What is the treatment for Attention Deficit Hyperactivity Disorder (ADHD) in adults?

Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Adults

The first-line treatment for adult ADHD is a combination of stimulant medication (methylphenidate or amphetamine formulations) and cognitive behavioral therapy (CBT), as this approach provides the most effective management of ADHD symptoms and improves quality of life. 1, 2

Pharmacological Treatment

First-Line Medications

1. Stimulants

   • Methylphenidate 3

     • Starting dose: 5 mg orally twice daily (preferably 30-45 minutes before meals)
     • Titration: Increase gradually by 5-10 mg weekly
     • Maximum recommended daily dose: 60 mg
     • Average effective dose: 20-30 mg daily
     • For adults with sleep difficulties: Administer last dose before 6 p.m.

   • Amphetamine formulations (alternative first-line option)

     • Consider if methylphenidate is not suitable or not tolerated

Second-Line Medications

1. Non-stimulants (when stimulants are ineffective, contraindicated, or not tolerated)

   • Atomoxetine 4

     • Starting dose: 0.5 mg/kg/day
     • Target dose: 1.2-1.8 mg/kg/day (maximum 1.5 mg/kg/day)
     • Administration: Can be given as once-daily morning dose or divided doses
     • Mean effective dose: Approximately 95 mg/day

   • Alpha-2 agonists

     • Extended-release guanfacine (Intuniv)
     • Extended-release clonidine (Kapvay)

   • Bupropion

     • Particularly beneficial for patients with comorbid depression
     • Lower risk of misuse/diversion for patients with substance use disorders

Psychosocial Interventions

Cognitive Behavioral Therapy (CBT)

• CBT is a critical component of adult ADHD treatment and should be implemented concurrently with medication 2, 5

• Typically delivered in 6-14 sessions, either individually or in groups of 4-10 participants 6

• CBT has shown significant effectiveness in:

  • Reducing ADHD symptoms (large effect size) 5
  • Improving comorbid anxiety and depression symptoms 5, 7
  • Enhancing daily functioning and quality of life

• Key CBT components for adults with ADHD:

  • Skills training for organization and planning
  • Time management strategies
  • Problem-solving techniques
  • Emotional regulation skills
  • Stress management

Coaching and Support

• ADHD coaching can help with:
  • Implementation of organizational strategies
  • Accountability for treatment adherence
  • Practical application of skills in daily life

Treatment Algorithm

1. Initial Assessment

   • Confirm ADHD diagnosis using DSM criteria
   • Screen for comorbid conditions (especially anxiety, depression, substance use)
   • Assess cardiac risk factors before starting stimulants

2. First-Line Treatment

   • Start methylphenidate at 5 mg twice daily
   • Begin CBT concurrently
   • Titrate medication based on response and side effects

3. If Inadequate Response or Intolerable Side Effects

   • Switch to alternative stimulant (amphetamine formulation)
   • If still inadequate, consider non-stimulant options

4. For Specific Comorbidities

   • Substance use disorder: Consider non-stimulant options first (atomoxetine, bupropion)
   • Anxiety/depression: Atomoxetine or bupropion may be particularly beneficial
   • Sleep disorders: Consider timing of stimulant doses or alpha-2 agonists

Monitoring and Follow-up

• Regular assessment of:
  • ADHD symptom response
  • Vital signs (blood pressure, heart rate)
  • Side effects (decreased appetite, sleep disturbances, irritability)
  • Weight changes
  • Emergence of tics or other adverse effects

Important Considerations

• Medication Warnings

  • Stimulants carry risks of abuse, misuse, and addiction 3
  • Store medications securely and dispose of unused medication properly
  • Contraindicated with MAOIs or within 14 days of MAOI discontinuation

• Cultural Considerations

  • Treatment approaches may vary across regions; Western guidelines typically recommend stimulants as first-line, while some Asian guidelines prioritize psychosocial interventions before medication 1

• Common Pitfalls

  • Undertreating comorbid conditions
  • Inadequate dose optimization
  • Focusing solely on medication without implementing behavioral strategies
  • Discontinuing treatment prematurely (ADHD often requires long-term management)

The combined approach of medication and CBT has consistently demonstrated superior outcomes compared to either treatment alone, with improvements in ADHD symptoms persisting beyond the treatment period 8, 6.