Pharmacotherapy for Comorbid Adult Attention-Deficit Hyperactivity Disorder and Stimulant Dependence: A Systematic Review

Comorbid adult attention-deficit hyperactivity disorder (ADHD) and stimulant dependence is widely recognized, but efficacy of pharmacotherapy in this patient population is not well established. We aimed to review whether pharmacotherapy is efficacious in reducing ADHD symptoms and stimulant use in comorbid adult ADHD and stimulant use disorder. English articles until June 2017 were systematically searched in electronic databases (MEDLINE and PsycINFO), an online clinical trials register (ClinicalTrial.gov), and through hand-search of article references. Randomized, double-blind, placebo-controlled trials that studied efficacy of pharmacotherapy in adults with comorbid ADHD and stimulant dependence were included. Two reviewers assessed studies for inclusion and extracted data; disagreements were resolved by consensus. Study outcomes included were changes in ADHD symptom severity, substance abstinence, treatment retention rates and safety. From the 1394 records identified, five trials (n=358) were included. Four studies involved methylphenidate; in another study extended-release mixed amphetamine were used. The comorbid stimulant was cocaine in three studies, and amphetamines in the rest. All were short-term studies involving predominantly young male adults conducted in outpatient settings. There is early promising but mixed evidence for therapeutic efficacy in improving ADHD symptoms. Stimulant medications did not worsen stimulant dependence or adverse effects of stimulant medications. Side effects were mild and tolerable. High attrition rates and small sample size limited the generalizability of findings. Current limited evidence suggests that stimulant treatment for comorbid adult ADHD and stimulant dependence is feasible. Welldesigned trials with adequate power are needed for more robust evidence on ADHD and stimulant use outcomes.

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Attention-deficit/hyperactivity disorder (ADHD) in adults: Specific clinical and therapeutic issues

European Psychiatry ◽

10.1016/j.eurpsy.2015.09.083 ◽

2015 ◽

Vol 30 (S2) ◽

pp. S27-S28

Author(s):

B. Rolland ◽

D. Da Fonseca ◽

M. Fatseas ◽

N. Simon

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Substance Use ◽

Substance Use Disorders ◽

Clinical Features ◽

Attention Deficit ◽

Adult Adhd ◽

Adhd Symptoms ◽

Addiction Medicine ◽

Global Functioning ◽

Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) was initially considered as a childhood psychiatric disorder. However, longitudinal observations have revealed that ADHD symptoms may persist in adulthood among approximately 50% of the patients . Adult ADHD is associated with impaired social outcome and frequent comorbidities such as mood disorders, personality disorders, and substance use disorders [2,3]. Correctly identifying and treating ADHD can significantly improve the global functioning and cognition of adult subjects, and reduce the intensity and frequency of the comorbid states [2,3]. Nonetheless, the clinical features of adult ADHD are clearly different from the youth form [1,2], and ADHD symptoms are easily mixed up in adults with symptoms of the comorbid conditions [2,3]. These clinical intricacies can make the diagnosis of ADHD difficult in adults. Moreover, the management of methylphenidate in adult subjects is also associated with specific risks and pitfalls, such as abuse and tampering behaviors, and additional safety risks . Put together, it appears crucial to identify and treat ADHD in adults, but the clinical and therapeutic complexities of adult ADHD require improved expertise and caution from adult psychiatrists and addiction specialists. In this thematic session of the 2015 French Psychiatry Congress, three French leading experts of adult ADHD will address the aforementioned clinical and therapeutic issues of the adulthood form of this disorder. David Da Fonseca, professor of child psychiatry in Marseille, will disentangle the clinical features of adult ADHD from the typical symptoms observed in the youth form. Mélina FATSEAS, associate professor of psychiatry and addiction medicine in Bordeaux, will specifically focus on the many and complex relationships observed between adult ADHD and substance use disorders. Last, Nicolas Simon, professor of addiction medicine and psychopharmacology in Marseille, will synthesize what are the very risks and issues with prescribing methylphenidate in adults.

