Manifestation of Adult Attention-Deficit/Hyperactivity Disorder: Desipramine
One study is available examining the efficacy of desipramine in the treatment of adult ADHD. The six-week, double-blind, placebo-controlled study assessed the differences in the reduction of ADHD symptoms in adults receiving desipramine or placebo. The research suggests that 68% of subjects receiving desipramine responded to treatment, compared with none of the subjects who received placebo.
As with the stimulant medications, numerous studies have reported an association between the use of desipramine and the risk of cardiovascular effects. Wilens et al. found that desipramine induced statistically significant changes in blood pressure among adults with ADHD. Stimulants and bupro-pion had the same effect.
In addition to the Taylor and Russo study, which had compared modafinil with dextroamphetamine and placebo, one other study has evaluated modafinil in the treatment of adult ADHD. Turner et al. examined the effects of modafinil on cognitive effects such as short-term memory, visual memory, and spatial planning. Although improvements for each of these measures were reported, it is difficult to compare the findings with studies of other medications in which measures of this type have not been used.
Summary of Other Medications
Among the nonstimulant drugs used for adult ADHD with-out specific FDA approval, bupropion and desipramine appear most often in the literature. Several additional drugs have been studied from time to time, but the results are not conclusive; most of the studies have been small and employ a less rigorous open-label design. Some of these medications include canadian venlafaxine (Wyeth), phenylalanine, and levodopa (e.g., Larodopa, Roche).
Nonpharmacological Treatment Options
Educational and behavioral interventions should be used in conjunction with medication treatment. Cognitive behavioral therapy is effective in decreasing the significant social impact of ADHD. Behavioral treatment options include family therapy, organizational skills training, social skills training, and individual psychotherapy. Psychological treatment is recommended for coexisting mental health conditions, such as depression and anxiety. Some evidence of success exists for other interventions such as biofeedback and vitamins.
Risk of Medication Abuse
Providers should use caution when prescribing stimulants to patients with coexisting psychiatric and psychosocial conditions. Long-term marijuana or alcohol abusers may also report inattention and poor concentration, which raise the possibility of ADHD. Substance abuse often coexists with ADHD and can complicate ADHD diagnosis. Approximately 7% to 25% of individuals receiving treatment for substance abuse also have ADHD.
Oral methylphenidate does not produce a “high,” because it arrives at the brain slowly; however, injecting liquid methylphenidate or snorting crushed tablets or the contents of a caplet can cause a high similar to that of cocaine. buy antibiotics canada
If there are concerns about substance abuse, stimulant drug therapy should be avoided. Because atomoxetine is not a stimulant, it carries a negligible risk of abuse and diversion. Thus, it may be a good treatment choice for patients who are at risk for substance abuse or who do not wish to take a controlled substance. In addition, the nonstimulant medications reviewed here do not carry the risk of abuse of stimulant medications. These medications may be beneficial if they can also treat existing comorbid psychiatric conditions.
If left untreated, adult ADHD is associated with exorbitant medical expenditures relating to symptoms and comorbidities. Stimulants are considered first-line therapy for ADHD in children and adolescents, but large, rigorous, randomized controlled trials are needed to better understand the effects of these drugs in treating adult ADHD.
The first of such studies, published by Spencer et al., should serve as a model for additional studies to help clinicians appreciate the benefits and risks associated with each of these drugs in adult ADHD. The two large phase 3 randomized, controlled trials and the open-label continuation study of atomoxetine represent the largest body of evidence supporting the use of any medication for the treatment of adult ADHD. These studies were conducted because the manufacturer sought approval of atomoxetine specifically for adults with ADHD.
Because most of the stimulant medications and other drugs used in the treatment of adult ADHD are available as generic versions, it is unlikely that studies of this magnitude will be conducted in adult populations. In addition, long-term studies examining the impact of ADHD agents in adults do not exist.
Comparing existing studies, which use different measures of outcomes, presents inherent challenges. Most of the measurement tools for ADHD are based on subjective patient-reported outcomes, and several different instruments were used in the studies reviewed here, including the CGI Scale, the ADHD Rating Scale, and the Conners Scale. Standardization of measurement instruments in future clinical research will help practitioners evaluate studies in the absence of comparative trials.