got a long way to go before I’m convinced about the sustained benefits. But hopeful.

: That’s one of the things that must be worked out. What is the long-term protocol? Do you do a repeat treatment every 6 months, for instance? How does that work?

That’s right. And for the EndeavorRx® they do have a very nice protocol for long-term treatment. They have thought that through. It will become a template for the future, for how these device-type treatments will be administered. But we’re going to end on that optimistic note, that in the future we’re going to see devices that may replace our drugs, may not. We probably will see more formulations of drugs, more non-stimulants. But practitioners need to know there are a lot of new formulations, new drugs out there, that they should take a close look at. Because it provides you with another tool in the toolbox, that can help your patients with ADHD. Thanks, everybody, for participating. I really enjoyed this discussion with you today.

Drs Stephen Faraone, Theresa Cerulli, Craig Chepke, and Andrew J. Cutler discuss novel drug delivery systems and provide take-home messages when treating an adult with ADHD.

Novel Drug Delivery Systems in ADHD and Take-Home Messages

: Something we haven’t talked about yet, because it is often misunderstood, is what do we mean by genetic testing? And I can’t tell you how many times this has come up when I’m doing a presentation, where clinicians are misunderstanding that somehow that helps you pick the right medication, or the right class of medication for patients. I want to emphasize the genetic testing that exists is simply metabolism. DNA-based evidence for how one might metabolize the medications we have available in psychiatry. And certainly, the amphetamines versus the methylphenidates. But it can’t choose the most efficacious medication. It can’t necessarily predict who truly is going to tolerate or not tolerate. It’s just a guide in thinking about how the individual patient may metabolize, faster or slower, that given drug that you’re about to prescribe. That’s it.

: Well, that’s not entirely true. These tests are mostly geared towards pharmacokinetics, as you’re talking about. But there are some pharmacodynamic tests embedded in there. And one that helps me with ADHD, believe it or not, is COMT. COMT is catechol-O-methyltransferase. That’s the enzyme that breaks down dopamine. Most of the time, an enzyme with a mutation is less effective. This is a mutation that makes it super charged. And it will chew up dopamine, especially in the prefrontal cortex. And patients who have that mutation, I have found, sometimes do better with an amphetamine, which is a little more potent at releasing dopamine, believe it or not. Now, it is true that you can use these tests to look at pharmacokinetics. For instance, methylphenidate is metabolized by CES-1, which is genetically variable. Amphetamine is mostly metabolized by CYP2D6, which we know is genetically variable. But you’re right. In general, they’re not as good at helping us pick the exact medication, with a couple of caveats. And these tests are evolving. I’m not an apologist. I’m not- I’m just trying to be realistic about them.

I’ve studied this a lot in my own career of pharmacogenetics. And number one, it’s very clear from all of the professional societies that are interested in this as The American Psychiatric Association, The American Academy of Child and Adolescent Psychiatry say that pharmacogenetic testing for everybody is not warranted at this time. The associations differ on whether it’s useful in specific cases. And I would say there’s some agreement that, in certain cases, it can be very useful. Particularly difficult cases, where- being hard to figure out what medication would work well. Maybe with, for example, this patient who’s tried so many drugs, and has failed so many drugs. In some cases, pharmacogenetics will discover a genetic variant that may explain what’s happening, and guide treatment. But it’s not going to be for everybody. In fact, there have been studies showing that people that use them on all patients can sometimes go outside of guideline treatment. Because if they’re used in a either too much of an algorithmic way, because they’re not, the evidence base for them is weak, sometimes it points somebody to a medication that actually wouldn’t be a first or a second-line treatment. And that’s not a good thing.

Stephen Faraone, PhD; Theresa Cerulli, MD; Craig Chepke, MD, FAPA; and Andrew J. Cutler, MD, discuss implications of pharmacogenetic testing in ADHD.

Implications of Pharmacogenetic Testing in ADHD

From fallacies to frustrations, experts shared insights on 

adult attention-deficit/hyperactivity disorder

 (ADHD) in a recent custom Around the Practice video discussion.

“There is controversy about how often ADHD persists from childhood into adulthood,” said panelist Andrew J. Cutler, MD. “In my clinical experience, the presentation can wax and wane, either the symptomatology or the impairments. Sometimes it has to do with the environment, its stressors, and various things going on.” Cutler is clinical associate professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, and the chief medical officer of the Neuroscience Education Institute.

