Laura J. Martin, MD
If you've been diagnosed with ADHD as an adult, chances are good that your doctor has prescribed a medication -- typically a stimulant -- and suggested cognitive behavioral therapy or even a life coach. She might also have suggested a good pocket planner.
Treating ADHD in adults requires a multi-pronged approach. Symptoms are generally treated with medicine.
But it's not just a matter of taking a pill. There is work to be done on practical stuff, such as getting organized, and on other emotional issues that often come with the territory.
The same kinds of medications used for childhood ADHD work in adults, says Lenard Adler, MD, a psychiatry professor at New York University Langone Medical Center and director of the Adult ADHD program at the NYU School of Medicine.
Stimulants such as Adderall, Concerta, Focalin, Vyvanse, and Ritalin in long-acting form are often prescribed for symptoms. Strattera, the only nonstimulant approved for treatment of adult ADHD, is also widely prescribed, he says.
Choosing the right medication for a patient with ADHD is often about avoiding worsening other health problems. For instance, Adler says he wouldn't prescribe a stimulant to a patient who has a substance abuse problem, because stimulants have a high potential for abuse.
Your history of taking ADHD drugs also matters. Adler finds out what the patient has taken previously and, because ADHD has a strong genetic link, what family members with ADHD have taken and tolerated.
Adler, a psychiatry professor at NYU's School of Medicine, has received grant/research support from various makers of ADHD drugs.
Adults with ADHD and a family history of heart disease and fainting should consider the effect of ADHD drugs, both stimulants and nonstimulants, although they are considered safe in the short term.
"They are generally safe medications," Adler says. But even patients taking Strattera need to have their blood pressure and pulse monitored. He starts patients on the lowest dose to gauge their tolerance.
Side effects that are common in stimulants include agitation, insomnia, and changes in blood pressure and pulse. Potential side effects of Strattera are similar and may also include nausea, Adler says.
That depends on your particular case.
"With kids, we recommend they stay on it throughout the school year. It helps them learn better. That's true for college students, too. Post-college, it's going to depend on the situation, the stressors, how they're handling them. Will you always stay on medication? It's an individual decision," says Angela Tzelepis, PhD, a psychiatry professor at Wayne State University who also runs a clinic in Grosse Pointe, Mich.
"Our focus is now on assisting patients in maintaining these improvements and continuing to make meaningful, positive changes in their lives," Adler says.
Most adults with ADHD don't just have ADHD; 75% to 80% also have disorders such as mood swings, anxiety, and substance abuse, according to a study published in BMC Medicine.
Depression and anxiety are often what brings an adult with ADHD into a therapist's office, Tzelepis says.
"Honestly, most adultswho are going to seek treatment aren't going to seek treatment for just ADHD," Tzelepis says. "My approach, and this is supported in the literature, is this is a neurobiological problem. The best treatment is going to involve a combination of medication and the therapy, or other nonpharmacologic interventions.''
For some people, the baggage that comes with ADHD is part of the problem.
"Some of the emotional issues you see have to do with not feeling good about themselves, feeling that they aren't capable and competent, because things they do take more effort and they internalize that," Tzelepis says. "The kind of feedback they get from others -- that they're lazy or if they worked harder they'd do better -- they constantly get the message they aren't good enough.''
Yes. Cognitive-behavioral therapy seems especially beneficial for adults with ADHD, mainly to help develop organizational skills. And if you have other mental health issues, you definitely need to start talk therapy.
If ADHD seems to be the patient's primary disorder, Tzelepis says she'll help a patient focus on "executive functions" including time management and planning.
In one case, a young woman who had flunked out of her first year of university after a stellar high school run came to Tzelepis to get on track. She had never had a bedtime or much structure to her days, and that was her downfall as a college student.
"It became clear she did have ADHD and hadn't been diagnosed because she was bright and was able to do well academically," Tzelepis says. Aside from getting her a calendar, Tzelepis helped the patient gain more mastery over her reactions and emotions.
The young woman spent a year at community college and is heading back to the university.
"What you need is therapy with goals that are specific to the behaviors and symptoms that are problematic. If you have difficulty keeping a calendar, how are you going to keep a calendar, what are the barriers?'' Tzelepis says. "It's not, 'how do you feel about keeping this calendar?'"
However, Adler says some patients may get better with ADHD medicine alone.
"They can make a change in their life, unlearn bad habits, use their organizers well, plan better, listen better. They don't need a psychosocial intervention," he says. "You can make a meaningful difference with these medicines.''
Coaching, a new industry that offers very specific problem-solving, can also work for some people, Tzelepis says.
"It's akin to what you have with a kid and a tutor," Tzelepis says. "I've referred people to coaches because I need to work on other pieces -- the emotional-psychological component of what is going on."
An Australian study that paired ADHD adults with coaches for eight weekly sessions found that most participants improved their organizational abilities and had reduced levels of anger that they maintained for a year after the therapy. Participants also had to complete homework exercises. The study was designed to target attention problems, low motivation levels, poor organizational skills, poor anger control, and impulsivity.
For the relatively few adults who only have ADHD symptoms, coaching or talk therapy may be the only thing necessary to put them back on track, Tzelepis says.
SOURCES:Angela Tzelepis, PhD, psychologist, assistant professor, department of psychiatry and neurosciences, Wayne State University, Detroit.Lenard Adler, MD, psychiatrist, professor, departments of psychiatry and child and adolescent psychiatry, New York University Langone Medical Center.Antshel, K. BMC Medicine, June 10, 2011.Barbaresi, W. Archives of Pediatric & Adolescent Medicine, March 2002; vol 156: pp 217-224.Kessler, R. American Journal of Psychiatry, April 2006; vol 163: pp 716-723.Stevenson, C. The Australian and New Zealand Journal of Psychiatry, October 2002; vol 36: pp 610-616.
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