Attention Deficit Hyperactivity Disorder in Adults

Last Updated: October 31, 2020

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This tool is designed to support primary care providers in screening, diagnosing and implementing treatment for adult patients (≥ 18 years) with attention deficit hyperactivity disorder (ADHD). ADHD in adulthood can be associated with significant impairment in occupational, academic, social and emotional functioning.1,2 The treatment of ADHD involves pharmacological and non-pharmacological interventions.

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Screening and diagnosis

Consider screening for ADHD in primary care in adults who present with executive function difficulties, including those who do not have a childhood diagnosis of ADHD. Recent studies have shown that a substantial proportion of individuals with adult ADHD were not diagnosed or recognized in childhood.3

Due to the barriers to accessing specialty care, this tool aims to empower and guide primary care providers to manage adult ADHD within the primary care setting. For additional support consult specialists across the province at OTN eConsult4 and find mentors at the Ontario College of Family Physician’s (OCFP) Collaborative Mental Health Network.5

Some opportunities for screening

Consider screening your patient who has:2

  • A hard time adjusting to structure and transitions in their life
  • Binge eating issues/fluctuating weight
  • Emotional dysregulation
  • Family dysfunction
  • Occupational instability
  • Persistent perceived underachievement
  • Poor adherence to healthy lifestyle
  • Risk taking behaviour
  • Treatment resistant anxiety and/or depression

Screening

Use the Adult ADHD self-report scale (ASRS-V1.1) symptom checklist to screen patients for ADHD.6 The ASRS-V1.1 is designed to encourage dialogue between you and your patient to identify if they have symptoms of ADHD.3 If the patient has symptoms highly consistent with ADHD in adults, then investigation is warranted using the diagnostic criteria below.6

Diagnosis

In order to diagnose for ADHD, symptom manifestations of hyperactivity/impulsivity and/or inattention should:7

If possible, ask the patient for permission to consult a third-party (a friend or family member) who is close to the patient and can offer further insight into their symptoms.

Talking points

Look for signs of ADHD and address it with your patient
“Were you diagnosed with ADHD as a child? You seem to have some symptoms of ADHD. Let’s do an assessment to check.”

Talk to your patient without judgment,stigma or bias
“Many people don’t know that they have been living with ADHD until adulthood. It is a treatable and common condition, affecting 3.4% of adults worldwide.”3

Categories of impairment

The following are examples of impairment that patients with ADHD may experience.

Educational

Problems with:
• Focusing
• Completing assignments
• Meeting deadlines

Family

Problems with:
• Family members
• Parenting
• Balancing their needs against those of their family

Life skills

Problems with:
• Weight control
• Sleeping
• Perceived underachievement
• Time management

Occupational

Problems with:
• Performing required duties
• Keeping a job
• Supervisors

Self-concept

Feels:
• Bad about themselves
• Frustrated with themselves
• Discouraged

Social

Problems with:
• Avoiding arguments
• Getting along with people
• Regulating emotions

Risk

Problems with:
• Aggressive driving
• Substance use
• Physical aggression

Adapted from the Weiss functional impairment rating scale (WFIRS-S)10

Initiating treatment

Develop a treatment plan with your patient that addresses their psychological, behavioural, occupational and educational needs.7

Take into account:7

  • How symptoms and impairments affect the patient’s daily life activities, including sleep7
  • The patient’s resilience and protective factors (positive self-esteem, success at school, steady employment, supportive family)7,11

Discuss the following with your patient:7

  • How to use the Specific, Measurable, Achievable, Realistic, and Timely (S.M.A.R.T.) goals framework to create S.M.A.R.T. methods for monitoring treatment effect (e.g. if a patient wants to focus more on their studies, be more financially responsible, manage their time better)12
  • How other diagnosed mental health or neurodevelopmental conditions might affect their treatment decisions
  • The benefits and risks of non-pharmacological and pharmacological treatments
  • The importance of adherence to their treatment plan
Talking points

Reassure patients that their treatment plan can be changed
“Nothing is set in stone. Your treatment options are negotiable, and we can always revisit at the next appointment.”