Cross-sectional studies also suggest a waxing and waning of symptoms in adults with ADHD, according to moderator Stephen Faraone, PhD, who is distinguished professor of psychiatry at SUNY Upstate Medical University in Syracuse, NY. Faraone noted about one-third of adults with ADHD will not appear to have ADHD if examined at a single point in time, because symptoms and functional impairments may change depending upon what is happening in patients’ lives.

“I kind of think of multiple sclerosis, this remitting-relapsing picture. That’s how I explain it to my patients,” added panelist Theresa Cerulli, MD, president and medical director of Cerulli and Associates. “It is rarer to see somebody go into ‘remission’ and stay in remission... It really is this kind of a sine wave with the longitudinal perspective.”

Thus, the panel agreed it is important to ensure patients are doing well and, if not, that they are given the treatment support they need. “If a patient has had history of ADHD and, after a period of time, they are only showing a few symptoms and they’re still impaired, they still have ADHD. We don’t require that they have the full symptom count to allow treatment,” Faraone said. “It would be a mistake to deny [them] treatment.”

Similarly, there is a misconception that adults who are successful and high-achieving cannot have 

. “I have had more than a few colleagues tell me that a patient thinks he has ADHD, but [the patient] went to medical school or went to law school and he is a high achiever, so how can he possibly have ADHD?” Faraone said. “There is actually a lot of research which... shows that people who have high IQs and ADHD are doing worse in life than people with high IQs who do not have ADHD. They do need help and should get it. We shouldn’t discriminate against high IQ people because they are good achievers, because they can do better if they are properly treated.”

“About 75% of the time, if you’re diagnosed with ADHD, you are going to have at least 1 comorbidity; and the data shows 60% of the time you are going to have 2 or more comorbidities,” Cerulli noted. “The complex medical histories that many of our adults can present with can become very challenging—people that have problems with blood pressure other 

 in adulthood—and we want to be very careful.”

Depression and anxiety are often comorbid psychiatric conditions, she added. And patients with both psychiatric and medical conditions “is more the rule of thumb than not.”

Faraone added that ADHD shares genetic risks and therefore comorbidity with somatic disorders, especially cardiometabolic conditions such diabetes and obesity. What makes matters worse is that the diabetes appears not to be as well managed when ADHD is not being managed.

Sleep issues are also common, although it often is not considered apart from the medications’ effects. “I think many practitioners don’t realize that, although insomnia and sleep problems are side effects of some ADHD medications, they’re also associated with ADHD in the absence of medication,” Faraone explained. “That’s been shown now by many studies and meta-analyses; it’s as strong as data gets. Patients need to be evaluated for preexisting 

. In some cases, if patients have sleep apnea and are treated, ADHD symptoms will be reduced pretty dramatically, with an effect size similar to a nonstimulant.”

Cutler noted that treatment choices are somewhat limited, adding that the available stimulant molecules (amphetamines and methylphenidates), both have similar and, importantly, very high effect sizes. There are some differences in how they work, he said, although they both block the reuptake of norepinephrine and dopamine.

“It is interesting that there are some patients who do better with one than the other; either they have a better response, or they tolerate one better than the other,” Cutler said. “One of the points I always like to make to clinicians is if you’ve been using methylphenidate, and the patient is not doing well, please switch over to the other—to the amphetamine. Always make sure you have tried both before you give up on them.”

There are safety and tolerability issues associated with 

, including insomnia, irritability, decreased appetite, cardiovascular risks, and the possibility of worsening psychiatric conditions, such as psychosis and mania. Plus, the panelists noted that stimulants carry a risk of abuse and diversion, although it is less likely with the long-acting varieties.

“I’m very, very much in favor of using extended-release formulations,” Craig Chepke, MD, FAPA, shared, adding that they are not all created equal and have changed over the years.

“An extended release from just 10, 15, 20 years ago is very primitive, compared to what’s coming out today,” said Chepke, Medical Director at Excel Psychiatric Associates, PA, and clinical assistant professor of psychiatry at State University of New York Upstate Medical University. “You’ve got a V-6 engine in 1969, versus a V-6 in 2022. You’re going to have a lot better parameters for this newer engine than you did for the old one.”

“I completely agree, Cutler said. “The newer [stimulants] tend to have a lot of superior delivery mechanisms. And that translates into a superior pharmacokinetic profile.”

