Clearing the Clinical Picture: Navigating Adult ADHD Treatment Amid Comorbidities and Misconceptions

The Psych Congress Network sat down with Tim Wilens, MD, chief of the Division of Child and Adolescent Psychiatry at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School, in September for an in-depth Q&A on adult attention-deficit/hyperactivity disorder (ADHD) treatment. Dr Wilens delves into the intricacies of diagnosing and treating ADHD in adults, especially when complicated by comorbidities. Dr Wilens emphasizes the importance of a comprehensive assessment, tackles prevalent misconceptions and stigmas surrounding ADHD, and addresses concerns about stimulant medications.

Answers have been lightly edited for clarity

Psych Congress Network: Can you share your approach to diagnosing and treating ADHD in adults, particularly when it presents with complex comorbidities that complicate the clinical picture? 

Tim Wilens, MD: It's important when you're diagnosing ADHD in adults to get a better understanding of what is currently occurring in the adult's life. Doing a full review of what is happening, what type of symptoms do you have currently? Are there things that may be attributable to psychosocial stressors? Is this a psychiatric comorbidity? For example, is there depression or anxiety or is there substance use? And if so, is that just obfuscating the diagnosis? Is it in addition to the diagnosis or is it mimic?

One of the most important components of the diagnosis of ADHD is systematically understanding the individual's childhood. Is there a track record of this individual having symptoms and impairment in childhood? Is it before the age of 12 through adolescence, through transitional years into adulthood? And if you hear that, their current symptoms, then they could have ADHD. Do they have depression? Do they have anxiety? Do they have substance issues? Do they have other things? There could be psychiatric comorbidity. 

PCN: How do you address the common misconceptions and stigmas associated with ADHD when working with patients and their families and how does this impact treatment strategies? 

Dr Wilens: There are a number of misconceptions and stigma around ADHD. And one of the best antidotes to that is education. A lot of the time that you're spending with families is helping them to understand 'what do we know about ADHD versus what are some of the stigmatizing comments made about it or what are some of the outright myths?'

For example, ADHD is not a real disorder. Wrong. They have a lot of data to show brain-based changes. We have a lot of data that says if you have these symptoms, they tend to track over time with a very predictable course, for example. Another one is that treating ADHD is worse than leaving ADHD untreated. Long-term data now show unequivocally that you have much better outcomes when you treat ADHD than when you don't treat ADHD. In fact, these long-term outcomes show reversal in some of the problematic sequelae that you get with ADHD.

Another common misconception and an area that I have dedicated my life to understanding is the notion that if you give kids stimulant medications, which are controlled substances, that puts them at risk for having a problem with stimulant use disorder like cocaine or methamphetamine or a substance use disorder. Again, totally wrong. A number of studies have looked at that and show in fact, treating ADHD reduces the likelihood of a substance use disorder. 

A series of studies that we've just published over the last few years with my colleagues at the University of Michigan and Texas have shown that, in fact, if you look at who misuses stimulants who are treated with medicines, it's people who have substance issues to begin with or people who are misusing their own medication.

Now, I do want to comment that we do need to monitor the appropriate use of stimulant medications by those people in whom they're prescribed. We have to, at a public health level, ensure that people aren't diverting their medicine and people aren't misusing stimulants who aren't prescribed stimulant medications. So I don't want to undersell the idea that these are controlled substances, but the notion that giving kids medicines that are stimulants could cause substance use is not correct. 

Then the last thing I'd like to say is that a lot of people say you want to treat people but only for a period of time when they're in school and that's it. Then when they get older, you stop it on both accounts. ADHD is there not only when you're in school, it's when you're out there playing or if you're driving or if you're with loved ones or friends and during peer interactions. All of those have shown a reversal in deficits when you treat the ADHD. 

The other thing we've learned is you want to keep these medications onboard when kids are leaving the home, going into independent settings—be it they're starting their own businesses, they're going into the trades, they're going into the military, or they're going to college. That's the time when they're independent and losing the structure of home that it's critical that they stay on their medications and learn to manage [ADHD] and monitor it themselves because that's where their early successes take foot. If you're not treating them, it makes it harder for them.

Timothy Wilens, MD, is chief of the Division of Child and Adolescent Psychiatry and is co-director of the Center for Addiction Medicine at Massachusetts General Hospital. He is the MGH Trustees Chair in Addiction Medicine and a professor of psychiatry at Harvard Medical School. Dr Wilens earned his MD at the University of Michigan Medical School in Ann Arbor and completed his residency in child, adolescent, and adult psychiatry at Mass General. Dr. Wilens’ research interests include the relationship among attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, and substance use disorders; embedded health care models, and the pharmacotherapy of ADHD across the lifespan. Dr Wilens is a distinguished fellow of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and is on the editorial boards or is a scientific reviewer for more than 35 journals.