Despite increasing recognition and diagnosis of ADHD in childhood, many people still fall through the cracks, especially those with the inattentive subtype, says Dr Pansy Lai, a mental health GP at Sydney’s Mindsight Clinic.
There’s sometimes a tendency to dismiss adults who come in saying they might have ADHD due to a perception they are jumping on a bandwagon or just want psychostimulants, but Dr Lai says these cases are the exception rather than the rule.
“Patients present because they experience significantly impairing symptoms that affect their functioning— causing real distress to their mental health, physical health and quality of life,” Dr Lai says.
In fact, ADHD often goes undetected and undiagnosed in adults. As a result, many adults with ADHD have spent years wondering what’s wrong.
“They come to us now because of a genuine desire to live a better life.”
So, what can GPs do to help make that a reality?
Take a developmental history, with a particular focus on their education.
This is crucial to determine a baseline, set realistic goals, and understand a person’s strengths, Dr Lai says. “And it provides that really important retrospective confirmation of childhood symptoms as required by the PBS authority.”
It’s important to assess how symptoms are impacting their function. For example, are difficulties with concentration, working memory or task initiation or completion causing problems at work? Are racing thoughts causing mental distress? Is social impulsivity affecting their relationships?
The Adult ADHD Self-report Scale is a helpful screening tool, she says. “It’s not diagnostic, but it’s very realistic and practical. They can do it in your rooms or take it home and bring it back.”
Comorbid conditions are common in adults with ADHD.
“The later detection and treatment, the more patients accumulate comorbid psychiatric and physical illnesses, and they often achieve poorer vocational, educational and relationship outcomes,” Dr Lai says.
Substance misuse disorder is also common. “Many people with ADHD self-medicate,” she says. “Cannabis or alcohol calms them down.”
“It’s important to explain that we understand why they are self-medicating, but that these drugs interact with psychostimulants. If they hope to start those, they need to be clean from these substances first.”
Eating disorders are also common and may be exacerbated by psychostimulants, so need to be managed prior to considering these medications, Dr Lai says.
Other differential and concurrent diagnoses include depression, anxiety, personality disorders, autism spectrum disorder, OCD and complex PTSD.
Dr Lai recommends completing a medical assessment and medical history before referring to a psychiatrist, and says it’s particularly important to assess cardiac risk.
Recent research found a 4% increased risk of cardiovascular disease for every year of cumulative psychostimulant medication use.
This increased risk is for hypertension and arterial disease, not for arrhythmias, heart failure, ischemic heart disease or thromboembolic issues, Dr Lai says.
“The increased risk stabilised after the first several years of medication use and stabilisation persisted over the follow up period.”
“As with any long-term medication, we want to weigh up benefits and risks. Our role is to manage the cardiac risk factors well and review blood pressure regularly.”
Dr Lai recommends starting antihypertensives if necessary and doing baseline bloods and an ECG, especially if there is a family history of heart disease.
She suggests referring for a cardiac assessment if the patient has any cardiac symptoms, history or examination findings.
Appetite suppression is the most common side effect of psychostimulant medication. Dr Lai recommends encouraging patients to eat before taking their medication and regularly throughout the day. Phone notifications can be a helpful reminder to eat.
Uncommon side effects include insomnia, palpitations, anxiety, jaw clenching, and hyperfocus, but many of these may improve with regular food intake. “Eating helps them metabolise properly,” she says. “And if someone’s not eating, they can become irritable, binge at the end of the day, or be unable to sleep.”
Reducing caffeine intake can also help, along with increasing the dose slowly, Dr Lai says.
Medication alone is often not enough to sufficiently improve a person’s mental, physical, emotional and relational wellbeing, Dr Lai says. GPs can provide advice on diet, sleep and exercise and refer people for psychological care.
Skills training and psychological strategies can provide further benefits apart from and in addition to psychostimulant medication, she says.
Examples include psychoeducation and training in mindfulness, emotional regulation, and practical and interpersonal skills. This may be provided by ADHD coaches, counsellors, psychologists, and GPs who are trained in Focussed Psychological Strategies.
“Because patients are so motivated to improve their lives, they really want to work on their skills,” Dr Lai says. “It’s very rewarding to give them that support.”
To hear more about how to assess and manage adult ADHD, plus lots more myth-busting, register here for Healthed’s upcoming webcast on Tuesday 20 February, 7pm AEDT.
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