Challenges of Treating ADHD with Comorbid Substance Use Disorder: Considerations for the Clinician

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.

Attention Deficit Hyperactivity Disorder: A Risk Factor for Premature Discontinuation of Inpatient Opioid Withdrawal Treatment

Background: Substance use disorders present a tremendous challenge within contemporary healthcare systems. Specifically, in the domain of opioid use disorders (OUDs), several foundational elements are crucial for the efficacious management of afflicted individuals. Regrettably, the premature discontinuation of inpatient opioid withdrawal treatment is a prevalent phenomenon. This study aims to elucidate the prevalence of the premature termination of inpatient opioid withdrawal treatment among patients with comorbid ADHD. Methods: We conducted a comprehensive assessment of all participants currently undergoing inpatient opioid withdrawal treatment. Our assessment protocol included the administration of the ADHD Self-Report Scale (ADHD-SR) and the Wender Utah Rating Scale (WURS-k). Additionally, participants who met the thresholds on one or both questionnaires underwent further evaluation using the Diagnostic Interview for ADHD in Adults (DIVA-2.0). Results: The prevalence of individuals diagnosed with ADHD within the studied cohort was determined to be 29.3%. Among the subset of participants identified as ADHD-positive, a notable 54.5% prematurely ceased therapy. In contrast, among those identified as ADHD-negative, the premature discontinuation rate was substantially lower at 28.3%. Conclusions: In summary, the impact of ADHD as a comorbid condition on the efficacy of inpatient opioid withdrawal treatment has been underscored. By identifying comorbid ADHD early in the treatment process, tailored therapeutic approaches may help to maximize the effectiveness of interventions and may improve patient outcomes. This underscores the importance of proactive screening for ADHD as a psychiatric comorbidity in optimizing the management of individuals undergoing inpatient opioid withdrawal treatment.

Treatment adherence rates across different psychiatric disorders and settings: findings from a large patient cohort

Approximately 50% of patients with psychiatric disorders do not fully adhere to the prescribed psychopharmacological therapy, significantly impacting the progression of the disorder and the patient's quality of life. The present study aimed to assess potential differences in terms of rates and clinical features of treatment adherence in a large cohort of psychiatric patients with different diagnoses attending various psychiatric services. The study included 307 psychiatric patients diagnosed with a primary major depressive disorder, bipolar disorder, anxiety disorder, schizophrenic spectrum disorder, or personality disorder. Patient's adherence to treatment was evaluated using the Clinician Rating Scale, with a cutoff of at least five defining adherence subgroups. One-third of the sample reported poor medication adherence. A lower rate of adherence emerged among patients with schizophrenic spectrum disorder and bipolar disorder. Subjects with poor adherence were more frequently inpatients and showed higher current substance use, a greater number of previous hospitalizations, and more severe scores at psychopathological assessment compared with patients with positive adherence. Poor adherence was associated with symptom severity and increased rates of relapses and rehospitalizations. In addition, substance use appears to be an unfavorable transdiagnostic factor for treatment adherence.

Navigating the Complex Intersection of Substance Use and Psychiatric Disorders: A Comprehensive Review

The co-occurrence of substance use disorders (SUDs) and psychiatric conditions, often referred to as comorbidity or concurrent disorders, presents intricate challenges in both diagnosis and treatment. This comprehensive narrative review aims to synthesize and critically evaluate the existing evidence surrounding the management of individuals with comorbid SUDs and psychiatric disorders. Comorbidity in these domains carries profound implications for clinical practice, research, and policymaking, emphasizing the need for a holistic understanding of the intricate dynamics that arise when these conditions coexist. This review explores recent research findings, evidence-based guidelines, and emerging trends within the field, offering valuable insights for clinicians, researchers, and policymakers seeking to navigate the complex terrain of comorbidity in substance use and psychiatric disorders.

Adult psychiatric and psychosocial outcomes of children with mild intellectual disability: a register follow-up of a population-based cohort

BACKGROUND

Very few longitudinal psychiatric and psychosocial outcome studies of children with mild intellectual disability (MID) have been performed.

METHODS

The study group was population based and consisted of 82 individuals, born in 1979-1985 and diagnosed in childhood at ages between 3 and 15 years with MID. In the present study, register data regarding school attendance, employment, economic situation, psychiatric diagnoses and criminal sentences were retrieved for the years 1997-2018, when the individuals were up to 39 years old.

RESULTS

At follow-up, data were obtained for 78 of the 82 individuals (47 male and 31 female). Mean age at follow-up was 36 years. Of the 78 individuals, 57 (73%) had exclusively received education for pupils with MID, but 21 (27%) had graduated from regular education of some sort (at least 9 years). Forty-four (56%) had never been employed, and 34 (44%) had been registered as employed for at least a shorter period. Forty-seven (60%) had received a sick pension at some point in adulthood. Of the 78 individuals, 44 (56%) had any psychiatric disorder recorded and about half of these (n = 21) had had inpatient treatment. A total of 31 of the 44 individuals in psychiatric care (70%) had ID noted as one of their diagnoses. Of the 78 individuals, 48 (62%) had support from the Act concerning Support and Service for Persons with Certain Functional Impairments (Swedish LSS law) as adults. Twenty-one individuals (27%) had had a criminal conviction, of whom five male individuals had been incarcerated.

CONCLUSIONS

Individuals with MID constitute a heterogeneous group with regard to severity of functional impairment, co-occurring psychiatric disorders and need of support from society. Primary health care, psychiatry and habilitation services need to work together in order to meet the multiple needs of this group.

Reducing Risk in the Treatment of Attention-Deficit/Hyperactivity Disorder Among Adults With Comorbidities

Recent widely publicized shortages in the U.S. supply of first-line medications for treatment of attention-deficit/hyperactivity disorder (ADHD) are thought to reflect increases in public awareness, help seeking, and treatment. ADHD is one of the most common neurodevelopmental disorders and is typically identified in childhood. In adulthood, ADHD symptoms are less likely to include hyperactivity, but inattention, impulsivity, and emotional dysregulation are common. Clinical evaluation of symptomatic adults who were not diagnosed as children requires corroboration of ADHD diagnostic symptoms in childhood and careful differentiation of ADHD from frequently co-occurring psychiatric and substance use disorders. Treatment of adult ADHD can result in improved functioning across multiple dimensions and comorbid disorders. Existing guidelines and consensus statements recommend an integrated approach to treating ADHD and all existing comorbid disorders, prioritizing the disorder that is creating the most difficulty for the individual. [Journal of Psychosocial Nursing and Mental Health Services, 62(1), 8-11.].