• Part Two: How a Psychiatrist Diagnoses and Treats ADHD in Adults

    by Matthew Goldenberg, D.O.
    on Oct 5th, 2016

In my Huffington Post article, “Part 1: Do You Have Adult ADHD? A Psychiatrist Explains How You Can Tell” (link pending publication), I described the most recent updates to the diagnostic criteria for adult Attention Deficit Hyperactivity Disorder (ADHD). These criteria can help individuals to better establish if their symptoms might meet criteria for ADHD. However, you should never rely on a self-diagnosis alone. If you think you might have ADHD (or any other psychiatric diagnoses), please always seek professional consultation from a Psychiatrist or Psychologist who is specially trained to differentiate the symptoms specific to mental health diagnoses.

Huffington Post: "Do you Have ADHD?" from Dr. Matthew Goldenberg on Vimeo.

"Part 1: Do You Have Adult ADHD? How You Can Tell"

As many individuals are often anxious about seeing a psychiatrist, I think it is important for the public to understand how mental health conditions are diagnosed and treated. Moreover, the more psychiatric and substance use disorders remain in the shadows, the more negative-stigma can persist. Once diagnosed, ADHD and other mental health conditions can be properly treated and managed. If you are currently suffering from these symptoms, or others, one of my goals in writing these articles is to give you hope and the information you need to get help. This is how I diagnosis and treat patients with ADHD...

 
I. How I Diagnose ADHD in Adults
 
A mental health professional should both establish an accurate diagnosis of ADHD (if it is present) and also rule out other psychiatric diagnoses that can mimic ADHD symptoms. For example, the symptoms of ADHD can be mimicked by Post Traumatic Stress Disorder (PTSD), mood spectrum disorders (depression and bipolar disorder) and substance use disorders and many others.
 
Therefore, when a patient presents for the first time, I always conduct an extensive interview in which I collect the patient’s history related to ADHD. You can read more about the diagnostic criteria for ADHD here (link pending).
 
Additionally, I also get a complete psychiatric history which always includes a screening for mood, anxiety, psychotic and substance use disorders. In some cases the symptoms thought to be related to ADHD are actually a manifestation of another psychiatric diagnosis. In other cases patients have presented with partially improved ADHD symptoms, and once their other psychiatric diagnoses were identified and treated, their ADHD symptoms fully resolved.
 
After collecting a thorough history from my patient, and with my patient’s consent, I will get collateral information from someone who knows the patient well. This helps to confirm the patient’s report and also ensures that nothing is missed or misinterpreted. For example, as there needs to be evidence of childhood onset of symptoms, parents may better recall school performance and other historical events. Additionally, I will collect any historical data that is available to establish the longitudinal nature of the ADHD symptoms. These could include report cards, doctors’ notes, work evaluations or other records related to symptomatology.
 
In order to individualize my treatment plan, and also to establish my patients’ baseline symptom burden, I utilize one or more screening and diagnostic tools. One such tool, and one of my favorites, is the Adult ADHD Self-Report Scale
 
I use this scale on the initial evaluation and at follow up visits to monitor for symptom improvement and as an outcome measure. Utilization of symptom scales helps to make the rating of the inherently subjective symptoms of ADHD more objective. Beyond being useful for providers I have found symptom scale scores to be very enlightening for patients. In most cases my patients’ report of their symptoms closely follows what is found on the symptom scales. However, in some cases the scale scores will differ from patients’ subjective report. When this occurs it is a good opportunity to provide education and guidance regarding ADHD diagnostic criteria and treatment expectations.
 
While not required to treat ADHD, in many cases I will get labs to rule out medical causes of symptoms that can mimic ADHD and related disorders. For example, medical conditions such as hyperthyroid and electrolyte abnormalities can mimic the inattention and poor concentration found in ADHD and depression. Another reason I obtain labs and vital signs (such as blood pressure and pulse) is to make sure my patients do not have any contraindications to medications that we may want to consider. If I have any concerns about my patients’ physical health I refer them to a primary care doctor for a physical exam and for consideration of further evaluation including an electrocardiogram (ECG).
 
Obtaining a thorough history, collateral information, symptom rating scale scores and labs usually takes two to three office visits. My goal is to make an accurate and complete diagnosis and also to formulate a treatment plan that takes my patients’ biological, psychological and social attributes into account. There is no one size fits all treatment approach. I always believe in the saying “measure twice and cut once”. Getting a complete understanding of my patients allows us to formulate a treatment plan that is most likely to help them achieve a full recovery and high mental and physical wellness and quality of life.
 
To read more about how I diagnose ADHD please read, Part III: Overcoming the Challenges of Diagnosing and Treating ADHD in Adults, (link pending).

II. How I Treat ADHD in Adults

How a Psychiatrist Treats ADHD: Non-Medication and Medication Treatment Options from Dr. Matthew Goldenberg on Vimeo.

