Clinical Burden of Adult ADHD

Theresa R. Cerulli, MD: Birgit, what impact does ADHD [attention-deficit/hyperactivity disorder] have on a patient’s quality of life, both work and personal?

Birgit H. Amann, MD: I’m reflecting on some of what my colleagues are saying and I’m thinking about how my adult patients commonly present. We’ll talk more about this shortly, but most commonly, these are patients who nobody has ever diagnosed for ADHD. They’ve come into me, and they’ve been treated with pretty much every antidepressant out there along the way because they’ve had symptoms such as being overwhelmed or anxious or irritable. Maybe it’s that ebb and flow or wax and wane, but it’s misconstrued as more of a mood disorder, even though we know that it could also be a mood disorder, coexistent with ADHD. Most of the time they haven’t been screened at all, as we’ve already referenced. And no consideration has been given to treating them for adult ADHD.

Rakesh Jain, MD, MPH: This is a great point. By definition, if a person has adult ADHD, they have not only a constellation of symptoms but impairment—an in impairment in 2 or more areas of functioning. It could be in their personal life, in their professional life, in their social life. My definition is at least 2 areas, and they can be quite profound. They often can be hidden because over a lifetime, a person has adapted their life to a lower level of functioning to cope with the ADHD symptomatology. This is the clinical burden of ADHD.

And let me directly address our colleagues who are listening. Think about it for a second. The purpose of life—in many ways, the whole direction of life—requires persistence of effort, attention, impulse control. Without those things, it’s very difficult to be successful in the 21st century. Imagine having deficits in that as a 25-year-old, a 40-year-old, a 65-year-old. How is it possible? How is it possible that with those deficits a human life could have flourished to their fullest? It’s not. Often as a rolling rock moves through life, it gathers moss. As we heard, sometimes anxiety disorders, mood disorders, and substance misuse disorders are gathered as corollary disorders. As clinicians, we tend to not always see people who say, “I’m having so much trouble with ADHD.” We tend to see people who have these difficulties in life that are persistent, that are chronic. Other disorders have stepped in. It becomes the responsibility of the clinician to appreciate that this burden could be coming from adult ADHD. They have to go through a process of differential diagnosis to address it and treat it.

David W. Goodman, MD: We have different patient populations. We talk about impairments, but from the clinician’s point of view, I’m concerned for clinicians who look at a physician, an attorney, or an accountant and say, “You can’t possibly have ADHD. You’ve become so successful or academically accomplished.” The issue of impairment shouldn’t be the basis of impairment of an average person. If you have an IQ of 140, you’re functioning at a level of 100. That’s relative impairment, but we don’t see that in the higher-functioning ADHD individuals.

On the reverse side, if you have somebody who has an IQ of 100 or 90 or even 80, and they’re impaired, let’s not assume that this is simply a function of IQ while missing the opportunity to make an ADHD diagnosis. I’m thinking about my high-functioning autistic patients whose IQs range, yet the ADHD is a significant impact in their impairment. We need to be careful to be able to accurately diagnostically appropriate the symptoms to the category that requires the most effective treatment. Greg, you’re nodding your head. What’s your experience?

Greg Mattingly, MD: Let me bring up something for the clinicians out there. Many of you may not be ADHD experts. When I talk to my friends in primary care, they’ll say, “I don’t take care for a lot of patients with ADHD.” I’ll say, “Of course you do.” They’re the patients you already know. They’re just not getting the right treatment at this point. If you’re taking care of people with depression, if you’re taking care of people with anxiety, if you’re taking care of people who lose their temper, if you’re taking care of people who tend to get fired from jobs because they’re forgetful, if you’re taking care of people who forget to take their medicines consistently, I guarantee that you have patients with ADHD.

If we run the numbers, if you’re taking care of people with mood disorders, about 1 of 5 also has ADHD. And ADHD is driving the bus. It’s been what’s causing problems in their life. If you have women with anxiety, maybe 1 of 3 has ADHD. You’ll find that ADHD was there earlier in life. As they’ve gotten older, they’ve developed anxiety on top of it. As David said, I was listening to you talk about the lawyer, the accountant, the person you’re taking care of, the nurse, 1 of your secretaries in your office. Any of those can be pictures and faces of somebody with ADHD.

Theresa R. Cerulli, MD: You all raise excellent points.

Transcript Edited for Clarity