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underline hover:no-underline decoration-gray-400" href="/authors/theresa-cerulli-md">Theresa Cerulli, MD</a><span class="mx-1">,</span></span><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/anthony-l-rostain-md-ma">Anthony L. Rostain, MD, MA</a></span></div></div></div><div class="max-w-full"><div class="flex flex-wrap sm:flex-nowrap items-center w-fit my-2"></div><div class="w-full flex flex-col sm:flex-row justify-between mt-2"><div class="block md:hidden "><div class="mt-2 flex items-center max-w-fit"><button title="Adult ADHD Treatment: Pharmacological Intervention" aria-label="facebook" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#3b5998"></circle><path d="M34.1,47V33.3h4.6l0.7-5.3h-5.3v-3.4c0-1.5,0.4-2.6,2.6-2.6l2.8,0v-4.8c-0.5-0.1-2.2-0.2-4.1-0.2 c-4.1,0-6.9,2.5-6.9,7V28H24v5.3h4.6V47H34.1z" fill="white"></path></svg></button><button aria-label="twitter" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg fill="#DC7633" 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c0.3-1.3,2.1-8.7,2.1-8.7s-0.5-1-0.5-2.5c0-2.4,1.4-4.1,3.1-4.1c1.5,0,2.2,1.1,2.2,2.4c0,1.5-0.9,3.7-1.4,5.7 c-0.4,1.7,0.9,3.1,2.5,3.1c3,0,5.1-3.9,5.1-8.5c0-3.5-2.4-6.1-6.7-6.1c-4.9,0-7.9,3.6-7.9,7.7c0,1.4,0.4,2.4,1.1,3.1 c0.3,0.3,0.3,0.5,0.2,0.9c-0.1,0.3-0.3,1-0.3,1.3c-0.1,0.4-0.4,0.6-0.8,0.4c-2.2-0.9-3.3-3.4-3.3-6.1c0-4.5,3.8-10,11.4-10 c6.1,0,10.1,4.4,10.1,9.2c0,6.3-3.5,11-8.6,11c-1.7,0-3.4-0.9-3.9-2c0,0-0.9,3.7-1.1,4.4c-0.3,1.2-1,2.5-1.6,3.4 c1.4,0.4,3,0.7,4.5,0.7c8.8,0,16-7.2,16-16C48,23.2,40.8,16,32,16z" fill="white"></path></svg></button><button aria-label="email" class="react-share__ShareButton" style="background-color:transparent;border:none;padding:0;font:inherit;color:inherit;cursor:pointer"><svg viewBox="0 0 64 64" width="32" height="32"><circle cx="32" cy="32" r="31" fill="#7f7f7f"></circle><path d="M17,22v20h30V22H17z M41.1,25L32,32.1L22.9,25H41.1z M20,39V26.6l12,9.3l12-9.3V39H20z" fill="white"></path></svg></button><a class="print-wrap flex justify-center items-center cursor-pointer"><svg id="print" xmlns="http://www.w3.org/2000/svg" width="24" height="24" fill="currentColor" class="print bi bi-printer" viewBox="0 0 16 16"> <path d="M2.5 8a.5.5 0 1 0 0-1 .5.5 0 0 0 0 1z"></path> <path d="M5 1a2 2 0 0 0-2 2v2H2a2 2 0 0 0-2 2v3a2 2 0 0 0 2 2h1v1a2 2 0 0 0 2 2h6a2 2 0 0 0 2-2v-1h1a2 2 0 0 0 2-2V7a2 2 0 0 0-2-2h-1V3a2 2 0 0 0-2-2H5zM4 3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1v2H4V3zm1 5a2 2 0 0 0-2 2v1H2a1 1 0 0 1-1-1V7a1 1 0 0 1 1-1h12a1 1 0 0 1 1 1v3a1 1 0 0 1-1 1h-1v-1a2 2 0 0 0-2-2H5zm7 2v3a1 1 0 0 1-1 1H5a1 1 0 0 1-1-1v-3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1z"></path></svg></a></div><style> .print-wrap { width: 32px; height: 32px; background: #7F7F7F; border-radius: 100%; } .print { background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><p class="py-2 mb-2 text-sm italic text-gray-600">Anthony Rostain, MD, MA, provides an overview of stimulants, nonstimulants, amphetamines, and methylphenidates for adult attention-deficit/hyperactivity disorder (ADHD) treatment.</p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class="relative"><div class="brightcove-fluid" autoplay=""></div></div><div class="pb-8"><div class="w-full flex"><div class="flex-none flex justify-center items-center cursor-pointer" style="width:40px"><svg stroke="currentColor" fill="currentColor" stroke-width="0" viewBox="0 0 512 512" class="text-2xl" height="30" width="30" xmlns="http://www.w3.org/2000/svg"><path d="M256 48C141.1 48 48 141.1 48 256s93.1 208 208 208 208-93.1 208-208S370.9 48 256 48zm43.4 289.1c7.5 7.5 7.5 19.8 0 27.3-3.8 3.8-8.7 5.6-13.6 5.6s-9.9-1.9-13.7-5.7l-94-94.3c-6.9-7.6-6.7-19.3.6-26.6l95.4-95.7c7.5-7.5 19.7-7.6 27.3 0 7.5 7.5 7.6 19.7 0 27.3l-81.9 81 79.9 81.1z"></path></svg></div><div class="flex-auto overflow-x-auto hide-scrollbar mt-4" id="gallery-container"><div id="gallery-inner-container" class="grid grid-rows-1" style="max-width:-80px;grid-template-columns:repeat(10, 0px)"><a href="/view/recent-spikes-in-adult-adhd-diagnoses" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 1.</span>Recent Spikes in Adult ADHD Diagnoses</h2></a><a href="/view/signs-and-symptoms-of-adult-adhd" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 2.</span>Signs and Symptoms of Adult ADHD</h2></a><a href="/view/treatment-goals-and-shared-decision-making-for-adults-with-adhd" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 3.</span>Treatment Goals and Shared Decision Making for Adults With ADHD</h2></a><a href="/view/adult-adhd-treatment-pharmacological-intervention" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><div class="bg-black text-white text-xs w-auto px-1 absolute z-50 right-5 top-1">Now Viewing</div><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd21e10176e568faf1aedf00b3376e38c7baf6367-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd21e10176e568faf1aedf00b3376e38c7baf6367-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd21e10176e568faf1aedf00b3376e38c7baf6367-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 4.</span>Adult ADHD Treatment: Pharmacological Intervention</h2></a><a href="/view/adult-adhd-treatment-access-to-different-drug-formulations" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 5.</span>Adult ADHD Treatment: Access to Different Drug Formulations</h2></a><a href="/view/adult-adhd-substance-abuse-challenges" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 6.</span>Adult ADHD: Substance Abuse Challenges</h2></a><a href="/view/adult-adhd-treatment-failure" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 7.</span>Adult ADHD Treatment Failure</h2></a><a href="/view/fda-approval-serdexmethylphenidate-dexmethylphenidate-for-adult-adhd-treatment" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd21e10176e568faf1aedf00b3376e38c7baf6367-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd21e10176e568faf1aedf00b3376e38c7baf6367-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fd21e10176e568faf1aedf00b3376e38c7baf6367-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 8.</span>FDA Approval: Serdexmethylphenidate/Dexmethylphenidate for Adult ADHD Treatment</h2></a><a href="/view/adult-adhd-treatment-serdexmethylphenidate-dexmethylphenidate" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fc8eb9998d02d8a81f5b2a753926d7b8d38b4ecfb-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 9.</span>Adult ADHD Treatment: Serdexmethylphenidate/Dexmethylphenidate </h2></a><a href="/view/future-adhd-treatment-options" class="pl-[5px] pr-[5px] text-center relative !no-underline !text-primary" style="width:0px cursor-pointer"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%27176%27%20height=%2799%27/%3e"/></span><img alt="" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=256&q=75 1x, /_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75 2x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F3fe235da42f27a79162d1a4783d5e867282658f8-1920x1080.png%3Ffit%3Dcrop%26auto%3Dformat&w=384&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span><h2 class="w-full flex-wrap text-center text-sm text-gray-700"><span class="text-sm text-gray-600 mr-2 font-bold">EP: 10.</span>Future ADHD Treatment Options </h2></a></div></div><div class="flex-none flex justify-center items-center cursor-pointer" style="width:40px"><svg stroke="currentColor" fill="currentColor" stroke-width="0" viewBox="0 0 512 512" class="text-2xl transition ease-in-out hover:scale-110" height="30" width="30" xmlns="http://www.w3.org/2000/svg"><path d="M48 256c0 114.9 93.1 208 208 208s208-93.1 208-208S370.9 48 256 48 48 141.1 48 256zm244.5 0l-81.9-81.1c-7.5-7.5-7.5-19.8 0-27.3s19.8-7.5 27.3 0l95.4 95.7c7.3 7.3 7.5 19.1.6 26.6l-94 94.3c-3.8 3.8-8.7 5.7-13.7 5.7-4.9 0-9.9-1.9-13.6-5.6-7.5-7.5-7.6-19.7 0-27.3l79.9-81z"></path></svg></div></div><style> /* Hide scrollbar for Chrome, Safari and Opera */ .hide-scrollbar::-webkit-scrollbar { display: none; } /* Hide scrollbar for IE, Edge and Firefox */ .hide-scrollbar { -ms-overflow-style: none; /* IE and Edge */ scrollbar-width: none; /* Firefox */ } </style></div><p class="pb-2"><strong>Theresa Cerulli, MD: </strong>Moving to a more complicated topic, how is ADHD being treated through pharmacologic interventions? We have so many choices now, it can be overwhelming. Can you give us an overview of stimulants and nonstimulants for ADHD, please?</p><p class="pb-2"><strong>Anthony Rostain, MD, MA: </strong>Sure. Just to summarize for the longest time we've known in studies with children that stimulant medications are highly effective in various domains. And over the last several decades, we now have comparable data in adults to say that stimulants are the first line of treatment because they reduce the symptoms of ADHD and improve functioning in various domains. Obviously, along with stimulants come some problems such as stigma or the possibility of misuse.