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Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry

  • Philip Asherson (a1), Wai Chen (a1), Bridget Craddock (a2) and Eric Taylor (a3)

Summary

Attention-deficit hyperactivity disorder (ADHD) is a common disorder affecting children and adults. Many young people treated with stimulants, as well as those in whom ADHD went unrecognised in childhood, need treatment as adults. Stimulants and atomoxetine effectively reduce ADHD symptoms at all ages and should be a standard treatment in general adult psychiatric practice.

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Copyright

Corresponding author

Philip Asherson, MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Denmark Hill, London SE5 8AF, UK. Email: p.Asherson@iop.kcl.ac.uk

Footnotes

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Declaration of interest

The authors' research is funded by the UK Medical Research Council, the Wellcome Trust and the US National Institute of Mental Health. P. A. received unrestricted research funds from Janssen-Cilag and has spoken at meetings sponsored by Janssen-Cilag and Eli Lilly.

Footnotes

References

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Asherson, P. (2004) Attention-deficit hyperactivity disorder in the post-genomic era. European Child and Adolescent Psychiatry, 13 (suppl. 1), 150170.
Asherson, P. (2005) Clinical assessment and treatment of attention deficit hyperactivity disorder in adults. Expert Review of Neurotherapeutics, 5, 525539.
Banaschewski, T., Coghill, D., Santosh, P., et al (2006) Long-acting medications for the hyperkinetic disorders: a systematic review and European treatment guideline. European Child and Adolescent Psychiatry, in press.
Faraone, S. V., Biederman, J., Spencer, T., et al (2000) Attention-deficit/hyperactivity disorder in adults: an overview. Biological Psychiatry, 48, 920.
Faraone, S. V., Spencer, T., Aleardi, M., et al (2004) Meta-analysis of the efficacy of methylphenidate for treating adult attention-deficit/hyperactivity disorder. Journal of Clinical Psychopharmacology 24, 2429.
Faraone, S. V., Biederman, J. & Mick, E. (2006) The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychological Medicine, 36, 159165.
Simpson, D. & Plosker, G. L. (2004) Atomoxetine: a review of its use in adults with attention deficit hyperactivity disorder. Drugs, 64, 205222.
Taylor, E., Dopfner, M., Sergeant, J., et al (2004) European clinical guidelines for hyperkinetic disorder – first upgrade. European Child and Adolescent Psychiatry, 13 (suppl. 1), 17130.
Weiss, M. & Murray, C. (2003) Assessment and management of attention-deficit hyperactivity disorder in adults. Canadian Medical Association Journal, 168, 715722.
Weiss, M., Murray, C. & Weiss, G. (2002) Adults with attention-deficit/hyperactivity disorder: current concepts. Journal of Psychiatric Practice, 8, 99111.
Wender, P. H. (1998) Attention-deficit hyperactivity disorder in adults. Psychiatric Clinics of North America, 21, 761774.

Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry

  • Philip Asherson (a1), Wai Chen (a1), Bridget Craddock (a2) and Eric Taylor (a3)

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Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry

  • Philip Asherson (a1), Wai Chen (a1), Bridget Craddock (a2) and Eric Taylor (a3)
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eLetters

Re: ADHD and Mood Disorders in Adults

Philip Asherson, Professor of Molecular Psychiatry
20 April 2007

Kuan and Young make the point that further research into the role of mood symptoms in ADHD is essential. In a recent study of 141 adult-ADHD cases, 95% were found to have mood symptoms, chiefly mood instability (Kooij, PhD thesis, 2007). We observe that in adult-ADHD, mood instabilityfrequently responds to stimulants in the same time-course as core ADHD symptoms; an observation reported by others. This has led to the suggestion that mood dysregulation might represent a core impairment in adult-ADHD, perhaps related to the same processes that cause dysregulationof other executive processes.

Despite these observations the relationship of ADHD to mood disordersis controversial. The controversy has arisen in the context of paediatric bipolar disorder (BPD), where the distinction with ADHD is made difficult if one chooses to view irritability as a sufficient manifestation of BPD and if the requirement for episodicity is not strictly applied. However, available validation studies for the construct of paediatric BPD use elation and/or grandiosity as cardinal symptoms, rather than irritability.Narrowly-defined PBD can be differentiated from ADHD, shows longitudinal stability, and has plausible familial aggregation patterns (1;2). Recent evidence suggests narrowly-defined BPD can be distinguished at the behavioural and electrophysiological level from broadly-construed BPD (5).Conversely, it has been argued that the intensity of irritability (3) and its temporal pattern (chronic or episodic) can distinguish BPD from ADHD (4). The family study of Hirschfeld-Becker is intriguing, yet the sample size is small (12 families with bipolar I parent(s), 11 with bipolar II parent(s)), and further work is needed to clarify the rates of ADHD among relatives with narrowly defined versus broadly defined BPD.

