Do stimulants improve functioning in adults with ADHD? A review of the literature

UK adult ADHD services in crisis

The UK's services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths. Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times. Underfunding has encouraged growth in independent providers, leading to fragmentation of service provision. Treatment delays carry a human and financial cost, imposing a burden on health, social care and the criminal justice system. A rethink of service procurement and delivery is needed, with multiple solutions on the table, including increasing funding, improving system efficiency, altering the service provision model and clinical prioritisation. However, the success of these solutions hinges on fiscal capacity and workforce issues.

Attention-deficit/hyperactivity disorder and inflammation: natural product-derived treatments-a review of the last ten years

OBJECTIVE

Attention-deficit hyperactivity disorder (ADHD) is a psychiatric disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. Stimulant medication is the main pharmacological treatment for ADHD. However, the traditional pharmacological treatments may have significant side effects; therefore, non-pharmacological approaches are needed. Thus, there has been growing interest in alternative herbal treatments. The aim of this review was to comprehensively assess the current evidence for plant-based treatment of ADHD in human and animal models, as well as their ability to modulate the inflammatory process.

METHODS

This study was an integrative review of the current evidence for the plant-based treatment of ADHD. The research involved using literature available on PubMed and Scopus databases.

FINDINGS

Spontaneously hypersensitive rats treated with baicalin exhibited significant reductions in locomotion, increased spatial learning skills, and increased levels of dopamine in the striatum. Supplementation with Sansonite improved memory and attention capacity. In human studies, Ginkgo biloba significantly improved the symptoms of inattention and reduced memory impairment. In studies conducted using Korean Red ginseng, Klamath, and Crocus sativus L., the patients showed significant improvements in symptoms of inattention and hyperactivity/impulsivity. Furthermore, we demonstrated that the identified plants modulate the inflammatory process through pro-inflammatory and anti-inflammatory cytokines, nitric oxide, Th cells, Toll-like receptor 4, and mitogen-activated protein kinases.

CONCLUSION

All the studies included in this review focused on plants with demonstrated potential against inflammatory processes, positioning them as promising candidates for ADHD treatment, due to their potential to attenuate or even prevent neuroinflammatory mechanisms.

A Digital Mental Health Support Program for Depression and Anxiety in Populations With Attention-Deficit/Hyperactivity Disorder: Feasibility and Usability Study

BACKGROUND

A total of 1 in 2 adults with attention-deficit/hyperactivity disorder (ADHD) struggles with major depressive or anxiety disorders. The co-occurrence of these disorders adds to the complexity of finding utility in as well as adherence to a treatment option. Digital therapeutic solutions may present a promising alternative treatment option that could mitigate these challenges and alleviate symptoms.

OBJECTIVE

This study aims to investigate (1) the feasibility and acceptance of a digital mental health intervention, (2) participants' engagement and retention levels, and (3) the potential efficacy with respect to anxiety and depression symptoms in a population with ADHD. Our main hypothesis was that a digital, data-driven, and personalized intervention for adults with coexisting ADHD and depressive or anxiety symptoms would show high engagement and adherence, which would be accompanied by a decrease in depressive and anxiety symptoms along with an increase in quality of life and life satisfaction levels.

METHODS

This real-world data, single-arm study included 30 adult participants with ADHD symptomatology and coexisting depressive or anxiety symptoms who joined a 16-week digital, data-driven mental health support program. This intervention is based on a combination of evidence-based approaches such as cognitive behavioral therapy, mindfulness, and positive psychology techniques. The targeted symptomatology was evaluated using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Barkley Adult ADHD Rating Scale-IV. Quality of life aspects were evaluated using the Satisfaction With Life Scale and the Life Satisfaction Questionnaire, and user feedback surveys were used to assess user experience and acceptability.

RESULTS

The study retention rate was 97% (29/30), and high engagement levels were observed, as depicted by the 69 minutes spent on the app per week, 5 emotion logs per week, and 11.5 mental health actions per week. An average decrease of 46.2% (P<.001; r=0.89) in depressive symptoms and 46.4% (P<.001; r=0.86) in anxiety symptoms was observed, with clinically significant improvement for more than half (17/30, 57% and 18/30, 60%, respectively) of the participants. This was followed by an average increase of 23% (P<.001; r=0.78) and 20% (P=.003; r=0.8) in Satisfaction With Life Scale and Life Satisfaction Questionnaire scores, respectively. The overall participant satisfaction level was 4.3 out of 5.