</p><p class="pb-2">And the fact that they don't last around the clock. So as long as they're active in you, the stimulant helps you to do better in a variety of ways. But then when they wear off, you’re back to your baseline ADHD individual self. Nonstimulants have the advantage then of being around the clock. They work 24 hours, and they don't have the abuse potential that most stimulants do. And there's less stigma. On the other hand, there's less data overall. And the other thing about nonstimulant is you do have to take them every day. So, there's less of a take one day, skip another, which sometimes happens when people want to alter their treatment with stimulant medication. So sometimes we use both in combination depending on the complexity of the presenting problems.</p><p class="pb-2">And again, we can talk later if you want about the side effects from these different types of treatment. But we tend to prefer using the longer-acting preparations of the stimulants because adults tend to have longer days, and it's much harder to remember throughout the day and to keep a steady effect of the medication if you're using immediate-release stimulants. So, the big change in our way of looking at stimulants over the past decade or so has really been to look at the data and say, we get better adherence and fewer problems when we prescribe long-acting medication preparations.</p><p class="pb-2"><strong>Theresa Cerulli, MD: </strong>So<strong>, </strong>2 questions come to mind. The first is, within stimulants there are amphetamines and there are methylphenidates, which can be confusing. How do you decide where to start? Do you have a preference for one category or the other? And if so, why? That's the one question. And it's because patients will ask, all the time, in practice. So, I'm curious how you approach that.</p><p class="pb-2">And then secondly, you mentioned some of the different formulations, immediate release, and extended release. Is there any data that helps us think about aids in treatment selection with regard to formulations?</p><p class="pb-2"><strong>Anthony Rostain, MD, MA: </strong>So, let's just start with the basic concept, which is overall methylphenidate has a very simple mechanism of action. It's really a reversible dopamine reuptake inhibitor that doesn't really do much more than block the transporter that's reuptaking the transmitter after it's been released. Amphetamine has a much more complex mechanism of action because it also makes more transmitters available in the vesicle. It also helps from the vesicle into the synapse. It increases the release of neurotransmitters. And we're talking about dopamine and epinephrine here. And it also reduces the breakdown, or the metabolism of the transmitter prismatically.</p><p class="pb-2">So, amphetamines are more complex in enacting; when you look at studies overall you could say there's a slightly higher effect size for amphetamines. And when you look at pharmacoepidemiologic data, it looks like about two-thirds of kids are on methylphenidate and only a third are on amphetamine. Around adolescence it's equal. And then in adults, the fractions are reversed. So, roughly, amphetamines are two-thirds to one-third depending on which study you're looking at.</p><p class="pb-2">Does that mean you should start with one or the other? I always say to talk with your patient about the difference in the profile. Find out if they've been on the medication before, many of our adult patients were treated as kids and have some remembrances of what did or didn't work and if other family members have been more or less successful on methylphenidate versus amphetamine. I don't like to say, “Well start with X,” because I do think that it really varies from patient to patient. If you're really concerned that a patient is not going to want to do more than one trial, then you're probably better off trying an amphetamine because there's a slightly higher effect size with amphetamines compared to methylate. But once again, you have a greater chance of side effects.</p><p class="pb-2"><strong>Theresa Cerulli, MD: </strong>Exactly.</p><p class="pb-2"><strong>Anthony Rostain, MD, MA: </strong>So, the appetite, suppression, insomnia a feeling of restlessness, a jitteriness, you are more likely to see. Now, with respect to what I think of as the immediate release are just what they sound like. They're released right away, and they're in and out within usually 4 hours.</p><p class="pb-2">When we use medications like mixed amphetamine salts extended release, what we have here is a biphasic release where half of the amphetamine is released immediately and the other half, is released about 4 hours later. People get confused with the term XR, extended release, because they think it means it's continuous, but it's really not. With mixed amphetamine salts XR, what you're really doing is giving an immediate and then a delayed release in 2 phases.</p><p class="pb-2">And then there are the more continuous-release preparations where you see over time the releases are distributed over, say, 8 to 10 hours and lasting up to 12 to 14 hours. And it's important to think about what the profile of the patient's problems are, and what's their day like. And that's why, for example, the continuous release is probably the one that I find is most widely preferred. 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We have so many choices now, it can be overwhelming. Can you give us an overview of stimulants and nonstimulants for ADHD, please?\n\nAnthony Rostain, MD, MA: Sure. Just to summarize for the longest time we've known in studies with children that stimulant medications are highly effective in various domains. And over the last several decades, we now have comparable data in adults to say that stimulants are the first line of treatment because they reduce the symptoms of ADHD and improve functioning in various domains. Obviously, along with stimulants come some problems such as stigma or the possibility of misuse.\n\nAnd the fact that they don't last around the clock. So as long as they're active in you, the stimulant helps you to do better in a variety of ways. But then when they wear off, you’re back to your baseline ADHD individual self. Nonstimulants have the advantage then of being around the clock. They work 24 hours, and they don't have the abuse potential that most stimulants do. And there's less stigma. On the other hand, there's less data overall. And the other thing about nonstimulant is you do have to take them every day. So, there's less of a take one day, skip another, which sometimes happens when people want to alter their treatment with stimulant medication. So sometimes we use both in combination depending on the complexity of the presenting problems.\n\nAnd again, we can talk later if you want about the side effects from these different types of treatment. But we tend to prefer using the longer-acting preparations of the stimulants because adults tend to have longer days, and it's much harder to remember throughout the day and to keep a steady effect of the medication if you're using immediate-release stimulants. So, the big change in our way of looking at stimulants over the past decade or so has really been to look at the data and say, we get better adherence and fewer problems when we prescribe long-acting medication preparations.\n\nTheresa Cerulli, MD: So, 2 questions come to mind. The first is, within stimulants there are amphetamines and there are methylphenidates, which can be confusing. How do you decide where to start? Do you have a preference for one category or the other? And if so, why? That's the one question. And it's because patients will ask, all the time, in practice. So, I'm curious how you approach that.\n\nAnd then secondly, you mentioned some of the different formulations, immediate release, and extended release. Is there any data that helps us think about aids in treatment selection with regard to formulations?\n\nAnthony Rostain, MD, MA: So, let's just start with the basic concept, which is overall methylphenidate has a very simple mechanism of action. It's really a reversible dopamine reuptake inhibitor that doesn't really do much more than block the transporter that's reuptaking the transmitter after it's been released. Amphetamine has a much more complex mechanism of action because it also makes more transmitters available in the vesicle. It also helps from the vesicle into the synapse. It increases the release of neurotransmitters. And we're talking about dopamine and epinephrine here. And it also reduces the breakdown, or the metabolism of the transmitter prismatically.