Pharmacological treatment options New

If a patient has a diagnosis of ADHD, pharmacological and non-pharmacological treatment should be used in parallel.

Considerations when prescribing

  • Revisit the patient’s S.M.A.R.T. goal methods to determine when their medication needs to be effective over an extended period of time (this can help determine if medication is losing effect during the day)2
  • Rule out contraindications to medication (e.g. uncontrolled hypertension, cardiovascular disease, uncontrolled epilepsy)2
  • When prescribing stimulants for ADHD, use extended-release once-daily preparations (see First-line treatment options)7
  • Prescribe medication for no more than three months and have patient come back for review of medication (see Maintenance and monitoring)2
  • Document the patient’s blood pressure, pulse rate, BMI/weight and ASRS-V1.1 score at baseline and all subsequent visits to measure the effect of treatment for monitoring purposes2,4
  • Choose extended-release stimulants because of the higher risk of diversion and misuse affiliated with immediate-release medications2
  • Be aware of possible diversion by some patients who may request these medications for cognitive enhancement or appetite suppression2
Talking points

Discuss the following when starting pharmacological treatment
“When starting at a low dose it’s not uncommon to feel like the same dose is no longer supportive. This is normal and expected and we can increase the dose based on your needs.”

“It is important to maintain a routine and to take your medications at the same time every day.”

“Avoid drinking excessive alcohol and caffeinated beverages while taking stimulants.”

The medication list below is recommended for adult patients ≥ 18 years. It does not address patient populations <18 years of age. For a more comprehensive list of medication information such as adverse effects, consult each individual product monograph.

First-line treatment options

Evidence supports the efficacy of the stimulants lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adult patients living with ADHD.2,15 If one stimulant doesn’t work consider conducting a trial with another stimulant listed below.2

Scroll (left-right) for details
  • Lisdexamfetamine
    (Vy vanse ®)16,17,18

    Product monograph

    Formulation

    • 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg and 70 mg capsules18
    • 10 mg, 20 mg, 30 mg, 40 mg, 50 mg and 60 mg tablets18

    Dosage

    • Initial: 20-30 mg19 once daily in the morning; may increase in increments of 10 mg or 20 mg at weekly intervals until optimal response is obtained
    • Maximum: 60 mg/day19,20

    Duration of action

    • 13–14 hours16

    Coverage

    • ODB ✓

    Cost of 30-day supply of mean dosage*

    • $120-150
    Adverse Effects
    Close

    Adverse Effects 16, 35

    Common adverse effects:

    Restlessness, irritability, anxiety, insomnia or anorexia, worsening of aggressive behaviour or hostility at the start of treatment

    • Paradoxical psychiatric effects such as rebound, restlessness, irritability, and increased aggression may be observed
    • Somatic effects such as insomnia, decreased appetite, tics, stomach ache, and headache are all common, especially at the beginning of therapy
    • The slower the rate of titration, the less severe the initial side effects
    • Many of these psychiatric and somatic side effects will endure throughout treatment, making drug holidays useful to assess impact of relative risk vs. benefit, and necessitating the regular monitoring of growth

    Discontinuation syndrome:

    Abrupt withdrawal after prolonged use may result in dysphoria, irritability or rebound in symptoms of ADHD, increase in sleep and appetite reported. Consider tapering over several weeks in patients who poorly tolerate discontinuation or have been on medication for longer than 3 months.

    If stimulants are taken in conjunction with an antipsychotic, sudden discontinuation may result in the emergence of extrapyramidal symptoms previously masked by the stimulant.