“If someone did have a problem—where one extended release formulation was too long-acting for them—we can switch them to a shorter- acting, extended release formulation,” Chepke explained. “And vice versa: If it’s too short of a short-acting, we don’t need to necessarily add a booster of an instant release, as has been common in the past. We can switch to a long-acting stimulant that is extra-long acting.”

Chepke noted patient education is important, especially when prescribing the long-acting varieties. “Some patients will want to go back to an instant release because they can tell when it is working,” he said. “And what I have to tell them is that’s not a good thing; that’s a buzz, that’s not a therapeutic effect you’re feeling. And you don’t need that buzz to have efficacy.”

There are also nonstimulants, including alpha-2 agonists and norepinephrine reuptake inhibitors, the panelists noted. Both are not controlled substances and both are considered effective—just not as “universally effective” as the stimulants. Cutler explained, “They don’t work for everybody, obviously, but they have a lot less of some of the baggage of the stimulants.”

There are some factors that should be considered when prescribing these agents, Cutler added. “If we’re talking about the norepinephrine reuptake inhibitors, we do have issues with blood pressure. They also have bolded warnings about 

. There are warnings around somnolence sedation as well, and you do have to worry about activation and the possibility of mania.”

Interestingly, the alpha-2 agonists have an opposite profile, he said, adding those medications are alsoused for hypertension. “We worry about lowering blood pressure, not increasing blood pressure,” Cutler commented. “And when used by themselves, they can be quite sedating.” Culter added these agents are currently only approved for children, not adults.

What about deciding between stimulants and nonstimulants? “We have to think about the risk/benefit ratio when we’re prescribing,” Chepke explained. “When I’m confident that someone has ADHD, it justifies the risk, in my mind, to prescribe stimulants because it is risky for non-treatment. However, when I’m not confident in that diagnosis of ADHD, that changes my risk/benefit calculus, and so nonstimulants rise in my decision tree.”

Cerulli also likes to consider comorbid conditions. If depression also presents, she might consider a nonstimulant that has some benefits for mood. “I like to collaborate with the patient, and say, ‘I’m going to be transparent in what I’m thinking, and there isn’t a right or wrong. You could say to me, ‘Look, no, I know I’m depressed, but I know the reason I’m depressed is that my ADHD is out of control. and I know in my life when I have my ADHD better managed that the 

 goes away.’ Then I would change the order,” she said.

Simularly, Cerulli is cautious about prescribing stimulants for patients with comorbid anxiety. “I’m not a big fan of combining anti-anxiety medications and stimulants as usually the risk with stimulants of worsening some anxiety symptoms in somebody already prone to anxiety. Depending on the patient and the situation, I’m just more careful before I go that route.”

Cutler reminded his colleagues that sometimes that anxiety is due to untreated or undertreated ADHD. “Sometimes you have to tease out the chicken and the egg. I have many patients—as I’m sure you do, too—who when I treat the ADHD, the anxiety gets better because a lot of the anxiety is that overwhelmed feeling,” he said. “They can’t keep track of things. They are always worrying: ‘What did I forget? What am I going to lose? What kind of mess did I make out of things?’ So, I think you have to carefully tease things out.”

“Although we have dozens, literally, of stimulants, and we have some nonstimulants as well, we still don’t have enough treatment options,” Chepke said. “One aspect is the small range of molecules that we have... And each one of those has certain pharmacokinetic limitations.”

Cutler agreed, saying additional options could potentially address safety profiles, too. “As people get older, I’m very concerned about cardiovascular issues, and other medical conditions, drug-drug interactions—because they’re on multiple medications. And the 2 approved nonstimulants—the norepinephrine reuptake inhibitors—have warnings about blood pressure and heart rate, as do stimulants.”

Additionally, Cutler would like to see options that address diverse symptomology, like executive function. “This is a big part of ADHD, especially in adults. And so medications that work for that [would be useful]. “

Cerulli added “robustness” to her wish list. “What I would like to see is a nonstimulant—or noncontrolled is probably better word—a noncontrolled medication for ADHD that is available 24/7,” she said. “It’s going to be there from the time you wake up in the morning until the time you put your head on the pillow in the evening.”

“I think also one that works consistently,” Cutler added. “My sense is that stimulants work pretty reliably for the vast majority of patients, and I think studies suggest it’s up to 80%, but nonstimulants are maybe more 40% to 60% of patients. So something that’s a little more consistent in more patients, too.”