\n\nSo, amphetamines are more complex in enacting; when you look at studies overall you could say there's a slightly higher effect size for amphetamines. And when you look at pharmacoepidemiologic data, it looks like about two-thirds of kids are on methylphenidate and only a third are on amphetamine. Around adolescence it's equal. And then in adults, the fractions are reversed. So, roughly, amphetamines are two-thirds to one-third depending on which study you're looking at.\n\nDoes that mean you should start with one or the other? I always say to talk with your patient about the difference in the profile. Find out if they've been on the medication before, many of our adult patients were treated as kids and have some remembrances of what did or didn't work and if other family members have been more or less successful on methylphenidate versus amphetamine. I don't like to say, “Well start with X,” because I do think that it really varies from patient to patient. If you're really concerned that a patient is not going to want to do more than one trial, then you're probably better off trying an amphetamine because there's a slightly higher effect size with amphetamines compared to methylate. But once again, you have a greater chance of side effects.\n\nTheresa Cerulli, MD: Exactly.\n\nAnthony Rostain, MD, MA: So, the appetite, suppression, insomnia a feeling of restlessness, a jitteriness, you are more likely to see. Now, with respect to what I think of as the immediate release are just what they sound like. They're released right away, and they're in and out within usually 4 hours.\n\nWhen we use medications like mixed amphetamine salts extended release, what we have here is a biphasic release where half of the amphetamine is released immediately and the other half, is released about 4 hours later. People get confused with the term XR, extended release, because they think it means it's continuous, but it's really not. With mixed amphetamine salts XR, what you're really doing is giving an immediate and then a delayed release in 2 phases.\n\nAnd then there are the more continuous-release preparations where you see over time the releases are distributed over, say, 8 to 10 hours and lasting up to 12 to 14 hours. And it's important to think about what the profile of the patient's problems are, and what's their day like. And that's why, for example, the continuous release is probably the one that I find is most widely preferred. But different strokes for different folks.\n\nTranscript edited for clarity","description":"Anthony Rostain, MD, MA, provides an overview of stimulants, nonstimulants, amphetamines, and methylphenidates for adult attention-deficit/hyperactivity disorder (ADHD) treatment.","author":[{"@type":"Person","name":"Theresa Cerulli, MD"},{"@type":"Person","name":"Anthony L. Rostain, MD, MA"}]}</script></div></div><div class="flex-none w-[300px] z-[9999] relative hidden md:block"><div style="top:5rem" class="sticky custom-spacing"><div class="collapse-container " style="overflow:hidden;max-height:900px;transition:max-height .4s ease-in-out"></div></div></div></div><div id="div-gpt-ad-pixel" style="width:1px;height:1px" class=""></div><noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-5V9L5PL" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><div id="footerOuterWrap" class="w-full bg-primary flex flex-col items-center justify-center"><div class="container w-[1340px]"><div id="footerInnerWrap" class="bg-primary w-full py-12"><div class="py-4 pl-4 flex flex-row items-center"><div class="flex flex-row flex-wrap w-[55%] h-full"><div class="w-[33%] p-1 my-0 cursor-pointer text-footer-text-color hover:text-footer-text-color/80 hover:underline"><a class="text-md" target="_self" href="/about">About</a></div><div 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We have so many choices now, it can be overwhelming. Can you give us an overview of stimulants and nonstimulants for ADHD, please?","_key":"caa6c616676d1","_type":"span","marks":[]}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"Anthony Rostain, MD, MA: ","_key":"a150917cfa260"},{"_type":"span","marks":[],"text":"Sure. Just to summarize for the longest time we've known in studies with children that stimulant medications are highly effective in various domains. And over the last several decades, we now have comparable data in adults to say that stimulants are the first line of treatment because they reduce the symptoms of ADHD and improve functioning in various domains. 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So, there's less of a take one day, skip another, which sometimes happens when people want to alter their treatment with stimulant medication. So sometimes we use both in combination depending on the complexity of the presenting problems.","_key":"378a52290f3c0"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"And again, we can talk later if you want about the side effects from these different types of treatment. But we tend to prefer using the longer-acting preparations of the stimulants because adults tend to have longer days, and it's much harder to remember throughout the day and to keep a steady effect of the medication if you're using immediate-release stimulants. So, the big change in our way of looking at stimulants over the past decade or so has really been to look at the data and say, we get better adherence and fewer problems when we prescribe long-acting medication preparations.","_key":"4a5787cb5db00"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal","_key":"d472be8593fa"},{"uploadAudio":null,"medias":null,"children":[{"_type":"span","marks":["strong"],"text":"Theresa Cerulli, MD: ","_key":"20720d72c7240"},{"_type":"span","marks":[],"text":"So","_key":"20720d72c7241"},{"_key":"20720d72c7242","_type":"span","marks":["strong"],"text":", "},{"_type":"span","marks":[],"text":"2 questions come to mind. The first is, within stimulants there are amphetamines and there are methylphenidates, which can be confusing. How do you decide where to start? Do you have a preference for one category or the other? And if so, why? That's the one question. And it's because patients will ask, all the time, in practice. So, I'm curious how you approach that.","_key":"20720d72c7243"}],"_type":"block","style":"normal","_key":"e725366a1a6c","markDefs":[],"upload_doc":null},{"_key":"15fd116f0f34","markDefs":[],"children":[{"_type":"span","marks":[],"text":"And then secondly, you mentioned some of the different formulations, immediate release, and extended release. Is there any data that helps us think about aids in treatment selection with regard to formulations?","_key":"ef0af80ea8660"}],"_type":"block","upload_doc":null,"uploadAudio":null,"medias":null,"style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Anthony Rostain, MD, MA: ","_key":"3751bbfb16db0"},{"_type":"span","marks":[],"text":"So, let's just start with the basic concept, which is overall methylphenidate has a very simple mechanism of action. It's really a reversible dopamine reuptake inhibitor that doesn't really do much more than block the transporter that's reuptaking the transmitter after it's been released. Amphetamine has a much more complex mechanism of action because it also makes more transmitters available in the vesicle. It also helps from the vesicle into the synapse. It increases the release of neurotransmitters. And we're talking about dopamine and epinephrine here. And it also reduces the breakdown, or the metabolism of the transmitter prismatically.","_key":"3751bbfb16db1"}],"_type":"block","style":"normal","_key":"9fc2d4c5a3e8","upload_doc":null,"uploadAudio":null,"medias":null},{"medias":null,"markDefs":[],"children":[{"_type":"span","marks":[],"text":"So, amphetamines are more complex in enacting; when you look at studies overall you could say there's a slightly higher effect size for amphetamines. And when you look at pharmacoepidemiologic data, it looks like about two-thirds of kids are on methylphenidate and only a third are on amphetamine. Around adolescence it's equal. And then in adults, the fractions are reversed. So, roughly, amphetamines are two-thirds to one-third depending on which study you're looking at.","_key":"38b19969831d0"}],"_type":"block","style":"normal","_key":"c3faf4736453","upload_doc":null,"uploadAudio":null},{"children":[{"_type":"span","marks":[],"text":"Does that mean you should start with one or the other? I always say to talk with your patient about the difference in the profile. Find out if they've been on the medication before, many of our adult patients were treated as kids and have some remembrances of what did or didn't work and if other family members have been more or less