CONCLUSIONS

The findings support the feasibility, acceptability, and value of the examined digital program for adults with ADHD symptomatology to address the coexisting depressive or anxiety symptoms. However, controlled trials with larger sample sizes and more diverse participant profiles are required to provide further evidence of clinical efficacy.

Treatment with stimulants and the risk of COVID-19 complications in adults with ADHD

Adults with attention deficit hyperactivity disorder (ADHD) have shown higher infection rates and worse outcomes from COVID-19. Stimulant medications are prescribed as the first-line treatment for ADHD in adults and mitigate risk of negative ADHD-related health outcomes, but little is known about the association between stimulant medications and COVID-19 outcomes. The objective of this study was to assess the risks of severe COVID-19 outcomes among people with ADHD who were prescribed stimulant medications versus those who were not. This retrospective cohort study used electronic health records in the TriNetX research database. We assessed records of adults with ADHD diagnosed with COVID-19 between January 1, 2020 and June 30, 2021. The stimulant cohort consisted of 28,011 people with at least one stimulant prescription; the unmedicated cohort comprised 42,258 people without prescribed stimulants within 12 months prior to their COVID infection. Multiple logistic regression modeling was utilized to assess the presence of critical care services or death within 30 days after the onset of COVID diagnoses, controlling for patient demographics, and comorbid medical and mental health conditions. The stimulant cohort was less likely to utilize emergency department, hospital, and intensive care services than the unmedicated cohort, and had significantly lower 30-day mortality. Further research, including prospective studies, is needed to confirm and refine these findings.

Usability and feasibility of a cognitive-behavioral mobile app for ADHD in adults

OBJECTIVE

Cognitive-behavioral therapy (CBT) has growing evidence of efficacy for Attention-Deficit/Hyperactivity Disorder (ADHD) in adults. Mobile health apps are promising tools for delivering scalable CBT. In a 7-week open study of Inflow, a CBT-based mobile app, we assessed usability and feasibility to prepare for a randomized controlled trial (RCT).

METHOD

240 adults recruited online completed baseline and usability assessments at 2 (n = 114), 4 (n = 97) and after 7 weeks (n = 95) of Inflow use. 93 participants self-reported ADHD symptoms and impairment at baseline and 7 weeks.

RESULTS

Participants rated Inflow's usability favorably, used the app a median of 3.86 times per week, and a majority of those using the app for 7 weeks self-reported decreases in ADHD symptoms and impairment.

CONCLUSION

Inflow demonstrated usability and feasibility among users. An RCT will determine whether Inflow is associated with improvement among more rigorously assessed users and beyond non-specific factors.

Personalized Remote Mobile Surveys of Adult ADHD Symptoms and Function: A Pilot Study of Usability and Utility for Pharmacology Monitoring

OBJECTIVE

Validate the usability and treatment-sensitivity of a remote SMS-based ADHD monitoring method.

METHOD

206 adults taking stimulants for ADHD participated. Participants selected ADHD symptoms and functional impairments that they anticipated to be stimulant-sensitive, which were rated via mobile messages up to 20 times over 10 days.

RESULTS

A majority of participants found it only somewhat or not at all difficult to identify an ADHD symptom sensitive to presence of stimulant medication, and 79% responded to at least one survey message. As expected, a majority of participants endorsed it was "easy" to participate, and less burdensome than a paper diary. Surveys significantly discriminated between on and off medication states, both between days, and within the same day.

CONCLUSION

Our findings suggest SMS-based monitoring of patient-selected ADHD-related challenges is both feasible and sensitive to stimulant treatment. This remote assay method may be a meaningful adjunct to in-visit treatment monitoring.

A community survey of adults with attention deficit hyperactivity disorder (ADHD) and their experience of medication effectiveness

OBJECTIVE

Survey of ADHD-affected adult participants attending educational meetings of 'ADDults with ADHD', to ascertain age of diagnosis and treatment effects of psychostimulant medication on symptoms across functional and emotional domains.

METHOD

From 2016 to 2019, self-assessments of functional impairment were collected from ADHD-affected adults attending educational meetings of an Australian community support organisation (ADDults with ADHD). Participants were asked to rate their functioning on and off medication. Some demographic and treatment details were also collected.

RESULTS

Questionnaires were collected from 117 attendees of five meetings. Their mean age was 42.5 (SD 15.0) years; their age of diagnosis and of starting treatment were 31.9 (SD 16.6) and 32.8 (SD 16.4) years, respectively, with no significant differences between men and women. Most (93%) reported symptom onset before age 18. Ninety (77%) had been treated medically, with self-ratings indicating significantly less impairment on treatment (p < 0.001).

