Adult ADHD – The Challenges of Diagnosing and Treating

In addition, stimulants carry risk for abuse potential. For this reason, patients with substance abuse problems need to be closely monitored with respect to their prescribed medication use. However, meta-analyses of 13 studies have demonstrated that the use of stimulant ADHD therapy does not increase the risk for developing substance use disorders but is, in fact, protective against it.^14,15 Stimulant treatment of ADHD early in life appears to reduce the risk for future substance use disorders by 50%.¹⁵



Despite the data supporting a protective effect of stimulants against substance abuse disorders, the enduring concern about the abuse and diversion potential of stimulants^15,16 as well as adverse reactions of current therapies reinforce the value of assessing new treatments for ADHD, and non-stimulant therapies (ie, atomoxetine, guanfacine, clonidine) in particular. Nevertheless, non-stimulants are not devoid of serious side effects. The only non-stimulant approved by the Food and Drug Administration (FDA) for use in adults with ADHD is atomoxetine, a selective norepinephrine reuptake inhibitor.¹⁷ Atomoxetine has a black box warning regarding suicidal ideation and has been associated with rare cases of severe liver injury and sudden cardiac events from post-marketing reports.¹⁷ Contrarily, recently published reports have demonstrated that neither stimulants nor non-stimulants increase the risk of serious cardiovascular events in young and middle-aged adults.^18,19 Yet, the use of these drugs must continue to be considered on a patient-by-patient basis, particularly in the older patient who may have one or more chronic cardiovascular conditions.  Such patients should be screened for cardiac abnormalities prior to initiation of ADHD medication.



Adult ADHD is not necessarily treated with pharmacotherapy alone. The results of recent research provide solid evidence that psychological approaches, notably cognitive behavioral therapy (CBT), amplify the effect of medication treatment in reducing ADHD symptoms and comorbid problems, and demonstrate improvements in functions associated with impairment.²⁰ Such findings support the recommendations of guidelines for a comprehensive treatment package that includes psychological and pharmacological treatments for adults with ADHD.²¹



More research is needed to understand the continuum of ADHD throughout the lifespan and whether persistence into adulthood can be curtailed with medication use in childhood.