Precision medicine—the ability to predict who responds to what medication—is on Faraone’s wish list. “We need to be able to have something that tells the clinician there’s a good chance that this person is going to do well on this nonstimulant or this is formulation. We are not there yet, but I do expect we are going to get there in 5 or 10 years.”

“What we need, of course, are probably some newer mechanisms that go beyond the traditional monoamines of norepinephrine and dopamine,” added Cutler, who is currently working on a triple reuptake inhibitor.”

Because there are no treatment guidelines for ADHD in adults in the United States, clinicians should keep the patient in the center of their treatment decisions, the panel agreed. That means individualizing treatment for efficacy and adherence as well as lots of patient education.

“It helps if you’ve got buy-in from the patient in the beginning,” Cerulli said. “You make that decision together, and you know there’s sort of a flow chart in both of your minds. If this isn’t a good fit, we know what to do next, and we know why we’re picking this one. If it is a ‘we’ decision, the chances of adherence are going to go up.”

, not just to help them with their symptoms, but also in general to help patients with their lives, their relationships, and their education/school and work. That is how you can take the whole picture into consideration, she explained.

“It’s not just about symptom control. That is one small piece,” Cerulli concluded. “The overall goal is having the patients’ lives improve, be better.”

There are no treatment guidelines for ADHD in adults in the United States, but you can still tackle this challenging diagnosis.

Tackling Treatment Issues in Adult ADHD

“So many adult patients—women—come in and are being newly diagnosed with ADHD [attention-deficit/hyperactivity disorder] for the first time,” Pamela Wall, PhD, PMHNP, FAANP, told attendees of the

 American Psychiatric Nurse Association 36th Annual Conference

. The goals for the session were to explain the reason for this phenomenon and to share some of the unique issues associated with ADHD in adult women.

Implicit bias was a top reason for missing the diagnosis earlier in women, Wall explained, as she conducted a mini-experiment with attendees. After asking attendees to visualize a child who is hyperactive, Wall surveyed the group to see what gender they saw; most of the audience pictured a boy.

In addition, she said what is known about 

 now versus what was known 20 or 30 years ago has changed, which allows for new adult cases to be diagnoses. Similarly, children often have mechanisms in place during their childhood that may hide the functional issues associated with ADHD—parents who set schedules and monitor them, schools with regimens, etc. These “safety nets” disappear as patients age and become adults, move out of their family home, go off to college, enter the workforce, etc.

To help illustrate this point, Wall shared a case example of a 30-year-old woman who initially presented with depressed mood, anxiety, panic, racing thoughts, and sleep onset insomnia. The patient was very successful in school growing up and credits that partially to strict schedules and expectations by her parents as well as her swimming regimen. In later sessions, she admitted to a history of struggling with concentration and organization and said she was often forgetful. After seeing success at a community college, she decided to move way to finish her education. Unfortunately, she struggled and received failing grades, so she moved back home. The current concentration issues are causing problems at her work as well as with her marriage, and thus she sought help.

Wall said patients like this often respond well to pharmacological treatment, even to the point of addressing other comorbidities like anxiety and depression. It is not uncommon, she added, for patients to tell her, “I feel calm for the first time in my life,” after initiating ADHD treatment.

There are differences between men and women with adult ADHD, Wall added. For instance, females may have higher hyperactivity and impulsivity than males, but it might register instead as restlessness. In some cases, the “restlessness” in women gets confused with anxiety, Wall noted. In terms of

, males usually have externalizing varieties like conduct disorder and oppositional defiant disorder. On the other hand, females tend to present with complaints of pain, anxiety, and somatoform disorder, she said. Girls with ADHD are also more likely to have disruptions in their relationships than boys, which results in lower self-esteem. Also important are the hormonal effects on ADHD in girls and women, she said. Finally, not all rating scales are normed for gender, Wall added. She said she uses the Conners rating scale for ADHD, as it has been normed for gender.

psychopharmacological and nonpharmacological treatments

 are successful for female patients, Wall noted. Stimulants are not recommended for women who are pregnant or breastfeeding, she added. Interestingly, she said girls respond better than boys with combined pharmacological and nonpharmacological treatment.

The APNA 36th Annual Conference was held October 19 - 22, 2022, in Long Beach, California. 

Why are more and more adult women being diagnosed with ADHD? A presentation at the APNA Annual Conference shed light on the issue.   

