Adult attention deficithyperactivity disorder and coexisting substance use

Adult attention – deficit/hyperactivity disorder and co-existing substance use disorder: epidemiology and clinical presentation Mirjana Delić, MD

• Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterised by persistent patterns of inattention and/or hyperactivity and impulsiveness that can lead to severe disruptive behaviour. 1 • Not only a childhood disorder. 2 -3 1. APA. Diagnostic and Statistical Manual of Mental Disorders – Text Revision. 4 th Edn. Washington DC: APA; 2000; 85– 93. 2. Asherson. Expert Rev Neurother 2005; 5: 525– 39. 3. Elia et al. N Engl J Med 1999; 340: 780– 8.

• ADHD has an adult prevalence rate of 2– 5%. 1, 2 • There is an estimated 40– 60% persistence into adulthood (the full blown or in „partial remission“). 3 • By adulthood there is a 1. 5: 1 M/F ratio of ADHD, and it is thought that females are likely to be underdiagnosed. 1 • A common reason for patient referral is that their child is diagnosed with ADHD first (20% of parents of children with ADHD will have ADHD themselves). 3 1. Kooij et al. BMC Psychiatry 2010; 10: 67. 2. Fayyad et al. Br J Psychiatry 2007; 190: 402– 9. 3. Faraone et al. Psych Med. 2006; 36: 159– 165

Worldwide Prevalence of ADHD in Adults • According to the 2007 WHO-WMH survey initiative, the estimated worldwide prevalence of adult ADHD is 3. 4% Country Belgium Colombia France Germany Italy Lebanon Mexico The Netherlands Spain USA Total a. Upper end of 95% CI is below the prevalence estimate for total sample b. Lower end of 95% CI is above the prevalence estimate for total sample 1. Fayyad et al. Br J Psychiatry 2007; 190: 402– 9. Prevalence, % (SE) n 4. 1 (1. 5) 1. 9 (0. 5)a 7. 3 (1. 8)b 3. 1 (0. 8) 2. 8 (0. 6) 1. 8 (0. 7)a 1. 9 (0. 4)a 5. 0 (1. 6) 1. 2 (0. 6)a 5. 2 (0. 6) 3. 4 (0. 4) 486 1, 731 727 621 853 595 1, 736 516 960 3, 197 11, 422

Potential Aetiological Factors Associated with ADHD • ADHD most likely has a multifactorial aetiology, including a combination of genetic and environmental risk factors: – -Approximately 80% of ADHD aetiology is linked to genetic factors – -Various environmental factors may also contribute as secondary causes Potential Aetiological Factors Associated with ADHD Group Timing Genetic Environmental Aetiological Factors Mutations in the dopamine receptor and dopamine transporter genes Prenatal Developmental cerebral abnormality, chromosome anomaly, virus, anaemia, hypothyroidism, iodine deficiency, exposure to drugs of abuse (e. g. nicotine) Perinatal Prematurity, low birth weight, anoxic-ischaemic encephalopathy, meningitis, encephalitis Postnatal Viral meningitis, encephalitis, cerebral trauma, thyroid dysfunction 1. Millichap. Pediatrics 2008; 121: e 358– 65.

Impact of ADHD Beyond Core Symptoms Healthcare System Family 33% in ER visits 1 10 x more outpatient visits 2 5 x more claims for outpatient prescription 2 3 x more inpatient admissions 2 2– 4 x more motor vehicle crashes 3, 4 Prone to emotional Familyoutbursts 5 -6 6, 11 5 to emotional outbursts Feels. Prone demoralised over constant failure Feels demoralized over constant failure 6, 11 5 -6 Low self-esteem Low self esteem 6, 11 More chaotic personal and family routines 6 11 More chaotic personal and family routines 7 Higher rate of of parental divorce/separation 12, 13 Higher rate 2 -4 x sibling fights 14 Patient Education and Employment Lower occupational status 8 in absenteeism 9 and work loss cost 9 -10 Poor academic grades for ability 6 Misses deadlines and often misplaces things 5 -6 Often late for work/appointments 5 -6 1. 2. 3. Leibson et al. 2001. Hodgkins et al. 2011. Sobanski et al. 2012. 4. 5. 6. Barkley et al. 1996. Searight et al. 2000. Weiss et al. 1999. 7. 8. 9. Society Difficulties making/sustaining friendships 5 Poor listening and inadequate social skills 5 Quick to anger/verbally abusive when angered 5 Poor financial management 6 Substance use disorders: 2 x risk 11 and earlier onset 12 Brown and Pacini. 1989. Manuzza et al. 1997. Secnik et al. 2005. Less likely to quit smoking 13 10. Birnbaum et al. 2005. 11. Biederman et al. 1998. 12. Milberger et al. 1997. 13. Pomerleau et al. 1995.

Clinical Presentation in Adults • Disorganisation (“doesn’t plan ahead”) • Forgetfulness (“misses appointments, loses things”) • Procrastination (“starts projects but can’t complete”) • Time management problems (“always late”) • Premature shifting of activities (“starts something but then quickly distracted by something else”) • Impulsive decisions (especially around spending, taking on projects, travelling, jobs or social plans) • Criminal offences (speeding, illegal drugs) • Unstable jobs and relationships Kooij & Francken. DIVA Foundation 2010.

