The 28th European Congress of Psychiatry (EPA) virtual meeting covered key topics and issues in ADHD, such as ADHD in adults, ADHD and psychiatric comorbidities, e-Mental Health technologies, non-pharmacological treatment for ADHD in adults, ADHD and women, and starting an ADHD clinic.
Symposium: Transdiagnostic perspective of ADHD among different mental disorders
ADHD and obesity: dopaminergic signalling as a biological link
Dr Nina Roth Mota (Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands) opened her presentation by highlighting that high comorbidity rates are a hallmark of ADHD and further increase the disease burden, and that ADHD is frequently associated with not only psychiatric disorders, but also somatic conditions such as obesity. Dr Mota explained that the clinical overlap between ADHD and obesity is well documented. She illustrated this by presenting results from a meta-analysis of 42 studies (N=728,136), which showed that the pooled prevalence of obesity was increased by ~70% in adults with ADHD and by ~40% in children with ADHD, compared with controls. She also noted that individuals receiving pharmacotherapy for ADHD were no longer at a higher risk of obesity compared with controls.1
Dr Mota went on to highlight that a recent genome-wide association study (GWAS) showed significant genetic correlations between ADHD and several obesity measures, including body mass index (BMI),2 and that despite the clinical and genetic correlations, the biological mechanisms driving this association are still largely unknown. However, some candidate systems, such as dopaminergic neurotransmission and circadian rhythm, have been suggested. Dr Mota then described that neuroimaging studies have found differences in specific volumes of brain regions associated with ADHD as well as BMI and obesity; specifically, that the volumes of the putamen and nucleus accumbens are reduced in patients with ADHD and are negatively correlated with BMI in the general population.3,4
In the final part of Dr Mota’s presentation, she discussed unpublished results from her study, which seeks to identify the biological mechanisms underpinning the genetic link between ADHD and obesity measures, and to investigate the association of overlapping genes with brain volumes.
Genetic sharing between ADHD and addictions
Dr Maria Soler Artigas (Department of Psychiatry, Mental Health and Addictions, Vall d’Hebron Research Institute, Barcelona, Spain) began her presentation by explaining that when we talk about substance-use disorders (SUDs), we refer to substances such as alcohol, coffee, opioids, stimulants (e.g. cocaine) and cannabis. She went on to state that SUD and ADHD have a complex aetiology, where genetic and environmental factors play a role.5,6 Dr Soler Artigas then explained that the heritability of ADHD is ~76%,7 and for SUD it ranges from 39% to 72%.8
To identify the specific genetic variants associated with SUD and ADHD, several GWAS have been conducted, and Dr Soler Artigas went on to describe key results from three such studies:
- In an ADHD GWAS (N=55,374), the authors identified 12 genetic variants for ADHD, one of which was the FOXP2 gene, which is involved in synapse formation and a neutral mechanism mediating the development of speech and learning.2
- An Alcohol Use Disorders Identification Test (AUDIT) GWAS (N=141,932) described 10 new genetic variants that were identified, including on chromosome 4, which is related to alcohol metabolism.9
- The Lifetime Cannabis Use GWAS (N=184,764) detected 6 genetic variants; the strongest finding was the CADM2 gene, previously associated with substance use and risk taking, on chromosome 3.10
Dr Soler Artigas then discussed whether there was a genetic correlation (i.e. the proportion of variance that two traits share due to genetic causes) between different SUDs and ADHD. A genetic correlation study by Sanchez-Roige and colleagues9 examined whether there was a correlation between alcohol (consumption and problematic use) and smoking and cannabis use. Results showed that there was a correlation between both alcohol consumption and problematic alcohol use and smoking and cannabis use; however, when psychiatric traits were examined, only a correlation between problematic alcohol use, but not consumption of alcohol, was found in patients with ADHD. These results confirmed those of Pasman and colleagues, published in 2018,10 which found a genetic correlation between smoking, alcohol and cannabis use and ADHD. Dr Soler Artigas concluded that there was a common genetic background of substance use across substances, and of substance use and ADHD.
During Dr Soler Artigas’s presentation, she also examined whether there was a causal link between risk factors and outcomes in patients with ADHD and SUD. Results from one of her own studies showed that ADHD (as a risk factor) appeared to have a causal effect on cannabis use (outcome), but when cannabis use was the risk factor, there was no causal effect on ADHD as an outcome.11 Likewise, a study by Treur et al.12 confirmed the causal link between ADHD and cannabis seen by Dr Soler Artigas’s group, and they also noted a link between ADHD and smoking initiation and a trend towards alcohol dependence, but no link between ADHD and alcohol use or coffee consumption; and in the opposite direction, they only found a causal link between smoking initiation and ADHD.
Dr Soler Artigas concluded that there was a common genetic background of substance use across substances and with ADHD, and that there is suggestive evidence of a causal role of ADHD for smoking initiation, cannabis use and alcohol dependence.