What signs and symptoms prompt testing for ADHD [attention-deficit/hyperactivity disorder] in adults?

I think the fact that most adults with ADHD have trouble with just everything from managing time and getting things done and following directions and even procrastination. These are very frustrating for people. There's also the impulsivity side managing emotions and being able to think before you speak, or not just jump into a million different directions, but to really be able to handle frustration for example, and not getting into too many traffic accidents or getting speeding tickets. All these things are signs of ADHD in adults.

And I think too often people will blame themselves or people will tell them just get with it. And in fact, this is not something that people aren't trying on their own to manage. From a psychosocial standpoint also relationships with family members, friends, and colleagues at work, can be really strained because of the person's ADHD. They'll forget important appointments, they'll interrupt people, they'll be seen as insensitive and flighty, and a lot of social rejection goes on. And it's been obvious that as we look at data from, say the National Epidemiologic Study that shows that the number 1 comorbidity of adults with ADHD is social anxiety disorder. And that's based, I think, a lot on having repeated experiences of social rejection or social failure.

It brings to mind a conversation I just had with one of my adult patients last evening, with regard to the pressure his ADHD diagnosis has put on his marriage. Because when someone's bright and otherwise holding down a job, his children and seemingly functioning 'fine,’ the other partners and those involved, close loved ones, don't necessarily see what it's like –

I know. You're so unforgiving. You're so smart.

It's really challenging. The divorce rate is twice as high when one member has ADHD, there's a lot of things. So outside of just school problems and work problems, I hope that people walk away understanding that ADHD is a problem with regulating attention, self-regulating behavior, and control of one's thoughts in terms of organizing, planning, and time management. It affects everything.

Oftentimes psychiatrists may attribute this to, say, things like a narcissistic personality disorder or even other cluster B kinds of disorders, when in fact the underlying self-regulation being the problem does lead to people having trouble acting in a way that we could say is either socially appropriate or mature enough for their age. So, they are very much in the doghouse. And of course, the other piece is that they feel low self-esteem as a result of this. So, there is a chronic sense of being inadequate, defective, and in some other way not meeting others’ expectations, which again leads to some unfortunate coping mechanisms such as over-reliance on alcohol or substances, a tendency to overcommit, and not be able to really deliver. And feeling constantly stressed out.

Anthony Rostain, MD, MA, describes some of the signs and symptoms of adult attention-deficit/hyperactivity disorder (ADHD), as well as the impact on psychosocial skills.

Signs and Symptoms of Adult ADHD

 PsychView presentation, “Novel Delivery System Utilized in the Treatment of Adult ADHD.” I'm Dr Theresa Cerulli. I'm a neuropsychiatrist practicing at Beth Israel Deaconess Medical Center in Boston, Massachusetts and in my private group practice, Cerulli and Associates in North Andover, Massachusetts, specializing in ADHD [attention-deficit/hyperactivity disorder] for over 20 years. I see kids, adolescents, and adults. I'm joined today by Dr Tony Rostain. Dr Rostain, please tell us about yourself.

Hi, great to be here. Currently, I'm the chairman and chief of psychiatry and behavioral health at Cooper University Health Care and Cooper Medical School of Rowan University in Camden, New Jersey. I spent 40 years at the University of Pennsylvania in Philadelphia, Pennsylvania, including the children's hospital. I moved into Emeritus, and I founded both a child ADHD program and also an adult ADHD program at CHOP [Children’s Hospital of Philadelphia] and at the University of Pennsylvania respectively, and I’m still very active as the past president of the American Professional Society of ADHD and Related Disorders.

So great to see you Dr Rostain, a pleasure to see you. You've done so much for the field of ADHD and I’m really looking forward to this discussion, so let's begin.

Thinking broadly, first can you briefly discuss the recent spike in attention-deficit/hyperactivity disorder, ADHD?

The good news is that our efforts to educate both the public and health professionals about the fact that ADHD exists in adults, I think this has become more and more recognized by a growing number of people. I also think ADHD symptoms really have an incredibly important impact on functioning in what we might call the digital environment or the digital world and trying to manage lots of things all at once. I think that if anything, ADHD has become more and more impairing as our society evolves to really require people to be able to start and self-start and do a variety of things on their own and not get off track. I guess social media in general has made it really easy for patients to learn more about ADHD. There are lots of people posting and teaching all the time so I think overall it's partly a greater recognition and also the fact that it's becoming more impairing in this modern world.