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Incidence of Internet addiction in adult attention deficit hyperactivity disorder

European Psychiatry ◽

10.1016/j.eurpsy.2017.02.457 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S396-S397

Author(s):

B. Tuzun Mutluer ◽

T.G. Yener Orum ◽

S. Sertcelik

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Internet Addiction ◽

Attention Deficit ◽

Internet Use ◽

Adult Adhd ◽

Rating Scale ◽

Self Report ◽

Adhd Symptoms ◽

Hyperactivity Disorder ◽

Dsm Iv

ObjectiveIn this study, it was aimed to determine the internet use properties of Adult Attention Deficit Hyperactivity Disorder (ADHD) patients who were followed-up at Haydarpasa Numune Research and Training Hospital, Psychiatry Department; ADHD Outpatient Clinic.MethodThirty participants who were diagnosed with adult ADHD aged between 18–31 years rated their ADHD symptoms in childhood retrospectively, using Wender Utah Rating Scale. Patients rated current adult ADHD symptoms with the Adult ADHD DSM-IV-Based Diagnostic Screening and Rating Scale (DSRS) and severity of symptoms measured by Adult ADHD Self-Report Scale (ASRS). Internet addiction (IA) was assessed with Young's Internet Addiction Scale (IAS). It was determined that, none of 30 Adult ADHD patients have been diagnosed with IA.29 of patient have moderate internet use although 1 of patients have risky internet use. The results revealed that total ASRS score (P = 0.020), total Adult ADHD DSM-IV-Based DSRS score (P = 0.036) and the Attention Deficit related properties subscale total score (P = 0.042) were significantly correlated with the IAS total score. Subscale of the self-report scales including; failing to finish schoolworks, chores, or duties at workplace, difficulty of following through on instructions (P = 0.017), restiveness; impaired inhibitory performance (P = 0.017), feeling not confident (P = 0.017), difficulty of managing time (P = 0.047), failing to give close attention to details or making careless mistakes (P = 0.037) are closely relevant to IAS total score.ResultIn conclusion, clinical features, which are characteristic of Adult ADHD could have same shared etiology with IA. Furthermore, ADHD patients are more likely to have an IA diagnosis. However, it was thought that this result had to be supported with studies including larger samples.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Computerized cognitive training in children and adolescents with attention deficit/hyperactivity disorder as add-on treatment to stimulants: feasibility study and protocol description

Trends in Psychiatry and Psychotherapy ◽

10.1590/2237-6089-2016-0039 ◽

2017 ◽

Vol 39 (2) ◽

pp. 65-76 ◽

Cited By ~ 7

Author(s):

Virginia de Oliveira Rosa ◽

Marcelo Schmitz ◽

Carlos Renato Moreira-Maia ◽

Flavia Wagner ◽

Igor Londero ◽

...

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Pilot Study ◽

Children And Adolescents ◽

Training Program ◽

Cognitive Training ◽

Attention Deficit ◽

Small Sample ◽

Adhd Symptoms ◽

Computerized Cognitive Training ◽

Hyperactivity Disorder

Abstract Background Cognitive training has received increasing attention as a non-pharmacological approach for the treatment of attention deficit/hyperactivity disorder (ADHD) in children and adolescents. Few studies have assessed cognitive training as add-on treatment to medication in randomized placebo controlled trials. The purpose of this preliminary study was to explore the feasibility of implementing a computerized cognitive training program for ADHD in our environment, describe its main characteristics and potential efficacy in a small pilot study. Methods Six ADHD patients aged 10-12-years old receiving stimulants and presenting residual symptoms were enrolled in a randomized clinical trial to either a standard cognitive training program or a controlled placebo condition for 12 weeks. The primary outcome was core ADHD symptoms measured using the Swanson, Nolan and Pelham Questionnaire (SNAP-IV scale). Results We faced higher resistance than expected to patient enrollment due to logistic issues to attend face-to-face sessions in the hospital and to fill the requirement of medication status and absence of some comorbidities. Both groups showed decrease in parent reported ADHD symptoms without statistical difference between them. In addition, improvements on neuropsychological tests were observed in both groups – mainly on trained tasks. Conclusions This protocol revealed the need for new strategies to better assess the effectiveness of cognitive training such as the need to implement the intervention in a school environment to have an assessment with more external validity. Given the small sample size of this pilot study, definitive conclusions on the effects of cognitive training as add-on treatment to stimulants would be premature.