One of the main questions to be addressed relates to how valid a diagnostic concept broadly-defined BPD is, or whether mood instability/irritability in the presence of ADHD may be more adequately described by a new dimension, such as mood dysregulation (6). Until the relevant empirical data become available, we see merit in maintaining the classic definition of mania, so that a diagnosis of bipolar disorder requires euphoria, grandiosity and episodicity, and the differential between ADHD and BPD remains explicit.

Reference List

(1) Geller B, Tillman R. Prepubertal and early adolescent bipolar I disorder: review of diagnostic validation by Robins and Guze criteria. J Clin Psychiatry 2005;66 Suppl 7:21-8.

(2) Geller B, Tillman R, Bolhofner K, Zimerman B, Strauss NA, Kaufmann P. Controlled, blindly rated, direct-interview family study of a prepubertal and early-adolescent bipolar I disorder phenotype: morbid risk, age at onset, and comorbidity. Arch Gen Psychiatry 2006 October;63(10):1130-8.

(3) Mick E, Spencer T, Wozniak J, Biederman J. Heterogeneity of irritability in attention-deficit/hyperactivity disorder subjects with andwithout mood disorders. Biol Psychiatry 2005 October 1;58(7):576-82.

(4) Leibenluft E, Cohen P, Gorrindo T, Brook JS, Pine DS. Chronic versus episodic irritability in youth: a community-based, longitudinal study of clinical and diagnostic associations. J Child Adolesc Psychopharmacol 2006 August;16(4):456-66.

(5) Rich BA, Schmajuk M, Perez-Edgar KE, Fox NA, Pine DS, LeibenluftE. Different psychophysiological and behavioral responses elicited by frustration in pediatric bipolar disorder and severe mood dysregulation. Am J Psychiatry 2007 February;164(2):309-17.

(6) Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ et al. Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry 2006 November 1;60(9):991-7.
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Conflict of interest: None Declared

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ADHD and Mood Disorders in Adults

Annie J. Kuan, Research Coordinator
01 February 2007

Asherson et al (2006) raise some important issues regarding adult attention-deficit hyperactivity disorder (ADHD). However, we would like to address further the concerns about mood disorders and ADHD.

The authors state that some symptoms of bipolar disorder (BD) are similar to those of ADHD but the distinction is not difficult. ADHD and classic euphoric mania (bipolar I) may be distinct but differentiation maybe difficult especially in bipolar II, bipolar spectrum disorder and episodes of mixed symptomatology. At times, it may be near-impossible to discriminate solely by symptoms. Irritability, excessive activity, impulsive behaviour, poor judgment and denial of problems are characteristic of both ADHD and BD, thus making diagnosis difficult. ADHDand BD also clearly occur together in the same individuals; the reported overall lifetime prevalence of comorbid ADHD in bipolar patients is 9.5% and comorbidity with unipolar disorder (UD) is also increased (Nierenberg et al, 2005).

Asherson and colleagues state that ADHD is a persisting trait while BD is episodic. However, inter-episodic symptoms are common in BD and thecourse of both BD and UD is frequently chronic; for example, up to 13% of BD patients report continuous cycling without a well-phase and 54% are notfully euthymic between episodes (Kupka et al, 2001).

Children of bipolar I mothers have increased rates of both UD and ADHD, further suggesting a neurobiological overlap of these three diagnoses. Hirshfeld-Becker et al (2006) report significantly higher rates (23.5%) of ADHD in offspring of bipolar parents compared to psychiatric comparison parents (8.4%) and non-psychiatric comparison parents (4.2%).

Drug treatments also overlap. Stimulant-type medication has been used in bipolar depression and newer medications such as atomoxetine have similar pharmacological characteristics to some antidepressants (Lydon & El-Mallakh, 2006). Catecholaminergic antidepressants are not only potentially of benefit to ADHD but may be less likely to destabilise BD.