CONCLUSION

Adults with ADHD reported substantial impairment but significant benefit from medication. Despite a mean age of over 30 at diagnosis, most recalled being symptomatic in childhood. This suggests many may experience a prolonged period of impaired function before starting treatment.

Psychometric Properties of the Weiss Functional Impairment Rating Scale: Evidence for Utility in Research, Assessment, and Treatment of ADHD in Emerging Adults

Objective: The current study examines psychometric properties of the Weiss Functional Impairment Rating Scale (WFIRS), a measure of adult ADHD-related impairment. It is a self-report questionnaire that provides a metric of overall life impairment and domain-specific dysfunction. Method: Using data from a large (N = 2,093), multi-institution sample of college students and including a subsample of collateral informants (n = 262), a series of analyses were conducted. Results: The WFIRS demonstrated robust internal reliability, cross-informant agreement on par or superior to other measures of ADHD symptomatology and impairment, and concurrent validity. The WFIRS was not shown to be uniquely associated with ADHD, as internalizing symptoms also associated with the total and domain scores. Conclusion: The use of the WFIRS in identifying ADHD-related impairment in emerging adults appears to be psychometrically supported, and will prove useful to clinicians and researchers.

Methamphetamine regulates βAPP processing in human neuroblastoma cells

Methamphetamine is a potent and highly addictive psychostimulant whose abuse has turned out to be a global health hazard. The multitudinous effects it exerts at the cellular level induces neurotoxic responses in the human brain, ultimately leading to neurocognitive disorders. Strikingly, brain changes, tissue damage and neuropsychological symptoms due to Meth exposure compels and necessitates to link the probability of risk of developing premature Alzheimer's disease, a progressive neurodegenerative disorder characterized by amyloid plaques composed of amyloid-β peptides and clinical dementia. These peptides are derived from sequential cleavages of the β-amyloid precursor protein by β- and γ-secretases. Previous studies reveals evidence for both positive and negative effects of Meth pertaining to cognitive functioning based on the dosage paradigm and duration of exposure revealing a beneficial psychotropic profile under some conditions and deleterious cognitive deficits under some others. In this context, we proposed to examine the effect of Meth on βAPP metabolism and βAPP-cleaving secretases in the human neuroblastoma SH-SY5Y cell line. Our results showed that Meth dose-dependently increases BACE1 expression and catalytic activity, while its effect on the α-cleavage of βAPP and on the expression and catalytic activity of the main α-secretase ADAM10 display a bell-curve shape. To our knowledge, the present study is the first to demonstrate that Meth can control βAPP-cleaving secretases. Moreover, we propose from these findings that the deleterious effect of Meth on cognitive decline might be an outcome of high dosage paradigm whereas acute and short-term drug use which stimulated sAPPα might produce improvements in cognition in disorders such as AD.

The efficacy of cognitive-behavioral therapy for older adults with ADHD: a randomized controlled trial

Older adults with ADHD exhibit significant functional impairment, yet there is little research to guide clinicians in evidence-based care of these adults. This study examined response to treatment in older adults who participated in a previous study of the efficacy of cognitive-behavioral treatment (CBT) in adult ADHD. It was hypothesized that older adults would respond less well to CBT than younger adults, given the cognitive demands of the treatment. As described in the original publication, 88 adults who met DSM-IV criteria for ADHD were randomized to receive either a manualized 12-week CBT group intervention targeting executive dysfunction or a parallel Support group. In the current study, outcomes for 26 adults, aged 50 or older, were compared with those of 55 younger adults with respect to inattentive symptoms assessed on a structured interview by a blind clinician, as well as on ratings by self and/or collateral on measures of attention, executive dysfunction, and comorbidity. Contrary to the hypothesis, older and younger adults were equally responsive to CBT on measures of attention. The older adults also responded as well to Support as to CBT on several outcome measures. The results provide preliminary evidence that CBT is an effective intervention for older adults with ADHD. The unexpected response to support highlights a possible age-specificity of effective therapeutic intervention that requires further investigation.

Functional impairment in adult bipolar disorder with ADHD

BACKGROUND

It is well established that patients with either bipolar disorder (BD) or attention-deficit/hyperactivity disorder (ADHD) present functional impairment even when in remission. Nevertheless, research on functional impairment with adult patients with bipolar disorder comorbid to ADHD (BD+ADHD) is very scarce. The main objective of the current report was to evaluate the overall and specific domains of functioning, in patients with BD+ADHD compared to patients with pure bipolar disorder (pBD) and healthy controls (HCs).