So well said, greater awareness for doing a better job I think getting the word out, but also, as you said, life has become more and more challenging for us, so trying to keep track, organize, manage our time and have goal-directed behaviors with good attention is challenging everyone, but certainly our ADHD patients. Let's add, you mentioned the digital world, COVID-19. Where do we begin here talking about the pandemic?

I think that COVID-19 may have led to a greater incidence of ADHD self-diagnosis. It may be because people are spending so much time on Zoom and working at home and finding it harder to function. The digital workplace is hard for many people with ADHD because normally it would be the environment that structures us and keeps us on task, so in familiar environments, but when you're at home and you've got all these other distractions and all the rest, I think that that was one factor.

I think the other is the disruption to just normal life that, again, required people to have to learn new routines and I think people with ADHD tend to have a little harder time getting routinized and then I guess, on the positive side, we could say that access to care via telehealth is easier. I actually think that the switch to telehealth has made it easier for people to get help.

I'm curious, are you using telehealth as far as diagnosis and management of adult ADHD and if so, what role do you think that's playing in your practice?

Obviously, we have to live within the regulations so it actually requires us, if we're going to use any kind of stimulant medication, for example, you can't just have never met the person in person. But I actually think that for my patients’ ADHD, once I've established a relationship with them and I'm convinced, and in the office, we've managed to ascertain that “Yes, indeed you have ADHD,” the follow-up visits are a lot better when they're on telehealth. People can literally stop what they're doing, check in with us, and get back to what they're doing. Many fewer no-shows for example, and much, much better adherence to the schedules.

That's been my experience as well. The no-show rate has gone down. There's more accessibility, at least online.

And it's also easier to then monitor treatment because I've begun to have just check-in visits that are briefer, but more frequent, because in the past you couldn't do that. People weren't going to travel to come to an appointment that's brief. But now you can do that especially when they're starting on medications, and you want to see how they're doing.

I want to circle back to thinking about what we said with regard to the spike in adults' ADHD. How has perhaps telehealth played a role in that, and how has this been reflected in underserved communities? Are we seeing the same spike?

As you know I'll make it explicit that ADHD diagnosis is lower within underserved communities, in part because of stigma, and mistrust. I believe there may be unconscious bias sometimes on the part of a provider, a psychiatrist, for example, thinking, well, this is all anxiety or depression, and maybe missing the root of this could be ADHD. And so, lack of awareness as well. I do think that the reliance now more and more on our digital community has really begun to break down some of that stigma if you will. And so, I'm seeing the beginnings of arising acceptance, at least in people heretofore who might not have thought they had ADHD.

Absolutely agree. The other bias I see, especially with adult ADHD, a lot of people won't come in afraid that people are just going to think that they're seeking substances.

That's huge. And that remains, by the way, when I hear people who delayed the diagnosis for years, Like, for example, I'm fortunate enough to do some assessments for the NFL [National Football League] and for professional athletes. You hear the story again and again. I knew I had it as a young person, but my parents really weren't willing to take me to the doctor because they didn't want to have me start on a stimulant medication. So, the stigma around stimulants is probably still one of the biggest hurdles we have to face. And I think part of it is the job of psychiatrists and other mental health providers to say, ADHD does not equal stimulants. ADHD is a condition; we need to understand it. It's got a chronic and a rather unremitting impact on functioning, and we need to approach it in a multiplicity of ways.

Theresa Cerulli, MD, and Anthony Rostain, MD, MA, discuss the recent spike of adult attention-deficit/hyperactivity disorder (ADHD) diagnoses and how this has been impacted by COVID-19 and telehealth.

Recent Spikes in Adult ADHD Diagnoses

 Craig, let’s talk about some other factors that might drive treatment selection. There are things like mechanism of action. There’s obviously efficacy, safety data, long-term use data, comorbidities. Can you give us a bird’s-eye view of how you put that all together when you think about what medication you’re going to choose for a patient?