There is thus a clinical and neurobiological overlap between ADHD, BDand UD. Asherson et al’s timely editorial has reminded us that ADHD in adults should not be overlooked and that further research is needed to clarify its’ impact on other adult psychopathology and comorbidity, particularly in mood disorders.

Declaration of Interest:None.

References:Asherson, P., Chen, W., Craddock, B., Taylor, E., et al (2007). Adult attention-deficit hyperactivity disorder: Recognition and treatment in general adult psychiatry. The British journal of psychiatry, 190, 4-5.

Hirshfeld-Becker, D. R., Biederman, J., Henin, A., et al. (2006). Psychopathology in the young offspring of parents with bipolar disorder: Acontrolled pilot study. Psychiatry research, 145(2-3), 155-167.

Kupka, R. W., Nolen, W. A., Altshuler, L. L., et al. (2001). The stanley foundation bipolar network. 2. preliminary summary of demographics, course of illness and response to novel treatments. The British journal of psychiatry.Supplement, 41, s177-83.

Lydon, E., & El-Mallakh, R. S. (2006). Naturalistic long-term useof methylphenidate in bipolar disorder. Journal of clinical psychopharmacology, 26(5), 516-518.

Nierenberg, A. A., Miyahara, S., Spencer, T., et al. (2005). Clinicaland diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: Data from the first 1000 STEP-BD participants. Biological psychiatry, 57(11), 1467-1473.

Corresponding author:Annie J. Kuan, BADepartment of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver BC, V6T 2A1, Canada.Tel: 604-827-3352Fax: 604-822-7756email: anniekuan@gmail.com

Co-author:Allan H. Young, MB, ChB, MPhil, PhD, FRCPsych, FRCPC, LEEF Chair in Depression ResearchDepartment of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver BC, V6T 2A1, Canada.
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Conflict of interest: None Declared

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ADULT ADHD

Wilfred J Levin, Medical Practitioner
01 February 2007

I advise on and the article recognising ADULT ADHDwas met with hope and cheer as so many on the website struggle to get recognised or treated for adult ADHD.(I have only read the absrtact.) Thisseems to be the accepted trend in the UK. I find this not only disturbing but puzzling. I gave my first lecture on adult ADHD in 1982 at a NationalConference in South Africa.World wide research certainly accepts the diagnosis and treatmet of this condition as valid and successsful. I am aware that the government has accepted the condition from a National Health point of view. Why then are there so many problems with diagnosis and treatment and why are doctors soreluctant to refer to specialists for final evaluation? Is this a problem of NHS or reluctant doctors?

There also appears to trend of repeat prescriptions for some children with ADHD by the Gp's with no or little monitoring or the use ofrating scales, on a regulsr basis. A small informal research project done on ADDERS suggests this is the norm rather than the exception. Consultantsseem to rarely see these children on a regular basis, as I am informed.TheGPs simply repeat scripts irrespective of whether the dose is effective ornot. It seems clear that the GPs are not experienced enough to monitor, tothe detriment of the patient but continue to write scripts assuming the consultants initial prescription is final. Nothing could be further from the truth!
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Adult ADHD in Prisons and Secure Forensic Psychiatric Units

Ramneesh Puri, Senior House Officer, Forensic Psychiatry
01 February 2007

Dear Editor,

We would like to draw the reader's attention to the other important subsets of psychiatric population that are often overlooked when considering Adult ADHD as a possible diagnosis i.e. The prison inmates andthe inpatients at secure Forensic psychiatry units.

We believe this group is very important because their disruptive ,restless and oppositional behaviour often represents a management challenge for the treating teams. These individuals tend to interact poorly with staff and other residents,they are highly unlikely to settle in ward activities and often show little benefit from therapeutic interventions,occupational therapy and educational activities. Worst of all they may actually disrupt others who wish to participate and/or inciterestlessness and dissatisfaction in others.

The authors Asherson et al have rightly pointed that the structured regimes sometimes mask symptoms and these patients should therefore be a focus of robust screening and diagnostic efforts.

Rosler et al (2004) have demonstrated prevalance rates of upto 45 % (using DSM IV criteria) in their study of young male German prisoners. We are not aware of similar studies in forensic inpatients.

We are at presently conducting a study looking at the prevelance of adult ADHD and associated comorbidity in the inpatient population of Caswell Clinic, a Regional Medium Secure Forensic Unit in Wales. One of the co-authors of the Rosler study, Prof J Thome, is directly involved as a supervisor.