Investigating the effects of physical activity on positive and negative affect in the everyday life of patients with ADHD – a mobile health approach
Dr Elena D Koch (Mental mHealth Lab., Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Karlsruhe, Germany) opened her presentation by stating that “mental health outcomes have been found to be positively influenced by physical activity, and physical inactivity has been found to have a negative impact on mental health outcomes”. She went on to highlight that physical activity has been found to be positively associated with affect and well-being in patients with depression, anxiety, bipolar disorder, borderline personality disorder and schizophrenia, as well as in healthy individuals.13 However, she noted that there is a paucity of studies investigating the effects of physical activity in adolescents and adults with ADHD, and that this has rarely been assessed using the ambulatory assessment method (a method of assessment that looks at changes in mood in real time). Dr Koch presented results from a study currently underway, which is investigating the effects of physical activity on positive and negative affect in the everyday life of patients with ADHD.
Dr Nina Roth Mota: “ADHD is frequently associated with not only psychiatric disorders but also somatic conditions such as obesity.”
Industry-sponsored symposium: Could it be ADHD? Missed or misdiagnosis of ADHD
(This symposium was initiated, organised and funded by Takeda)
ADHD and comorbid conditions – different or differential diagnoses?
The first presentation of this symposium, chaired by Dr Duncan Manders (Child and Adolescent Mental Health Service, NHS Lothian, Edinburgh, UK), was given by Dr Peter Mason (Private Practice, Liverpool, UK), who began by looking at the number and type of comorbidities that patients experienced at the time they were first diagnosed with ADHD. He presented results from a Spanish study that showed that at first presentation, 66.2% of adults had ≥1 comorbid psychiatric condition, and that on average there were 2.4 comorbidities per patient.14 Results from this study showed that ~40% of adult patients with ADHD had comorbid SUD, and that rates of comorbid anxiety disorder, affective disorder and personality disorder were high.14
Dr Mason went on to acknowledge that despite the high prevalence of ADHD in general psychiatric patients, many patients with ADHD remain undiagnosed or misdiagnosed for the following reasons15-18:
- There may be a lack of recognition/misunderstanding of ADHD.
- Age-dependent changes in the presentation of symptoms displayed may lead to missed diagnoses.
- Adults with ADHD may adjust their behaviour in order to cope with symptoms.
- Comorbidities can hide or mask ADHD symptoms.
Dr Mason highlighted that because symptoms of ADHD may overlap with other psychiatric disorders, it can be difficult to form a diagnosis18; however, he noted that in his clinical experience, one of the distinctive features of ADHD is that the symptoms are persistent, whereas in depression, bipolar disorder, anxiety and substance misuse, symptoms can be intermittent and, in the case of bipolar disorder, highly episodic.
With regards to treatment, Dr Mason noted that, in his experience, it is important to treat the most severe symptoms first. He also explained that if children with ADHD were treated during childhood, symptoms of anxiety, depression and alcohol misuse were reduced; however, this was not the case in patients with comorbid bipolar disorder or other substance misuse disorders.19 In the final part of his presentation, Dr Mason presented results from a qualitative systematic review of short-term studies, which indicated that if you treat ADHD, patients’ risk of injuries decreases, criminality decreases, and comorbid substance misuse and depressive symptoms are reduced.20
Dr Mason concluded his presentation by summarising the following key points:
- ADHD is comorbid with other psychiatric conditions and will be present in about one-fifth of your psychiatric outpatients, as general adult psychiatrists.
- The symptoms of ADHD overlap with the symptoms of other psychiatric disorders, so ADHD and the comorbidities can often be misdiagnosed or not identified.
ADHD and comorbid mood disorders in adults
Dr Greg Mattingly (Washington University School of Medicine, Midwest Research Group, St. Charles, MO, USA) gave a presentation that covered the following: 1) the overlapping signs and symptoms of mood disorders and ADHD in adults; 2) the importance of recognising ADHD in your clinical practice; and 3) assessment, diagnosis and management of ADHD in adults with comorbid mood disorders. Dr Mattingly began by highlighting that ADHD should be thought of as a journey through a patient’s life, and that it is the physician’s role to help their patients navigate that journey.
Dr Mattingly focused on the shared symptoms, stress diathesis, shared genetics and shared neural connectivity of mood disorders and ADHD.2,18,21 He explained that the shared genetic heritability between major depression and ADHD was highly correlated and highly overlapping, and when individual depressive symptoms with ADHD, such as neuroticism and negative subjective well-being, were examined, similar significance of the overlap between these two conditions was observed.2 He went on to highlight the key results from a landmark study that examined neural connectivity in adults with ADHD, which showed that the more severe a patient’s symptoms and the longer a patient had been untreated, the more disconnected their brain was when it came to functional connectivity.21
In answering the question “Why is it important to recognise ADHD in your clinical practice?”, Dr Mattingly began by emphasising that mortality rates for school-aged children with ADHD were 58% higher than non-ADHD populations, and in adulthood, the mortality rate for ADHD was 4-times that of the general population,22 demonstrating that ADHD has one of the highest mortality rates among psychiatric conditions. Examples of reasons for this high mortality rate include untreated ADHD, suicide, homicide and injury.23 The number of comorbidities also has a significant effect on mortality rates, as demonstrated by Sun et al. (2019),24 who showed that mortality rates for ADHD plus one, two or three other comorbidities were 4-times, 8.5-times and 15-times higher, respectively, than the general population.
