Adult ADHD: Current state-of-the-art therapy

A basic treatment resulting in significant relief is often psychoeducation. In a next step a psychiatrist will discuss both pharmacological and psychotherapeutic treatment approaches available. During these conversations with their pychiatrists, patients often ask about alternative treatments such as sports, neurofeedback or supplementation of dietary supplements. These are, however, currently discussed controversially and still need further evaluation, an aim that is also pursued by CoCA.

Drug treatment should be initiated if the symptoms in at least one area of life affect the patient. For the selection of the appropriate drug a psychiatrist should discuss the patient’s preferences and physical and mental comorbidities. Before start of treatment, a cardiovascular evaluation should be done. In most countries first-line treatment consists of methylphenidate and atomoxetine.

Methylphenidate (MPH) is considered first-choice due to its high efficacy and good tolerability. The evidence from clinical studies is good. MPH has a duration of 3-6 hours, sustained release preparations of about 8 h. According to the NICE guidance, patients should start with the lowest possible dose of e.g. two times 5 mg milligram up to a maximum recommended dose of 100 mg per day. Typical side effects include headache, restlessness, insomnia and a slight increase of blood pressure and pulse, while tics, arrhythmia or anxiety are rarer side effects. Contraindications are psychotic symptoms, glaucoma, hyperthyroidism and pregnancy.

Atomoxetine, a norepinephrine reuptake inhibitor, is the agent of choice for comorbid present substance-related disorders. The recommended daily dose is 1.2 mg / kg bodyweight; the maximum daily dose is 100 mg. More frequent side effects are headache, loss of appetite, nausea, erectile dysfunction, and mood swings. There may be a moderate increase in heart rate or blood pressure increase.

Apart from drug treatment, psychotherapy is considered by some guidelines as effective treatment too. However, the COMPAS-study showed that clinical management is as effective as psychotherapy. Most published psychotherapeutic interventions for the treatment of ADHD in adulthood are concepts that are based on the cognitive-behavioral therapy.

Cognitive-behavioral methods of treatment for ADHD in adults have been effective in both individual settings as well as in group settings. Group settings offer the advantage of learning and discussing with other affected patients in a guided and moderated setting.

Under the premise that the symptoms of borderline personality disorder and ADHD partly overlap (emotional instability, impulsivity) an ADHD treatment manual was published, which is based on the dialectical-behavioral according to Marsha Linehan. The patients learn skills for dealing with tension and stress, strategies for emotion regulation and mindfulness-based attention.

As attention deficit is a core symptom, some psychotherapists tried to implement so called “mindfulness-based approaches”, e.g. an 8-week mindfulness training with daily exercises that leads to a significant reduction in ADHD core symptoms (attention deficit disorder, hyperactivity and impulsivity).

Patients often ask about alternative treatments such as sports, neurofeedback or supplementation of dietary supplements