Image of Rakesh Jain, MD From TEAM ADHD

Rakesh Jain, MD, MPH

Associate clinical professor, Department of Psychiatry and Behavioral Sciences, University of Texas Medical School, Houston, TX

Dr. Jain is a board-certified psychiatrist with a specialty in depression. He received his medical degree from the University of Calcutta in India and completed his residency and fellowship training at The University of Texas Medical School.

Treating Comorbid Complex ADHD: Part 1

Dr. Rakesh Jain, an adult, child, and adolescent psychiatrist, discusses the treatment of comorbid complex ADHD in this two-part series.

Hello, dear colleagues. It’s a true pleasure to be able to talk to you today. My name is Rakesh Jain and I’m an adult, child, and adolescent psychiatrist and a proud member of Team ADHD. Team ADHD is an educational initiative, with the main goal of creating and deepening discussion of issues of treating, educating about, and managing ADHD.

Today, I’ll address the issue of comorbidities in ADHD. Comorbidities are common in ADHD, with the most common comorbidities being oppositional defiant disorder, conduct disorder, anxiety disorders, major depressive disorder, and substance abuse disorders. As you will undoubtedly note, the pattern of comorbidities changes significantly over the course of a lifetime. In particular, depressive and substance use disorders increase in prevalence in adolescent and adult patients with ADHD.1,2

The American Academy of Pediatrics specifically includes the assessment of comorbidities in their ADHD diagnostic guidelines. Step 1 is to determine the presence of ADHD-specific symptoms; step 2 is to rule out any alternative causes of these symptoms; and step 3 is to evaluate for the presence of any comorbid disorder or disorders.3

Let’s talk about the evolving thinking regarding treatment of ADHD and its comorbidities. The older treatment paradigm was to treat any and all comorbidities first, then wait it out, and only then treat ADHD. The new paradigm suggests treating all disorders at the same time. Emerging evidence strongly supports the wisdom of taking this approach, which is to respect and treat both ADHD and all its comorbidities with equal attention.4,5

Let’s turn our attention to 1 specific comorbidity of ADHD, major depression. Having comorbid complex ADHD confers an unusually high risk of treatment resistance to antidepressants. In fact, the numbers are strikingly high, with more than a two-times higher risk of treatment resistance for patients with ADHD and major depression compared to major depression alone. That’s the bad news. The good news is that treating ADHD may reduce the risk of antidepressant resistance in this population.6

In addition, treating ADHD may reduce the risk of these comorbidities, as well as moderate negative outcomes in patients with comorbid conditions. You will notice that treating ADHD reduces the risk of substance abuse by 31%, the 3-year risk of recurrence of depression by 43%, the risk of substance abuse recurrences by 61%, and the risk of motor vehicle accidents by approximately 40%. All of these data persuade us to consider treating both ADHD and all of its potential comorbidities.7-10

Let’s shift gears and examine another issue. Treatment must address the time outside of school and work, too. As these two 24-hour clocks demonstrate, the lives of children, adolescents, and adults with ADHD are not limited to finite times during the day, but they extend to include the entire day. We clinicians must respect this 24-hour clock that all patients live by, whether these patients have comorbidities or not.4,11

With that, I thank you very much for your attention, and on behalf of Team ADHD, I appreciate you being part of this educational initiative.

REFERENCES: 1.Turgay A, Ansari R. Major depression with ADHD: in children and adolescents. Psychiatry (Edgmont). 2006;3(4)20-32. 2.Kollins SH. ADHD, substance use disorders, and psychostimulant treatment: current literature and treatment guidelines. J Atten Disord. 2008;12(2):115- 125. 3.American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011;128(5):1007-1022. 4.Mattingly GW, Anderson RH. Optimizing outcomes in ADHD treatment: from clinical targets to novel delivery systems. CNS Spectr. 2016;21:45-59. 5.Faraone SV, et al. Attention- deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1:1-23. 6.Chen MH, et al. Attention-deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: a nationwide longitudinal study. Eur Neuropsychopharmacol. 2016;26(11):1760- 1767. 7.Chang Z, et al. Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry. 2014;55(8);878- 885. 8.Chang Z, et al. Medication for attention- deficit/hyperactivity disorder and risk for depression: a nationwide longitudinal cohort study. Biol Psychiatry. 2016;80(12);916-922. 9.Bihlar Muld B, et al. Long-term outcomes of pharmacologically treated versus non- treated adults with ADHD and substance use disorder: a naturalistic study. J Subst Abuse Treat. 2015;51:82-90. 10.Chang Z, et al. Association between medication use for attention-deficit/ hyperactivity disorder and risk of motor vehicle crashes. JAMA Psychiatry. 2017;74(6):597-603. 11.Jain R, et al. Addressing diagnosis and treatment gaps in adults with attention- deficit/hyperactivity disorder. Prim Care Companion CNS Disord. 2017;19(5):17nr02153.

