Paying Attention to Adult ADHD

Many of us in clinical practice have been challenged with adults presenting with the diagnosis of attention-deficit hyperactivity disorder. Many of these adults have either diagnosed themselves through their own investigation or describe sometimes foggy histories of being diagnosed with this disorder as children. But somewhere, somehow, their treatment for the condition stopped, and now it has again become manifest.

Growing consensus exists that the central feature of ADHD is disinhibition. Animal models suggest that this condition is associated with an imbalance in the dopaminergic and noradrenergic systems characterized by decreased dopamine activity and increased norepinephrine activity. Clinical manifestations include poor self-regulation, an inability to prevent immediate responding, and difficulty with attention and goal-directed behavior and thought.

Available data suggest that between 30% and 70% of children with ADHD continue to exhibit symptoms into adulthood. Hyperactivity, however, is more difficult to discern in adults. Adults typically present with work-related issues and poor organizational skills.

Psychostimulants are a mainstay of therapy. But we need to remain cautious and circumspect about the patients requesting them to treat the disorder. Moreover, the addictive nature of stimulants, the chronicity of this condition, and the existence of potentially comorbid conditions in adults have led many experts to recommend a trial of a nonstimulant agent first.

Bupropion is an antidepressant that has an effect on both dopamine and norepinephrine, and has demonstrated efficacy for the treatment of adults with ADHD. Dr. Narong Maneeton and colleagues conducted a meta-analysis of randomized trials evaluating the efficacy, acceptability and tolerability of bupropion in adults with ADHD (Psychiatry Clin. Neurosci. 2011;65:611-7). Five published trials with a total of 349 subjects were included.

The overall response rate of the bupropion-treated group was significantly greater than that of placebo-treated (relative risk, 1.67; 95% CI: 1.23-2.26). Two other studies have reported bupropion response rates between 53% and 76%, with doses ranging from 200 mg/day to 450 mg/day. A positive effect on ADHD symptoms can be seen at 2 weeks after initiation of therapy.

Bupropion is a great choice as an initial agent for patients who screen positive for the condition and have a compelling history. For patients who fail this approach, referral for a definitive diagnosis and assistance with dosing and management of psychostimulants is completely justified.

Dr. Ebbert is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are solely those of the author.

Many of us in clinical practice have been challenged with adults presenting with the diagnosis of attention-deficit hyperactivity disorder. Many of these adults have either diagnosed themselves through their own investigation or describe sometimes foggy histories of being diagnosed with this disorder as children. But somewhere, somehow, their treatment for the condition stopped, and now it has again become manifest.

Growing consensus exists that the central feature of ADHD is disinhibition. Animal models suggest that this condition is associated with an imbalance in the dopaminergic and noradrenergic systems characterized by decreased dopamine activity and increased norepinephrine activity. Clinical manifestations include poor self-regulation, an inability to prevent immediate responding, and difficulty with attention and goal-directed behavior and thought.

Available data suggest that between 30% and 70% of children with ADHD continue to exhibit symptoms into adulthood. Hyperactivity, however, is more difficult to discern in adults. Adults typically present with work-related issues and poor organizational skills.

Psychostimulants are a mainstay of therapy. But we need to remain cautious and circumspect about the patients requesting them to treat the disorder. Moreover, the addictive nature of stimulants, the chronicity of this condition, and the existence of potentially comorbid conditions in adults have led many experts to recommend a trial of a nonstimulant agent first.

Bupropion is an antidepressant that has an effect on both dopamine and norepinephrine, and has demonstrated efficacy for the treatment of adults with ADHD. Dr. Narong Maneeton and colleagues conducted a meta-analysis of randomized trials evaluating the efficacy, acceptability and tolerability of bupropion in adults with ADHD (Psychiatry Clin. Neurosci. 2011;65:611-7). Five published trials with a total of 349 subjects were included.

The overall response rate of the bupropion-treated group was significantly greater than that of placebo-treated (relative risk, 1.67; 95% CI: 1.23-2.26). Two other studies have reported bupropion response rates between 53% and 76%, with doses ranging from 200 mg/day to 450 mg/day. A positive effect on ADHD symptoms can be seen at 2 weeks after initiation of therapy.

Bupropion is a great choice as an initial agent for patients who screen positive for the condition and have a compelling history. For patients who fail this approach, referral for a definitive diagnosis and assistance with dosing and management of psychostimulants is completely justified.

Dr. Ebbert is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are solely those of the author.

Many of us in clinical practice have been challenged with adults presenting with the diagnosis of attention-deficit hyperactivity disorder. Many of these adults have either diagnosed themselves through their own investigation or describe sometimes foggy histories of being diagnosed with this disorder as children. But somewhere, somehow, their treatment for the condition stopped, and now it has again become manifest.

Growing consensus exists that the central feature of ADHD is disinhibition. Animal models suggest that this condition is associated with an imbalance in the dopaminergic and noradrenergic systems characterized by decreased dopamine activity and increased norepinephrine activity. Clinical manifestations include poor self-regulation, an inability to prevent immediate responding, and difficulty with attention and goal-directed behavior and thought.

Available data suggest that between 30% and 70% of children with ADHD continue to exhibit symptoms into adulthood. Hyperactivity, however, is more difficult to discern in adults. Adults typically present with work-related issues and poor organizational skills.

Psychostimulants are a mainstay of therapy. But we need to remain cautious and circumspect about the patients requesting them to treat the disorder. Moreover, the addictive nature of stimulants, the chronicity of this condition, and the existence of potentially comorbid conditions in adults have led many experts to recommend a trial of a nonstimulant agent first.

Bupropion is an antidepressant that has an effect on both dopamine and norepinephrine, and has demonstrated efficacy for the treatment of adults with ADHD. Dr. Narong Maneeton and colleagues conducted a meta-analysis of randomized trials evaluating the efficacy, acceptability and tolerability of bupropion in adults with ADHD (Psychiatry Clin. Neurosci. 2011;65:611-7). Five published trials with a total of 349 subjects were included.

The overall response rate of the bupropion-treated group was significantly greater than that of placebo-treated (relative risk, 1.67; 95% CI: 1.23-2.26). Two other studies have reported bupropion response rates between 53% and 76%, with doses ranging from 200 mg/day to 450 mg/day. A positive effect on ADHD symptoms can be seen at 2 weeks after initiation of therapy.

Bupropion is a great choice as an initial agent for patients who screen positive for the condition and have a compelling history. For patients who fail this approach, referral for a definitive diagnosis and assistance with dosing and management of psychostimulants is completely justified.

Dr. Ebbert is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are solely those of the author.