ADHD Comorbidities Complicate Diagnosis of the Disorder

In this video, Andrew J. Cutler, MD, discusses the comorbidities of attention-deficit/hyperactivity disorder (ADHD) and how they can complicate the diagnosis and treatment of the disorder. The comorbidity may appear to be the presenting disorder, but clinicians may overlook ADHD, said Dr. Cutler, who is an associate professor of psychiatry at SUNY Upstate Medical University, Syracuse, New York.

Dr. Cutler also discusses the misconceptions in this topical area and how they impact clinical practice.

Hello, I'm Dr. Andrew Cutler, Clinical Associate Professor of Psychiatry at SUNY Upstate Medical University. Today, I'm interested in talking with you about ADHD and its comorbidities and how these comorbid complications can complicate the diagnosis and treatment.

When we're talking about ADHD, we classically think about the core symptoms of ADHD, which divide into two clusters. We call them the symptoms of inattention and the symptoms of hyperactivity-impulsivity.

Now, the DSM-5, which is our manual for making diagnoses, recognizes 18 symptoms. 9 of them are for the inattention and 9 for hyperactivity-impulsivity, but there's a number of other associated conditions and comorbid conditions that are very common.

As a matter of fact, three-quarters of patients with ADHD have at least one other condition in addition to the ADHD, and a very high percentage have two or more. Now, these comorbidities can change from childhood through adolescence into adulthood.

Most common comorbidities in childhood are behavioral disorders, such as oppositional defiant disorder and conduct disorder, and also anxiety, tic disorders, and various learning disorders. As children age into adolescence and adulthood, depression becomes one of the most common comorbidities, along with anxiety. As many as 40 percent of adults, for instance, will have depression or anxiety. Also, substance abuse begins to become common as well.

The problem with these comorbidities, or the issue, certainly, is that they can really complicate the diagnosis in a couple of ways. One of the ways is that the comorbidity may appear to be the presenting problem, and so that may be recognized -- say, depression or anxiety -- but the ADHD may be missed.

This can lead to inadequate or potentially inappropriate treatment. Another way is that the ADHD might be recognized, but the comorbid condition may not be fully appreciated. The treatment may focus on the core symptoms of ADHD and not adequately address the comorbid conditions.

Very often, we use to have different treatments to treat the ADHD core symptoms and the comorbid conditions. For instance, we might use a stimulant to treat the ADHD, but for anxiety or the oppositional defiant disorder or tic disorder, we might have to do something else.

We might have to add another medication, or we might have to use a different medication for the ADHD other than a stimulant. For instance, with tics, we would probably not want to use a stimulant, if we can help it, so the various non-stimulants might be an option.

If we're talking about adolescents and adults with depression or anxiety, very often, we would use a core medication for the ADHD, such as a stimulant, and we might have to add something, such as an SSRI or perhaps an SNRI to treat the depression or anxiety.

Now, if we were to use a non-stimulant, unfortunately, none of the available non-stimulants works very well for depression. For instance, Strattera, which is atomoxetine, that molecule was originally studied as an antidepressant and failed, so it doesn't adequately address that.

Now, there is a newer medication, a newer non-stimulant, a non-scheduled medication, that was recently FDA approved. It's viloxazine extended release. The brand name is Qelbree. Now, interestingly, the viloxazine molecule was actually approved as an antidepressant in Europe for over 20 years.

It was never formally approved in the United States up until now. We have confidence that this molecule has established antidepressant and potentially anti-anxiety efficacy. Potentially, using this medication, we could treat -- and it's an FDA approved for -- the core symptoms of ADHD, where it demonstrated efficacy in clinical trials.

We could potentially use this medication to kill two birds with one stone, if you will, or to treat the core symptoms of ADHD and perhaps mood or anxiety disturbances as well. It's an exciting time in the development of treatments for ADHD.

I think one of the misconceptions when we're talking about comorbidities is that, classically, the thinking was go after the comorbidity first, and then later treat the ADHD. I think now, what we want to do is consider going after both at the same time.

Maybe look for the most serious thing that's going on. For instance, if there's suicidal ideation or something very serious that needs to be addressed. Otherwise, try to provide balanced treatment for both the ADHD and the comorbid conditions. Thank you very much.

Andrew J. Cutler, MD is the Chief Medical Officer at Neuroscience Education Institute, Carlsbad, California, and a Clinical Associate Professor of Psychiatry at SUNY Upstate Medical University, Syracuse, New York.  He holds a BS in Biology from Haverford College, and obtained his medical degree from the University of Virginia School of Medicine, Charlottesville, Virginia. Dr. Cutler completed his medical internship and residencies in both Internal Medicine and Psychiatry at the University of Virginia Health Sciences Center. He is board certified in Internal Medicine by the American Board of Internal Medicine and in Psychiatry by the American Board of Psychiatry and Neurology.  He is also a Certified Physician Investigator (CPI) by the Association of Clinical Research Professionals (ACRP).

Dr. Cutler has been conducting clinical research since 1993, and has been a Principal Investigator on over 400 clinical trials in a variety of CNS and medical indications. He has authored more than 100 peer-reviewed scientific articles and has presented more than 300 abstracts and posters at scientific meetings around the world.  He is a peer reviewer for several prominent medical journals and has served on several editorial boards.

Dr. Cutler is a member of the American Psychiatric Association (APA), the Florida Psychiatric Society (FPS) and the American Medical Association (AMA).