    Note:

    • Monitor patient for suicidal thoughts/ideation; consider a change in treatment if concerns arise.
  • Methylphenidate controlled-release capsules (Biphentin®)16,21,22

    Product monograph

    Formulation

    • 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg and 80 mg capsules22

    Dosage

    • Initial: 10–20 mg QAM PO; may increase by 5–10 mg Q 7 days16
    • Maximum: 80 mg/day16

    Duration of action

    • 10 –12 hours16

    Coverage

    • ODB ✓

    Cost of 30-day supply of mean dosage*

    • $90–120
    Adverse Effects
    Close

    Adverse Effects 16, 35

    Common adverse effects:

    Restlessness, irritability, anxiety, insomnia or anorexia, worsening of aggressive behaviour or hostility at the start of treatment

    • Paradoxical psychiatric effects such as rebound, restlessness, irritability, and increased aggression may be observed
    • Somatic effects such as insomnia, decreased appetite, tics, stomach ache, and headache are all common, especially at the beginning of therapy
    • The slower the rate of titration, the less severe the initial side effects
    • Many of these psychiatric and somatic side effects will endure throughout treatment, making drug holidays useful to assess impact of relative risk vs. benefit, and necessitating the regular monitoring of growth

    Discontinuation syndrome:

    Abrupt withdrawal after prolonged use may result in dysphoria, irritability or rebound in symptoms of ADHD, increase in sleep and appetite reported. Consider tapering over several weeks in patients who poorly tolerate discontinuation or have been on medication for longer than 3 months.

    If stimulants are taken in conjunction with an antipsychotic, sudden discontinuation may result in the emergence of extrapyramidal symptoms previously masked by the stimulant.

    Note:

    • Monitor patient for suicidal thoughts/ideation; consider a change in treatment if concerns arise.
  • Methylphenidate controlled-release capsules (Foquest ®) 16,21,23

    Product monograph

    Formulation

    • 25 mg, 35 mg, 45 mg, 55 mg, 70 mg, 85 mg and 100 mg capsules23

    Dosage

    • Initial: 25 QAM PO; may increase by 10–15 mg Q 5 days16
    • Maximum: 100 mg/day16
    • Patients who are already taking methylphenidate can convert to the next lower strength of Foquest® based on the total methylphenidate daily dose16

    Duration of action

    • 16 hours16

    Coverage

    • ODB ?

    Cost of 30-day supply of mean dosage*

    • $120–150
    Adverse Effects
    Close

    Adverse Effects 16, 35

    Common adverse effects:

    Restlessness, irritability, anxiety, insomnia or anorexia, worsening of aggressive behaviour or hostility at the start of treatment

    • Paradoxical psychiatric effects such as rebound, restlessness, irritability, and increased aggression may be observed
    • Somatic effects such as insomnia, decreased appetite, tics, stomach ache, and headache are all common, especially at the beginning of therapy
    • The slower the rate of titration, the less severe the initial side effects
    • Many of these psychiatric and somatic side effects will endure throughout treatment, making drug holidays useful to assess impact of relative risk vs. benefit, and necessitating the regular monitoring of growth

    Discontinuation syndrome:

    Abrupt withdrawal after prolonged use may result in dysphoria, irritability or rebound in symptoms of ADHD, increase in sleep and appetite reported. Consider tapering over several weeks in patients who poorly tolerate discontinuation or have been on medication for longer than 3 months.

    If stimulants are taken in conjunction with an antipsychotic, sudden discontinuation may result in the emergence of extrapyramidal symptoms previously masked by the stimulant.

    Note:

    • Monitor patient for suicidal thoughts/ideation; consider a change in treatment if concerns arise.
  • Methylphenidate bilayer controlled-release tablets (Concerta ®)16,21,24

    Product monograph

    Formulation

    • 18 mg, 27 mg, 36 mg, and 54 mg tablets24

    Dosage

    • Initial: 18 mg QAM PO; may increase by 9–18 mg Q 7 days16
    • Maximum: 72 mg/day16,19
    • Consult product monograph for dose conversion from other methylphenidate formulations16
    • Note: When possible, use the brand name product of this medication as the generic brand version does not have the same bioequivalence and does not work the same2

    Duration of action

    • 12 hours16

    Coverage

    • Partially Covered by ODB

    Cost of 30-day supply of mean dosage*

    • $30–60
    Adverse Effects
    Close

    Adverse Effects 16, 35

    Common adverse effects:

    Restlessness, irritability, anxiety, insomnia or anorexia, worsening of aggressive behaviour or hostility at the start of treatment

    • Paradoxical psychiatric effects such as rebound, restlessness, irritability, and increased aggression may be observed
    • Somatic effects such as insomnia, decreased appetite, tics, stomach ache, and headache are all common, especially at the beginning of therapy
    • The slower the rate of titration, the less severe the initial side effects
    • Many of these psychiatric and somatic side effects will endure throughout treatment, making drug holidays useful to assess impact of relative risk vs. benefit, and necessitating the regular monitoring of growth

    Discontinuation syndrome:

    Abrupt withdrawal after prolonged use may result in dysphoria, irritability or rebound in symptoms of ADHD, increase in sleep and appetite reported. Consider tapering over several weeks in patients who poorly tolerate discontinuation or have been on medication for longer than 3 months.

    If stimulants are taken in conjunction with an antipsychotic, sudden discontinuation may result in the emergence of extrapyramidal symptoms previously masked by the stimulant.

    Note:

    • Monitor patient for suicidal thoughts/ideation; consider a change in treatment if concerns arise.

* Please note that dispensing fees have not been included
Note: reference to brand names does not imply endorsement of any of these products

Second-line treatment options

Offer atomoxetine to adults if:7

  • They cannot tolerate lisdexamfetamine or methylphenidate; or
  • Their symptoms have not responded to separate six-week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses
  • Atomoxetine (Strattera ®)16,25,26

    Product monograph

    Formulation

    • 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg and 100 mg capsules26

    Dosage

    • Initial: 60 mg then 80 mg/day
    • Maintain dose for a minimum of 7-14 days before adjusting
    • Maximum: 100 mg/day 19,27
    • Note: Generic versions of this medication work well2

    Duration of action

    • 24 hours19

    Coverage

    • Partially covered by ODB

    Cost of 30-day supply of mean dosage*

    • $120-150
    Adverse Effects
    Close

    Adverse Effects

    Common adverse effects:

    Rhinitis, upper abdominal pain, nausea, vomiting, decreased appetite, weight loss (seen initially, especially if dose titrated too rapidly but levels off with time), dizziness, headache, fatigue, emotional liability, insomnia (more common in adults), sexual dysfunction.

    Discontinuation syndrome:

    No evidence to date that suggests a drug discontinuation or withdrawal syndrome exists.

    Note:

    • Monitor patient for suicidal thoughts/ideation; consider a change in treatment if concerns arise.

* Please note that dispensing fees have not been included
Note: reference to brand names does not imply endorsement of any of these products

Titration

Titrate starting at the lowest appropriate dose according to the product monograph, the patient’s symptoms and adverse effects until dose optimisation is achieved (i.e. the patient experiences reduced symptoms; a positive behaviour change; or, improvements in education, employment and relationships, while reporting potential tolerable adverse effects).

  • Most patients will notice initial improvement but it may also take a number of months to get the choice of medication and dosage into the range where the patient has the optimum benefit2
  • Progress should be reviewed regularly – initially at one month and then less frequently as the patient stabilizes
  • Review of ADHD symptoms, impairments and side effects should be discussed. The ASRS-V1.1 can also be used as a scale to follow changes in the patient’s executive function. Inquiry as to how patients are managing with their S.M.A.R.T. methods are also important2,7
  • Dose titration must be slower and monitored more carefully in patients with co-morbid conditions, neurodevelopment disorders and medical conditions as outlined in Treatment for patients with comorbid conditions and differential diagnosis

Non-pharmacological treatment options

Non-pharmacological treatment should always be discussed when prescribing medication for ADHD in order to optimize the effects of the patients treatment.2 When available, the following maybe helpful:

  • Consider a structured, supportive psychological intervention focused on ADHD, such as cognitive behavioural therapy (CBT)7
  • Consider offering a print out of the Patient resources section for more information on ADHD coaches, counselling, food and nutrition, healthy lifestyle modifications, vocational advice, financial resources and other tips

