Some adults with ADHD may struggle to make and carry out executive decisions, for example, choosing goals and then taking and maintaining actions that consistently move toward those goals. The individual may have difficulty with tasks that involve prioritizing, organizing, and maintaining focus for long periods. Psychotherapies, CBT, and medications such as long-acting stimulants have shown efficacy.
(SUD) Is complex and often involves an individual using substances inappropriately and in spite of the fact that they may be causing the person harm. Using more than one substance, usually referred to as polysubstance use, may occur in adult patients with ADHD. Instruct patients on the risks associated with using alcohol alongside stimulants, as there could be an unintended effect or decreased efficacy of the medication. To prevent this from occurring, providers can prescribe medications with non-stimulant medication such as atomoxetine, viloxazine, or methylphenidate.
When patients have a co-occurring anxiety disorder, a provider may add on an SSRI (selective serotonin reuptake inhibitor) or SNRI (serotonin-norepinephrine reuptake inhibitor). These patients need careful monitoring as serotonin syndrome is possible due to a combination of stimulants and SSRIs.
The most common medication prescribed for patients with adult ADHD is bupropion. Be sure to monitor the patient closely while starting this medication. Antidepressants can increase thoughts of suicide, especially if the patient has had these thoughts previously. And any change to the patient’s mood and/or actions that are new or worse, such as nervousness or restlessness, should always be reported.
The medication prescribed varies from patient to patient, depending on a history of or current substance use disorder, anxiety, depression, pregnancy, side effects, and/or adverse effects. Combination treatment of medication and cognitive-behavioral therapy (CBT) are standard first-line treatments.
Distractibility, impulsivity, hyperactivity, memory, time management, procrastination, and social skills are all assessed in order to diagnose patients with ADHD. Asking the patient how these specific items affect them day-to-day can allow for proper diagnosis and refined treatment plans.
With a robust response, efficacy is seen, but dosing may be adjusted based on activity type (academic or vocational). A partial response may be seen when patients have comorbid diagnoses such as depression, anxiety, or pregnancy. Adjunctive psychotherapy and cognitive behavioral therapy are often used to target the cognitive executive response. A lack of response will require adjustment to the dose of the stimulant. If there is an intolerance to the side effects, a decrease in dosage or a different medication may be required.
Patients must regularly see their prescribing physician to follow up and ensure current dosing is working and side effects, if any, are managed appropriately. Often, the patient will have a limited amount of refills on a specific dose. This limit may be intended to maintain compliance with follow-up appointments. Most patients will undergo cardiovascular studies as stimulants can have adverse side effects if there are underlying issues.
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