Comorbidities in Patients with ADHD

Theresa R. Cerulli, MD: We started to talk earlier about comorbidities. Let’s dig in a little more. How many patients with ADHD [attention-deficit/hyperactivity disorder] have coexisting comorbidities? What are some best practices for diagnosing and treating such patients in primary care and in psychiatry?

Andrew Cutler, MD: As far as how common it is, the majority of patients with ADHD have comorbidities. This is very important because we talked about educating our colleagues and how to look for these things. Statistics show that up to two-thirds of kids will have a comorbidity. It goes up in adulthood. Perhaps 80% to 90% of adults have comorbidities. We need to teach primary care and other providers that ADHD is predominantly a comorbid disorder. If you diagnose ADHD, you need to look for those comorbidities, and vice versa. If you see 1 of these common comorbidities and it’s not responding well, you need to think about ADHD.

Birgit Amann, MD, PLLC: Primary care providers are mandated to do this as part of their visit. When I go to any of my doctors, I’m doing a PHQ-9 [Patient Health Questionnaire–9] prior to seeing who I’m there to have an appointment with. By doing that, they’re looking at depression. Some of them may have other rating scales that they throw in. Hopefully they do more for ADHD.

Andrew Cutler, MD: I learned from our friend Greg Mattingly to do certain screeners with every new evaluation. I do PHQ-9 for depression, I do the RMS [Rapid Mood Screener] to look for bipolar disorder, I do the GAD-7 [General Anxiety Disorder–7] to look at anxiety, and I’ll do an ADHD-RS [rating scale] or the adult ADHD screener.

Birgit Amann, MD, PLLC: Right. As you said earlier, Theresa, that’s so important, not just looking for 1 or the other but all of it. We do that too. Our new patients have a whole battery of screeners, and we see them again within a week to review all those and go from there.

Theresa Cerulli, MD: It sounds as if you’ve all read the updated guidelines from the American Academy of Pediatrics and from the SDBP, the Society for Developmental Behavioral Pediatrics. They’ve weighed in to update their guidelines within the last couple of years—both societies—to say that the comorbidities are important. You have to not only diagnose and treat the ADHD and the comorbidity simultaneously, not 1 before the other. That’s important, so they’ve made these action items in both the diagnostic and treatment guidelines for ADHD. That’s really important. It sounds as if everybody in this group is on top of that. In the past, the thought was that if you treat the ADHD, then the comorbidity will get better on its own. It may, but it may not. Most important, if you don’t even screen for the comorbidity, you can’t know it’s there. For starters, in the beginning when you’re diagnosing ADHD, you also should be looking for those comorbidities. That’s the standard of care now.

Michael Feld, MD: A lot of people don’t look for substance abuse hard enough or know how to look for it.

Andrew Cutler, MD: Yes.

Michael Feld, MD: I always try to look for it. Also, when do you figure out whether there’s a learning disability involved? We know that the comorbidities with learning disability is significant and can impact ADHD functioning, even if they’re on medication. I’ve been realizing clinically, over the last several years, we look for anxiety disorders, but I don’t think trauma is pushed consistently enough.

Andrew Cutler, MD: Yes.

Theresa Cerulli, MD: Yes.

Michael Feld, MD: Because there is so much PTSD, not just from a sexual assault but from so many forms of trauma that are truly affecting people. We also have to look for sleep issues.

Andrew Cutler, MD: Yes, 100%.

Transcript edited for clarity