 This is a continuation of the discussion we’ve been having all day. Is that it’s very individualized. But it comes down to a couple common threads. First, are we looking at stimulants versus non-stimulants, when talking about pharmacological techniques? A number of guidelines, including the Canadian ADHD guidelines, recommend not just the stimulants as first-line treatment, but long-acting stimulants. I want to reiterate again that we should be favoring the long-acting stimulants. And then when you look at which family of stimulants. That varies, as well. Both are efficacious. One can work well for one, and not for another. But in general, there was a meta-analysis that was done, and a systematic review a couple of years ago, showing that the best risk/benefit ratio for adolescence, in their opinion, was methylphenidate. And for adults, best risk/benefit was for amphetamines. That’s still not a hard and fast rule, though. Many clinicians will, even in adults, start with a methylphenidate if they’ve been untreated before. Often, I will do that. It depends on the individual patient. Figuring out what is going to fit their needs. Theresa brought up earlier, and Andy echoed it, the shared decision making. Very crucial. Because no matter what we think, if the patient doesn’t have a say in it, A, they’re not going to adhere to it. And B, it’s probably not going to be as good of a fit as we think it is. Because we can only assess so much. Taking that guideline information, and that knowledge that we have from our education, our experience. And then coupling that, and partnering with the patient, of their lived experience, that they’re the expert on. And concluding together on how to impact the person’s life in the best way. Trying to marry the individual experience with the guidelines, and everything in between, on a continual basis.

: And Andy, do you have an evidence-based hierarchy in your choice of medications for adults with ADHD?

 It would be nice if we had some type, as you mentioned, some type of biomarker or precision medicine guidance. I always joke. Our friends in other fields of medicine, such as oncology, they can do a test and tell you the best chemotherapy. And if we had something like that, we’d be like real doctors, is what I always joke. But how I think about it is this. And let me also back up and say, unfortunately, in America- Craig referenced the CANMAT [Canadian Network for Mood and Anxiety Treatments] guidelines. In America, we don’t yet have adult ADHD treatment guidelines. I know you, Steve, are working on those and we need them.

The American Professional Society for ADHD and Related Disorders is initiating, this month, a program to develop guidelines for treating- diagnosing and treating ADHD in adults. We’re hoping it’ll be ready by early next year.

: And I know you’ve published some quality indicators that are extremely helpful, to help guide us. As Craig said, we would agree. Just as with kids, stimulants have the best effect size, the best efficacy data, and are usually considered first-line, I would say. Unless there’s a situation where a patient is not appropriate for a stimulant, or refuses a stimulant, for whatever reason. Substance abuse, cardiovascular safety issues, whatnot. Certainly, we must remember, if somebody has a bipolar disorder, we need to manage that. Then you could be adequately mood stabilized. We’ll treat them with an atypical antipsychotic first. Then you can consider treating the ADHD. Between the amphetamine, I completely agree with Craig 100% while it is true that amphetamines probably do, in general, work a little better for adults, I’ve done the clinical trials with the newer extended-release methylphenidates in adults. And it had some do very well. I’m not averse to using those in adults. I have sort of the feel for who’s better for an amphetamine, who’s better for an methylphenidate. It’s not necessarily scientific, just from years of seeing patients. And then I tailor the formulation and the duration into this. I want to revisit this case for a second. Because I think we assumed here that I’m not clear on. She said that she can’t turn it off. She’s taking this mixed amphetamine salt extended release, and at the end of the workday, she can’t shut it off, and has some trouble with insomnia. Most people would look at that and think, “Oh, the medicine’s lasting too long and causing the insomnia.” But I think those of us experienced ADHD providers have said, “No. Wait a minute. It's possible it wore off too soon. The ADHD came roaring back, and that’s why she can’t shut off.” And I think that’s more likely, considering that mixed amphetamine salt XR is one of the ones Craig referred to earlier. That, while we call it extended-release, it’s not as extended release or as not long-acting as some of the others. And very often, I hear that, too, where there’s insomnia. But as we talked about it, it could be from the ADHD. It’s just they can’t unwind- mind off. Do I switch now to an even longer-acting formulation? Do I augment with a booster? Which is not ideal, because now I’m prescribing immediate release. What are the various comorbidities that I’m trying to address? These are all some of the ways that I think through what my treatment plan is going to be.

ADHD experts discuss factors that drive treatment selection when selecting therapy for an adult with ADHD.