successful on methylphenidate versus amphetamine. I don't like to say, “Well start with X,” because I do think that it really varies from patient to patient. If you're really concerned that a patient is not going to want to do more than one trial, then you're probably better off trying an amphetamine because there's a slightly higher effect size with amphetamines compared to methylate. But once again, you have a greater chance of side effects.","_key":"12eba40567f00"}],"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"282f8630241c","markDefs":[]},{"children":[{"_key":"1289de6404f70","_type":"span","marks":["strong"],"text":"Theresa Cerulli, MD: "},{"_type":"span","marks":[],"text":"Exactly.","_key":"1289de6404f71"}],"_type":"block","style":"normal","upload_doc":null,"uploadAudio":null,"medias":null,"_key":"b912f85477d4","markDefs":[]},{"medias":null,"_type":"block","style":"normal","_key":"02683874139d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Anthony Rostain, MD, MA: ","_key":"da77ef97a31e0"},{"_type":"span","marks":[],"text":"So, the appetite, suppression, insomnia a feeling of restlessness, a jitteriness, you are more likely to see. Now, with respect to what I think of as the immediate release are just what they sound like. They're released right away, and they're in and out within usually 4 hours.","_key":"da77ef97a31e1"}],"upload_doc":null,"uploadAudio":null},{"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"71fe17eb9036","markDefs":[],"children":[{"_type":"span","marks":[],"text":"When we use medications like mixed amphetamine salts extended release, what we have here is a biphasic release where half of the amphetamine is released immediately and the other half, is released about 4 hours later. People get confused with the term XR, extended release, because they think it means it's continuous, but it's really not. With mixed amphetamine salts XR, what you're really doing is giving an immediate and then a delayed release in 2 phases.","_key":"749a9cd782550"}],"upload_doc":null},{"upload_doc":null,"uploadAudio":null,"medias":null,"_type":"block","style":"normal","_key":"f6994a7893bb","markDefs":[],"children":[{"_type":"span","marks":[],"text":"And then there are the more continuous-release preparations where you see over time the releases are distributed over, say, 8 to 10 hours and lasting up to 12 to 14 hours. And it's important to think about what the profile of the patient's problems are, and what's their day like. And that's why, for example, the continuous release is probably the one that I find is most widely preferred. 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I can’t stop scrolling through Instagram during my Zoom team meeting!” or someone else say “My mood is all over the place! I’m probably bipolar or something.” Many individuals have intermittent, waxing, and waning symptomatology, which does not cause any distress or decline in functionality. The truth is, all of us have times during which we experience inattentiveness. In fact, during this podcast, our listeners may have already lost their focus, or we may lose our train of thought, but this is simply normal human tendency, and it does not mean we have a clinical diagnosis such as ADHD. In training, it is important to learn and understand normal human behaviors and tendencies to avoid pathologizing normal human behavior or medicating unnecessarily. ","_key":"3c3de410752e1"}]},{"children":[{"_type":"span","marks":["strong"],"text":"LEM: How often do you see patients who don’t necessarily meet the diagnostic criteria of ADHD? Do they have other diagnoses, and if so what are these? 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However, this is a product of systemic changes that have promoted a very competitive schooling atmosphere. It is no longer enough to earn straight A’s or ace the SATs. Let me give you an example. Mary comes home from school and needs to complete a few hours of homework and studying followed by swim practice followed by piano practice followed by a few more homework assignments. Mary repeats this schedule on a daily basis, and becomes demoralized and frustrated. She begins to avoid her friends and family. Her inattentiveness becomes evident to her parents and teachers, and her grades begin to plummet, and her school refers her family to me. In situations like these, I discuss expectations and counsel the family to support the child or teen’s wellness. Mary may be demoralized or depressed. Providing a stimulant may only exacerbate her anxiety, and thereby, worsen her depression. The treatment would involve therapy and possibly an SSRI if warranted. 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Charlie would benefit from behavioral therapy or parent management training for oppositional defiant disorder. Charlie does not have ADHD, and a medicine would not be helpful. In such cases, when I have shared this information with patients, they have sometimes expressed sadness or frustration about the diagnosis. ","_key":"ec0e6f5f57c61"}]},{"_type":"block","style":"normal","_key":"d2e32606db8d","markDefs":[],"children":[{"_key":"d2e32606db8d0","_type":"span","marks":[],"text":"Many parents present to me hoping their children have ADHD when they do not. You may wonder why they would hope this were the case. Parents, understandably, can experience burnout and fatigue, and look to us physicians to expedite change and provide help. Therapy can take time to work, and medicine sometimes seems like a quick fix. I have open and candid discussions with parents to set expectations and reiterate that there is no magic pill or instant solution."}]},{"_type":"block","style":"normal","_key":"acd556d0a498","markDefs":[],"children":[{"_type":"span","marks":[],"text":"What I explain to parents is that medicines do not change behavior. Likewise, medicines do not make homework seem more interesting than Fortnite or Call of Duty. Medicine does not simply result in improved grades. Overall, it is pivotal that we have open conversations, and answer questions about the avenues of treatment and the risk of medicating when medication is not warranted.","_key":"acd556d0a4980"}]},{"_type":"block","style":"normal","_key":"1375beb4d98c","markDefs":[],"children":[{"_key":"1375beb4d98c0","_type":"span","marks":["strong"],"text":"LEM: What can you say about anxiety in children?"}]},{"markDefs":[],"children":[{"text":"Leela Magavi, MD:","_key":"5adf36c7ecad0","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" Anxiety is often misdiagnosed as ADHD as the features overlap. In fact, anxiety is what child and adult psychiatrists see the most in clinic. I evaluate individuals of all ages, and most of my patients see me for anxiety. Anxiety can present as inattentiveness, restlessness, impulsivity and irritability. For example, Sheila presents with restlessness and perfectionistic tendencies. She procrastinates and puts off tasks due to fear of failure. She appears fidgety and nervous in class, and asks her teachers and parents to repeat themselves. ","_key":"5adf36c7ecad1"}],"_type":"block","style":"normal","_key":"5adf36c7ecad"},{"_key":"50177eac1453","markDefs":[],"children":[{"text":"Sheila has generalized anxiety disorder. Once her anxiety is treated, these symptoms resolve, and her school performance improves. Other kids like Sheila may present with concerns about ADHD, but actually are experiencing symptoms of depression, which can cause increased processing speed and impaired working memory, and thus, affect cognition and academic performance. Similarly, after treating depression, inattentiveness and what appeared to be ADHD symptoms, improve.","_key":"50177eac14530","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_key":"221670c2894c","markDefs":[],"children":[{"_key":"221670c2894c0","_type":"span","marks":["strong"],"text":"LEM: What are some common comorbidities, and how would you tackle these concerns in the clinic?"