What is the best psychiatric plan for a 67-year-old female with adult Attention Deficit Hyperactivity Disorder (ADHD) currently being treated with 15 mg of Adderall (amphetamine and dextroamphetamine) IR (Immediate Release)?

Psychiatric Plan for 67-Year-Old Female with Adult ADHD on Adderall IR 15 mg Daily

Switch from immediate-release Adderall 15 mg daily to a long-acting amphetamine formulation (lisdexamfetamine 30-50 mg daily or mixed amphetamine salts extended-release 20-30 mg daily) to provide superior adherence, more consistent all-day symptom control, and lower risk of rebound effects. 1, 2

Immediate Medication Optimization

Primary Recommendation: Transition to Long-Acting Formulation

• Long-acting stimulant formulations are strongly preferred over immediate-release preparations for adults with ADHD due to better medication adherence, lower risk of rebound effects, and more consistent symptom control throughout the day, which is critical for individuals with executive dysfunction. 1, 2

• The current dose of 15 mg Adderall IR daily is suboptimal both in formulation and likely in total daily dose, as the maximum daily dose of amphetamines can reach 40 mg. 2

• Lisdexamfetamine (Vyvanse) 30-50 mg once daily is the preferred option as it provides 12-14 hours of coverage, has lower abuse potential, and is abuse-deterrent due to its prodrug formulation. 2

• Alternatively, mixed amphetamine salts extended-release (Adderall XR) 20-30 mg once daily can be used if lisdexamfetamine is not accessible. 3, 2

Systematic Titration Protocol

• Begin with lisdexamfetamine 30 mg daily and titrate weekly in 10-20 mg increments based on symptom response and tolerability, up to 70 mg daily if needed. 2

• Titration should occur over 2-4 weeks with weekly dose adjustments based on systematic assessment, as stimulant effects are seen immediately. 2

• The goal is to titrate to optimal effect, not arbitrary dose limits—underdosing is a common pitfall that leads to inadequate treatment response. 2

Comprehensive Assessment at Establishment Visit

Diagnostic Confirmation and Comorbidity Screening

• Screen for substance use disorders, as prescribing psychostimulants to adults with comorbid substance abuse is of particular concern. 1, 3

• Assess for comorbid anxiety and depression, as these are frequently associated with ADHD and may require concurrent treatment. 1, 3

  • The presence of anxiety does not contraindicate stimulant use but requires careful monitoring. 1
  • If depressive symptoms are present, both ADHD and depression should be treated concurrently, as depression is not a contraindication to stimulant therapy. 3

• Evaluate for cardiovascular risk factors including uncontrolled hypertension, symptomatic cardiovascular disease, or arrhythmias, which would contraindicate stimulant use. 2

• Screen for active psychosis or mania, which are contraindications for stimulant use. 3

Baseline Monitoring Parameters

• Obtain baseline vital signs (blood pressure and pulse), as regular cardiovascular monitoring is necessary with stimulant use. 1, 2

• Document baseline weight, as appetite suppression is a common adverse effect. 2

• Assess baseline sleep patterns, as insomnia is a common adverse effect that may require intervention. 1, 2

Ongoing Monitoring Strategy

Regular Follow-Up Schedule

• Schedule weekly contact during the initial titration phase (first 2-4 weeks) to assess response and adjust dosing. 2

• Transition to monthly visits during maintenance phase to monitor efficacy and adverse effects. 2

Systematic Symptom Assessment

• Monitor core ADHD symptoms (inattention, hyperactivity, impulsivity) using standardized rating scales at each visit. 2

• Assess functional improvement in at least two different settings (work, home, social), as effectiveness evaluation should be based on reduction in core ADHD symptoms and improvement in functional domains. 1

• If anxiety symptoms are present, track them systematically to ensure comorbid anxiety is not worsening with stimulant treatment. 1

Safety Monitoring

• Monitor blood pressure and pulse at each visit, as both can be elevated by stimulants. 1, 2

• Assess for common adverse effects including:

  • Loss of appetite and weight changes 1, 2
  • Insomnia or sleep disturbances 1, 2
  • Anxiety or agitation 1, 2
  • Headaches 2
  • Social withdrawal 2

• Monitor for signs of misuse or diversion, particularly given the controlled substance status of amphetamines. 3

Management of Comorbid Conditions (If Present)

If Depression Emerges or Persists

• If ADHD symptoms improve but depressive symptoms persist, add an SSRI to the stimulant regimen, as there are no significant drug-drug interactions between stimulants and SSRIs. 3

• SSRIs remain the treatment of choice for depression, are weight-neutral with long-term use, and can be safely combined with stimulants. 3

• Do not assume a single antidepressant will effectively treat both ADHD and depression—no single antidepressant is proven for this dual purpose. 3

If Anxiety is Present or Worsens

• Continue stimulant therapy while monitoring anxiety symptoms closely, as stimulants can indirectly reduce anxiety by improving executive function and reducing ADHD-related functional impairment. 1

• If anxiety worsens significantly, consider adding an SSRI or switching to a non-stimulant option (see below). 1, 3

If Substance Use History is Identified

• Long-acting formulations with lower abuse potential are strongly preferred, such as lisdexamfetamine or extended-release methylphenidate formulations that are resistant to diversion. 3, 4

• Implement urine drug screening to ensure compliance and detect any return to substance use. 3

• Consider atomoxetine (60-100 mg daily) as an alternative if substance abuse risk is high, as it is an uncontrolled substance with lower abuse potential. 3, 2

Alternative Non-Stimulant Options (If Stimulants Fail or Are Contraindicated)

Second-Line Pharmacotherapy

• Atomoxetine 60-100 mg daily is the only FDA-approved non-stimulant for adult ADHD, though it requires 4-6 weeks to achieve full effect. 3, 2

  • Start at 40 mg daily and titrate by 20 mg increments every 7-14 days. 2
  • Monitor for suicidality and clinical worsening, particularly in the first few weeks. 3

• Extended-release guanfacine (1-4 mg daily) or extended-release clonidine can be used as monotherapy or adjunctive therapy with stimulants, with effect sizes around 0.7. 1, 3

  • These are particularly useful if sleep disturbances are present, as they can be administered in the evening due to their sedative effects. 1, 3

• Bupropion is a second-line agent for ADHD compared to stimulants and should not be used alone to treat both ADHD and depression. 3

Adjunctive Psychosocial Interventions

• Cognitive Behavioral Therapy (CBT) is the most extensively studied and effective psychotherapy for adult ADHD, focusing on time management, organization, planning, and adaptive behavioral skills, with increased effectiveness when combined with medication. 1, 5

• Mindfulness-Based Interventions (MBIs) show evidence for managing ADHD in adults, helping with inattention symptoms, emotion regulation, executive function, and quality of life. 1

Critical Pitfalls to Avoid

• Avoid underdosing—titrate to optimal effect within safe limits rather than stopping at arbitrary low doses. 2

• Do not prematurely switch medications—complete a full dose range trial (including higher doses within safe limits) before declaring medication failure. 2, 6

• Never use MAO inhibitors concurrently with stimulants due to risk of hypertensive crisis—at least 14 days should elapse between discontinuation of an MAOI and initiation of stimulants. 3

• Do not use weight-based dosing for stimulants in adults, as it is not supported by evidence. 2

• Avoid continuing immediate-release formulations long-term when long-acting options provide superior outcomes. 1, 2