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The Mediating Effects of Self-Esteem and Harm Avoidance on the Association between Social Anxiety Symptoms and Adult Attention Deficit Hyperactivity Disorder Symptom Severity in Turkish Inpatients with Alcohol Use Disorder

Iranian Journal of Psychiatry ◽

10.18502/ijps.v16i3.6253 ◽

2021 ◽

Author(s):

Cuneyt Evren ◽

Elvan Cicekci ◽

Gokhan Umut ◽

Bilge Evren ◽

Kubra Durmus Cicek

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Social Anxiety ◽

Attention Deficit ◽

Symptom Severity ◽

Alcohol Use Disorder ◽

Adult Adhd ◽

Self Esteem ◽

Harm Avoidance ◽

Adhd Symptoms ◽

Hyperactivity Disorder

Objective: The first objective of this research was to examine the association of the symptom severity of social anxiety with the adult attention deficit hyperactivity disorder (ADHD) symptom severity in Turkish patients with alcohol use disorder (AUD). The second objective was to examine if harm avoidance and self-esteem mediated this relationship. Method: This cross-sectional analysis was performed among 151 inpatients with AUD at the Bakirkoy/AMATEM, a treatment center for substance use disorder, in Istanbul. Patients were examined with the Liebowitz Social Anxiety Scale (LSAS), the Adult ADHD Self-Report Scale (ASRS), the Rosenberg Self-Esteem Scale (SES), and the temperament dimension of Harm Avoidance (HA). Using SPSS-20 software, the data was analyzed using Pearson correlations, multivariate analysis of covariance (MANCOVA), and multiple linear regressions. Results: The scales scores were mildly correlated with each other. The low self-esteem and high HA were related with the inattentive (IN) dimension of ADHD, whereas low self-esteem solely predicted hyperactivity/impulsivity (HI) dimension of ADHD in MANCOVA. In the linear regression analysis, the severity of social anxiety, particularly avoidance dimension, was associated with the symptom severity of ADHD. In the second step of the analysis, together with the avoidance dimension of social anxiety, self-esteem was associated with the symptom severity of ADHD. However, in the third step, after including HA as an independent variable in the analysis, the avoidance dimension of social anxiety was no longer associated with the severity of adult ADHD symptoms, whereas self-esteem together with HA (particularly “anticipatory worry and pessimism” [HA-1], and “asthenia and fatigability” [HA-4]) predicted. Conclusion: Findings of the present study shows that although the symptom severity of social anxiety is associated with the severity of ADHD symptoms among inpatients with AUD, among dimensions of social anxiety, the avoidance dimension plays a main role in this relationship. Also, while the self-esteem partially mediates this relationship, HA seems to have a full mediator effect on this relationship.

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Unrecognized Attention-Deficit/Hyperactivity Disorder in Adults Presenting with Other Psychiatric Disorders

CNS Spectrums ◽

10.1017/s1092852900014036 ◽

2008 ◽

Vol 13 (11) ◽

pp. 977-984 ◽

Cited By ~ 76

Author(s):

Russell A. Barkley ◽

Thomas E. Brown

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Psychiatric Disorders ◽

Attention Deficit ◽

Adult Adhd ◽

Adhd Symptoms ◽

Treatment Regimens ◽

Text Revision ◽

Hyperactivity Disorder ◽

Poor Treatment ◽

Comorbid Adhd

ABSTRACTMany adults with a diagnosed psychiatric disorder also have attention-deficit/hyperactivity disorder (ADHD). In many cases, comorbid ADHD is unrecognized and/or undertreated. Differential diagnosis of adult ADHD can be challenging because ADHD symptoms may overlap with other psychiatric disorders and patients may lack insight into their ADHD-related symptoms. Current ADHD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision may prevent appropriate diagnosis of many patients with significant ADHD symptoms. Adults may not be able to provide a history of onset of symptoms during childhood, and it may be difficult to confirm that ADHD symptoms are not better accounted for by other comorbid psychiatric conditions. Comorbid ADHD is most prevalent among patients with mood, anxiety, substance use, and impulse-control disorders. ADHD can negatively affect outcomes of other comorbid psychiatric disorders, and ADHD symptoms may compromise compliance with treatment regimens. Furthermore, unrecognized ADHD symptoms may be mistaken for poor treatment response in these comorbid disorders. In these individuals, ADHD pharmacotherapy seems to be as effective in reducing core ADHD symptoms, as it is in patients who have no comorbidity. Limited evidence further suggests that ADHD therapy may help to improve symptoms of certain psychiatric comorbidities, such as depression. Therefore, management of ADHD may help to stabilize daily functioning and facilitate a fuller recovery.