}],"_type":"block","style":"normal"},{"style":"normal","_key":"2e33d01eacf0","markDefs":[],"children":[{"text":"Leela Magavi, MD:","_key":"2e33d01eacf00","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" ADHD often presents with various comorbid disorders inclusive of anxiety, depression and bipolar disorder. In these cases, once the mood and anxiety disorder is stabilized, and if ADHD symptoms continue to impair functionality, a medication for ADHD can be started. In cases where kids have ADHD and ODD, kids would benefit from a combination of therapy and stimulants. In cases where kids have ADHD and tic disorder, they may benefit from habit reversal therapy, an alpha agonist for tics, impulsivity and hyperactivity, and possibly a stimulant as well. ","_key":"2e33d01eacf01"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"LEM","_key":"3e87a74e23aa0"},{"_type":"span","marks":[],"text":": ","_key":"3e87a74e23aa1"},{"_type":"span","marks":["strong"],"text":"Any take-home messages about how ADHD presents in real-world experience that show how treatment can make a significant difference in a child’s life?","_key":"3e87a74e23aa2"}],"_type":"block","style":"normal","_key":"3e87a74e23aa","markDefs":[]},{"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"d4281f85406a0"},{"marks":[],"text":" The take-home is when a child truly has ADHD and he or she receives treatment, the results are evident and life-changing for everyone involved. I have had the invaluable opportunity to treat Mark, a seven-year-old boy suffering from ADHD. During play therapy, I have learned that the reason he often gets angry at school is because he is tired of other children teasing him about “not reading good.” During another session, he used toy cars to share his goal with me, exclaiming, “I want to be a police officer one day!” As Mark improved with weekly therapy and treatment with Focalin extended release or dexmethylphenidate, a stimulant medication, he gained confidence. This experience was particularly memorable and rewarding.","_key":"d4281f85406a1","_type":"span"}],"_type":"block","style":"normal","_key":"d4281f85406a","markDefs":[]},{"_key":"df4915813685","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: Older adolescents and young adults have been known to abuse ADHD medications to help improve their studying stamina and grades. Besides being illegal, what are some of the dangers associated with this practice?","_key":"df49158136850"}],"_type":"block","style":"normal"},{"style":"normal","_key":"93a337bc2faf","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"93a337bc2faf0"},{"_type":"span","marks":[],"text":" Each year, academic expectations build. The competition is real and appears to be increasing relentlessly. It is harder and harder to get into colleges. Even kindergarten and first grade seem harder than they ever used to be. Teens and young adults often use their peers’ ADHD medications, or illegally purchase them to gain a competitive advantage, or use them recreationally. Some individuals even take stimulants solely to stay up later because they have so much to finish and so little time.","_key":"93a337bc2faf1"}],"_type":"block"},{"_key":"fbbe11355125","markDefs":[],"children":[{"text":"The truth of the matter is, when someone does not have ADHD, they may not benefit significantly from taking a stimulant. They may feel more energetic, but the data from pilot studies have suggested that cognition itself may not improve. We do not completely understand the dangers associated with use of stimulants in someone who does not have ADHD as ethical concerns limit our ability to study this. Some of my patients who have admitted to using stimulants without a diagnosis of ADHD have experienced concerns including weight loss, anxiety, depression, psychosis, insomnia, hypertension, and other cardiac concerns. I want to encourage all listeners to spread awareness and encourage friends and loved ones to be evaluated by a physician prior to trying medications.","_key":"fbbe113551250","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"Stimulants can cause myocardial infarction, cardiomyopathy, and even sudden death. Although the risk is low, it is not worth taking. Patients with a personal or family history of cardiac events may require further work-up prior to initiating medications. Due to addiction concerns, some parents do not want their children who have ADHD to take medications. As opposed to those who do not have ADHD, for kids who do have ADHD, we have large, validated studies which indicate the significant and helpful effect of stimulants. Long-term studies suggest that treating ADHD reduces unemployment, divorce and addiction concerns longitudinally.","_key":"bc181e29b22a0","_type":"span"}],"_type":"block","style":"normal","_key":"bc181e29b22a"},{"style":"normal","_key":"3ebca9ee93aa","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: ADHD treatment options have come a long, and now include various formulations, long-acting dosing, patches, and even a video interface. How should clinicians decide what medications to prescribe to their patients?","_key":"3ebca9ee93aa0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"f0c525ee36750"},{"_type":"span","marks":[],"text":" It is important to comprehensively assess the child and learn about his or her genetic predisposition, temperament, behavior and life story prior to selecting a medication. There are many options, and new agents continue to gain approval. For children who are young and primarily impulsive and hyperactive, and if really warranted due to functional impairment, I may consider using an alpha agonist such as clonidine extended release also known as Kapvay, or guanfacine extended release also known as Intuniv. These are blood pressure medications. I often use these alongside stimulants as it allows the use of lower stimulant doses.","_key":"f0c525ee36751"}],"_type":"block","style":"normal","_key":"f0c525ee3675"},{"markDefs":[],"children":[{"_key":"561fd504fbce0","_type":"span","marks":[],"text":"Alpha agonists do not target inattention as well as stimulants do, and I explain this to parents who prefer nonstimulant options. Other nonstimulant options are Wellbutrin also known as bupropion, which is an antidepressant, and atomoxetine also known as Strattera, which is a selective norepinephrine reuptake inhibitor, also helpful for anxiety. The common stimulant families are methylphenidates and amphetamines. I always start with methylphenidates, and then transition to amphetamines if warranted due to side effect profiles. I use long-acting agents and add on immediate release if warranted for longer duration of action. Patches, liquid formulations and some capsules are helpful when kids have difficulty swallowing. Lisdexamfetamine or Vyvanse is an option for those who have a history of substance use as this medication is metabolized differently, and decreases addiction potential."}],"_type":"block","style":"normal","_key":"561fd504fbce"},{"children":[{"_type":"span","marks":[],"text":"I think it’s wonderful that we are learning more and more about the brain and medications that could help these children. I’m very grateful to my colleagues who are partaking in research and helping us answer these questions. Most recently, which I am delighted to share with parents and listeners, we have learned that a videogame called Endeavor Rx, has been FDA approved for kids between ages 8 and 12 who have been diagnosed with ADHD. For those who are interested, you may join the online waitlist, made available by the developing company, Akili Interactive.","_key":"6605964aab220"}],"_type":"block","style":"normal","_key":"6605964aab22","markDefs":[]},{"style":"normal","_key":"740d652723b8","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: Are there concrete tools or scales to help diagnose ADHD?","_key":"740d652723b80"}],"_type":"block"},{"markDefs":[],"children":[{"marks":["strong"],"text":"Leela Magavi, MD:","_key":"c781ce68a6970","_type":"span"},{"marks":[],"text":" ADHD is a clinical diagnosis and symptoms need to be present in more than one setting. Scales and tools such as the Child Behavior Checklist, Conners-Wells, Vanderbilt, Swanson Nolan and Pelham are helpful, but not necessary for diagnosis. I view them as additional pieces of information, and occasionally, to monitor progress.","_key":"c781ce68a6971","_type":"span"}],"_type":"block","style":"normal","_key":"c781ce68a697"},{"style":"normal","_key":"15f14613a2d6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I personally use the Vanderbilt scale most often. I find it interesting to ask mom and dad to complete the Vanderbilt scale independently and compare their responses with the teachers. When the numbers align and are high, this is more indicative of ADHD. If the teacher’s scores are very high, but the parents’ scores are low, this may mean that the teacher needs more help in the classroom setting due to high student to teacher ratio, among other things. If the teacher’s scores are low, and the parents’ scores are high, it may mean that the child is exhibiting behavioral concerns at home for particular reasons. Sometimes, only one parent scores high, which may be due to a mismatch in temperament and personality traits.","_key":"15f14613a2d60"}],"_type":"block"},{"_key":"cf421e336077","markDefs":[],"children":[{"_key":"cf421e3360770","_type":"span","marks":["strong"],"text":"LEM: Are CT, PET, EEG, and MRI reliable diagnostic tools for children?"