Dr. Matthew Goldenberg discusses the treatment options available to adults with ADHD.

There are two distinct treatment modalities for ADHD, 1) Behavioral Modifications and 2) Medications. Prior to presenting to my office for help, many patients have already tried some coping techniques, including adopting time management strategies, scheduling/organizational aids and modifying their environments to be less distracting. Your doctor should pick up on the coping techniques that you are employing with a thorough diagnostic evaluation like the one described above.
 
While most patients present after these steps have failed, some patients do present without having tried behavioral techniques. In nearly all cases, I educate my patients regarding behavioral techniques and recommend a trial before considering medications.
 
Many of my patients utilize both behavioral modifications and medications to obtain complete control of their ADHD symptoms. Therefore, it is important to have a complete understanding of both, as behavioral modifications may not only improve outcomes but also decrease the amount of medication needed to achieve remission of the symptoms of ADHD.
 
1) Behavioral Modifications and Psychotherapy
Every patient I see in my practice receives psycho-education regarding ADHD. This is background information related to the symptoms, diagnoses and management of ADHD.  By having a better understanding and background of the disorder, and the problems they face, many patients feel a sense of relief. It is not uncommon that my patients have been blaming themselves, often feeling like a failure, due to the impairment in functioning caused by the symptoms of ADHD. Many patients report being mislabeled as lazy or unintelligent. Psycho-education and supportive therapy can be very therapeutic and healing.[3]
 
Some of the topics we cover in the first few visits include: time management, problem solving, prioritizing and organizational skills. It is important that we discuss specific areas where the patient has suffered, including social failures, problems with self-esteem, difficulties maintaining relationships, temper outbursts, potential antisocial behavior, etc.[3]
 
Beyond psycho-education there are several specific and distinct psychotherapeutic modalities that have been tailored to address ADHD. These therapies are well studied and include individual and group cognitive-behavioral therapy, family therapy, and other interventions.[3, 4] For patients with severe ADHD, I often highly recommend and refer patients to group therapy, or support groups, as patients can interact with individuals with similar symptoms, share ideas and coping strategies. Family and marriage counseling can also be helpful for both the patient and spouse (and other family members) to understand how ADHD contributes and maintains conflicts and dysfunction within the marital and/or family unit; and how the family and spouse can play a role in rebuilding the relationships.[3]
 
The psycho-education I provide and psychotherapies I employ are patient specific and tailored to patient preferences. Some patients prefer groups, while others prefer individual or couples therapy. In many cases the psycho-education and psychotherapies are provided during visits when we are simultaneously discussing and managing medications which are outlined next.
 
 
2) Medications
In my experience, most cases of moderate to severe ADHD require medication, in addition to psychotherapies, in order to significantly restore functioning and decrease deficits caused by the symptoms of ADHD. My goal is to customize the treatment plan to best address the patient’s specific preferences, symptomatology and other co-occurring physical and mental health diagnoses.
 
There are two distinct classes of medications used to treat ADHD, A) Non-stimulants and B) Stimulants:
 
A) Nonstimulants
In my practice I usually do not initiate treatment with a nonstimulant unless the patient has a preference to do so or if there is a contraindication to stimulant medications.
 
Some patients prefer trying medications that do not have the abuse potential of stimulant medications and do not require the barriers and safety measures of controlled substances such as prescription drug monitoring programs, a limit of 30 days of medication and no refills on prescriptions.
 
Conversely, if the patient’s history alerted me to specific health conditions, such as cardiac disease, or history of substance use disorders, I will recommend a trial with a nonstimulant.
 
Nonstimulant treatment options include atomoxetine, quanfacine, clonidine and bupropion.[5] As a brief review of these treatment options:
 
1) Atomoxetine[5]: Can be a good option in patients with comorbid anxiety disorders as it works by selectively inhibiting the reuptake of norepinephrine. This is a similar mechanism to selective serotonin reuptake inhibitors (i.e. Prozac and Zoloft) and is exactly how norepinephrine reuptake inhibitor’s (SNRI) work (i.e. Cymbalta).
 
2) Bupropion (Wellbutrin)[5]: While not FDA approved for the treatment of ADHD, I have had some patients who have reported their ADHD symptoms improved when the bupropion was started for other indications such as depression and smoking cessation. Like Atomoxetine, Bupropion’s norepinephrine reuptake inhibition, which raises norepinephrine levels, is thought to be the mechanism in which it improves ADHD symptoms.
 
3) Tricyclic Antidepressants[5]: Also not FDA approved for treatment of ADHD and work through the same mechanism of increasing serotonin and/or norepinephrine levels. Like bupropion, I have had several patients whose ADHD symptoms improved when this class of medications was used for other conditions (namely depression and anxiety). In some cases it seemed likely their inattention symptoms may have be a manifestation of their underlying depression/anxiety and not true ADHD.
 