Common Symptoms • Inattention • Over-activity • Impulsiveness DSM criteria (core symptoms) • Ceaseless mental activity (distracted mind) • Mood lability / emotional dysregulation • Low tolerance of frustration • Low self-esteem • Variable performance Asherson. 1 st European Network Adult ADHD Conference. London, 2011. Associated Symptoms

Hyperactivity-related problems • Inability to relax • Restless sleep • Excessively active lifestyle • Constant purposeless motion of extremities • Stimulus seeking or anti-social behaviours 1. Epstien J, Johnson D, Conners CK. Conners Adult ADHS Diagnostic Interview for DSM IV. North Towanda, NY: Multi-Health Systems; 1999)

Impulsivity-related problems • Disinhibited behaviour • Alcohol, cannabis, cocaine, tobacco, caffeine abuse • Family violence • Speaking out or making decisions without considering 1. Epstien J, Johnson D, Conners CK. Conners Adult ADHS Diagnostic Interview for DSM IV. North Towanda, 1999.

Inattention-related problems • Disorganisation and inefficiency • Procrastination • Failure to plan ahead • Forgetfulness • Difficulty in multitasking • Misjudging how long it takes to perform tasks • Inability to complete tasks • Distractibility • Poor ability to follow long explanations 1. Epstien J, Johnson D, Conners CK. Conners Adult ADHS Diagnostic Interview for DSM IV. North Towanda, NY: Multi-Health Systems; 1999. 2. Asherson. 1 st European Network Adult ADHD Conference. London, 2011

Diagnosing ADHD: DSM-5 Criteria • The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development • Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years • Several symptoms are present in at least 2 settings (e. g. home, work, school, with friends-relatives, other activities) • Symptoms interfere with social, occupational, and/or academic functioning • Symptoms not due to another mental disorder APA. Diagnostic and Statistical Manual of Mental Disorders 5 th Edn. Washington DC: APA; 2013; 59– 60.

Classifying ADHD: DSM-5 Criteria 1 • Presentations: – -Combined – -Predominantly inattentive – -Predominantly hyperactive-impulsive • Inattention (at least 5 symptoms for age >17) • Hyperactivity-impulsivity (at least 5 symptoms for age >17) – -ADHD in 'partial remission‘ – -Mild, Moderate, or Severe depending on few, intermediate, or many symptoms in excess of requirements, and minor, intermediate, or marked impairment, respectively APA. Diagnostic and Statistical Manual of Mental Disorders 5 th Edn. Washington DC: APA; 2013; 59– 60

Diagnostic Methods 1: Clinical diagnostic interview: Evaluate each of the 18 items (DSM/ICD) both currently and retrospectively, and screen for comorbid disorders 2: Evaluation of impairments/needs: Matching symptoms to impairments is key to the diagnosis (developmental history important) 3: Screening instruments Used to screen for ADHD and monitor treatment response (Adult ADHD Self-Report Scale) 4: Psychometric tests: Not sufficiently predictive, but a useful addition to the assessment (includes: IQ-specific reading/mathematics difficulties, slow and variable responses, response inhibition, working memory, choice impulsivity) 1. Asherson. 1 st European Network Adult ADHD Conference. London, 2011.

Adult ADHD Treatments • Assess the relative severity of the substance use disorder (SUD), the symptoms of ADHD, and any other comorbid disorders. • Stabilizing or addressing the SUD should be the first priority when treating an adult with SUD and ADHD. 1. Wilens TE. J Clin Psychiatry. 2004; 65 Suppl 3: 38 -45

Multimodal Approach to Treatment • Treatment should include: - Pharmacotherapy Psychoeducational - Psychological Non-pharmacological treatment Psychosocial

• The clinician should begin pharmacotherapy with medications that have little likelihood of diversion or low liability, such as bupropion and atomoxetine, and, if necessary, progress to the stimulants. • Careful monitoring of patients during treatment is necessary to ensure compliance with the treatment plan. 1 1. Wilens TE. J Clin Psychiatry. 2004; 65 Suppl 3: 38 -45

Pharmacotherapy Stimulants Atomoxetine Antidepressants (bupropion, desipramine) Antihypertensive medications: clonidine and guanafacine (impulsivity and hyperactivity) • Antinarcolepsy medication (modafinil) • Stimulants are effective in about 70% of patients with ADHD; their use in some parts of Europe is still controversial in both children and adults. • •

Does stimulant medications increase the risk of substance abuse in adulthood? • Stimulant therapy in childhood does not increase the risk for subsequent drug and alcohol abuse disorders later in life. • Growing evidence has shown that stimulants, particularly longacting formulations, can be given safely and are not routinely abused in substance-abusing populations. Mariani and Levin, 2006, 2007; Wilens et al, 2008

Non-pharmacological Treatment 1. Education of patients and their families (psychoeducation) 2. Psychological interventions (cognitive-behavioural therapy, family therapy) 3. Psychosocial interventions – – – Supportive coaching Marital/family counselling Career counselling Technology School/workplace accommodations Advocacy

Conclusions • The age-dependent change in the presentation of ADHD symptoms • People suffering from ADHD are often stereotyped as lazy, bad or agressive, or considered to have a behavioral or special needs problem rather than a mental health disorder that requires treatment • Identification of comorbid conditions: mood, anxiety, psychotic, organic and SUD (in addition to personality, tic and autistic spectrum disorders) • Diagnosis should include a detailed account of the developmental history; external validation • Multimodal tretment

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