Treating Comorbid Complex ADHD: Part 2

Dr. Rakesh Jain, an adult, child, and adolescent psychiatrist, discusses the treatment of comorbid complex ADHD in this two-part series.

Hello, my name is Rakesh Jain and I’m an adult, child, and adolescent psychiatrist and a member of Team ADHD. In this video, I will discuss the treatment of comorbid complex ADHD.

The excellent and highly instructive Canadian ADHD practice guidelines, CADDRA emphasize several key points. It is generally advisable to treat the most impairing psychiatric disorder first. However, you must also consider the most impairing and treatable disorders. If you have a patient with psychosis, a severe mood disorder, substance use disorders, or any type of bipolar disorder, these should be identified and likely treated prior to ADHD. Also, expression of suicidal or violent thoughts needs to be addressed as a priority. Note that these CADDRA guidelines only recommend severe mood disorders as treatment priorities. For mild or moderate depression, it is advisable to treat ADHD and its comorbidities concurrently.1

CADDRA guidelines also emphasize that ADHD treatment can contribute to reducing comorbid mood- and anxiety-related symptoms and impairment. When possible, medications should be selected that have the least negative effect on cognition, as treatment-related cognitive impairment can aggravate ADHD symptoms. Lastly, it is important to consider drug-drug interactions and adverse events when we’re choosing polypharmacy for patients with ADHD and comorbid psychiatric disorders.1

Now let’s look at the use of stimulants in ADHD. Relative contraindications include use in patients with Tourette’s syndrome, the presence of marked anxiety, bipolar disorder, or risk of substance abuse. It is also important to realize that up to 30% of ADHD patients with comorbid major depression may experience dysphoria when treated with stimulants. Rare, but severe adverse effects that can occur with stimulants include onset of tics, acute anxiety, depression, psychosis, and mania. All of these issues need to be kept in mind when we are considering stimulant medications for treating ADHD.2,3

Nonstimulant medications are not controlled substances and have a lower abuse potential. They do not usually exacerbate underlying tic disorders and can be used in children, and, for that matter adolescents and adults, with significant anxiety and sleep disorders. I might add that, in my opinion, depressive disorders follow the same paradigm as anxiety and sleep disorders when considering the use of nonstimulant medication. Lastly, mild sedative effects may actually be beneficial in patients who have aggression.4

Let’s look at differentiating depression from ADHD. There are overlapping symptoms, such as problems with motivation, problems concentrating, restlessness or irritability. There are also non-overlapping symptoms to keep in mind, including feelings of sadness or hopelessness, feeling tired or slowed down, changes in eating or sleeping behaviors, neurovegetative symptoms, and thoughts of death or suicide. Also, depression tends to be episodic, while the symptoms of ADHD tend to be continuous.1

When treating ADHD and comorbid major depression, I would like to make 4 points. Point 1 is that treatment of ADHD must be considered initially if patients present with mild depression. Two, for severe depression or suicidal risk, I do believe, and I support the CADDRA guidelines, that treatment for depression must be the priority. Three concurrent treatment of ADHD and major depression is often required – use of both an antidepressant and ADHD medications occurs quite commonly.1

Thank you very much for being part of this educational presentation from Team ADHD.

REFERENCES: 1.CADDRA Canadian ADHD Practice Guidelines 2018. https://www.caddra.ca/wp- content/uploads/CADDRA-Guidelines-4th- Edition_-Feb2018.pdf. 2.Masi L, Gignac M. Clin Psychiatry. 2015:1(1):5;1-9. 3.Faraone SV et al. Attention-deficit/hyperactivity Disorder. Nat Rev Dis Primers. 2015;1:1-23.. 4.Daughton JM, et al. Review of ADHD pharmacotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry. 2009 48(3):240-248.


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