Dr Mattingly then sought to answer the question “How do you recognise ADHD in clinical practice?”. Using an example of a patient with depression, he explained that if the patient was not getting better with treatment, it was important to take a step back and ask yourself “What else could it be?” and discuss the following with your patients:
- Their childhood and family history
- Their mood during a preferred task
- What happens to them when they are stressed or frustrated.
Dr Mattingly explained that when evaluating patients for ADHD, it is typical to use multiple stages of assessment.15,25-27 Firstly, he recommended that a screening test should be conducted, for example, the Adult ADHD Self-Report Scale (ASRS) scale (6 items), developed by the World Health Organization, which patients can fill out easily in the waiting room. Secondly, it is important to identify the patient and family needs, i.e. what is their chief complaint and what is driving them to be at this appointment? Thirdly, a clinical evaluation should be conducted during which the patient’s history is evaluated thoroughly (including developmental history and family history) and rating scales are used to help assess general behaviour and psychosocial functioning, ADHD symptomatology and comorbidities. Finally, if there is time, it is recommended that a clinical interview with the patient’s partner/spouse, parent/guardian and teacher is conducted.
The final part of Dr Mattingly’s presentation discussed the benefits of treating ADHD, using results from a study by Shaw et al. (2012),28 which demonstrated benefits in driving and obesity (100% in both groups), self-esteem, social functioning, academic outcomes, drug/addictive outcomes, antisocial outcomes, service use and occupation in treated patients with ADHD compared with untreated patients. Dr Mattingly also provided viewers with an insight into the results from a systematic review and network meta-analysis conducted by Cortese and colleagues (2018), which showed that at 12 weeks, all three major classes of treatment (non-stimulants, methylphenidate and amphetamines) were more effective than placebo in children and adolescents – with amphetamine being the most effective.29 In the adult studies, amphetamine, atomoxetine and methylphenidate were more effective than placebo, with methylphenidate being the most effective.29
Dr Mattingly concluded his presentation with the following take-home message: “You see it every day, it’s a place where you can make a dramatic difference in your patients’ lives, and ADHD is too important to ignore.”
Recognising, diagnosing and managing ADHD in adults with comorbid conditions: ‘top tips’ for clinical practice
In an expert panel Q&A session, Dr Duncan Manders was joined by Dr Lotta B Skoglund (Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden), Professor Allan H Young (King’s College London, London, UK), Dr Peter Mason and Dr Greg Mattingly.
During the Q&A session, it was agreed that the following top tips were key in clinical practice.
Recommendations when diagnosing patients
- The most important thing is to look for a lifelong pattern of symptoms and behaviour; for example, there is evidence to suggest that people with bipolar disorder and comorbid ADHD have a much earlier onset of their affective disorder and more frequent episodes.
- Build a rapport with your patient and let them talk about their experience, and then tease out symptoms that are specific to ADHD.
- As ADHD is persistent, ensure that you collect information about symptoms across the lifespan by taking a developmental history.
- In women and girls, consider the changes that the patient may experience related to their menstrual cycle; for example, 2 weeks before their period date, patients may have excessive ADHD symptoms or become more impulsive, it can be harder to regulate emotions, and impulsivity can get worse.
- Examples of rating scales used by the panel included: the ADHD Rating Scale-IV (ADHD-RS-IV) with adult prompts, the Depression, Anxiety and Stress (DAS) scale for mood disorders, and the Weiss Functional Impairment Rating Scales for patients’ functioning. All rating scales used should be repeated at follow-up appointments to ensure patients’ progress is being adequately monitored.
Recommendations for guidelines and treatment approaches:
- In the UK, National Institute of Health and Care Excellence (NICE) guidelines are available,25 and there are also the European consensus guidelines,15 similar to NICE guidance. Both guidelines recommend stimulants as first-line treatment and then non-stimulants as second-line or, in NICE guidance, as third-line treatments.
- In terms of which stimulants to choose, generally speaking, the panel of experts advised that to improve adherence, a slow-release/long-acting stimulant should be used.
- In treatment-naïve patients diagnosed with ADHD and a comorbid condition, they noted that it is essential that the most severe condition is treated first.
- Before treatment initiation, it is important to develop realistic treatment goals, as treatment optimisation is determined by whether or not the patient achieves those goals.
- Monitor progress by following-up with rating scales to give an indication as to whether treatment has been optimised.
- Examine the areas in the patient’s life that have changed and improved.
- It is imperative that if a patient does not show improvements, comorbidities should always be considered.
Dr Peter Mason: “So when you have patients who you suspect have ADHD, it’s really important that they’re carefully assessed and get a management plan that includes the treatment for their ADHD alongside the comorbid condition.”
Dr Greg Mattingly “They may not be recognised, they may not be diagnosed, but all I’ll say is you’re already an ADHD expert. You’ve seen these patients. You’ve seen these patients do things impulsively. You’ve seen these patients get themselves in trouble. You’ve seen these patients come in to see you because they’re demoralised. You’ve seen these people because quite often they don’t respond as well to an antidepressant as you would expect or like for them to respond.”