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Can the MMPI Predict Adult ADHD? An Approach Using Machine Learning Methods

Diagnostics ◽

10.3390/diagnostics11060976 ◽

2021 ◽

Vol 11 (6) ◽

pp. 976

Author(s):

Sunhae Kim ◽

Hyekyung Lee ◽

Kounseok Lee

Keyword(s):

Machine Learning ◽

Attention Deficit Hyperactivity Disorder ◽

Random Forest ◽

Attention Deficit ◽

Adult Adhd ◽

Minnesota Multiphasic Personality Inventory ◽

Self Report ◽

Adhd Symptoms ◽

Linear Discriminant ◽

Hyperactivity Disorder

(1) Background: Adult attention-deficit/hyperactivity disorder (ADHD) symptoms cause various social difficulties due to attention deficit and impulsivity. In addition, in contrast to ADHD in childhood, ADHD in adulthood is difficult to diagnose due to mixed psychopathologies. This study aimed to determine whether it is possible to predict ADHD symptoms in adults using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) with machine learning (ML) techniques; (2) Methods: Data collected from 5726 college students were analyzed. The MMPI-2-Restructured Form (MMPI-2-RF) was used, and ADHD symptoms in adults were evaluated using the Attention-Deficit/Hyperactivity Disorder Self-Report Scale (ASRS). For statistical analysis, three ML algorithms were used, i.e., K-nearest neighbors (KNN), linear discriminant analysis (LDA), and random forest, with the ASRS evaluation result as the dependent variable and the 50 MMPI-2-RF scales as predictors; (3) Results: When the KNN, LDA, and random forest techniques were applied, the accuracy was 93.1%, 91.2%, and 93.6%, respectively, and the area under the curve (AUC) was 0.722, 0.806, and 0.790, respectively. The AUC of the LDA method was the largest, with an excellent level of diagnostic accuracy; (4) Conclusions: ML using the MMPI-2 in a large group could provide reliable accuracy in screening for adult ADHD.

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Malingered Attention Deficit/Hyperactivity Disorder on the Conners’ Adult ADHD Rating Scales: Do Reasons for Malingering Matter?

Journal of Psychoeducational Assessment ◽

10.1177/0734282917696934 ◽

2017 ◽

Vol 36 (6) ◽

pp. 552-561 ◽

Cited By ~ 6

Author(s):

Carolyn Cook ◽

Melissa T. Buelow ◽

Esther Lee ◽

Ashley Howell ◽

Brittni Morgan ◽

...

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Attention Deficit ◽

Adult Adhd ◽

Rating Scales ◽

Adhd Group ◽

Adhd Symptoms ◽

Extra Time ◽

Hyperactivity Disorder ◽

The Impact ◽

Adhd Rating Scales

Malingering is a significant assessment concern in adults undergoing evaluations for attention deficit/hyperactivity disorder (ADHD) and may occur for a number of reasons, including access to medication and/or accommodations. Therefore, it is important to investigate ways to determine accuracy of self-reported ADHD symptoms. The present study used a simulation design to examine the impact of reasons for malingering on the Conners’ Adult ADHD Rating Scales (CAARS) Symptom subscales and the CAARS infrequency index (CII). Participants ( N = 157) were randomly assigned to one of three conditions: best effort, malingering for stimulant medication, or malingering for extra time accommodations. The three groups were compared with 34 individuals reporting previous diagnosis of ADHD. Results showed that individuals in both malingering groups scored higher than controls on all CAARS subscales and CII. Individuals in the medication malingering group, but not the extra time malingering group, scored higher than the ADHD group on CII and several CAARS subscales whose content overtly reflects ADHD symptomatology. Findings emphasize the influence of malingering on self-reported ADHD symptoms and the need to assess for malingering in ADHD evaluation. Results also suggest that reason for malingering might differentially affect self-report of ADHD symptoms.

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Attention-deficit hyperactivity disorder in adults

Advances in Psychiatric Treatment ◽

10.1192/apt.5.2.112 ◽

1999 ◽

Vol 5 (2) ◽

pp. 112-119 ◽

Cited By ~ 2

Author(s):

Brian Toone ◽

Maria Clarke ◽

Susan Young

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Support Group ◽

Attention Deficit ◽

Adult Adhd ◽

Psychiatric Comorbidity ◽

Hyperkinetic Disorder ◽

Adhd Symptoms ◽

Children With Adhd ◽

Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) and hyperkinetic disorder are well-established diagnoses in children, with estimates of prevalence in pre-adolescent children from 3 to 5%. Until recently ADHD was not thought to persist beyond adolescence, but results from long-term prospective outcome studies indicate that 30–70% of children with ADHD exhibit some symptoms as adults. Recognition of this disorder is important as the persistence of ADHD symptoms has been shown to be associated with academic and occupational failure and high rates of psychiatric comorbidity. With the establishment of a UK support group (LADDER) and increasing media attention highlighting this problem it is likely that there will be an increased demand for psychiatric assessment of adult ADHD in the next few years.