}],"_type":"block","style":"normal"},{"style":"normal","_key":"b18578dd856d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"b18578dd856d0"},{"_type":"span","marks":[],"text":" Brain imaging is not warranted for the diagnosis of ADHD. I rarely ever order it unless necessary for another reason. I may consider an EEG or MRI if I am concerned about epilepsy presenting like ADHD or absence seizures during which the child may appear to be staring into space when they are in fact having a seizure. Brain imaging may also be helpful in post-concussion syndrome in which individuals may have difficulty with inattentiveness and mental fatigue, and may benefit from a stimulant although they do not have ADHD.","_key":"b18578dd856d1"}],"_type":"block"},{"style":"normal","_key":"071fafa784b5","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Nevertheless, brain imaging has helped us learn a lot about ADHD. Converging evidence from various imaging studies has helped us assess differences in brain volume, diffusion properties of white matter tracts, and cortical features in typically developing children compared to those with ADHD. Psychoradiology is a developing field and may help guide our treatment planning in the future.","_key":"071fafa784b50"}],"_type":"block"},{"style":"normal","_key":"a825cba3465b","markDefs":[],"children":[{"marks":["strong"],"text":"LEM: Do you transition patients out of your care to a general psychiatrist?","_key":"a825cba3465b0","_type":"span"}],"_type":"block"},{"_key":"3ac92d5f299c","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"3ac92d5f299c0"},{"_type":"span","marks":[],"text":" Some child psychiatrists only evaluate and treat children, but I treat individuals of all ages and enjoy this diversity. I provide a mixture of medication management and therapy, and establish strong bonds with my patients. I always tell my adolescents that there’s no magic button that turns on and makes an eighteen-year-old instantly an adult. Every individual transitions into adulthood at a different pace. Being an adult is tough, and I evaluate patients at all ages who struggle with this transition. For this reason, I do not think child psychiatrists necessarily need to transition their patients to an adult psychiatrist.","_key":"3ac92d5f299c1"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: We used to hear that children “grow out of” ADHD. Now, data show that adults can and do have the disorder. Is it possible to outgrow ADHD?","_key":"437543176f8f0"}],"_type":"block","style":"normal","_key":"437543176f8f"},{"_type":"block","style":"normal","_key":"e739231bca74","markDefs":[],"children":[{"text":"Leela Magavi, MD:","_key":"e739231bca740","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" ADHD is essentially a neurodevelopmental disorder, which can affect individuals at any age. It is chronic in nature, but presentations vary at different life stages. The frontal lobe is the last to develop and mature, and there are many changes that occur with brain plasticity. For example, children display a decrease in symptoms of hyperactivity and impulsivity as they mature. Many children with ADHD still have the condition as adults, and are highly susceptible to other psychiatric disorders. I do evaluate adults who have never been diagnosed with ADHD as children who present to see me for the first time. Some of them experience impulsivity and have difficulty with relationships and work for this reason. Others who were diagnosed as children have relayed that their ADHD symptoms have evolved over time. It is pivotal for physicians to titrate down on medications as warranted and consider discontinuing medication if individuals are faring well off of them and when symptoms no longer affect functionality. In these cases, I like to take a conservative approach and recommend daily exercise, sleep hygiene techniques, and other behavioral strategies.","_key":"e739231bca741"}]},{"markDefs":[],"children":[{"_key":"c4a1175098ca0","_type":"span","marks":[],"text":"Finally, every individual with ADHD whom I have had the pleasure of treating has something special to offer. For my kids who ask me if this diagnosis means they are not smart, I remind them that this is not the case. Albert Einstein was suspected to have ADHD and as were other notable people, such as Walt Disney, and Michael Jordan. 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","gptTakeaways":"• ADHD in adults is underdiagnosed, often masked by comorbid conditions, leading to significant psychosocial impairments.\n\n• Accurate diagnosis requires comprehensive history-taking, standardized tools, and functional assessments to differentiate from other psychiatric disorders.\n\n• ADHD prevalence in adults is 2.5%, with high comorbidity rates with bipolar disorder, major depressive disorder, and substance use disorder.\n\n• Early identification and treatment of ADHD can significantly improve long-term psychiatric and functional outcomes.","published":"2024-10-29T15:00:00.000Z","audioUrl":"https://s3.us-east-1.amazonaws.com/ai-generated-audios/www.psychiatrictimes.com/f342d221-1cb4-4d1a-b967-dc97ae542521_1729884140454.4a9fe7ab-e3a9-4d2b-b53c-049067621b1d.mp3","title":"ADHD: Overlooked Cause of Persistent Anxiety and Depression in Adults","authorMapping":[{"_updatedAt":"2024-10-25T19:06:44Z","url":{"current":"parinda-parikh-md","_type":"slug"},"displayName":"Parinda Parikh, MD","_createdAt":"2024-10-25T19:06:44Z","_rev":"VUkuE34wajTefC0u4bZBF0","_type":"author","_id":"53b26b44-11c0-4263-83ea-dc2a4dbb016b","biography":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Parikh ","_key":"9158fad88e2a0"},{"_key":"9158fad88e2a1","_type":"span","marks":["em"],"text":"is a faculty member at Weill Cornell Medical College and Second Arc Psychiatric Associates in White Plains, New York."}],"_type":"block","style":"normal","_key":"c1db3f5b242a"}]},{"url":{"current":"chujun-chen-md","_type":"slug"},"displayName":"Chujun Chen, MD","_createdAt":"2024-10-25T19:07:26Z","_rev":"HZIB0LLkBhvyiAmq6rj8Zy","_type":"author","_id":"06e75d85-dc0f-4a49-a76b-1256d76a7bfe","biography":[{"markDefs":[],"children":[{"_key":"ef7f47f0f9560","_type":"span","marks":["strong"],"text":"Dr Chen "},{"text":"works in the Department of Psychiatry at Second Xiangya Hospital of Central South University in Changsha, China.","_key":"ef7f47f0f9561","_type":"span","marks":["em"]}],"_type":"block","style":"normal","_key":"0acc2b784204"}],"_updatedAt":"2024-10-25T19:07:26Z"},{"displayName":"Smit Jayeshkumar Patel, MD","_createdAt":"2024-10-25T19:07:55Z","_rev":"VUkuE34wajTefC0u4bZUO1","_type":"author","_id":"8fa3907a-b3e0-420d-a57f-db832f60f370","biography":[{"children":[{"_type":"span","marks":["strong"],"text":"Dr Patel ","_key":"65bf7c688a5b0"},{"_type":"span","marks":["em"],"text":"works at the Government Medical College and New Civil Hospital in Gujarat, India.","_key":"65bf7c688a5b1"}],"_type":"block","style":"normal","_key":"e5c3c7b9fcd9","markDefs":[]}],"_updatedAt":"2024-10-25T19:08:55Z","url":{"_type":"slug","current":"smit-jayeshkumar-patel-md"}}],"_type":"article","_id":"f342d221-1cb4-4d1a-b967-dc97ae542521","ExcludeFromPubMedXML":false,"articleType":"News","body":[{"imgcaption":[{"markDefs":[],"children":[{"_key":"5de4f3c538b60","_type":"span","marks":[],"text":"1STunningART/AdobeStock"}],"_type":"block","style":"normal","_key":"b548d309db26"}],"_key":"2e09c71be811","_type":"figure","widthP":50,"disableTextWrap":false,"alignment":"left","disableLightBox":true,"alt":"ADHD","asset":{"_ref":"image-480b7b29f69d9743ec4d45ba543c1fc8e7aa932f-6000x3375-jpg","_type":"reference"}},{"children":[{"text":"CLINICAL REFLECTIONS","_key":"11f9c42e020e0","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"e6c9b9f0e836","markDefs":[]},{"style":"normal","_key":"8183bcc74619","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Case Vignette","_key":"4d32cd6e40330"}],"_type":"block"},{"_type":"block","style":"normal","_key":"c79ba3cedd87","markDefs":[],"children":[{"_type":"span","marks":[],"text":"“Simon,” a 21-year-old man, presents for an evaluation of treatment-resistant anxiety. He experiences psychological anxiety, which interferes with his focus and concentration, causing difficulties with initiating and sustaining tasks. A review of his past psychiatric history reveals that he began seeing a therapist for panic attacks and severe anxiety that seemed to come out of nowhere when he was in middle school. He had consulted 3 different psychiatrists but had not found any of their treatments effective. He denies any history of mania or psychosis.","_key":"9cd90f73486b0"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"8272b37840170"}],"_type":"block","style":"normal","_key":"5cdf5dee1872","markDefs":[]},{"style":"normal","_key":"ca10fc119f89","markDefs":[],"children":[{"_type":"span","marks":[],"text":"He received cognitive behavior