4) Clonidine and Guanfacine[5]: Extended-release clonidine is widely used, but also not FDA approved for the treatment of adult ADHD. Additionally, short and long-acting formulations are commonly used to treat the hyperactive component of childhood ADHD. This class of medications acts on a different mechanism than the medications discussed above. Clonidine and Guanfacine are both agonists of alpha-2 receptors which may regulate the part of the brain thought to impact impulsiveness and self-control (the prefrontal cortex). I have seen countless cases where these medications have reduced hyperactivity, impulsiveness and distractibility in children, where these symptoms are more predominant than in adults. Additionally, I have found Guanfacine to be especially helpful for patients with a history or concern for stimulants abuse.
 
PROTIP: Clonidine has a non-specific action as it interacts with several alpha-2 receptors. Guanfacine specifically binds to the alpha-2A receptor which leads to a reduction in norepinephrine release and decreases the firing in the locus coeruleus.[6] Due to its more specific mechanism of action, Guanfacine is less sedating and has a longer duration of action than clonidine.[3]
 
B) Stimulants
The reason why I prefer stimulants as the initial treatment option, unless the patient has a preference for a non-stimulant or contraindication for stimulants, is that they are the most effective class of medications for the treatment of ADHD in adults. Stimulants have a responsiveness rate of 70%–80%, while the remaining 20-30% of patients either do not have an adequate response or have intolerable side effects.[3] In my experience, most patients with moderate to severe ADHD will not get an adequate treatment response from a non-stimulant and will inevitably later require a stimulant.
 
It is well established that stimulants are the drug class of choice when treating adult ADHD and work by increasing dopamine and norepinephrine levels in the brain.[5] There are about 14 stimulants on the market in the U.S., both immediate release and extended release formulations, and most are derived from either methylphenidate or amphetamine[5]:
 
1) Methylphenidate[7]: Works by increasing levels of dopamine and norepinephrine through inhibiting their reuptake. Side effects are usually mild and the most common are insomnia, abdominal discomfort, headache, and loss of appetite. Other side effects include agitation, palpitations, increased heart rate and/or blood pressure and nervousness. However, the side effects are generally minimal and well tolerated by patients. Methylphenidate comes in several short acting formulations, including the well-known brand name Ritalin and several long acting forms of which Concerta is a well-known brand name. There is potential, and therefore concern, of abuse as intranasal use produces rapid effects that are similar to that of cocaine.
 
2) Amphetamine[3]: Has the distinct mechanism of action of directly stimulating the release of dopamine and norepinephrine, in addition to inhibiting their reuptake. Side effects are the same as those of Methylphenidate and are also dose-dependent, generally mild to moderate in most patients, and tend to decline in intensity over time. Currently, there are two distinct formulations available in both immediate and extended release versions: 1) dextroamphetamine (Dexedrine), 2) mixed amphetamine salts (Adderell). These medications are well studied and all preparations have been found to be safe and effective in the treatment of ADHD in adults.
 
Overall, methylphenidate and amphetamine’s effects are similar and most patients will respond to both drugs. However, 36% of patients respond preferentially to amphetamine compounds, while 26% of patients respond preferentially to methylphenidate compounds. About 10% do not respond to either one[3]. Therefore, in some cases when my patients have not responded or tolerated one, they will respond well to the other.
 
Long-acting stimulant formulations are now the standard of care. This is due to their improved control of ADHD symptoms, improved patient adherence and possibly less abuse potential.[3] Patients with ADHD may be more adherent to long-acting formulations because they only require one or two administrations per day. Conversely, patients may forget to take their medications three or four times a day, as required with some immediate release formulations.[3]
 
Diagnosing and treating ADHD presents several unique challenges that must be overcome to achieve strong outcomes. To read more about these challenges and how I overcome them, please read Part III: Overcoming the Challenges of Diagnosing and Treating ADHD in Adults, (link pending).
 
 

Overcoming the Challenges of Diagnosing and Treating ADHD in Adults from Dr. Matthew Goldenberg on Vimeo.

Dr. Goldenberg describes how patients and physicians can overcome the challenges associated with ADHD in Adults.

Author Matthew Goldenberg, D.O. Matthew Goldenberg D.O. is double Board Certified in Psychiatry and Addiction Psychiatry and is a certified Medical Review Officer (MRO). He is an expert in the evaluation and treatment of mental health disorders and is an addiction specialist for adults in his private practice in Santa Monica, California. Dr. Goldenberg also provides addiction psychiatry consultations to some of the nation’s top residential and outpatient treatment programs in the Los Angeles area and is experienced in the evaluation and treatment of professionals working in safety-sensitive positions. In addition to his clinical work, Dr. Goldenberg is an active author, researcher and invited speaker at local and national conferences. He also volunteers his time as a Clinical Instructor in the Department of Psychiatry at UCLA and is an Assistant Professor of Psychiatry at Cedars Sinai Medical Center.

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