Treating Patients With Adult ADHD During the Ongoing COVID-19 Pandemic

There are many aspects of Adult ADHD that need greater attention during the ongoing COVID-19 pandemic, including feelings of isolation and the need for proper nutrition, says ADHD Section Editor, Vladimir Maletic, MD, MS. Dr Maletic, who is also clinical professor of neuropsychiatry and behavioral science at the University of South Carolina School of Medicine, Greenville, offers tips for clinicians treating patients with adult ADHD during the ongoing COVID-19 pandemic as well as tips for patients living with the disorder. 

Read the transcript:

Meagan Thistle: Hello, Psych Congress Network. I'm your Associate Digital Editor, Meagan Thistle and I'm sitting here today with Vladimir Maletic, who is also our ADHD section editor. Vlad, if you'd like to further introduce yourself.

Dr Vladimir Maletic: I would be delighted, Meagan. As you have heard, my name is Vladimir Maletic. I'm a Clinical Professor of Psychiatry at USC School of Medicine in Greenville, South Carolina and I'm delighted to be able to join you and talk about these very important topics related to ADHD in face of COVID-19 pandemic.

Thistle: Thank you again for sitting with us today. So you touched on the impact it had in their day-to-day lives. How has COVID-19 also impacted the diagnosis and also the treatment of adult ADHD?

Dr Maletic: In a very significant way. I've also mentioned the issue with more inattentiveness, more emotional dysregulation, more pronounced comorbidities. Sometimes, speaking about concerns related to diagnosis of ADHD. ADHD was hiding in plain sight, so since there is more substance use, sometimes substance use was the focus of diagnostic interview. Sometimes those were anxiety symptoms, sometimes those were mood symptoms and unless we took a very detailed longitudinal history, we would often miss ADHD. Why I'm saying that longitudinal history is so important? For a couple of reasons. By definition, one would anticipate that onset of ADHD was prior to age 12. There are some exceptions to that rule. There are studies indicating that sometimes ADHD reaches clinical threshold later on in life, although the milder form of symptoms was present earlier on. Nonetheless, typically ADHD would have an onset before age 12.

The other part that is interesting, majority of the time ADHD will predate major depressive disorder. So what came first? So 90% of the time ADHD is going to come first and therefore again, having timeline is really important. When it comes to substance use over 95% of the time ADHD will predate substance use and with anxiety it's more a 50/50 proposition, in a sense that anxiety disorders may start before ADHD just as much as ADHD can start before anxiety disorders. So there is that diagnostic challenge of discerning what is the figure and what is the background in making appropriate diagnosis? Second part that was problematic is patients with ADHD, their symptoms fluctuate. Maggie Sibley did some wonderful studies showing that there's fluctuation in ADHD symptomatology.

The levels of symptoms are not constant over time so in stressful circumstance it would exacerbate. That would be the time when they would decide this is a good time for me to seek help but access to healthcare providers was diminished. Furthermore, even if they managed to get appointments as new patients during that time, many practitioners despite emergency measures were very reluctant to prescribe for example, stimulant medications, control substances without having an in-person appointment. Just to remind everybody that there were regulations prior to COVID-19 epidemic or pandemic that one did have to have face to face contact before prescribing stimulants. This requirement was suspended due to medical emergency but many clinicians are either not aware of this or still think it is unsafe to prescribe controlled substances unless they have in person conversation with the patient.

Dr Maletic: But the other thing that was reported in the studies is both patients and clinicians felt that virtual appointments were of value but were not as deep an experience as face to face. Finally, during the virtual appointment, depending on the size of our screen, we would pretty much see our patients from chest up. A lot of the time fidgeting, restlessness, movement of feet, hands would not be in full view and that of course is very important diagnostic information.

So there were a lot of limitations both in access, in terms of treat choices when it comes to certain practitioners and then some challenge in terms of differential diagnosis, based on everything that was going on, because this was truly a perfect storm in many ways for patient suffering from ADHD.

Thistle: So in addition to taking a look at that whole picture, the longitudinal side of things and also getting used to that new normal and doing things over Zoom, like we are now, what other tips do you have for clinicians who are currently treating patients with adult ADHD?

Dr Maletic: Many tips. In order for our treatment and even diagnosis to be more successful it is good idea to inquire about a lifestyle of our patients. Are they socially isolated as alone? If so, that is a risk factor that is likely to exacerbate their symptomatology and frankly, looking at patients who overall have mental health problems it's a risk factor for suicide. So that would be something that would be important to inform ourselves of. What is the structure in our patient's lives right now? Do they have a reasonable sleep wakefulness cycle? It is really important to talk to them about importance of getting enough sleep because in terms of functional impairment, which is already problematic, if they're not getting enough sleep, their ADHD symptomatology will be much more pronounced. What kind of diet or dietary changes have taken place? Many of our patients, including patients who have ADHD, have resorted to eating more fast food, it's now convenient.