We shall be using a mix of self rating scales (eg.CAARS), diagnostic interviews (eg.SCID-CV), informant ratings (family, staff) and other objective supporting evidence of symptoms to make diagnoses.

The south west wales LREC has granted a favourible ethics opinion andthis study would form the basis of a dissertation for MSc from the CardiffUniversity.The rationale is to identify unmet needs and offer appropriate treatment to those who fulfil diagnostic criteria.

Refrences:

1.Rosler M ,Retz W , Retz-Junginger P, et al (2004)

Prevalence of attention deficit–/hyperactivity disorder

(ADHD) and comorbid disorders in young male prison

inmates.European Archives of Psychiatry and Clinical

Neuroscience.254(6)365-71
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Conflict of interest: None Declared

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Adult ADHD- are we missing something?

Lakshmiprabha Ramasubramanian, senior house officer
01 February 2007

Dear editor,The editorial on Adult ADHD by Asherson et al is extremely useful and relevant under current circumstances. As more and more people are being suspected of having the disorder yet as psychiatrists we are faced with dilemmas about its diagnosis and management.Approximately 4% of adults worldwide suffer from ATTENTION DEFICIT HYPERACTIVITY DISORDER.Longitudinal studies in adults show that even though symptoms of hyperactivity and impulsivity may decay ,inattention tends to persist.In addition cognitive deficits especially executive function deficits occur.They suffer from problems encoding and manipulating information and difficulties with organisation and time management.Even though the editorial has included diagnosing ADHD in Adults I would like to add a few points.In diagnosing Adult ADHD one should consider retrospective self reports,reports of childhood ADHD symptoms by parents and professionals corroborated by clinical interview,DSM-4 criteria,ADHD rating scales,conners rating scales and Brown attention deficit disorder and Wender-Reimherr scales in adults.Also CT and MRI scans show smaller volumes in frontal cortex,cerebellum and subcortical structures.Zametkin et al found reduced global and regional glucose metabolism in premotor cortex and superior prefrontal cortex in PET studies.

I agree with the authors that we must not mis-specify Adult ADHD as it has serious implications in academic acheivement,career development,automobile driving and interpersonal relationship for the affected person and effective management can make lasting differences in their lives.
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Conflict of interest: None Declared

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Canadian recommendations for using long acting stimulants in reducing driving risk.

Laurence Jerome, Psychiatrist
04 January 2007

I would like to support the observations of Asherson et al on the long term risks of serious accidents in adults with ADHD, specifically in relation to increased driving risk for novice drivers.Readers of the British Journal of Psychiatry may be interested in the recent recommendations in the latest Canadian Medical Association handbook for physicians on Fitness to Drive, December 2006(1).

In the last edition of the Handbook on Fitness to Drive 2000 (2), Attention Deficit Hyperactivity Disorder (ADHD) was mentioned for the first time as a reportable condition. In the December 2006 Handbook more specific advice is given to physicians regarding novice drivers with ADHD.Physicians are now advised to consider the use of long-acting stimulants based on recent meta-analysis data examining the effects of a variety of medications used to treat ADHD. “Young drivers with ADHD show a normalization of dysfunctional driving behaviors on a driving simulator and on the road driving performance with long-acting Methylphenidate (OROSMPH) in comparison to the other stimulant and non-stimulant treatments forADHD" (3).

To our knowledge this is the first time that clinical research has demonstrated that medications improve driving performance in a vulnerable psychiatric population. The CMA’s decision to incorporate evidence-based medicine findings in their new handbook is a new development. Previous recommendations were based on consensus opinion of an expert panel. This clearly has important public-health implications and further research should be done to extend this area of knowledge.

Laurence Jerome

Adjunct Professor of PsychiatryThe University of Western OntarioLondon Ontarioljerome@rogers.com

REFERENCE

1. “Determining Medical Fitness to Operate Motor Vehicles” CMA Drivers Guide, 7th Edition, Ottawa (On): Canadian Medical Association; 2007

2. Determining medical fitness to drive: A guide for physicians.

Canadian Medical Association. Sixth Edition. Ottawa (ON): Canadian Medical Association; 2000.

3. Jerome L, Segal A, Habinski L. “What We Know About ADHD and Driving Risk: A Literature Review, Meta-Analysis and Critique” J. Can Acad. Child Adolesce. Psychiatry 15:3, August 2006, 105-125
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Conflict of interest: None Declared

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