The efficacy of atomoxetine in treating adult attention deficit hyperactivity disorder (ADHD): A meta-analysis of controlled trials

Current nonstimulant medications for adults with attention-deficit/hyperactivity disorder

INTRODUCTION

Stimulants, including methylphenidate and amphetamines, are the first-line pharmacological treatment of ADHD in adults. However, in patients who do not respond or poorly tolerate stimulants, non-stimulant medications are usually recommended.

AREAS COVERED

The authors provide a narrative review of the literature on non-stimulant treatments for adult ADHD, including controlled and observational clinical studies conducted on adult samples. Atomoxetine has been extensively studied and showed significant efficacy in treating adult ADHD. Issues related to dosing, treatment duration, safety, and use in the case of psychiatric comorbidity are summarized. Among other compounds indicated for ADHD in adults, antidepressants sharing at least a noradrenergic or dopaminergic component, including tricyclic compounds, bupropion, and viloxazine, have shown demonstratable efficacy. Evidence is also available for antihypertensives, particularly guanfacine, as well as memantine, metadoxine, and mood stabilizers, while negative findings have emerged for galantamine, antipsychotics, and cannabinoids.

EXPERT OPINION

While according to clinical guidelines, atomoxetine may serve as the only second-line option in adults with ADHD, several other nonstimulant compounds may be effectively used in order to personalize treatment based on comorbid conditions and ADHD features. Nevertheless, further research is needed to identify and test more personalized treatment strategies for adults with ADHD.

Characterizing Clinical Heterogeneity in a Large Inpatient Addiction Treatment Sample: Confirmatory Latent Profile Analysis and Differential Levels of Craving and Impulsivity

Background:

Individuals with substance use disorders (SUDs) have highly heterogeneous presentations and identifying more homogeneous subgroups may foster more personalized treatment. This study used SUD and other psychiatric indicators to characterize latent subgroups of patients in a large inpatient addiction treatment program. The resulting subgroups were then analyzed with respect to differences on clinically informative motivational mechanisms.

Methods:

Patients (n = 803) were assessed for severity of SUD (ie, alcohol use disorder, drug use disorder), post-traumatic stress disorder, anxiety disorders, and major depressive disorder. Confirmatory latent profile analysis (CLPA) was used to identify latent subgroups, hypothesizing 4 subgroups. Subgroups were then characterized with respect to multiple indicators of impulsivity (ie, delay discounting and impulsive personality traits via the UPPS-P) and craving.

Results:

The CLPA confirmed the hypothesized 4-profile solution according to all indicators (eg, entropy = 0.90, all posterior probabilities ⩾.92). Profile 1 (n = 229 [32.2%], 24.9% female, median age in range of 45-49) reflected individuals with high alcohol severity and low psychiatric severity (HAlc/LPsy). Profile 2 (n = 193 [27.1%], 29.3% female, median age in range of 35-39) reflected individuals with high drug and psychiatric severity (HDrug/HPsy). Profile 3 (n = 160 [22.5%], 37.6% female, median age in range of 45-49) reflected individuals with high alcohol severity and psychiatric severity (HAlc/HPsy). Profile 4 (n = 130 [18.3%], 19.4% female, median age in range of 35-39) reflected individuals with high drug severity and low psychiatric severity (HDrug/LPsy). Both high comorbid psychiatric severity subgroups exhibited significantly higher craving and facets of impulsivity.

Conclusions:

The results provide further evidence of 4 latent subgroups among inpatients receiving addiction treatment, varying by alcohol versus other drugs and low versus high psychiatric comorbidity. Furthermore, they reveal the highest craving and impulsivity in the high psychiatric comorbidity groups, suggesting targets for more intensive clinical intervention in these patients.

Adult attention-deficit Hyperactivity disorder: From clinical reality toward conceptual clarity

There is ambiguity about the clinical picture and concept of attention-deficit hyperactivity disorder (ADHD) in adults. Relevant literature was extracted from various search engines, analyzed, and interpreted. Available literature suggests a significant prevalence of ADHD in the adult population affecting the quality of socio-occupational functioning. Inattentiveness was more commonly present than hyperactivity-impulsivity. Frequent comorbidities with other psychiatric disorders like anxiety disorders and substance use disorders were noted. Pharmacological management and psychotherapy have been found effective in its management. ADHD is a disorder across the lifespan and fairly prevalent among adults. Greater awareness and more research are required for a better understanding of Adult ADHD and its effective management.

Situating adult attention-deficit/hyperactivity disorder in the externalizing spectrum: Etiological, diagnostic, and treatment considerations

Adult attention-deficit/hyperactivity disorder (ADHD) has a population prevalence of 5%. However, its prevalence is much higher in mental health and substance use treatment settings. It is associated with significant physical and psychiatric morbidity, as well as social, occupational, and legal consequences. Adult ADHD is considered to be a part of the externalizing spectrum with which it shares both homotypic comorbidity and heterotypic continuity across the lifespan. This is attributable to a shared genetic basis, which interacts with environmental risk factors such as nutritional deficiencies and psychosocial adversity to bring about epigenetic changes. This is seen to result in a lag in brain maturation particularly in the areas of the brain related to executive functioning (top-down regulation) such as the prefrontal and cingulate cortices. This delay when coupled with impairments in reward processing, leads to a preference for immediate small rewards and is common to externalizing disorders. Adult ADHD is increasingly understood to not merely be associated with the classically described symptoms of hyperactivity, impulsivity and inattention, but also issues with motivation, emotional recognition and regulation, excessive mind wandering, and behavioral self-regulation. These symptoms are also observed in other disorders which overlap with the externalizing spectrum such as oppositional defiant disorder, conduct disorder, antisocial and borderline personality disorder. It is therefore important to develop both broad-based and specific interventions to be able to target these deficits which can reduce the burden and improve outcomes.