Pharmacotherapy of attention deficit hyperactivity disorder in adults

Attention deficit hyperactivity disorder (ADHD) in adults is an increasingly recognised condition that is associated with substantial functional impairment. Adults with ADHD present with a developmental derivation of symptoms reminiscent of those in juveniles, most notably inattention and distractibility and, less commonly, hyperactivity and impulsivity. Psychiatric comorbidity with mood, anxiety, substance use and antisocial personality disorders are often found in adults with ADHD. As with children with ADHD, the mainstay of treatment in adults with the disorder is pharmacotherapy. In contrast to the vast amount of data available on the treatment of children with ADHD, there have been only a limited number of medication studies in adults with the disorder. Nine studies (n = 245) of psychostimulants and 16 studies (n = 273) of nonstimulant medications, including antidepressants, antihypertensives and amino acids, have been published. A review of the literature indicates that the majority of controlled investigations assessed the effects of psychostimulants, while nonstimulant agents have generally been studied under open conditions. Stimulant medications tend to result in a dose-related improvement in ADHD symptoms. The limited data suggest that standard dosages of antidepressants are effective. Agents with catecholaminergic activity have efficacy in ADHD, whereas those with predominately serotonergic properties appear not to be effective. The majority of studies suggest that stimulants are the most effective available agents for adults with ADHD, and these drugs remain the treatment of choice. In cases of psychiatric comorbidity, residual symptoms or adverse effects, limited data suggest benefit from combining medications. Cognitive-based psychotherapy used in association with medications may play a role in treating dynamic issues, residual symptomatology and comorbid psychopathology. Future controlled studies applying stringent diagnostic criteria and outcome methodology are necessary to define further the range of pharmacotherapeutic options for adults with ADHD.