Calorie-dense foods are problematic because there is increased body mass, particularly related to lack of exercise and more sedentary lifestyle. Well, it is important to in context of ADHD because ADHD has the strongest genetic association with obesity. This is not very well known but we know that about association between ADHD and risk for smoking, alcohol consumption, anxiety, depression, emotional dysregulation, and risk for obesity is greater than all of those. So again, if we look at a dietary change, sedentary lifestyle, decreased exercise, all of those contributes to the risk and increase the risk of having metabolic abnormalities and as we know, those are again a risk for being hospitalized and having a more severe COVID-19.

So understanding the context of our patient's life is really important. Understanding if they have supports, if they're socially connected, very, very important. Has there been substance use? Many of my patients of ADHD have started using in many states illegal drugs such as marijuana. Well, of course, that will impact on their functioning and that will impact on their cognition and attention and executive function. This is also something to be taken into account. So there are multiple factors, some of them rather closely associated with circumstances during the pandemic, especially early phases of pandemic, where there is more social isolation and more loneliness. Again, all of those can affect presentation and even treatment response to ADHD medications.

Thistle: So you discussed isolation, diets, and sedentary lifestyle. Are there any-

Dr Maletic: level of exercise, assessing quality of life, very important. Yes.

Thistle: Yes. So from a patient perspective, is there anything else that you would offer a patient with adult ADHD during this time period? So shifting from that clinical lens to now patient perspective.

Dr Maletic: The patient perspective. Well, this may be my bias but given the data about not adhering to preventive measures and more severe form of COVID-19 infection in individuals who have ADHD, I would strongly suggest that they adhere to preventive measures, including wearing a mask when it is appropriate. I would definitely suggest that they be vaccinated because if we think about patients have obesity as having increased risk related to COVID infections. Again, there is very, very small difference in risk of hospitalization, severe symptoms between individuals who are obese and who have ADHD. So same rules would apply. I would say, it is specific circumstance but try to have a more balanced diet. Now it's more important than ever. Adhere to something that would resemble Mediterranean diet principles. It also has anti-inflammatory benefit.

Something that we don't think about but there are several studies suggesting that in stressful circumstances and definitely if in these individuals are sick, in patients who have ADHD do have greater inflammatory response. So having components of [an] anti-inflammatory diet may mitigate the course of illness in case they become infected with COVID-19 virus and overall having good and healthy diet is not going to harm anything. Do schedule exercise. That is very important. Think about remaining in contact with your treatment team, if there is one and even if there isn't one and there is no dire need, consider making contact with mental health practitioners because this is a good time to have a fallback plan, if it's necessary. A safety net so to say.

Dr Maletic: Do maintain your social contacts, do not isolate yourself, keep in touch with your family members, with your close friends. Obviously, if one has a partner, work on nurturing that relationship. Again, important for overall wellbeing. So these are... Make sure you're getting enough sleep and exercise obviously. Adhere to taking medications. There's a significant difference, I spoke about the risk of being COVID positive if patient has ADHD, that risk is completely dismissed, nullified if the patient is in treatment. So a treatment actually has direct relevance for the risk of becoming COVID positive. So there are again many, many aspects that now need greater emphasis than in usual circumstances.

Thistle: Thank you for sharing that. Is there anything else you'd like to add that we haven't touched on?

Dr Maletic: I think we have pretty much covered it.

Thistle: Great.

Dr Maletic: So, it's not business as usual, that is something that I would like to point out and I would encourage both patients and also the mental health providers to make sure that we don't miss ADHD, that we don't miss conversation about lifestyle that may have a significant impact on diagnosis and treatment outcomes and I would definitely encourage patients to stay in touch.

Thistle: Thank you. Thank you so much, Vlad for sitting down with us. This is always a pleasure and Psych Congress Network, if you found this interesting and helpful to you, please check back in our ADHD topic center and center of excellence. Thank you so much.

Dr Maletic: Very good. Again, well always a pleasure chatting with you, Meagan and I also wish our audience health and prosperity in these difficult times and to know that their efforts are deeply appreciated.

Thistle: Absolutely. Thank you so much, Vlad.

Dr Maletic: Thank you.

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.