METHOD

162 subjects from 3 groups were compared: 63 pBD, 23 BD+ADHD and 76 HCs. All the patients with BD had been euthymic for at least 6 months and they were recruited at the Hospital Clinic of Barcelona. All the participants were assessed with the 17-item Hamilton Depression Rating Scale (HAM-D), the Young Mania Rating Scale (YMRS) and the Functioning Assessment Short Test (FAST). Clinical, and sociodemographic data were also recorded.

RESULTS

Clinical groups, pBD and BD+ADHD, showed lower overall functioning (p < 0.001) in each domain of the FAST scale compared to the HCs. Moreover, the Tukey post hoc test revealed that the BD+ADHD group showed a worse score than pBD in the cognitive domain of the FAST. However, after controlling for potential confounding variables, only the HDRS scores (p < 0.026) remained significant for the cognitive domain of the FAST.

LIMITATIONS

The small sample size of the comorbid BD+ADHD group.

CONCLUSIONS

Adult patients with BD+ADHD showed the worst scores in functioning compared with the HCs, but did not show more severe functional impairment than the pBD group except for the cognitive domain. Therefore our findings suggest that depressive symptoms in adults with BD+ADHD may negatively influence cognitive functioning. Further studies are needed to confirm our findings for the management of BD+ADHD.

Do Pharmaceuticals Improve Driving in Individuals with ADHD? A Review of the Literature and Evidence for Clinical Practice

Attention-deficit/hyperactivity disorder (ADHD) is defined as a disorder of impaired attention and/or behavioral control. Studies suggest that the condition can dispose individuals to a higher risk of automobile accidents. ADHD symptoms respond to pharmacotherapy in a majority of uncomplicated cases. Evidence on how pharmacotherapies for ADHD impact driving behavior or outcomes could allow clinicians to support on-road safety rationally. We therefore undertook a review to identify the evidence base to date indicating positive or negative effects of pharmacotherapies on driving behavior in individuals with ADHD. Further, we evaluated the level of evidence for these effects, their specificity to ADHD, and how they may inform clinical care. We identified studies involving pharmacotherapy for ADHD that evaluated driving-related activities or outcomes. We then categorized these studies by the mode of measurement used and by the ADHD specificity of the driving behaviors measured. Finally, we extracted themes of interest to clinical practice in pharmacologic intervention. In total, 14 studies, involving 2-61 subjects diagnosed with ADHD, looked at computer-measured, observer-measured, or self-reported driving behavior correlates of pharmacotherapy during simulation or on-road driving. Of these studies, 13 involved psychostimulant agents and two used atomoxetine. All but three investigations (one of methylphenidate, one of mixed amphetamine salts, and one of atomoxetine) found favorable changes in measures such as steering and braking behaviors or reaction to unexpected events. One study found adverse effects on driving at hour 17 following mixed amphetamine salt administration. Four studies compared two pharmacotherapies, and each found differences in measured driving behavior between the therapies. One study explored impact on ADHD-specific driving impairments, and the same study was the only one to explore correlation of clinical measures (ADHD symptoms and self-reported driving behavior) with medication-associated changes-finding dissociation between changes in ADHD symptoms and changes in measured driving measures. While data to date are limited on the ADHD-specific effects of pharmacotherapies used for ADHD on driving, it is clear from our review that these agents have effects on driving-relevant behaviors. Further research is urgently needed to develop an evidence base for clinically predictable effects of pharmacotherapy on driving safety in individuals with ADHD. If possible, clinicians should evaluate the positive and negative effects of pharmacotherapy on driving in their clients.

A Prospective 30-Year Follow-Up of ADHD Associated With Perinatal Risks

OBJECTIVE

Longitudinal follow-up of ADHD suggests a poorer outcome in those affected. Studies extending to 30 years however are rare. We investigated the adult outcome of ADHD associated with perinatal risks (PRs), treated non-pharmacologically.

METHOD

A study group of 122 participants (86 men, 36 women) with PR-associated ADHD was followed-up from birth and compared with a control group also prospectively studied.

RESULTS

The study group showed more cognitive, motor perception, and learning impairments as well as psychiatric problems at ages 5, 9, and 16. At age 30, the study group reported less education, more involuntary job dismissals and more alcohol abuse. Self-reported ADHD symptoms were still prevalent in adulthood.

CONCLUSION

ADHD symptoms persist and impair the long-term educational, occupational, and psychiatric outcome. ADHD in participants with PR appears to follow a course seen in studies of unselected ADHD.