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Machine-learning-based diagnosis of drug-naive adult patients with attention-deficit hyperactivity disorder using mismatch negativity

Translational Psychiatry ◽

10.1038/s41398-021-01604-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Sungkean Kim ◽

Ji Hyun Baek ◽

Young Joon Kwon ◽

Hwa Young Lee ◽

Jae Hyun Yoo ◽

...

Keyword(s):

Machine Learning ◽

Attention Deficit Hyperactivity Disorder ◽

Attention Deficit ◽

Mismatch Negativity ◽

Adult Adhd ◽

Adult Patients ◽

Adhd Symptoms ◽

Hyperactivity Disorder ◽

Drug Naïve ◽

Source Level

AbstractRelatively little is investigated regarding the neurophysiology of adult attention-deficit/hyperactivity disorder (ADHD). Mismatch negativity (MMN) is an event-related potential component representing pre-attentive auditory processing, which is closely associated with cognitive status. We investigated MMN features as biomarkers to classify drug-naive adult patients with ADHD and healthy controls (HCs). Sensor-level features (amplitude and latency) and source-level features (source activation) of MMN were investigated and compared between the electroencephalograms of 34 patients with ADHD and 45 HCs using a passive auditory oddball paradigm. Correlations between MMN features and ADHD symptoms were analyzed. Finally, we applied machine learning to differentiate the two groups using sensor- and source-level features of MMN. Adult patients with ADHD showed significantly lower MMN amplitudes at the frontocentral electrodes and reduced MMN source activation in the frontal, temporal, and limbic lobes, which were closely associated with MMN generators and ADHD pathophysiology. Source activities were significantly correlated with ADHD symptoms. The best classification performance for adult ADHD patients and HCs showed an 81.01% accuracy, 82.35% sensitivity, and 80.00% specificity based on MMN source activity features. Our results suggest that abnormal MMN reflects the adult ADHD patients’ pathophysiological characteristics and might serve clinically as a neuromarker of adult ADHD.

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The Moderating Effect of Attention-Deficit Hyperactivity Disorder Symptoms on the Relationship Between Procrastination and Internalizing Symptoms in the General Adult Population

Frontiers in Psychology ◽

10.3389/fpsyg.2021.708579 ◽

2021 ◽

Vol 12 ◽

Author(s):

Mana Oguchi ◽

Toru Takahashi ◽

Yusuke Nitta ◽

Hiroaki Kumano

Keyword(s):

Attention Deficit Hyperactivity Disorder ◽

Attention Deficit ◽

Internalizing Symptoms ◽

Adult Adhd ◽

Adult Population ◽

Moderating Effect ◽

Self Report ◽

Adhd Symptoms ◽

Cross Sectional Survey ◽

Hyperactivity Disorder

Background: The symptoms of attention-deficit hyperactivity disorder (ADHD) are known to exacerbate the effect of cognitive-behavioral impairments on emotional burden. Although adults with ADHD frequently experience procrastination and internalizing symptoms such as depression and anxiety, few studies have examined whether the association between procrastination and internalizing symptoms differs by ADHD symptoms.Objective: This study aimed to examine the moderating effect of ADHD symptoms on the association between procrastination and internalizing symptoms.Method: A cross-sectional survey was conducted among 470 adults (mean age=26.57, standard deviation=2.93) using self-reported questionnaires: Adult ADHD Self-Report Scale, General Procrastination Scales, Patient Health Questionnaire-9, and State–Trait Anxiety Inventory.Conclusion: Participants with more substantial ADHD symptoms experienced more procrastination and internalizing symptoms than those with the less substantial ADHD symptoms. Therefore, procrastination constitutes the treatment target for those suffering from ADHD and comorbid internalizing symptoms. Alternatively, there was no enhancing effect of ADHD symptoms on the association between procrastination and internalizing symptoms. It is necessary to examine more precise and valid hypotheses and underlying mechanisms of procrastination in high and low ADHD symptom groups.

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