therapy and was subsequently treated with various psychiatric medications, including buspirone, fluoxetine, escitalopram, phenelzine, mirtazapine, bupropion, aripiprazole, quetiapine, olanzapine, pregabalin, clonazepam, lorazepam, valproate, lamotrigine, lithium, and ketamine. However, Simon reports no psychological improvement with these medications. On the contrary, he experienced multiple adverse effects, including a panic-like electric shock reaction with phenelzine, a dystonic reaction with antipsychotics, and 2 grand mal seizures with bupropion. At the time of evaluation, Simon was taking buspirone 30 mg twice daily, pregabalin 150 mg, lamotrigine 200 mg, lithium 450 mg at night, and mirtazapine 30 mg. Simon came in frustrated, requesting to discontinue all his medications. After a thorough evaluation, including a review of his developmental history, it was found that he had exhibited characteristics of inattention and hyperactivity since elementary school. A subsequent Jasper/Goldberg Adult ADD Screening Examination indicated undiagnosed attention-deficit/hyperactivity disorder (ADHD). Simon was therefore started on viloxazine 100 mg, titrated to 200 mg over 1 week while continuing lamotrigine 200 mg and tapering off all other medications.","_key":"525aaccca0460"}],"_type":"block"},{"_type":"block","style":"normal","_key":"5c96a878ada8","markDefs":[],"children":[{"marks":[],"text":"","_key":"bb5724cb4f960","_type":"span"}]},{"_key":"f02e34b2ab1b","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"ADHD in Adulthood","_key":"67af674718dd0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"23f1ee651316","markDefs":[{"href":"https://www.psychiatrictimes.com/topics/adhd","_key":"0ebb173e14ae","nofollow":true,"blank":true,"_type":"link"}],"children":[{"_key":"78a017fee66f0","_type":"span","marks":[],"text":"ADHD is a multifactorial and clinically heterogeneous disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. It can impose significant financial burdens and stress on families and is also associated with adverse academic and vocational outcomes. Although "},{"_type":"span","marks":["0ebb173e14ae"],"text":"ADHD","_key":"f8e297773415"},{"_type":"span","marks":[],"text":" is recognized as a childhood-onset neurodevelopmental disorder, its prevalence in adults should also be acknowledged.","_key":"ecfc26ed7d46"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"","_key":"36bd1d4a41520"}],"_type":"block","style":"normal","_key":"238e8f7abe85","markDefs":[]},{"children":[{"_type":"span","marks":[],"text":"A recent meta-analysis has reported that the prevalence of ADHD in children and adolescents is estimated to be 5.29%, the prevalence of ADHD in adults aged 19 to 45 years is estimated to be 2.5%. Approximately 15% children with ADHD will persist into their adulthood, with 40% to 60% partially remitted.","_key":"25eb3d79731e0"},{"_type":"span","marks":["superscript"],"text":"1","_key":"0bd8b8e8e0dc"},{"_type":"span","marks":[],"text":" In some cases, adults remain undiagnosed until they reach their 30s or 40s, only discovering they have ADHD after their children are diagnosed. A national wide investigation done in an East-Asian country indicated a percentage of 34.7% in first year university students presented with symptoms suggestive of probable ADHD.","_key":"a480c25ea38f"},{"marks":["superscript"],"text":"2","_key":"e73e40299743","_type":"span"},{"_type":"span","marks":[],"text":" Even in European countries, where ADHD should have been better recognized and treated, the prevalence of undiagnosed ADHD in adult psychiatric patients was 9.27%, and “hidden” ADHD is associated with an increased suicide risk among these patients.","_key":"bc920d345818"},{"_key":"f0b2b80b90d6","_type":"span","marks":["superscript"],"text":"3"}],"_type":"block","style":"normal","_key":"e1a7b30a06fa","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"532e81209b0a0"}],"_type":"block","style":"normal","_key":"cbcd2085b330"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Previous review has emphasized that ADHD can persist throughout one's lifespan and often presents as a chronic condition. If left untreated, the symptoms of ADHD can lead to significant psychosocial impairment,","_key":"8d729e80228e0"},{"_key":"452034749254","_type":"span","marks":["superscript"],"text":"4"},{"text":" and leading to maladaptive behaviors including self-medicating by using recreational drugs, alcohol, and nicotine.","_key":"359c09da26bb","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"5","_key":"10e0e2b351fa"}],"_type":"block","style":"normal","_key":"eacec2cb260b"},{"_key":"cf0973b9e993","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"b36459dadc4a0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"4a7db3e1935f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Diagnosing adult ADHD is challenging due to limited guidelines and consensus. Once seen as a childhood disorder, ADHD is now recognized to persist into adulthood, but this shift has outpaced clinical approaches, leading to inconsistent diagnosis.","_key":"9b74d7adc0f20"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4f4a5178680d0"}],"_type":"block","style":"normal","_key":"03860cff7bbf"},{"style":"normal","_key":"c6a425e4bf6b","markDefs":[],"children":[{"_key":"6554366bb06a0","_type":"span","marks":[],"text":"Key challenges in adult ADHD diagnosis include:"}],"_type":"block"},{"_key":"2d2a75c4c95a","markDefs":[],"children":[{"_key":"c6e4072329b00","_type":"span","marks":[],"text":"1. Symptom overlap. ADHD symptoms in adults (eg, inattention, impulsivity) often overlap with conditions like depression and anxiety, complicating diagnosis."}],"_type":"block","style":"normal"},{"style":"normal","_key":"4f2b2387a2d5","markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Retrospective diagnosis. Adult diagnosis relies on evaluating childhood symptoms, which may have been undiagnosed or misunderstood.","_key":"7d957495a9210"}],"_type":"block"},{"markDefs":[],"children":[{"_key":"45b6b967de1e0","_type":"span","marks":[],"text":"3. Cultural/societal differences. ADHD prevalence varies by region due to stigma and health care differences, leading to \"hidden\" cases."}],"_type":"block","style":"normal","_key":"c7934544f797"},{"_type":"block","style":"normal","_key":"8cfd9cf42b2e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. Gender bias. Women are often underdiagnosed as their symptoms are less hyperactive and more inattentive, sometimes mistaken for stress or mood disorders.","_key":"d8fb0e223c240"}]},{"_key":"0085e39bcd22","markDefs":[],"children":[{"_key":"b931066961220","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"These are some of things a clinician should keep in mind while considering a patient to be suffering from adult ADHD. These include:","_key":"c417be1200a90"}],"_type":"block","style":"normal","_key":"0bcaaf7a00a1"},{"_type":"block","style":"normal","_key":"c99bc4f07b74","markDefs":[],"children":[{"_type":"span","marks":[],"text":"1. Comprehensive history. Gather detailed information on childhood behavior, academic issues, and coping strategies. Family history of ADHD may provide further insights.","_key":"976d069f63960"}]},{"style":"normal","_key":"d8e9c8806d64","markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Use diagnostic tools. Employ standardized tools like the Adult ADHD Self-Report Scale (ASRS) to assess symptoms.","_key":"cf7a641929ad0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Assess developmental milestones. Examine the developmental trajectory, noting if symptoms persisted into adulthood even with coping strategies.","_key":"8244155701b30"}],"_type":"block","style":"normal","_key":"94992a513d96"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. Evaluate functional impairment. Diagnose ADHD only if symptoms impair major areas of life (work, relationships, etc).","_key":"ccf2bee5a24a0"}],"_type":"block","style":"normal","_key":"376535c5d94e"},{"_type":"block","style":"normal","_key":"8d1af34d086b","markDefs":[],"children":[{"text":"5. Rule out other conditions. Conduct differential diagnoses to exclude psychiatric conditions with similar symptoms.","_key":"ee9bd28033710","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_key":"c8813cf9c7a20","_type":"span","marks":[],"text":"6. Psychoeducation and collaboration. Educate patients on ADHD as a lifelong condition and collaborate with other specialists for comprehensive care."