Case 3: Factors Driving Treatment Selection in Adult ADHD

 We’ve followed along with our discussion. It’s not just about symptom control. That is one small piece. I would start with the overall goal is having the patients’ lives improve, be better. To be well-managed, to be able to take a treatment approach that both pharmacologic and non-pharmacologic interventions work for them, with minimal adverse effects, problems, hurdles, and with good adherence needed. What am I talking about? Overall, want to do a lot of psychoeducation with the patient. Help them with their symptomatology, but also just generally in their lives. With their family relationships, with their peer relationships, with their work productivity, with their school, in terms of academic performance. It’s, how do you create an individualized treatment plan that takes the whole picture into consideration? That their lives are better, and that we’re at least minimizing the downside or adverse effects as much as possible.

: This patient is a good example, because she had been treated, but she complains that she has no off button after work. It sounds like, almost, driven like a motor thing that kids have. What do we do in that case when somebody needs to have medication after work? Because for her, apparently, it’s not working when she leaves work.

: Back to what Andy described when we talked about medications, stimulants, and non-stimulants. The non-stimulants are there 24/7. This may be somebody who could benefit from a non-stimulant, or the combination. We have some patients that need both a non-stimulant, but a little bit of low-dose stimulant with it. It could be that we change the time of day she’s exercising, for example. It’s not about just medication. It’s about altering one’s daily schedule. It’s looking at if they’re working with an ADD coach. Maybe it’s a problem; their symptomatology is worse towards the end of the day because they’re not getting enough sleep the night before. They’re night owls. A lot of times, with ADHD, they’re phase-delayed in their sleep patterns. Working on sleep hygiene. It just must be tailored to that individual. And I mean both the pharmacologic and non-pharmacologic interventions. A typical thing I have people do aside from the diagnosis, it’s, “Walk me through your typical day. What does a day look like for you, from the time you get up until the time you go to bed?” And then the second question is, “And what aspect of that day do we need to see improved, that could be easier, better for you?” Knowing that the answer might be all the above. But start somewhere.

: The other thing I always assess is caffeine use. And caffeine with a stimulant is an interesting, tricky combination. I always want to know; how much caffeine are they using? And I always joke, “Show me an adult with ADHD who doesn’t use caffeine, and I’ll show you a leprechaun.” I’m sure they exist. The other thing is over-the-counter medications. I have been shocked sometimes when people bring me bottles of things they’re buying over the counter, and they’re taking. And they’re just loaded with stimulants that are not obvious. There are various alkaloids. There are things like guarana seed, that are all stimulants.

Theresa Cerulli, MD, and Andrew J. Cutler, MD, provide insight on goals of therapy for patients with ADHD.

Case 3: Treatment Goals in Adult ADHD

This is a 24-year-old female diagnosed with ADHD at the age of 14. Has presented to her psychiatrist after multiple treatment failures. Prior to this visit, her ADHD was handled by her pediatrician, and then by her primary care provider. When she was diagnosed at age 14, her pediatrician had tried multiple therapies. But she failed therapy, either due to lack of efficacy, lack of adherence, and lack of understanding of how to use the therapy.

Between 14 and 16, this patient first tried some non-pharmacologic approaches. And these failed for lack of efficacy. During ages 16 to 17, she was tried on OROS methylphenidate, and that failed due to lack of GI absorption. Ages 17 to 18 tried a patch form of methylphenidate. That seemed to work, but she had reactions to the patch- adverse reactions to the patch, at the site of the patch. And she couldn’t use the patch. Ages 18 to 21, patient switched to an immediate-release form of mixed amphetamine salts. She could not tolerate mixed amphetamine salts. And they had also showed some lack of efficacy. The next attempt at age 21 was lisdexamfetamine, but that wasn’t covered by insurance. And then she was switched to atomoxetine, which was not effective. Now, at the age of 22, she was started on extended-release mixed amphetamine salts, 15 mg. She’s been on this medication since graduation and finds it to be very effective. Yet she complains that there is no off button when she is done working and cannot enjoy the rest of her evening. She has tried to skip days of not taking the medication. However, due to the nature of her work as an accountant, working 8 to 9 hours a day in her office at home, she found it to be a necessity. She has also admitted taking an antihistamine at night, to help her sleep. Upon reading notes from her PCP, it’s noted that she has had 2 previous encounters with abusing illicit substances in her teen years. However, there has not been any recurrences in the past few years. Her brother also had a history of substance abuse, but she no longer lives with him. The patient admits to smoking one pack of cigarettes every 4 days but is trying to stop smoking. She claims she only smokes when she is stressed.

Stephen Faraone, PhD, presents the case of a 24-year-old patient with ADHD.

ADHD