The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5

Importance

Recognition that adult attention-deficit/hyperactivity disorder (ADHD) is common, seriously impairing, and usually undiagnosed has led to the development of adult ADHD screening scales for use in community, workplace, and primary care settings. However, these scales are all calibrated to DSM-IV criteria, which are narrower than the recently developed DSM-5 criteria.

Objectives

To update for DSM-5 criteria and improve the operating characteristics of the widely used World Health Organization Adult ADHD Self-Report Scale (ASRS) for screening.

Design, Setting, and Participants

Probability subsamples of participants in 2 general population surveys (2001-2003 household survey [n = 119] and 2004-2005 managed care subscriber survey [n = 218]) who completed the full 29-question self-report ASRS, with both subsamples over-sampling ASRS-screened positives, were blindly administered a semistructured research diagnostic interview for DSM-5 adult ADHD. In 2016, the Risk-Calibrated Supersparse Linear Integer Model, a novel machine-learning algorithm designed to create screening scales with optimal integer weights and limited numbers of screening questions, was applied to the pooled data to create a DSM-5 version of the ASRS screening scale. The accuracy of the new scale was then confirmed in an independent 2011-2012 clinical sample of patients seeking evaluation at the New York University Langone Medical Center Adult ADHD Program (NYU Langone) and 2015-2016 primary care controls (n = 300). Data analysis was conducted from April 4, 2016, to September 22, 2016.

Main Outcomes and Measures

The sensitivity, specificity, area under the curve (AUC), and positive predictive value (PPV) of the revised ASRS.

Results

Of the total 637 participants, 44 (37.0%) household survey respondents, 51 (23.4%) managed care respondents, and 173 (57.7%) NYU Langone respondents met DSM-5 criteria for adult ADHD in the semistructured diagnostic interview. Of the respondents who met DSM-5 criteria for adult ADHD, 123 were male (45.9%); mean (SD) age was 33.1 (11.4) years. A 6-question screening scale was found to be optimal in distinguishing cases from noncases in the first 2 samples. Operating characteristics were excellent at the diagnostic threshold in the weighted (to the 8.2% DSM-5/Adult ADHD Clinical Diagnostic Scale population prevalence) data (sensitivity, 91.4%; specificity, 96.0%; AUC, 0.94; PPV, 67.3%). Operating characteristics were similar despite a much higher prevalence (57.7%) when the scale was applied to the NYU Langone clinical sample (sensitivity, 91.9%; specificity, 74.0%; AUC, 0.83; PPV, 82.8%).

Conclusions and Relevance

The new ADHD screening scale is short, easily scored, detects the vast majority of general population cases at a threshold that also has high specificity and PPV, and could be used as a screening tool in specialty treatment settings.

Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

One fourth to one half of parents of children with attention-deficit/hyperactivity disorder (ADHD) have ADHD themselves, complicating delivery of evidence-based child behavioral and pharmacological treatments. In this article, we review the literature examining the relation between parent ADHD and outcomes following behavioral and pharmacological treatments for children with ADHD. We also review research that has incorporated treatment of parent ADHD (either alone or in combination with child treatment) with the goal of improving parenting and child outcomes. Finally, we offer recommendations for future research on the relation between parent ADHD and evidence-based treatment outcomes for their children, with the purpose of advancing the science and informing clinical care of these families.

Pharmacological Treatment of ADHD in Addicted Patients: What Does the Literature Tell Us?

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate pharmacologic treatment of attention deficit/hyperactivity disorder (ADHD) in patients with substance use disorder (SUD) • Assess the causes of the diminished efficacy of ADHD medication in patients with comorbid SUD OBJECTIVE: Substance use disorder (SUD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur, and the presence of ADHD complicates the treatment of the addiction. Pharmacotherapy is a potent intervention in childhood and adult ADHD, but findings have been mixed in adolescent and adult ADHD patients with SUDs. This review focuses on several contributing factors and possible explanations, with implications both for future research and for clinical practice.

METHOD

This systematic review examined all randomized, placebo-controlled trials of pharmacotherapy for ADHD in adult and adolescent SUD patients.

RESULTS

The number of studies is limited, and several studies are hampered by qualitative flaws. The results, in general, are inconclusive for most medications studied, but more recent trials using psychostimulants in robust dosing have demonstrated significantly positive results.

CONCLUSION

In reviewing these trials, possible explanations relating to the particular characteristics and problems of this complex patient group are discussed. Several factors, including ADHD symptom severity, psychiatric comorbidity, persistent drug use, choice of medication, and concomitant psychosocial intervention, influence study results. Taking these factors into account may improve the likelihood of detecting significant effects in future research, as the recent positive trials have indicated, and may help in the appropriate selection of pharmacotherapy in clinical practice.

