Functional Impairments Associated With ADHD in Adulthood and the Impact of Pharmacological Treatment.

OBJECTIVE: Among untreated adults, functional impairments associated with ADHD are widespread and cumulative, and can include social, educational, and professional impairments, increased risk of accidents and mortality, and reduced quality of life. Here, we review the most prominent functional impairments in adults with ADHD and summarize evidence describing the potential role of medication in improving outcomes. METHOD: Articles related to the search terms "ADHD," "adult," and functional impairments were identified through Google Scholar and PubMed and selected for inclusion based on four criteria: strength of evidence, relevance to current challenges in adult ADHD, impact on the field, and recency of the results. RESULTS: We identified 179 papers to support the conclusions on the relationship between ADHD and functional impairments, and the impact of pharmacological therapy on functional impairments. CONCLUSION: This narrative review provides evidence that pharmacological treatment can be effective in minimizing not only the symptoms of ADHD, but its functional consequences as well.

Systematic Review: Nonmedical Use of Prescription Stimulants: Risk Factors, Outcomes, and Risk Reduction Strategies.

OBJECTIVE: To review all literature on the nonmedical use (NMU) and diversion of prescription stimulants to better understand the characteristics, risk factors, and outcomes of NMU and to review risk-reduction strategies. METHOD: We systematically searched PubMed, PsycINFO, and SCOPUS from inception to May 2018 for studies containing empirical data about NMU and diversion of prescription stimulants. Additional references identified by the authors were also assessed for inclusion. RESULTS: A total of 111 studies met inclusion criteria. NMU and diversion of stimulants are highly prevalent; self-reported rates among population samples range from 2.1% to 58.7% and from 0.7% to 80.0%, respectively. A variety of terms are used to describe NMU, and most studies have examined college students. Although most NMU is oral, non-oral NMU also occurs. The majority of NMU is associated with no, or minor, medical effects; however, adverse medical outcomes, including death, occur in some individuals, particularly when administered by non-oral routes. Although academic and occupational performance enhancement are the most commonly cited motivations, there is little evidence that academic performance is improved by NMU in individuals without attention-deficit/hyperactivity disorder. CONCLUSION: NMU of stimulants is a significant public health problem, especially in college students, but variations in the terms used to describe NMU and inconsistencies in the available data limit a better understanding of this problem. Further research is needed to develop methods to detect NMU, identify individuals at greatest risk, study routes of administration, and devise educational and other interventions to help reduce occurrence of NMU. Colleges should consider including NMU in academic integrity policies.

The Adult ADHD Quality Measures Initiative.

Objective: Quality measures (QMs; also known as Quality Indicators) quantify health care processes, outcomes, patient perceptions, and organizational structure and/or systems that are relevant to the provision of high-quality health care. We describe the first phase of a project that has as its ultimate goal the creation and validation of QMs for tracking the screening, diagnosis, treatment, and clinical follow-up of adults with ADHD. This will fill an important gap in the field of Adult ADHD because QMs for adult ADHD do not exist. Method: We followed the guidelines of the U.S. Agency for Healthcare Research and Quality (AHRQ) for the development of QMs. These guidelines call for two phases: (1) Identify Candidate QMs and (2) Assess Candidate QMs. This article describes the results of our Phase 1 activities. To generate QMs for adult ADHD, we took the following steps: (a) searched the clinical/research literature for adult ADHD QMs; (b) convened a multidisciplinary panel comprising clinical and research experts and had them brainstorm potential QMs in the areas of screening, diagnosis, treatment, follow-up, care coordination, and patient experience; (c) compared these QMs with existing guidelines for adult ADHD to see if any potential QMs had been missed, this led to a draft list of 46 QMs; (d) had 28 ADHD experts rate the importance, reliability, validity, feasibility, and usability of the QMs. Results: The literature review found several QMs for ADHD in youth but none for ADHD in adults. The brainstorming session generated 52 QMs. The survey showed that all of these QMs were highly rated but that there was sufficient variability in ratings to prioritize some QMs over others. Conclusion: Based on these results, we prioritized QMs to carry forward into the next phase of the project. This work fills an important gap for the clinical care of adult patients with ADHD and helps to set a precedent for mental health, which has lagged behind other areas of medicine in developing QMs.

Atomoxetine monotherapy compared with combination therapy for the treatment of ADHD: a retrospective chart review study.

OBJECTIVE: To analyze Clinical Global Impression-Severity (CGI-S) in ADHD patients treated with atomoxetine (ATX) monotherapy versus ATX combination therapy with another ADHD-indicated medication. METHODS: This was a 2-site retrospective observational chart review study of child and adult ADHD patients, not necessarily treatment naïve, but treated ≥50 days post baseline with an endpoint assessment. To adjust for measured confounders, monotherapy (n = 77) versus combination (n = 108) cohort comparisons were performed using propensity score stratification and adjusted ANCOVA. RESULTS: There were no significant baseline cohort differences after propensity stratification. CGI-S scores after a mean 264 days of treatment were not statistically significantly different between cohorts, with no cohort differences observed in any assessed symptom subcategory. The cohorts were similar in discontinuation due to any reason, adverse event, and lack of efficacy. CONCLUSION: ATX combination therapy showed no evidence of additional benefit over ATX monotherapy in the treatment of ADHD in a community-based setting.

Atomoxetine treatment in adults with attention-deficit/hyperactivity disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a CNS disorder that has its onset in childhood, but often persists into adulthood. There is growing recognition that adult ADHD can result in multiple negative consequences for individuals. ADHD is also often associated with a number of comorbid psychiatric disorders. Atomoxetine (ATX), a nonstimulant, selective noradrenergic reuptake inhibitor, was approved in the United States in 2002 for the treatment of ADHD in children and adolescents, as well as adults. We review here the safety and efficacy of ATX in adults with ADHD, including data in special populations, functional outcomes, as well as provider and patient real-world perceptions. METHODS: We searched the databases Embase, MEDLINE and PsycINFO using the terms 'ADHD' and 'adult' and 'ATX' capturing publications from January 1, 1998, to March 27, 2014. Only publications in English were considered. RESULTS: ATX demonstrated significantly greater improvement than placebo (PBO) on the Conners Adult ADHD Rating Scale-Investigator rated:Screening Version (CAARS-Inv:SV) in all trials (N = 6; total score difference ranged from -3.5 to -5.5). For long-term trials using the CAARS-Inv:SV, ATX demonstrated significantly greater improvement than PBO in three of four trials (total score differences ranged from -0.1 to -6.0). In short-term studies, ATX showed significantly greater improvement than PBO on the Adult ADHD Quality-of-Life scale total score in three of three studies, but results were mixed on the Sheehan Disability Scale. Three studies of ATX have reported statistically significant improvement (compared with PBO) on the Behavior Rating Inventory of Executive Function-Adult Version Self Report scale. The most common adverse events (occurring in ≥ 10% of patients taking ATX) were nausea, dry mouth, decreased appetite, insomnia and fatigue. CONCLUSIONS: ATX is an important treatment option for the right patient. ATX can provide long-term, consistent symptom relief and functional improvement for adults with ADHD.