Symposium: e-Mental Health across the lifespan
Mindfulness and virtual reality in adults with ADHD: results of a randomised, controlled clinical trial
Professor J Antoni Ramos-Quiroga (Department of Psychiatry, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain) began by explaining the issues with the current treatment options for adults with ADHD, which include partial responses, low adherence and costs of new treatments. For example, people with ADHD may forget to take their medication or may find it hard to find the time to attend psychological therapy every week. Professor Ramos-Quiroga stated that there is a need for treatment with improved adherence, flexibility, availability and sustainability, and proposed that the answer may lie within e-Health. With e-Health, people may receive therapy from their own home, at flexible times and however often they need it. Professor Ramos-Quiroga explained that virtual reality is an engaging form of therapy that has helped patients to deal with phobias as well as demonstrating restorative power in neurological disorders through increased plasticity. Furthermore, virtual reality activates the same brain areas that are activated during normal perception, so that the changes created in neural networks are similar to if patients had learned through their own normal perception.30
The topic of mindfulness was introduced as the suggested type of therapy to be delivered through virtual reality. Mindfulness is a third-wave cognitive behavioural treatment, shown to be effective in multiple medical diseases and mental disorders with long-term neurological effects and maintenance.31,32 It can be used as a single or combined treatment, of approximately 6–10 sessions.33 Professor Ramos-Quiroga presented evidence demonstrating the effectiveness of mindfulness therapy for ADHD, from results of a meta-analysis in which effect sizes for inattention symptoms were –0.66 and for hyperactivity symptoms were –0.56.34
Professor Ramos-Quiroga then presented results from a randomised, controlled trial currently underway to investigate whether mindfulness therapy via virtual reality in adults with ADHD could 1) improve core symptoms, as well as anxiety and depression symptoms; 2) reduce treatment time; and 3) improve adherence.
The ‘Super Brains’ app for ADHD
Professor Sandra Kooij (PsyQ B.V., Psycho-Medical Programs, The Hague, The Netherlands) presented data on a new app for adults with ADHD entitled ‘Super Brains’. She introduced the co-creation experience expert for Super Brains, Rutger den Hollander (CEO, Super Brains). Rutger had wanted to develop an app to help him deal with his ADHD, and so hopefully help the rest of the world with ADHD too. He had experienced great treatment before, but it had only lasted half a year, upon which he reflected that “treatment lasts a short time, but ADHD is lifetime!”.
The Super Brains app was developed over 5 years with the goal of making it easier for people to cope with the chaos and impulsivity of ADHD. Professor Kooij explained the importance of developing the app with someone who had experience of ADHD, to avoid the usual problem of professionals developing treatment based on their own language and experiences, which may not necessarily capture the needs and experiences of the patient. The Super Brains app was designed to make the patient feel that they are the ‘boss’ in their brain and over their treatment, by filling out their own treatment files after consultations, rather than the therapist doing so. Super Brains also uses blended care so that patients meet face-to-face, as well as digitally, with a professional, with the aim of making treatment more effective and shortening waiting lists. Other features of the app include an agenda with reminders and goals, with which you are offered habits to take up and a reward system for developing them. Professor Kooij emphasised that there is a greater need to use reward when treating patients with ADHD to help them achieve their goals.
Rutger den Hollander then explained aspects of the app and how they are aimed at adults with ADHD. For example, the reminders are delivered as questions by a virtual doctor rather than just simple messages. The personalised medicine approach of the app allows patients to test out the habits, with progress made like it is in a game, using points and levels to encourage learning about which habits are best for them. A Bluetooth-linked medicine dispenser is in development, which will be linked to the app to track medication use too. Currently, Super Brains is available for free as a basic version and can be used on a desktop too. A podcast called BrainShare is also in development for professionals to share their knowledge and learn from each other as well as each other’s patients.
Since it started in The Netherlands in April 2020, 800 adult ADHD patients in treatment and 250 professionals are using Super Brains 2–3 times per day, which is more than the 2–3 times per week frequency originally estimated. Out of over 4000 habits in combination used by patients, the app makes it possible to track which habits are most popular. Online group-therapy sessions using video chat are also available within the app, and comprise basic coaching including psychoeducation, skills training and self-esteem, in a schema-focused therapy group. The next steps of the app development are to research its feasibility, research ADHD behaviour over time, and develop wearables, for example a bracelet to link physical measures such as blood pressure and heart rate to the app. Professor Kooij concluded by saying that their hope is for Super Brains to open a new era of blended, more efficient and patient-friendly care, in which we will learn together to improve upon it.
Professor J Antoni Ramos-Quiroga: “Virtual reality mindfulness may be quite effective in treating ADHD.”
Rutger den Hollander: “Treatment lasts a short time, but ADHD is lifetime.”
Should we stimulate prescribing stimulants?
