Comorbid Conditions in Patients With ADHD

In this podcast, Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry, University of South Carolina School of Medicine, Greenville, discusses the risks associated with comorbid conditions in patients with attention deficit/hyperactivity disorder (ADHD) and strategies for treating them.

Dr Maletic previously spoke at the Psych Congress 2020 psychopharmacology preconference on "ADHD Across the Lifespan: How Neurobiology Informs Our Treatment Choice."

Read the transcript:

What are some of the approaches in treatment of comorbid conditions, and what kind of risks do they constitute? They're associated with multiple risks. The one that would obviously be most concerning has to do with mortality.

If individuals have 2 or more comorbid conditions compared to individuals who have just plain ADHD, their mortality is about 10-fold greater, obviously a very serious association of ADHD, something that cannot be ignored.

In addition to that, presence of comorbidities, as we've mentioned, is associated with endurance of ADHD. These are individuals who do not typically grow out of ADHD, and it is also associated with inadequate response to stimulant agents alone.

What can be done about addressing these comorbidities? It obviously depends on what the comorbidity is. In younger patients, more children and younger adolescents, we tend to see oppositional defiant disorder, conduct disorder, tic disorders, anxiety disorders, as more prominent comorbid conditions.

In individuals who are older adolescents and into young adulthood, we tend to see more mood disorders, so we will see more major depressive disorder. We do see still anxiety disorders. We'll see bipolar disorder, and we'll see increasing rates of substance use disorders.

What we will do depends on what the comorbidity is. If it is anxiety, a consideration is using medicines that have efficacy for anxiety, such as SSRIs and SNRIs.

If there are tics, SSRIs have a mild benefit, provide mild benefit. Alpha-2 agonists also provide mild benefit. One can consider dopamine-2 antagonists and partial agonists, antagonists in very conservative doses in younger patients.

If there's bipolar disorder, mood-stabilizing agents and second-generation atypical antipsychotics are actually indicated, not all of them but few are indicated for child and adolescent-onset of bipolar disorder.

If we're dealing with depression, obviously any agent that is approved antidepressant can be helpful. Some of them like bupropion actually have evidence of efficacy in ADHD, as well as in treatment of depression.

If we're dealing with oppositional defiant and conduct disorder, overall treatment of ADHD can benefit these individuals. It is probably a good idea to consider some psychosocial interventions.

Having child-focused family therapy, helping children develop various strategies for dealing with emotional instability or unstable sense of identity, all of those things can be quite helpful. Both individual and family-oriented interventions can be helpful in that setting.

Vladimir Maletic, MD, MS, is a clinical professor of psychiatry and behavioral science at the University of South Carolina School of Medicine in Greenville, and a consulting associate in the Division of Child and Adolescent Psychiatry, Department of Psychiatry, at Duke University in Durham, North Carolina. Dr. Maletic received his medical degree in 1981 and his master’s degree in neurobiology in 1985, both from the University of Belgrade in Yugoslavia. He went on to complete a residency in psychiatry at the Medical College of Wisconsin in Milwaukee, followed by a residency in child and adolescent psychiatry at Duke University.