For additional support consider consulting the Canadian ADHD Resource Alliance (CADDRA) Guide to ADHD psychoeducation for tips on engaging in pyschosocial treatment with your patient.28

Treatment for patients with comorbid conditions and differential diagnosis

About 75% of adults with ADHD will have at least one other mental health condition (e.g. anxiety, a mood disorder, personality disorder or substance use disorder) or a comorbid neurodevelopmental condition (e.g. autism spectrum disorder or a learning/intellectual disability).7,29 Consultation with a psychiatrist or psychologist may be required for complex cases (see Provider resources).2 The comorbid conditions in this section are common in adults with ADHD, but it is not an exhaustive list.

Talking points

“We will need to treat your other conditions for you to start feeling better. In order to do this, we will address the most important issues first.”

Select comorbid condition to view details

For adults with ADHD experiencing an acute psychotic (e.g. hallucinations, delusions and disorganized thinking)or manic episode (e.g. abnormally upbeat, jumpy or wired, increased activity, energy or agitation, decreased need for sleep):7,30,34

  • Stop stimulant medication for ADHD7
  • Consider resuming or starting new ADHD medication after the episode has been treated2,7

Consider the same medication choices to patients who have ADHD comorbid to an anxiety disorder as offered to patients who have ADHD without a comorbid condition.7

In situations where anxiety is exacerbated by the ADHD, treat the anxiety first.2


Note: anxiety is often secondary to unsupported ADHD2

Patients with co-occurring bipolar disorder and ADHD should be stabilized on a therapeutic dose of a mood-stabilizing medication before treating ADHD with a stimulant.1

All patients should be monitored with regular blood pressure and pulse rate checks.

  • If a patient has significant cardiovascular disease or a family history of sudden cardiac death in young family members, referral to a cardiologist should be undertaken prior to treatment 2

For patients with ADHD and co-occurring depression, consider combining ADHD treatment with an antidepressant.

If a patient has treatment-resistant depression, then the primary concern may be the undiagnosed ADHD. When the ADHD is treated, the continued use of antidepressants may not be required.1,2

In adults with ADHD and an active SUD, the SUD is to be acknowledged and ideally stabilized before starting pharmacotherapy for ADHD:1

  • Treatment with atomoxetine may be recommended as it has limited abuse potential1
  • Lisdexamfetamine is also recommended because of its unique chemical properties that makes it difficult to abuse2

Patients with SUD benefit from additional structure in dispensation and monitoring for their safety:

  • Consider daily observed doses at the pharmacy

Maintenance and monitoring

Guidance for conducting follow-up visits with patients

The recommended time frame after initiating treatment should be at three months, unless clinical indicators warrant the need for an earlier visit. See below on considerations to address during the follow-up visit.

  • Ongoing maintenance of the following is recommended: appetite, weight, sleep, cardiovascular, and wellness, including sexual performance2
  • Revisit the patient’s S.M.A.R.T goal methods for monitoring treatment effect from before treatment onset to assess the patient’s areas of improvement and change2
  • Ask patient if they notice the medication wearing off during the day (avoid adding a top-up medication)
  • Monitor and record the effectiveness of the patient’s medication for ADHD by conducting the ASR S-V1.1 at each visit to monitor for improvement7
  • Encourage the patient to monitor and record the effects associated with their medication, both positive and negative7,31
Review of medication and discontinuation
  • Review ADHD medication at least once a year and discuss with the patient whether medication should be continued7
  • Atomoxetine can be stopped at anytime without tapering2,20,35
  • When tapering is warranted for lisdexamfetamine or methylphenidate, please decide based on patient’s medical history and needs (i.e. if they have prolonged use of a stimulant and/or they are taking another medication in conjunction such as antipsychotics)35
  • Continue to document patient factors to monitor treatment effects at follow-up visits

Resources

Provider resources

Patient resources

* Costs may be associated

References