Professor Ramos-Quiroga opened this presentation by stating “Yes, you should prescribe a stimulant when you have a clear diagnosis of ADHD”. ADHD is a chronic disorder that starts in childhood and increases the risk of substance misuse in adulthood.35 Professor Ramos-Quiroga went on to highlight that if a person has ADHD and comorbid SUD, they had a 5-times higher mortality risk than a person without ADHD and SUD; and that this risk increased to 8-times higher in people with ADHD, oppositional defiant disorder or conduct disorder, and SUD.22
Professor Ramos-Quiroga introduced ADHD and substance misuse by presenting results from a study of first-year college students (N=1253; aged 17–20 years), which showed that ~8% were taking stimulants for non-medical use,36 and he advised that their reasons for doing so were to increase cognitive performance and final scholar achievement. Professor Ramos-Quiroga then presented results from a nationally representative household population study of adults aged ≥18 years (N=102,000), which showed that 6.6% used prescription stimulants overall: 4.5% used without misuse, 1.9% misused without use disorders, and 0.2% had use disorders; the most common motivation for stimulant misuse was to stay alert and improve cognitive performance.37
The importance of diagnosis of ADHD by clinical interview and careful differential diagnosis was discussed, with emphasis on the overlap of symptoms between ADHD and other comorbid psychiatric disorders.18 Professor Ramos-Quiroga shared the European Treatment Guidelines for adults with ADHD, which state that psychoeducation should be used first and, if pharmacotherapy is required, the first-line treatment for adults with ADHD is stimulants; long-lasting extended-release formulations are preferred for reasons of adherence to treatment, coverage throughout the day without the need for multiple dosing, and for the protection against abuse and to avoid rebound symptoms. The second-line treatment is atomoxetine, and in those patients at risk of SUD, atomoxetine may be the preferred first-line treatment.38
Professor Ramos-Quiroga went on to discuss the results of a systematic review of double-blind randomised studies by Cortese et al. (2018),29 which showed that stimulants (amphetamines and methylphenidate) were more effective than placebo.29
Professor Ramos-Quiroga explained that several double-blind, randomised efficacy trials have been conducted in patients with ADHD and SUD, and he remarked that it was uncommon to have a clinical trial of a treatment in a disorder plus a comorbidity. One of the most important results he highlighted was that there was a decreased risk of drug misuse in treated patients with ADHD and comorbid SUD.39
Professor Ramos-Quiroga then emphasised the importance of using stimulant drugs not only to control the ADHD symptoms, but also to control the consequences of ADHD; for example, the risk of suicidal behaviour, violence, criminality and traffic accidents.40-43 He stated that “It is important to acknowledge that yes, we know that these drugs can have a risk of misuse in some but if they are used with a correct diagnosis for ADHD, the use of these medications are related to a decrease in very important and severe repercussions of ADHD.”
In the final part of his presentation, Professor Ramos-Quiroga presented the recommendations from the International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder39:
- Consider adequate medical treatment of both ADHD and SUD.
- Always consider a combination of psychotherapy and pharmacotherapy.
- Integrate the ADHD and other psychiatric comorbidity treatment with SUD treatment as soon as possible.
- Psychotherapy, preferentially targeting the combination of ADHD and SUD, should be considered.
- Long-acting methylphenidate, extended-release amphetamines, and atomoxetine are effective in the treatment of comorbid ADHD and SUD, and up-titration to higher dosages may be considered in some patients. The abuse potential is limited with long-acting agents.
- Caution and careful clinical management is needed to prevent abuse and diversion of prescribed stimulants.
Professor Ramos-Quiroga concluded his presentation by highlighting that all patients with SUD should be evaluated for ADHD, and should receive the appropriate treatment after a confirmed diagnosis.
Professor J Antoni Ramos-Quiroga: “It is essential to assess substance use patterns routinely among all ADHD patients to screen and assess for SUD as a psychiatric comorbidity.”
EPA course: Non-pharmacological treatment of adult ADHD
Professor Alexandra Philipsen (Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany) opened the live interactive session by highlighting that ADHD is a common disorder, beginning in childhood but frequently continuing into adulthood, and that over the lifespan ADHD can cause severe negative psychosocial consequences, such as dysfunctional cognition, affective impairment and functional impairment. Therefore, it is important to carry out cognitive restructuring and new skills training with adult patients with ADHD.
Professor Philipsen advised that the NICE and German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) guidelines provide guidance on non-pharmacological treatment,25,44 and she emphasised that although pharmacotherapy is effective in the treatment of ADHD, a multimodal treatment approach should be taken, with psychotherapy complementing pharmacotherapy. During this session, Professor Philipsen specifically focused on psychoeducation, cognitive behavioural therapy (CBT), dialectical behavioural therapy (DBT), mindfulness and complementary non-pharmacological interventions for adults with ADHD.
Professor Philipsen presented the results from the first published study on psychoeducation for adults with ADHD, undertaken by Wiggins and colleagues in 1999,45 which indicated positive effects on disorganisation, inattention and emotional lability, but also potentially negative effects on self-esteem. She then described the results from the 12-week study of psychoeducation and CBT in adults with ADHD by Vidal et al. (2013),46 which showed that both treatments were associated with statistically significant improvements in inattention, hyperactivity, impulsivity and self-esteem. Professor Philipsen noted that the similarities seen in these results could be due to the overlap between the sessions in each of the programmes.