Attention-deficit hyperactivity disorder in adults: A systematic review and meta-analysis of genetic, pharmacogenetic and biochemical studies

The adult form of attention-deficit/hyperactivity disorder has a prevalence of up to 5% and is the most severe long-term outcome of this common disorder. Family studies in clinical samples as well as twin studies suggest a familial liability and consequently different genes were investigated in association studies. Pharmacotherapy with methylphenidate (MPH) seems to be the first-line treatment of choice in adults with attention-deficit hyperactive disorder (ADHD) and some studies were conducted on the genes influencing the response to this drug. Finally some peripheral biomarkers were identified in ADHD adult patients. We believe this work is the first systematic review and meta-analysis of candidate gene association studies, pharmacogenetic and biochemical (metabolomics) studies performed in adults with ADHD to identify potential genetic, predictive and peripheral markers linked specifically to ADHD in adults. After screening 5129 records, we selected 87 studies of which 61 were available for candidate gene association studies, 5 for pharmacogenetics and 21 for biochemical studies. Of these, 15 genetic, 2 pharmacogenetic and 6 biochemical studies were included in the meta-analyses. We obtained an association between adult ADHD and the gene BAIAP2 (brain-specific angiogenesis inhibitor 1-associated protein 2), even after Bonferroni correction, with any heterogeneity in effect size and no publication bias. If we did not apply the Bonferroni correction, a trend was found for the carriers allele 9R of dopamine transporter SLC6A3 40 bp variable tandem repeat polymorphism (VNTR) and for 6/6 homozygotes of SLC6A3 30 bp VNTR. Negative results were obtained for the 9-6 haplotype, the dopamine receptor DRD4 48 bp VNTR, and the enzyme COMT SNP rs4680. Concerning pharmacogenetic studies, no association was found for the SLC6A3 40 bp and response to MPH with only two studies selected. For the metabolomics studies, no differences between ADHD adults and controls were found for salivary cortisol, whereas lower serum docosahexaenoic acid (DHA) levels were found in ADHD adults. This last association was significant even after Bonferroni correction and in absence of heterogeneity. Other polyunsaturated fatty acids (PUFAs) such as AA (arachidonic acid), EPA (eicosapentaenoic acid) and DyLA (dihomogammalinolenic acid) levels were not different between patients and controls. No publication biases were observed for these markers. Genes linked to dopaminergic, serotoninergic and noradrenergic signaling, metabolism (DBH, TPH1, TPH2, DDC, MAOA, MAOB, BCHE and TH), neurodevelopment (BDNF and others), the SNARE system and other forty genes/proteins related to different pathways were not meta-analyzed due to insufficient data. In conclusion, we found that there were not enough genetic, pharmacogenetic and biochemical studies of ADHD in adults and that more investigations are needed. Moreover we confirmed a significant role of BAIAP2 and DHA in the etiology of ADHD exclusively in adults. Future research should be focused on the replication of these findings and to assess their specificity for ADHD.

Pharmacological treatment of attention-deficit/hyperactivity disorder: assessing outcomes

A substantial body of evidence has supported the efficacy and safety of pharmacological treatment available for attention deficit/hyperactivity disorder (ADHD). There is increasing agreement that the important treatment outcomes for ADHD extend beyond improvement in core symptoms and that a more generic (or global) concept of remission is the overarching goal of treatment. However, there is no consensus on the best definition of remission or on how best to conceptualize and measure broader treatment outcomes. In this article, we provide an overview of the various methods and approaches to measuring treatment outcomes for ADHD with respect to symptoms, impairment, quality of life, adverse events and safety as well as cognition. We will describe the ways that they may be used within routine clinical practice and think ahead about the kinds of studies that are required to move the field forward.

Is Adult Attention-Deficit Hyperactivity Disorder Being Overdiagnosed?

This review offers a perspective on the question as to whether attention-deficit hyperactivity disorder (ADHD) is being overdiagnosed in adults. Considering underlying causes as well as consequences, we conclude that the diagnosis of adult ADHD should be made cautiously, making use of multiple sources of information, including self-report, clinical interviews, collateral information, childhood documentation, and neuropsychological testing. Routine screening with symptom checklists is insufficient, and stimulant response is diagnostically uninformative. The causes of overdiagnosis may include changes in diagnostic thresholds, poor diagnostic practices, and advertising by the pharmaceutical industry. Overdiagnosis leads to overtreatment, and dramatic increases in prescriptions for adult ADHD during the last decade should arouse concern.

Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review

Certain characteristics of attention-deficit/hyperactivity disorder (ADHD) in children have long been known to differ by gender. What has not been as widely studied is whether gender is similarly associated with ADHD differences in adults. In this review, the relation between gender and adult ADHD prevalence, persistence, impairment, comorbidity, cognitive functioning, and treatment response was examined across 73 studies. Although gender was related to several characteristics and correlates of adult ADHD, it appeared that many of these gender differences may be at least be partially attributed to methodological artifacts or social and cultural influences, rather than fundamental differences in the expression of ADHD in men and women. We highlight how understanding the nature of the relation between gender and ADHD across the lifespan is complicated by a number of methodological difficulties, and offer recommendations for how emerging research and clinical practice can better incorporate gender into the conceptualization of ADHD in adulthood.

Should we keep on? Looking into pharmacogenomics of ADHD in adulthood from a different perspective

A considerable proportion of adults with attention-deficit/hyperactivity disorder (ADHD) do not respond to the treatment with methylphenidate. This scenario could be due to inherited interindividual differences that may alter pharmacologic treatment response. In this sense, in 2012 we conducted a systematic search on PUBMED-indexed literature for articles containing information about pharmacogenomics of ADHD in adults. Five studies were found on methylphenidate pharmacogenomics and the only significant association was reported by one particular study. However, this single association with the SLC6A3 gene was not replicated in two subsequent reports. In the present review, although we could not find additional pharmacogenomics studies, we discuss these up-to-date findings and suggest new approaches for this field. Additionally, using systeomic-oriented databases, we provide a broad picture of new possible candidate genes as well as potential gene-gene interactions to be investigated in pharmacogenomics of persistent ADHD.

Aiming for remission in adults with attention-deficit/hyperactivity disorder: The primary care goal

Attention-deficit/hyperactivity disorder (ADHD) is often undiagnosed and undertreated in adults, resulting in wide-ranging problems and functional deficits in patients' lives. In addition, psychiatric comorbidities unrelated to symptom severity may be present. However, effective treatment that can alleviate symptoms and bring about meaningful improvements in functionality is available. Primary care providers can play a crucial role in recognizing and diagnosing ADHD, initiating and monitoring treatment, and obtaining consultations or arranging referrals when necessary, all with the goal of achieving and maintaining remission. Fulfillment of this role requires a practical understanding of the diverse clinical manifestations of ADHD in patients stratified by age and sex, and familiarity with current treatment guidelines. Although there is no absolute consensus on the criteria by which remission is defined, treatment response may be guided by objective ratings of global symptom severity and patients' self-reports of changes in their ability to cope with routine daily tasks, academic and vocational responsibilities, and social relationships. Although there has been much research into the genetic and neurophysiologic basis of ADHD, it is more important for primary care providers to appreciate that ADHD is a chronic condition requiring lifelong follow-up and that clinical presentation and response to treatment can vary widely among patients and over time in the same patients. Such variability makes the management of ADHD challenging, but the opportunity to bring about dramatic improvement in patients' lives makes it imperative for primary care providers to be competent in this area. This review provides primary care clinicians with a practical definition of remission in adults with ADHD, to emphasize that symptom reduction does not necessarily mean intact functionality, and to suggest a multidisciplinary approach aimed at achieving the greatest possible reduction of symptoms and normalization of functionality.

Attention-deficit/hyperactivity disorder treatment: what are the long-term cardiovascular risks?

INTRODUCTION

This drug safety review provides an update on the long-term cardiovascular risks of therapeutic stimulant class medication for children and adults with attention-deficit/hyperactivity disorder (ADHD).

AREAS COVERED

Relevant literature on the long-term (defined as ≥ 12 months) cardiovascular effects of stimulant class medications for ADHD was sought using PubMed searches for clinical literature, epidemiological reports, as well as reviews of post-marketing data and clinical guidelines/consensus statements. Comparison was made to the non-stimulant atomoxetine.

EXPERT OPINION

Long-term cardiovascular risks of stimulants for healthy children and adults with ADHD are limited to minor mean elevations in blood pressure (≤ 7 mmHg) and heart rate (≤ 10 bpm). In a sizeable minority of individuals these elevations are greater and/or reach a clinical threshold. Subjective complaints may also be anticipated during long-term treatment, yet without an increase in serious cardiac outcomes above background rates per age. Future research is needed on possible latent or cumulative cardiovascular risks in healthy individuals, as well as the longer-term cardiovascular safety in vulnerable populations.

