1. Treatment of Adult ADHD: Expect the Unexpected Grand Rounds Cairns Hospital March Rigo Van Meer

2. Video interviews In the original presentation video interviews with patients were presented. For privacy reasons these video’s are not on the internet and are left out of this downloadable version of the presentation

3. Warning for students
My experiences and the opinions I have formed on the basis of those experiences differ on many counts from commonly accepted notions about adult ADHD and the use of stimulant treatment.

4. Goal Make doctors and (mental) health workers more aware of adult adhd
Make them consider adhd as a possibility and treat it
Sharpen clinical acumen in diagnosing adhd
Give an impression of treatment results

5. Attention Deficit / Hyperactivity Disorder in Adults
Diminished capacity to concentrate & focus
Impulsivity
In children “hyperactivity”. In adults feeling stressed / on edge most of the time
From trivial to very severe
Highly genetic
Problems in the frontal lobe
High co-morbidity with other psychiatric disorders
Not depression OR adhd but AND
Not Bipolar OR adhd but AND
Etc. etc.

6. Epidemiology adult ADHD
General population: 4%
Psychiatric population: 10% to 20%
Males in jail: 45%
Tourette syndrome: 65%
Methamphetamine users: 40%
Personality disorder
M/F=2 (in practice 3 to 4)
Patients with Acquired Brain Injury can have very similar symptoms 6

7. Comorbidity 78% of cases has comorbidity
Depression
20-30%
BPAD 8%
Anxiety disorders
Substance abuse
25-45%
Personality Disorders: Antisocial, Borderline
25% 7

8. Simple Adult ADHD “a uni student with concentration problems” (from: ADDults with ADHD (NSW) Inc)

9. Complex Adult ADHD Difficult psychiatric presentations (ED, Clinic)
Unclear psychiatric diagnosis, personality disorder
High psychosocial stress
Unemployed
Is stressed/ on edge
Unhappy / depressed / anxiety
No direction in life, going nowhere
Fed up with the way his/her life goes
Anger issues
Heavy alcohol use
Heavy marijuana use
Speed/ methamphetamine use
Offending
Jail

10. Psycho stimulants Short acting (3 to 4 hours) Long acting (24 hours)
Methylphenidate (Ritalin)
Dexamphetamine
Long acting (24 hours)
Methylphenidate ER (Concerta, Ritalin LA)
Mixed amphetamine salts: Adderall (not in Australia)
Dexamphetamine precursor: Vyvanse (new in Australia)
Atomoxetine (Strattera, non stimulant)
Not Addictive
Do not make you “high”
Performance improvement in non-adhd subjects doubtful
Keep you awake 10

11. General effects of stimulant treatment in ADHD
Stimulants have a QUALITATIVELY DIFFERENT effect on people with adhd then on others Stimulants in adhd CALM DOWN The effect is large and often dramatic The effect is almost immediate Stimulants in non-adhd persons DO NOTHING apart from keeping you awake

12. Common opinion: Stimulants hinder your sleep butt… in many patients with adhd sleep actually improves as long as the stimulants are not taken late in the afternoon

13. Common opinion
Stimulants diminish appetite and cause weight loss butt.. Many patients report some nausea and loss of appetite in the first days of treatment, while in the long run their appetite improves and they start to eat more regular

14. Common opinion: Stimulants cause psychosis and can’t be used in patients with a psychotic illness but… Some patients report that they can cope better with their psychotic symptoms when on stimulants

15. Common opinion: Stimulants have little or no influence on the use of alcohol
but..
patients report a dramatic decrease in the urge to drink alcohol and in the actual use of alcohol

16. How to diagnose?
Think of it
Look for it 16

17. Red flags in psychiatric patients
Difficult patient
Many problems/symptoms Diagnosed with:
Bipolar disorder, depression, anxiety
Antisocial personality disorder
Borderline personality disorder
Alcohol abuse
Substance abuse Anger issues
Little effect of anti-depressants, anti-psychotics
Quetiapine sometimes helps (sleep, relaxation)
Always ask:
If you have ever tried speed / ice / methamphetamine / Ritalin / dexamphetamine
What effect did it have on you?

18. Nobody gets addicted to Ritalin or dexamphetamine
Not Addictive
Nobody gets addicted to Ritalin or dexamphetamine
On the contrary, it costs parents effort to keep their children on their medication and almost all of them have stopped by the age of 21.
Patients often forget to take their meds (ever heard of a cigarette addict who forgets to smoke his/her cigarettes?)
No tendency of dose increase
No craving
There is no withdrawal on stopping (although some have a “come down” when the medication works out at the end of the day, especially on Ritalin)
Ever diagnosed and treated a patient with Ritalin or Dexamphetamine addiction?

19. What patients say I get things done now My mind is much clearer
I don’t procrastinate any more
I think more positive
I feel motivated
I hardly drink alcohol anymore
I’m not depressed anymore
I got my life back 19 37

20. Messages
ADHD is a common and serious psychiatric disorder that can severely mess up the patients life (and that of others)
Comorbidity is the rule
A trial of Ritalin or Dexamphetamine is easy, short and safe
Often spectacular therapeutic results
Please treat 20

21. Adult ADHD lessons learned 1
I found reading about adult adhd treatment for complex adhd particularly unhelpful. Many general statements and warnings, little practical guidance. Guidelines, even from the Queensland Government, contain errors and misconceptions.
Dose of Ritalin 10mg or Dexamphetamine 5mg is between 2 and 15 tablets daily, with an average of 6 to 8.
Under-dosing gives many problems, as patients will use the dose they need, and run out of their tablets too soon. Once the right dose is found, patients do not want to increase the dose.
Dexamphetamine has fewer side effects and is felt as “softer” than Ritalin. Dexamphetamine is therefore in general the better medication
Stimulant treatment:
As a rule reduces the urge to drink alcohol or to smoke dope.
Often will improve sleep dramatically.
Often has a general improvement in mood -> anti depressants can be stopped.
Makes patients more motivated and think more positive

22. Adult ADHD lessons learned 2
Patients with adhd who seek treatment are often treated negatively and condescending by doctors and pharmacists. Patient with adhd who seek treatment are sometimes branded as “drug seeking”. When they try another doctor they are “doctor shopping”.
Many patients with adhd use marijuana or alcohol to dampen their constant feeling of stress and unrest.
Dexamphetamine and methylphenidate are not addictive. Patients who do not have adhd find these drugs in general unpleasant.
Illegal use of amphetamines is often self medication for adhd. Proper treatment of adhd decreases crime and keeps people out of jail (and out of ED).
Drug and alcohol abuse are not a contra-indication for treatment, but an indication

23. ADHD in adults can be from trivial to very severe
Severe cases can be compounded by depression, anxiety, angriness and aggression, social deterioration, loss of meaning in life, illegal drug use and incarceration.
Treatment of severe cases often gives spectacularly positive results that are life changing. These successful treatments are in my experience one of the very rewarding things a psychiatrist can do in his profession.

24. Actively diagnosing and treating adult ADHD will:
Increase quality of life of ADHD patients and families
Convert some long term psychiatric treatment failures into successes
And will contribute to…
Decrease alcohol abuse and consequences of alcohol abuse
Decrease use of marijuana
Decrease use of methamphetamine and speed
Keep people out of jail
Keep people out of hospital