Dr Philipsen then reviewed the data from the 8-week PEGASUS study, which was a psychoeducational programme based on theories from CBT, neuropsychology and cross-disciplinary evidence regarding ADHD,47 the goal of which was to increase the participants’ knowledge of ADHD in order for them to facilitate management of their ADHD in their daily life. Results showed that overall treatment satisfaction was good among both individuals with ADHD and their significant others. As an example programme of CBT, Professor Philipsen went on to describe the modules published by Safren et al. in 2005,48 which comprised three core modules: 1) psychoeducation, planning/organisational skills (three sessions); 2) “distractibility delay” by alarms/timers (three sessions); and 3) cognitive restructuring (three sessions). Additional optional modules also covered procrastination, frustration/anger management, stress reduction, assertiveness training, and communication skills (stay on topic, keep eye contact). With regards to the efficacy of non-pharmacological treatments, Professor Philipsen highlighted that a multimodal treatment approach was more effective than medication alone by presenting key results showing that CBT plus pharmacotherapy was more effective than pharmacotherapy alone in adult ADHD.48,49
Professor Philipsen went on to present results from the 1-year COMPAS study, which was the first 12-month, randomised, controlled, multicentre study to evaluate the effects of a disorder-tailored psychotherapy (a DBT-based group programme) in adult ADHD compared with clinical management (psychiatric counselling without any behavioural management) in combination with methylphenidate treatment or placebo.50 Results showed that group intervention did not outperform individual clinical management with regards to the primary outcome. However, psychological interventions did result in better outcomes during the 1-year period when combined with methylphenidate compared with placebo,51 and from a subjective point of view, the group DBT treatment was more effective than clinical management.52 The COMPAS study demonstrated a maintained improvement in ADHD symptoms, with results indicating that methylphenidate treatment combined with the group programme or individual clinical management continues to provide a benefit even at 1.5-year follow-up,53 thus showing that multimodal treatment programmes really can help adult patients with ADHD.
Professor Philipsen went on to discuss studies examining the effects of mindfulness programmes, highlighting that in the short-term, mindfulness showed improvements compared with treatment as usual,54 but not compared with psychoeducation.55 However, Professor Philipsen did note that there was room for potential bias in results from mindfulness studies; for example, patients cannot be blinded to treatment,56 or the structured-group effect may influence the results.
Professor Philipsen then presented results from a meta-analysis of non-pharmacological treatments, which showed that treatment with CBT improved quality of life, emotional dysregulation, depression and anxiety symptoms, and a significant between-group effect was obtained only on quality of life, emotional dysregulation and self-esteem for DBT and mindfulness-based therapies.57
In the final part of Professor Philipsen’s presentation, she discussed the results from a study that examined the effect of exercise (30 minutes of cycling at moderate intensity) on brain activation in adult patients with ADHD (n=23) compared with healthy controls (n=23).58 Results showed that the patients with ADHD showed increased brain activation during successful inhibition in the exercise compared with the controls, in parietal, temporal and occipital regions. There was also a significant benefit in mean reaction time observed in those patients who had done the exercise compared with controls.59
Next, Dr Natasha Liu-Thwaites (Adult ADHD and ASD Service, Maudsley Hospital, London, UK) provided the audience with an insight into her clinical experience of using non-pharmacological interventions. First, she provided some of her reasons for considering non-pharmacological interventions; for example, non-pharmacological treatment may be considered for patients who experience milder ADHD symptoms, in patients who have contraindications/side effects with pharmacotherapy, as add-on therapy if a patient has residual symptoms of ADHD with pharmacotherapy, or if a patient does not wish to take pharmacotherapy for ADHD. She highlighted the importance of a comprehensive treatment approach, and noted that although pharmacotherapy is usually considered first, psychoeducation, advice on diet and lifestyle, and psychological and behavioural interventions are also important.
Dr Liu-Thwaites went on to describe how, in her clinical practice, at the end of an assessment session she would provide her patients with some basic coping strategies, such as using alarms on watches or phones as reminders, as well as recommendations for resources such as websites, local support groups or blogs/forums, and general advice on subjects such as sleep or driving. Dr Liu-Thwaites highlighted that there is limited evidence to support the efficacy of lifestyle, exercise, diet and physical health; however, she would discuss the importance of a generally healthy lifestyle with her patients and provide recommendations such as the importance of regular exercise, having a healthy diet, abstaining from illicit drugs and smoking, and limiting alcohol and cannabis.
Workshop: Your attention please: let's talk about ADHD!
ADHD in adults: diagnosis and treatment
Professor Ramos-Quiroga began this workshop by describing some of the symptoms and problems that patients with ADHD may experience across the lifespan. For instance, at pre-school, behavioural problems are likely, whereas school-age and adolescent patients may experience academic and legal problems, social maladaptation, poor self-esteem, injuries and SUDs. By adulthood, there is a risk of vocational problems, interpersonal relations, addictions and accidents.35 Professor Ramos-Quiroga then described the increased risk of mortality associated with having ADHD; in particular, he noted that people with ADHD plus specific comorbidities of oppositional defiant disorder or conduct disorder and SUD have an 8-fold increased mortality risk compared with people with ADHD alone.22
Professor Ramos-Quiroga emphasised that it is essential to make the right diagnosis and offer good treatment for ADHD. He went on to note that the NICE guidelines for the diagnosis and management of ADHD are probably the most well-known guidelines.25 He also drew the audience’s attention to the European Consensus Statement on diagnosis and treatment of adult ADHD (2019), which has a section entitled “neurodevelopmental disorders across lifespan”, developed by the European Psychiatric Association (EPA).38
Professor Ramos-Quiroga explained that the main symptoms of adult ADHD are inattention, hyperactivity-impulsivity (with hyperactivity present to a lesser extent in adults compared with children), emotional lability and motivational deficit.60 He went on to describe the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5TM) criteria for ADHD, drawing particular attention to16:
- Criteria A, in which six or more symptoms of inattention or hyperactivity-impulsivity should be present for at least 6 months.