Addressing attention-deficit/hyperactivity disorder in the workplace

Although generally considered a childhood disorder, attention-deficit/hyperactivity disorder (ADHD) can persist into adulthood and impede achievement in the workplace. Core ADHD symptoms of inattention, hyperactivity, and impulsivity can be associated with poor organization, time management, and interpersonal relationships. Employment levels, earning power, and productivity are reduced among individuals with ADHD compared with those without ADHD. Furthermore, the costs of employing individuals with ADHD are higher because of work absences and lost productivity. The primary care provider plays an integral role in managing ADHD symptoms and providing the necessary resources that will help individuals with ADHD succeed in the workplace. Pharmacotherapy can reduce ADHD symptoms and improve functioning; however, it is also important to consider how positive traits associated with ADHD, such as creative thinking, can be used in the workplace. Workplace accommodations and behavioral therapies, such as coaching, can also enhance time management and organizational skills. This review describes how ADHD symptoms affect workplace behaviors, the effect of ADHD on employment and workplace performance, and the management of ADHD in working adults.

Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study

OBJECTIVE

To investigate the association between drug treatment for attention-deficit/hyperactivity disorder (ADHD) and risk of concomitant suicidal behaviour among patients with ADHD.

DESIGN

Register based longitudinal study using within patient design.

SETTING

Linkage of multiple national registers in Sweden.

PARTICIPANTS

37,936 patients with ADHD born between 1960 and 1996 and followed from 2006 to 2009 for treatment status by ADHD drug treatment and suicide related events (suicide attempt and completed suicide).

MAIN OUTCOME MEASURE

Incidence rate of suicide related events during ADHD drug treatment periods compared with that during non-treatment periods.

RESULTS

Among 37,936 patients with ADHD, 7019 suicide related events occurred during 150,721 person years of follow-up. At the population level, drug treatment of ADHD was associated with an increased rate of suicide related events (hazard ratio 1.31, 95% confidence interval 1.19 to 1.44). However, the within patient comparison showed a reverse association between ADHD drug treatment and rate of suicide related events (0.89, 0.79 to 1.00). Among stimulant users, a reduced within patient rate of suicide related events was seen during treatment periods (0.81, 0.70 to 0.94). Among non-stimulant/mixed users, no significantly increased within patient rate of suicide related events during non-stimulant treatment periods was seen (0.96, 0.72 to 1.30).

CONCLUSIONS

This study found no evidence for a positive association between the use of drug treatments for ADHD and the risk of concomitant suicidal behaviour among patients with ADHD. If anything, the results pointed to a potential protective effect of drugs for ADHD on suicidal behaviour, particularly for stimulant drugs. The study highlights the importance of using within patient designs to control for confounding in future pharmacoepidemiological studies.

Stimulant medication for ADHD in opioid maintenance treatment

OBJECTIVE

The use of central stimulant medication in adults with attention deficit hyperactivity disorder (ADHD) who receive opioid maintenance treatment remains controversial and empirical evidence is limited. Because of the abuse potential of stimulant drugs, Norway has restrictions on prescribing central stimulants to individuals who have substance use disorders or who are on opioid maintenance treatment. In this naturalistic study, we describe experiences from a program through which central stimulant medication was administered to patients with ADHD receiving opioid maintenance treatment.

METHODS

This report is based on a program evaluation of a combined treatment project designed to provide stimulant medication to patients with adult ADHD who were receiving opioid maintenance treatment. As part of the clinical treatment, patients were monitored closely for any medical issues or adverse medication reactions and provided regular urine samples for analysis and information regarding demographics, treatment goals, legal involvement, diagnoses, substance abuse, and ADHD symptoms. Monitoring occurred at baseline, at 2 months (after patients being stabilized on the central stimulant), and again at 3, 6 and 24 months.

RESULTS

Among 42 patients initially offered the combined treatment, 24 were actually eligible, 20 started the combined treatment, and 10 stayed in the program. We were not able to identify a single major cause of treatment dropout. Patients reported significantly fewer symptoms of ADHD at the 6- to 8-week point, regardless of whether the data were analyzed using an intent-to-treat (all participants) or per-protocol (only those with complete data at all points) method. Even though self-assessed ADHD scores dropped significantly during treatment, the scores still remained fairly high, suggesting persistent functional impairment. Neither severe complications nor increase in substance abuse were observed during treatment with central stimulants.

CONCLUSIONS

These findings show some promise with regard to the safety and utility of central stimulant medications for patients with ADHD who are receiving opioid maintenance treatment. Our study has methodological limitations, and systematic, well-designed clinical investigations are needed to increase the knowledge base.