}],"_type":"block","style":"normal","_key":"df92cee40474"},{"_key":"864805faa4ed","markDefs":[],"children":[{"text":"7. Consider subtle symptoms. Watch for less overt symptoms in adults, like procrastination, emotional dysregulation, or chronic lateness.","_key":"82342300658a0","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"54ca78332806","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"95941b2297b40"}]},{"_type":"block","style":"normal","_key":"7250d2b03270","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Improving global ADHD guidelines and diagnostic consistency requires cross-cultural studies and refinement of tools like the ","_key":"d8e70cdb938e0"},{"_key":"d8e70cdb938e1","_type":"span","marks":["em"],"text":"DSM-5"},{"text":". Clinicians should combine thorough history-taking, structured tools, and functional assessment to accurately diagnose and treat adult ADHD. Education and addressing the stigma are also key to bridging the gap in adult ADHD diagnosis and care.","_key":"d8e70cdb938e2","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"676ca03b21bc0"}],"_type":"block","style":"normal","_key":"cf13f9ac2eb7"},{"markDefs":[],"children":[{"_key":"bb2f1b7a29b70","_type":"span","marks":["strong"],"text":"Psychological Burden"}],"_type":"block","style":"normal","_key":"792124e6595b"},{"_key":"0d798da204dd","markDefs":[],"children":[{"_key":"1e1e5f32be250","_type":"span","marks":[],"text":"The underlying ADHD symptoms experienced by adults can lead to functional impairments, affecting their academic and vocational performance, daily activities, and social interactions. These impairments may further contribute to a significant psychological burden."}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_key":"adb72b84db910","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"39efd0ef5625"},{"_key":"4274104dc55e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In today's fast-paced modern society, patients' procrastination, inattentiveness, and disruptive behaviors, if unnoticed and untreated, can place them in difficult situations, leading to significant psychosocial stress, which may further contribute to the development of other psychiatric disorders. Undiagnosed ADHD can have negative impacts on self-esteem and self-worth,","_key":"a2d69d2b30760"},{"_type":"span","marks":["superscript"],"text":"5","_key":"104b2c45cce6"},{"_type":"span","marks":[],"text":" and is associated with higher rates of current depression, alcohol abuse, and greater emotional and interpersonal difficulties when compared with patients who do not have ADHD.","_key":"16b583c30733"},{"_type":"span","marks":["superscript"],"text":"6,7","_key":"2e7d8c0cf292"},{"_type":"span","marks":[],"text":" Research has shown that undiagnosed adults with potential ADHD symptoms may have a higher coexistence of mental comorbidities, sleep problems, and physical comorbidities, they also experience greater work productivity impairment, increased health care resource usage, and lower health-related quality of life.","_key":"02d0bfdb04c3"},{"_type":"span","marks":["superscript"],"text":"8","_key":"35c0d7c53e3e"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"60beb00895ce0"}],"_type":"block","style":"normal","_key":"d6a6463ae4e7"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"ADHD and its Comorbidities","_key":"f29860f45df20"}],"_type":"block","style":"normal","_key":"e2be4d7b278e"},{"_key":"26ae4be16984","markDefs":[{"_key":"fbfcb8be7eaa","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/bipolar"},{"_key":"8036786d0e72","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/major-depressive-disorder"},{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F0c19b9683fbb83270537c15f6647d225b38727a0-402x376.jpg%3Ffit%3Dcrop%26auto%3Dformat\u0026w=828\u0026q=75","_key":"9cc5026f6df6"}],"children":[{"_type":"span","marks":[],"text":"Prevalence of ADHD is 2.5% in adults.","_key":"ba85512325ab0"},{"_type":"span","marks":["superscript"],"text":"1","_key":"27b8d9e61313"},{"_type":"span","marks":[],"text":" Individuals with ADHD have symptoms like deficient inhibitions, problems with memory, decision-making, and emotional decision-making, which can lead to a misdiagnose as they are symptoms of other conditions. ADHD shares symptomatology with ","_key":"cd058883908b"},{"_type":"span","marks":["8036786d0e72"],"text":"major depressive disorder","_key":"4d3fd273e94e"},{"text":" (MDD; low hedonic tone, irregular sleep, and appetite), generalized anxiety disorder (GAD; fidgeting, irritability), ","_key":"ba88112b052c","_type":"span","marks":[]},{"_type":"span","marks":["fbfcb8be7eaa"],"text":"bipolar disorder","_key":"f968901c4531"},{"text":" (episodic fluctuations, excessive talking), and substance use disorder (SUD; social withdrawal) (as illustrated in ","_key":"f22339d7d75d","_type":"span","marks":[]},{"_type":"span","marks":["strong","9cc5026f6df6"],"text":"Figure","_key":"ba85512325ab1"},{"_type":"span","marks":[],"text":"). ADHD has an especially high prevalence with bipolar disorder, with rates ranging from 9.5% to 21.2%.","_key":"ba85512325ab2"},{"marks":["superscript"],"text":"9","_key":"31ec43e5c85a","_type":"span"},{"_type":"span","marks":[],"text":" With MDD, ADHD prevalence has been reported to be between 9% to 16%.","_key":"da0d12c6ae05"},{"_type":"span","marks":["superscript"],"text":"10","_key":"6a2f49d86fa7"},{"_type":"span","marks":[],"text":" There is also an increased risk of ADHD in patients of GAD, with risk rising by about 50% more than in the general population.","_key":"370a1aeb62b6"},{"marks":["superscript"],"text":"11","_key":"20124d2d6934","_type":"span"},{"_key":"f9ff414ee573","_type":"span","marks":[],"text":" ADHD is more common in patients with social anxiety. Finally, SUD is about twice as likely in patients with ADHD. It is bidirectional, arising due to neurological factors, increased impulsivity, other comorbidities, and any attempts to self-medicate."}],"_type":"block","style":"normal"},{"imgcaption":[{"markDefs":[],"children":[{"_key":"32413b859ef90","_type":"span","marks":["strong"],"text":"Figure."},{"_key":"32413b859ef91","_type":"span","marks":[],"text":" Adult ADHD and Various Comorbid Disorders"}],"_type":"block","style":"normal","_key":"cae505994764"}],"_key":"5ae70fa9e25d","asset":{"_ref":"image-0c19b9683fbb83270537c15f6647d225b38727a0-402x376-jpg","_type":"reference"},"alt":"Figure. Adult ADHD and Various Comorbid Disorders","blank":true,"disableLightBox":true,"_type":"figure","alignment":"right","widthP":50,"disableTextWrap":false},{"_type":"block","style":"normal","_key":"832579b100cd","markDefs":[],"children":[{"text":"","_key":"bf669a3552060","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"marks":[],"text":"ADHD is a common but often underrecognized and undertreated psychiatric disorder in adults, presenting with symptoms from other possible diagnoses. Screening for ADHD in adults presenting with these comorbidities can identify patients who may benefit from targeted management. While ADHD in adults presents variably, it can often be detected with a few key clinical questions and validated assessment scales like Adult ADHD Self-Report Scale (ASRS) or the Conners' Adult ADHD Rating Scales (CAARS). Early and effective treatment of ADHD can significantly improve long-term psychiatric and functional outcomes. When ADHD coexists with other psychiatric conditions, the more severe disorder should be prioritized in treatment. In the coming years, more work on genetic and organic causes of ADHD may help identify new points for targeted treatment and ultimately help the patients.","_key":"737f29683c100","_type":"span"},{"text":"12","_key":"3ab0c1d8a5a7","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"9a658a073593"},{"children":[{"_type":"span","marks":[],"text":"","_key":"c829a039374f0"}],"_type":"block","style":"normal","_key":"6b7f3c4a43b4","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts","_key":"6c9bd9735a080"}],"_type":"block","style":"normal","_key":"53fb1f8d44cd"},{"style":"normal","_key":"249fe31744e8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Identifying ADHD correctly is essential, especially when it is hidden by cooccurring illnesses. Properly identifying ADHD, particularly when it is masked by comorbid conditions, plays a significant role in developing an appropriate treatment plan. Such cases have been documented, demonstrating the challenges in diagnosing ADHD when other disorders are present.","_key":"d54e2154e9cf0"},{"text":"13","_key":"a9bdb0398003","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" This marks the importance of screening for ADHD, particularly in patients with treatment-resistant anxiety or MDD. In these situations, a misdiagnosis may result in the patient receiving poor treatment and unsuitable medication, worsening their condition. Therefore, a thorough evaluation for ADHD should be a standard component of the diagnostic process in patients who do not respond to conventional therapies for anxiety or MDD. 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