- Criteria B, several symptoms were present prior to age 12 years.
- Criteria C, several symptoms were present in more than two settings.
Professor Ramos-Quiroga went on to list the rating scales he uses in his clinical practice to assist with the diagnosis of ADHD: a semi-structured interview, self-report scales (e.g. the ADHD Rating Scale, the ASRS), observer scales, neuropsychological tests and the Diagnostic Interview for ADHD in Adults (DIVA) 2.0, which is available in many languages (www.divacenter.eu).
In the final section of his presentation, Professor Ramos-Quiroga reiterated for the audience who may have missed his previous presentation entitled “Should we stimulate prescribing stimulants?” that the European Treatment Guidelines for adults with ADHD state that psychoeducation should be used first and, if pharmacotherapy is required, the first-line treatment for adults with ADHD is stimulants; long-lasting extended-release formulations are preferred for reasons of adherence to treatment, coverage throughout the day without the need for multiple dosing, and for the protection against abuse and to avoid rebound symptoms. The second-line treatment is non-stimulants.38
Professor Ramos-Quiroga concluded that ADHD remains an undertreated disorder in adults, with a high cost in terms of mortality. He emphasised the importance of comprehensive clinical assessments and guidelines such as the NICE guidelines for the stepwise management of ADHD.
For whom is the diagnosis and treatment of ADHD useful: for the child, the parents, the psychiatrist or the society?
Throughout his presentation, Professor Bruno Falissard (Psychiatry, Biostatistics, Université Paris-Sud, Paris, France) provided his clinical experience regarding the pros and cons associated with a diagnosis of ADHD and its treatment. He began his presentation by highlighting the positive aspects for the patient of having a diagnosis and treatment, which included: having less symptoms, doing better in school, having less stigma through being a patient rather than just a troublesome student, and being part of a group of people with ADHD meaning that patients no longer felt alone with their problems. The negative aspects included: the side effects of pharmacological treatment and symbolic side effects of taking medicine, such as being labelled as ‘mentally ill’. Professor Falissard then moved on to the pros and cons for the parent; pros included that they may no longer feel like the ‘culprits’ or that their child is ‘rude’ once their child had a diagnosis, there may be less stigma experienced, and the child may start performing better at school. The cons included feeling responsible for their child’s treatment, in that they are deciding the treatment by giving medication to their child and changing them in this way, so there may be feelings of guilt over any long-term effects that the child experiences. For the physician, Professor Falissard presented pros including solving a problem by giving a diagnosis, and feeling heroic for finding an efficient treatment for the patient. The cons included ‘feeling unwell’ in treating only the surface symptoms of a more complex problem, and the responsibility for any long-term effects.
Professor Falissard went on to discuss the wider-scale impact of diagnosing and treating ADHD on society as a whole. He gave the example of sociologist Norber Elias’s idea that society ‘hates impulsivity and the associated lack of responsibility’; and Paul Virilio’s idea that a diagnosed and treated child with ADHD becomes compatible with the ‘Rapid Society’, that is, the child without treatment was too fast, but now with treatment they fit in with the rapid style of life and become efficient. Professor Falissard questioned whether the frantic quest for performance and for people to be effective at work and within society should be the sole focus, especially in young children. Professor Falissard then emphasised the responsibility of psychiatrists to consider the sensitivity of this issue, and whether treating ADHD is about more than just medicine and instead a social issue.
Professor Falissard concluded that in practice, psychiatrists should ask themselves the question “For whom is my diagnosis and my proposal of treatment for ADHD useful?”. He highlighted that the duty of the psychiatrist is to make it clear that the patient comes first and to remember that they are treating children, therefore the treatment must be good for the patient rather than only for society.
How did we start our ADHD clinic and research from scratch?
Dr István Bitter (Department of Psychiatry and Psychotherapy, Semmelweis University Balassa u.6., Budapest, Hungary) gave a presentation aimed at early-career psychiatrists, describing his own journey in the field of ADHD research in Hungary. He explained that he had no formal training in ADHD, and that before 2005 there were no adult ADHD services or ADHD research being carried out in Hungary. After meeting Frank Bymaster in 2001, he was introduced to research into the drug atomoxetine, which is used to treat ADHD. Due to his interest in psychopharmacology, he pursued this interest in atomoxetine, which in turn introduced him to the topic of ADHD.
With his research group, Dr Bitter went on to study the prevalence of adult ADHD in 17 general practices in Hungary (N=3529; aged 18–60 years). The prevalence estimates calculated based on DSM-IV diagnostic criteria were 2.3% in males, 0.91% in females, 2.02% in those aged ≤40 years and 0.70% in those aged >40 years. 61 These results were similar to those of a meta-analysis conducted by Simon et al. in 2009,62 which estimated the pooled prevalence of adult ADHD to be 2.5%. This suggested to Dr Bitter that their adult ADHD prevalence rates were lower than those published in the early 2000s and similar to those widely accepted today.
In 2005, around the same time that research into adult ADHD was picking up momentum, Dr Bitter’s adult ADHD clinic opened in Hungary. The clinic began their own research and started to offer CBT as well as pharmacological therapy.
