Treatment of Adult ADHD:

Expect the Unexpected

Grand RoundsCairns HospitalMarch 14 2014

Rigo Van Meer

Video interviews

In the original presentation video interviews with patients were presented.

For privacy reasons these video’s are not on the internet and are left out of this downloadable version of

the presentation

Warning for students

My experiences and the opinions I have formed on the basis of those experiences differ on many counts from commonly accepted notions about adult ADHD and the use of stimulant treatment.

Goal

• Make doctors and (mental) health workers more aware of adult adhd

• Make them consider adhd as a possibility and treat it

• Sharpen clinical acumen in diagnosing adhd

• Give an impression of treatment results

Attention Deficit / Hyperactivity Disorderin Adults

• Diminished capacity to concentrate & focus• Impulsivity• In children “hyperactivity”. In adults feeling stressed / on

edge most of the time

• From trivial to very severe• Highly genetic• Problems in the frontal lobe• High co-morbidity with other psychiatric disorders

• Not depression OR adhd but AND• Not Bipolar OR adhd but AND• Etc. etc.

•

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Epidemiology adult ADHD

• General population: 4%• Psychiatric population: 10% to 20%• Males in jail: 45%• Tourette syndrome: 65%• Methamphetamine users: 40%• Personality disorder • M/F=2 (in practice 3 to 4)

• Patients with Acquired Brain Injury can have very similar symptoms

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Comorbidity 78% of cases has comorbidity

Depression 20-30%

BPAD 8%

Anxiety disorders 20-30%

Substance abuse 25-45%

Personality Disorders:Antisocial, Borderline

25%

Simple Adult ADHD

“a uni student with concentration problems”

(from: ADDults with ADHD (NSW) Inc)

Complex Adult ADHD

• Difficult psychiatric presentations (ED, Clinic)• Unclear psychiatric diagnosis, personality disorder• High psychosocial stress• Unemployed• Is stressed/ on edge • Unhappy / depressed / anxiety• No direction in life, going nowhere• Fed up with the way his/her life goes• Anger issues• Heavy alcohol use• Heavy marijuana use• Speed/ methamphetamine use• Offending• Jail

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Psycho stimulants

• Short acting (3 to 4 hours)• Methylphenidate (Ritalin)• Dexamphetamine

• Long acting (24 hours)• Methylphenidate ER (Concerta, Ritalin LA)• Mixed amphetamine salts: Adderall (not in Australia)• Dexamphetamine precursor: Vyvanse (new in Australia)• Atomoxetine (Strattera, non stimulant)

• Not Addictive• Do not make you “high”• Performance improvement in non-adhd subjects doubtful• Keep you awake

General effects of stimulant treatment in ADHD

Stimulants have a QUALITATIVELY DIFFERENT effect on people with adhd then on others

Stimulants in adhd CALM DOWNThe effect is large and often dramaticThe effect is almost immediate

Stimulants in non-adhd persons DO NOTHING apart from keeping you awake

Common opinion:Stimulants hinder your sleep

butt…

in many patients with adhd sleep actually improves as long as the stimulants are not taken late in the

afternoon

Common opinion

Stimulants diminish appetite and cause weight lossbutt..

Many patients report some nausea and loss of appetite in the first days of treatment, while in the long run their appetite improves and they start to

eat more regular

Common opinion:Stimulants cause psychosis

and can’t be used in patients with a psychotic illness

but…

Some patients report that they can cope better with their psychotic symptoms when on stimulants

Common opinion:Stimulants have little or no influence on the use of

alcoholbut..

patients report a dramatic decrease in the urge to drink alcohol and in the actual use of alcohol

How to diagnose?

Think of it

Look for it

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Red flags in psychiatric patients

Difficult patientMany problems/symptomsDiagnosed with:

Bipolar disorder, depression, anxietyAntisocial personality disorderBorderline personality disorder

Alcohol abuseSubstance abuseAnger issuesLittle effect of anti-depressants, anti-psychotics

Quetiapine sometimes helps (sleep, relaxation)

Always ask: If you have ever tried speed / ice / methamphetamine / Ritalin / dexamphetamineWhat effect did it have on you?

Not Addictive

Nobody gets addicted to Ritalin or dexamphetamine

•On the contrary, it costs parents effort to keep their children on their medication and almost all of them have stopped by the age of 21.•Patients often forget to take their meds (ever heard of a cigarette addict who forgets to smoke his/her cigarettes?)•No tendency of dose increase •No craving •There is no withdrawal on stopping (although some have a “come down” when the medication works out at the end of the day, especially on Ritalin)

Ever diagnosed and treated a patient with Ritalin or Dexamphetamine addiction?

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What patients say

• I get things done now• My mind is much clearer• I don’t procrastinate any more• I think more positive• I feel motivated• I hardly drink alcohol anymore• I’m not depressed anymore• I got my life back

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Messages• ADHD is a common and serious psychiatric disorder that can severely

mess up the patients life (and that of others)• Comorbidity is the rule• A trial of Ritalin or Dexamphetamine is easy, short and safe • Often spectacular therapeutic results• Please treat

Adult ADHD lessons learned 1

• I found reading about adult adhd treatment for complex adhd particularly unhelpful. Many general statements and warnings, little practical guidance. Guidelines, even from the Queensland Government, contain errors and misconceptions.

• Dose of Ritalin 10mg or Dexamphetamine 5mg is between 2 and 15 tablets daily, with an average of 6 to 8.

• Under-dosing gives many problems, as patients will use the dose they need, and run out of their tablets too soon. Once the right dose is found, patients do not want to increase the dose.

• Dexamphetamine has fewer side effects and is felt as “softer” than Ritalin. Dexamphetamine is therefore in general the better medication

• Stimulant treatment:

• As a rule reduces the urge to drink alcohol or to smoke dope.

• Often will improve sleep dramatically.

• Often has a general improvement in mood -> anti depressants can be stopped.

• Makes patients more motivated and think more positive

Adult ADHD lessons learned 2Patients with adhd who seek treatment are often treated negatively and condescending by doctors and pharmacists. Patient with adhd who seek treatment are sometimes branded as “drug seeking”. When they try another doctor they are “doctor shopping”.

Many patients with adhd use marijuana or alcohol to dampen their constant feeling of stress and unrest.

Dexamphetamine and methylphenidate are not addictive. Patients who do not have adhd find these drugs in general unpleasant.

Illegal use of amphetamines is often self medication for adhd. Proper treatment of adhd decreases crime and keeps people out of jail (and out of ED).

Drug and alcohol abuse are not a contra-indication for treatment, but an indication

ADHD in adults can be from trivial to very severe

Severe cases can be compounded by depression, anxiety, angriness and aggression, social deterioration, loss of meaning in life, illegal drug use and

incarceration.

Treatment of severe cases often gives spectacularly positive results that are life changing. These successful treatments are in my experience one of the very

rewarding things a psychiatrist can do in his profession.

Actively diagnosing and treating adult ADHD will:

Increase quality of life of ADHD patients and familiesConvert some long term psychiatric treatment failures into successes

And will contribute to…Decrease alcohol abuse and consequences of alcohol abuseDecrease use of marijuanaDecrease use of methamphetamine and speedKeep people out of jailKeep people out of hospital