Counseling Points - January 2009 - (Page 10)

group stated, “The cardiovascular effects of MAS XR [mixed amphetamine salts, extended release, Adderall XR®] appear minimal in patients with ADHD who are otherwise in good physical health; they are similar to those reported for pediatric patients and with both shortand long-acting amphetamines and methylphenidate, as well as the non-stimulant atomoxetine. While the AHA guidelines regarding the evaluation of heart rate and BP at baseline and during follow-up pertain to children and adolescents, we believe these same guidelines should apply to adults as well.”2 oxetine. The clinician needs to communicate with the individual to let him/her know that the response to atomoxetine will take longer and is estimated at 30% compared with the 60%-70% response rate seen with stimulants.54 In dosing these medications, the clinician should start low and go slow, titrating to the dose that provides optimal improvement. Adult ADHD Psychiatric Co-morbidities and Treatment Prior to the initiation of treatment for ADHD, the clinician must evaluate for other co-morbid psychiatric disorders that may be contributing to an adult’s diminished level of functioning. Generally, co-morbidities require that the clinician first treat the most impairing psychiatric disorder.The lifetime prevalence of co-morbid psychiatric and learning disorders is estimated to be as high as 80% in adults with ADHD.56 Commonly co-occurring disorders include mood disorders (i.e., major depression, bipolar disorder, and dysthymia), anxiety disorders, substance use disorders, personality disorders, and learning disabilities.56 It is important to understand the relationship of a comorbid disorder as it relates to ADHD. Did the individual develop depression and/or anxiety as a result of his/her functional impairments related to the ADHD? Did the depression and/or anxiety exacerbate the symptoms of ADHD, contributing to the development of the functional impairment? Are these symptoms the result of individual entities? For example, if the depression is related to the impairments caused by the ADHD, then the individual’s response to antidepressants may not be as robust, and the individual may even seem treatment resistant. In this situation, treating the ADHD often improves the depressive symptoms.57,58 ADHD with co-morbidities is associated with more functional impairment than ADHD alone, as well as a more complex treatment course.When there are co-morbid disorders present, such as depression, anxiety, or substance abuse, that impair cognitive ability, it is difficult to assess which impairments are actually related to the ADHD.58 Managing Side Effects Reduced Appetite. Decreased appetite occurs less frequently with longer-acting stimulants than shorter-acting agents and usually abates if the medication is taken on a daily basis. It is sometimes recommended that the person eat before taking the medication, have a small lunch, and then eat dinner after the medication has worn off. Other strategies to ensure adequate nutrition include taking supplements, consuming high-protein snacks, and eating several small meals over the course of the day. Rebound. Some patients experience rebound (usually described as a mixture of sadness, irritability, and lethargy) as a stimulant medication is wearing off. Strategies for minimizing this include using the longer-acting formulations, or augmenting with a smaller dose of a short-acting stimulant during rebound time to decrease its impact. Sleep Difficulty. Sleep problems may be related to stimulant use or to ADHD itself. For this reason, it is important at the start of treatment to inquire as to how the individual is sleeping. Sleep difficulties related to stimulant use usually improve after the first week of therapy; if they don’t, changing the time at which the stimulant is dosed or switching to a different duration stimulant can be effective. Irritability or Jitteriness. Both irritability and jitteriness are experienced by some people using stimulants, but these side effects usually subside after the first week of treatment. If they don’t, the individual should be advised to avoid caffeine and other stimulating substances. The dose of the stimulant can be decreased, another stimulant preparation can be tried, or clonidine (Catapres®) or guanfacine (Tenex®) can be added to the regimen to treat this side effect.54 ADHD and Substance Use Disorders Nine to thirty percent of adults with ADHD have problems with drug abuse or dependence as identified by Wilens.59 He recommends treating the substance use disorder first. At the same time, the clinician can utilize a nonstimulant medication (e.g., atomoxetine or bupropion) to treat ADHD symptoms. If these medications are ineffective, consider a stimulant trial in persons who have attained at least 2 months of sobriety. Wilens advises the clinician to carefully monitor individuals with ADHD Nonstimulant Treatments for Adult ADHD Atomoxetine, which is approved for the treatment of adult ADHD, should also be considered as an option. Adults who do not respond to stimulants; have a co-morbid anxiety disorder, weight loss, or insomnia; and those who do not wish to use stimulants may respond to atom- COUNSELING POINTS™ 10

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Counseling Points - January 2009

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