Dr Bitter then explained that one of the key issues they faced within the clinic was that ADHD was a ‘hidden comorbidity’, which meant that some patients were being treated for other psychiatric disorders but not receiving the diagnosis of ADHD they needed in order to be referred to the ADHD clinic for help.
Dr Bitter concluded that it is always possible to begin research in a new field, and that if motivation and a minimum amount of support is available, high-level clinical services and research can be achieved within a short time for adult ADHD.
The silent minority: females with ADHD
Dr Ozge Kilic (Department of Psychiatry, Koç University Hospital, Istanbul, Turkey) began by introducing the clinical picture of ADHD, including its predominant symptoms of inattention and hyper focus, hyperactivity-impulsivity, emotional dysregulation, excessive mind-wandering and executive function deficits.63-65 She described the prevalence of ADHD in females and males, including the discrepancy in the sex ratio between clinic and community, and that girls with ADHD were more likely to remain unidentified and untreated,66 with clinical referrals in boys typically exceeding those for girls at a ratio range of 3:1 to 16:1.67 Dr Kilic introduced the ‘female protective effect’ theory, which suggests that females may need to reach a higher threshold of genetic and environmental exposures for ADHD to be expressed, potentially accounting for the lower prevalence in females and higher familial transmission rate within in families where females are affected.67
Dr Kilic continued to describe studies suggesting that symptom severity in females may be lower and less overt, so that inattentive girls are more often missed. ADHD symptoms in females may become more obvious later, during periods of social or educational transition, and may be exacerbated by hormonal changes during the menstrual cycle, pregnancy and menopause. Furthermore, ADHD symptoms may be mistakenly attributed to affective disorders, anxiety or low self-esteem. Females may also have better coping strategies than males, which may no longer work when they face salient life challenges.68
Dr Kilic highlighted that a problem with assessments for ADHD is that the evidence is largely compiled from research on male subjects. She went on to explain that medication recommendations do not differ by sex, but that treatment with ADHD medications is generally not advised during pregnancy or breastfeeding.
Dr Kilic then introduced the concept of females with ADHD as a silent minority. They are a minority due to their lower prevalence, and in terms of silence, inattentive symptoms are both more prone and more prevalent in females with ADHD, therefore Dr Kilic concluded that it can be said they are ‘silenced’. Females often receive a diagnosis later in life than males do. Furthermore, their pattern of functioning may differ from that of boys, related to pervasive range of social dysfunction. Childhood hyperactivity in girls is a risk factor for disrupted relationships with peers and the opposite sex, but not parents in adolescence. In addition, girls with hyperactivity are at risk for anxiety.69
Finally, Dr Kilic concluded that the broad discrepancy in the ratio of males to females with diagnosed ADHD may be due to the lack of recognition and/or referral bias in females. Females with ADHD may present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. Dr Kilic hopes that, in the future, a better understanding of gender differences in ADHD is possible, with the hope to improve recognition, referral and ultimately enhance longer-term clinical outcomes and patient well-being.
Professor J Antoni Ramos-Quiroga: “ADHD is an undertreated disorder in adults in Europe with a high cost in terms of mortality.”
Professor Bruno Falissard: “We have first to remember that we are treating children and that our treatment has to be good for them and not only society.”
Dr István Bitter: “The best combination is to run a clinic and a research centre together.”
Dr Ozge Kilic: “In terms of silence, we can say that inattentive symptoms are more prone, more prevalent in females with ADHD, therefore we can say they are more silent.”
Oral communication: Genetics and molecular neurobiology
Culturally equivalent translation into Spanish of the 31-item Adult ADHD Self-Report Scale (ASRS)
Dr Javier Bernácer (Institute for Culture and Society, University of Navarra Mind-Brain Group, Pamplona, Spain) began this session by noting that the ASRS is the recommend rating scale for diagnosis of adults with ADHD. He went on to summarise the history of the 31-item ASRS scale, which was first proposed in 2005 as an 18-item scale comprising two subscales: inattention and hyperactivity.70 In 2010, it was modified to include non-DSM criteria symptoms, and was found to more consistently predict the presence of ADHD.71 A new screening scale was added in 2017 to account for the new DSM-5TM criteria, as well as non-DSM symptoms.72 By 2018, the scale reached 31 items, with new subscales of executive function and emotional dysregulation being added.73
Dr Bernácer described the current situation of the scale with respect to being translated into Spanish. Items 1–18 have been translated into Spanish and validated; however, items 7–18 are Latino American translations, and items 19–31 have no translation. Dr Bernácer emphasised that in line with World Health Organization guidelines, there was a need to have a culturally equivalent translation of the ASRS-31 into Spanish.74,75 The first step of this method is a forward translation, involving directly translating the items into Spanish. The second step is pre-testing and debriefing, by presenting the translated scale to volunteers in a semi-structured interview to see if they understand the items. Afterwards, this debriefing is evaluated by an expert panel, who would review the scale to reach a final version.
Dr Javier Bernácer: “The goal of this research is very easy; to have a culturally equivalent translation into Spanish of the ASRS-31.”
Disclaimer: The views expressed here are the views of the presenting physicians and not those of Takeda
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