Around the Practice: Management of Adult with Attention Deficit/Hyperactivity Disorder (ADHD) - Episode 13

Patient Case #2: Impressions and Challenges in Adult ADHD

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Experts in psychiatry provide insight on a patient case as well as discuss challenges with ADHD.

Stephen Faraone, PhD: Let's start with Dr Chepke, what is your initial impression of the case? And what types of challenges does this kind of patient present to you?

Craig Chepke, MD, FAPA: All of them, all the challenges. This is a very complicated case, this ties together a lot of things we've been discussing over this entire session, that the person has medical comorbidities, they have psychiatric comorbidities, diagnostically difficult to tell what of the depression and anxiety is related to the ADHD. She's been on multiple treatments and has not had good response, both in terms of efficacy and tolerability. She's got a lot going on, unfortunately, and at a very young age as well. She's got cardiometabolic issues and risk factors for later heart disease, we've got to get her on track in a lot of ways. She's already doing some psychotherapy which is a big positive prognostic factor for her. She's using mindfulness and meditation, she's doing yoga, she's got some positive predictive factors there but we've got to figure out how to get her on track pharmacologically to help her to accomplish all this because if she's got untreated ADHD and she's trying to do all this, she's not going to be as successful. If we can get her on the right type of treatment, I would hope her success rate at engaging at everything she's already doing will get that much greater.

Stephen Faraone, PhD: Dr Cerulli, this patient presents with multiple comorbid psychiatric disorders and symptoms, can you walk us through how you would manage the patient? Which comorbid psychiatric disorder would you treat first, and why?

Theresa Cerulli, MD: First, let me say that whoever wrote this case must have been looking at my patient charts before. This sounds like most of the patients, it might be complex, but it's also a common presentation. This is ADHD with at least 2 comorbid psychiatric conditions with depression and anxiety. This patient also has co-existing medical conditions. This is more the rule of thumb than not, this is what ADHD looks like. Where I begin is where the patient is now, not just their history. This patient is coming in saying they're depressed. The chief complaint was decreased energy and depressed mood, to tease out, let's start with where the patient is, this is what's bothering them. It's the symptom that getting most in the way of their life, they're not on an antidepressant currently. The tools they're using, the non-pharmacologic tools they're using to try to manage the depression, including mindfulness, it's not working. Yoga and mindfulness. They've already, in terms of the anxiety, they've already said that is milder, if we look back at the case, the anxiety is mild, the depression is moderate. To me, it's to listen closely, listen to that chief complaint, and start by at least saying you want to begin there, but don't disappoint the patient to say you didn't hear the rest. "I hear the anxiety there, I know you've got the history with ADHD, we clearly have to do a better job at managing everything. But given you're telling me you're depressed; I want to focus on that first, in this session."

Andrew J. Cutler, MD: What's interesting about that is she talks about enjoying socialization, enjoying time with friends, she's very hopeful, still out looking for a job. So, I'm not disagreeing that she's depressed, but I'm wondering if going after the ADHD might help that at the same time. You could certainly co-manage and go for both at the same time.

Theresa Cerulli, MD: Absolutely, Andy. And I want to say that we do, and in fact, the new action items on our guidelines are to look at the comorbidities and ADHD at the same time and to treat both, but I would lean, in terms of taking the patient where they're at, to make sure the depression is a big part of that discussion, and that depression in and of itself can cause people to have problems with focus and concentration. I would lean towards starting a program that's trying to address both, I might be leaning towards a non-stimulant that might also have some benefits for mood, for example. And then be shifting gears to talk more about the ADHD in the next session. But I fully agree, and it’s a good debate, there's no right or wrong answer here, and that's the other thing, I like to just collaborate with the patient, and say, "This is what I'm thinking, 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 depression goes away.'" If we're having that discussion, then I change the order. But to not take the patient where they're at and address the depression as part of the initial discussion would be, I think, a disservice to this patient.

Andrew J. Cutler, MD: She also says though that the therapist and she agreed that a big part of her depression is the stress of losing the job. While she's depressed, we've got to help the ADHD so she can get a job and function at work too. It really is very intertwined, isn't it?

Transcript edited for clarity