Category: ADHD

Non-stimulant Treatment Options for Adult Attention Deficit Hyperactivity Disorder (ADHD)

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The estimated prevalence of adult ADHD in the United States is often cited at 4.4%, referencing a 2021 report on the results of the National Comorbidity Survey [1]. Many studies have documented the impact of untreated adult ADHD on morbidity and mortality. Adult ADHD is also associated with an increased risk for anxiety disorders, bipolar disorder, major depression, substance use disorders, and intermittent explosive disorder.

Our PCL program has received numerous calls regarding the treatment of adult ADHD. Frequently, the questions surround the use of non-stimulant medications. Additionally, there are patients who would prefer to try non-pharmacologic interventions before considering augmentation with a medication. 

Cognitive Behavioral Therapy (CBT) has shown efficacy for adult ADHD in multiple research trials. CBT has not only been shown to be effective for core ADHD symptoms, but several adult studies have also noted a benefit for CBT in certain quality of life measures. Many participants note that CBT can be a game changer for procrastination, for example. CBT for ADHD also helps patients challenge their negative self-beliefs, which can improve co-morbid mood and anxiety symptoms.

Atomoxetine is a norepinephrine reuptake inhibitor that is FDA-approved for adult ADHD. This medication is not a stimulant and has almost no abuse potential. Both atomoxetine and stimulants are more effective than placebo for adult ADHD.  Most algorithms refer to atomoxetine as a 2nd-line medication intervention (with stimulants being 1st-line). However, there are no blinded, head-to-head trials comparing these two classes. 

Atomoxetine is metabolized by cytochrome p450 2D6 and thus there are potential drug interactions. It also has a Black Box Warning for suicidality in certain patient populations.  Atomoxetine can trigger mania or hypomania, which is especially notable given the higher rate of bipolar disorder in adults with ADHD. For a complete list of atomoxetine’s potential side effects, please refer to medication reference material (MicroMedex, etc.).

If you would like more information on treatment options for adult ADHD, please call the Psychiatry Consultation Line (877-WA-PSYCH/877-927-7924) and one of our psychiatrists would be happy to review the data with you and how it applies to your patient. Similarly, if you have questions regarding treatment of ADHD in perinatal patients, please contact our Perinatal Psychiatry Consultation Line at 877-725-4666.

[1] Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB, Walters EE, Zaslavsky AM. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006 Apr;163(4):716-23. doi: 10.1176/ajp.2006.163.4.716. PMID: 16585449; PMCID: PMC2859678.

Author

Ryan Kimmel, MD

Dr. Kimmel is the Chief of Psychiatry at both UWMC campuses, Montlake and Northwest, and Director of Psychiatric Consultation and Telepsychiatry Programs, including the Psychiatry Consultation Line. His clinical focus is on working with patients who are hospitalized with simultaneous psychiatric and medical issues. Academically, Dr. Kimmel most often teaches psychiatry trainees about psychopharmacology for refractory mood, anxiety, and psychotic disorders.

Related Resources

UW Psychiatry and Addictions Case Conference (PACC)

Cognitive Behavioral Strategies for ADHD, presented by Katherine Walukevich-Dienst, PhD

ADHD Update: Clinical and Diagnostic Issues, presented by Mark Stein, PhD, ABPP

Treating ADHD in the Setting of Bipolar Disorder, presented by Kimiko “Koko” Urata, MD

The UW PACC is a free, weekly teleconference connecting community providers from across Washington with UW Medicine psychiatrists, psychologists, and addictions experts. Sessions include both an educational presentation and (de-identified) clinical case presentations allowing providers an opportunity to receive feedback and recommendations from interdisciplinary attendees. CME is available for free or for a small fee. Visit the PACC website for more information.

Non-stimulants for adult ADHD

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While the data on the efficacy of stimulants in adult ADHD is robust, we have had numerous calls to the PCL program from providers seeking information on medications that have a lower misuse and abuse potential.

Atomoxetine has an FDA indication for adult ADHD. Atomoxetine is often thought of as the first-line medication for adult ADHD in patients with a history of substance use disorder. There are several studies that demonstrate an improvement in quality of life ratings, for example, with longer term use in patients with ADHD. Atomoxetine selectively inhibits norepinephrine reuptake and medications with this mechanism of action convey a risk of psychosis and mania, especially in patients with a personal or family history of bipolar disorder or psychosis. Like many medications with an antidepressant-like mechanism of action, atomoxetine has a black box warning for increased suicidality in children, adolescents and young adults.

Bupropion does not have an FDA indication for ADHD, though there are meta-analyses that suggest it has some utility. Bupropion is FDA-approved for major depressive disorder. The symptom of poor concentration can be magnified when patients with ADHD experience a major depressive episode. For some of these patients, bupropion might help both disorders. Providers should keep in mind, however, that bupropion is not effective for anxiety disorders. Moreover, some patients with anxiety disorders find that bupropion worsens their anxiety symptoms. Like atomoxetine, bupropion has a black box warning for suicidality in patients under the age of 25. Bupropion can also cause mania and psychosis, particularly in patients with a personal or family history of bipolar disorder or psychosis. Bupropion can increase the risk of seizure and is contraindicated in patients with eating disorders.

While guanfacine has an FDA indication for pediatric ADHD, it does not have an FDA indication for adult ADHD. Some authors are pessimistic about its utility in adult ADHD. Overall, the data is mixed and there have only been a few controlled studies, though research is actively being done and the efficacy (or lack thereof) of guanfacine in adult ADHD may be more clearly articulated in the next few years. Guanfacine is an alpha-2 agonist that is used to treat hypertension and thus it has a unique side effect profile compared to atomoxetine or bupropion.

If you are considering using any of the medications discussed above, please first review your own reference material for full details on side effects, dosing, adjustment in the setting of renal or hepatic impairment, cautions/contraindications, monitoring requirements, and safety in pregnancy and lactation. We most often use Micromedex, UpToDate, or Epocrates. Additionally, there are free databases available to Washington State providers at https://heal-wa.org/professions/. You can also call the Psychiatry Consultation Line (877-927-7924) for clinical advice on using these medications in the treatment of adult ADHD as well as assessment, treatment decisions and monitoring of mental health conditions in general. Even in complicated clinical scenarios, discussing a patient’s care with a colleague can lead to a path forward.

Author
Ryan Kimmel, MD
Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Chief of Psychiatry, University of Washington Medical Center
Medical Director, Psychiatry Consultation Line

Learn More
Cognitive Behavioral Therapy (CBT) for adult ADHD: does ADHD need therapy (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Kristen Lindgren, PhD, ABPP
The objectives of this presentation are to 1) review diagnostic criteria for ADHD, 2) understand the Role of CBT in the Treatment of adult ADHD, and 3) describe how combined medication and CBT can benefit adults with ADHD

Treating ADHD in SUD patients: how do I treat patients with ADHD and SUDs without making them addicted to stimulants? (pdf)
UW Psychiatry and Addictions Case Conference series (UW PACC)*
Presenter: Robert Sise, MD, MBA, MPH
The objectives of this presentation are to 1) review general considerations in diagnosis of adult ADHD, 2) explore multimodal treatment for adult ADHD with co-occurring SUDs, 3) discuss risks and benefits of pharmacotherapy, and 4) explore how ADHD treatment should be coordinated with SUDs treatment.

*The UW Psychiatry and Addictions Case Conference series (UW PACC) is a free, weekly teleconference that connects community providers with UW Medicine psychiatrists and addictions experts. Sessions include both an educational presentation on an addictions or psychiatry topic and case presentations where providers who participate receive feedback and recommendations for their patients.