Managing Nonspecific Psychiatric Complaints of Focusing and Concentration Problems
Begin with a systematic three-step diagnostic process: first, conduct a comprehensive psychiatric evaluation to determine if symptoms meet DSM-5 criteria for ADHD (requiring childhood onset before age 12, symptoms in multiple settings, and functional impairment); second, systematically screen for alternative or comorbid conditions including depression, anxiety, substance use, and medical illnesses; and third, use standardized rating scales from multiple informants to confirm the diagnosis before initiating treatment. 1, 2
Step 1: Establish Whether ADHD Criteria Are Met
Core Diagnostic Requirements
Obtain detailed symptom history documenting at least 5 symptoms of inattention persisting for at least 6 months in adults (6 or more in those under age 17), including difficulty sustaining attention, seeming preoccupied, poor attention to detail with careless mistakes, difficulty completing tasks due to distraction, organizational challenges, and reluctance to engage in tasks requiring sustained mental effort. 1, 3
Verify childhood onset by establishing that symptoms were present before age 12 years, as this is mandatory for ADHD diagnosis. Without documented or reported manifestations before this age, the diagnosis cannot be made. 4, 1
Confirm cross-situational impairment by documenting that symptoms occur in at least two settings (home, work, school, social situations) and cause significant functional impairment in academic, occupational, or social domains. 1, 3
Use the Adult ADHD Self-Report Scale (ASRS-V1.1) as your first-line screening tool, with a positive screen defined as checking "often" or "very often" for 4 or more of the 6 questions in Part A. 2, 3
Obtain collateral information from a spouse, significant other, parent, or friend, as adults with ADHD often have poor insight and underestimate the severity of their symptoms and resulting impairments. 4
Critical Pitfall to Avoid
- Do not diagnose ADHD based solely on current symptoms. The requirement for childhood onset before age 12 is absolute. Patients presenting with new-onset concentration problems in adulthood, particularly first-time psychiatric presentations, require careful evaluation for alternative diagnoses. 4, 1
Step 2: Screen Systematically for Alternative and Comorbid Conditions
Depression as Primary Consideration
Evaluate thoroughly for major depressive disorder, as DSM-5 core symptoms explicitly include difficulty thinking, concentrating, and decision-making—symptoms that directly overlap with ADHD presentation. 1, 5
In older adults with cognitive complaints and mood changes, consider that depression may represent early dementia rather than pseudodementia, requiring longitudinal assessment rather than immediate treatment. 1
Screen for the full depressive syndrome including prominent and persistent depressed or dysphoric mood interfering with daily functioning (nearly every day for at least 2 weeks), plus at least 4 of the following: change in appetite, change in sleep, psychomotor agitation or retardation, loss of interest or decreased sexual drive, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and suicidal ideation. 5
Other Psychiatric Conditions
Screen systematically for anxiety disorders (generalized anxiety disorder, social phobia, panic disorder, OCD), as these commonly cause concentration difficulties and may be the primary diagnosis rather than ADHD. 4, 1
Evaluate for bipolar disorder, particularly in patients with mood instability, as this is frequently misdiagnosed as ADHD in adults. 4
Assess for personality disorders, especially borderline and antisocial personality disorder, which commonly co-occur with or mimic ADHD symptoms. 4, 1
Obtain detailed substance use history including alcohol and drugs, as substance intoxication and withdrawal can mimic ADHD symptoms, and substance use disorders have high comorbidity with ADHD. Consider obtaining a urine drug screen. 4, 1
Medical Conditions
Conduct medical history, physical examination, and screening laboratory tests to rule out medical conditions that can cause concentration problems, including thyroid disorders, sleep apnea, narcolepsy, seizures, and in older adults, Alzheimer's disease and related dementias. 4, 1
In older adults specifically, consider minimal hepatic encephalopathy, vascular disease, medication effects, and mixed etiology with multiple contributing conditions. 1
Use of Structured Assessment Tools
Administer the Weiss Functional Impairment Rating Scale-Self (WFIRS-S) to measure ADHD-specific functional impairment across multiple domains. 2
Consider additional validated scales including the Brown Attention-Deficit Disorder Scale for Adults or the Conners Adult ADHD Rating Scale for comprehensive symptom assessment. 4
Step 3: Treatment Algorithm Based on Diagnostic Findings
If ADHD Diagnosis Is Confirmed
Initiate stimulant medication as first-line treatment (methylphenidate or amphetamine preparations), as these are most effective for addressing attentional and cognitive symptoms with large effect sizes. 2, 3, 6
Prefer long-acting stimulant formulations as they are associated with better medication adherence. 2
Start with approximately one-half the standard ADHD starting dose if the patient has significant medical comorbidities, and titrate slowly with careful monitoring for side effects. 4
If stimulants are contraindicated or not tolerated, consider atomoxetine as a second-line option, or bupropion which has efficacy for both ADHD symptoms and comorbid depression. 2, 7
If Depression Is the Primary Diagnosis
Treat the depression first with appropriate antidepressant therapy (such as sertraline for major depressive disorder), as treating depression may resolve the concentration difficulties. 5
Monitor concentration symptoms during depression treatment, as improvement in depressive symptoms often leads to improvement in cognitive symptoms. 8
If ADHD and Depression Co-occur
Treating ADHD can improve both conditions, with 56.7% of patients showing improvement in depressive symptoms when ADHD is treated, as untreated ADHD exacerbates depression through chronic functional impairment. 2
Consider sequencing treatments to address the condition causing greatest impairment first, while monitoring for risks such as stimulant abuse or suicidal ideation. 4
Ongoing Management Considerations
Manage ADHD as a chronic condition following principles of the chronic care model, with regular follow-up visits to assess treatment response and adjust medications as needed. 4, 3
Use standardized rating scales at follow-up to track changes in both ADHD and comorbid symptoms objectively. 2
Incorporate psychoeducation and cognitive-behavioral therapy as adjunctive treatments to help develop organizational skills and coping strategies. 2, 6
Periodically re-evaluate the long-term usefulness of medication treatment for the individual patient, as ADHD treatments are frequently not maintained over time despite persistent impairments. 4