ADHD in Adults: Diagnosis, Treatment, and what Telehealth can (and can’t) do
ADHD is everywhere these days. It can seem like everyone has a diagnosis, is looking for a diagnosis, or suspects they may have a diagnosis. Certainly, social media plays a role here, with videos and posts frequently trending on the topic of ADHD. While there has been a large increase in diagnoses in the US, these are largely in adults, not children.
How ADHD is diagnosed
As of writing, ADHD remains a clinical diagnosis. This means that there is no blood test, brain imaging, or even standardized testing sufficient or required to make a diagnosis of ADHD. In that vein, while many doctors, psychiatrists included, demand neuropsychiatric testing to make this diagnosis, that requirement is not evidence-based. Requiring such extensive testing is cost-prohibitive, time-consuming, takes months to schedule, and for someone who may actually have ADHD, represents a near insurmountable obstacle to care.
The standard criteria for diagnosing ADHD come from the DSM-5-TR. These criteria have been critiqued from the start, and rightfully so, as both overly broad and ambiguous, while simultaneously exclusionary and ableist towards certain subpopulations (non-whites, women, as a few examples). An interesting and often overlooked criterion is that the signs and symptoms of ADHD must have been present before age 12. In practice, this is almost impossible to verify unless someone was already diagnosed by that age. For an adult coming in for an initial visit, we must rely on ancient history, unless we want to start digging through old report cards or calling elderly parents for collateral.
Still, the takeaway is that ADHD does not develop in adulthood. To that end, the DSM-5-TR also includes a caveat that ADHD is essentially a diagnosis of exclusion. This means that the signs and symptoms of ADHD cannot be better explained by another disorder, including mood disorders (depression, bipolar disorder), anxiety disorders, and substance use disorders. They must also be present for at least 6 months and actively impairing one’s ability to function.
In short, ADHD is diagnosed differently by everyone, which is not a great look for the field of psychiatry. And yet, anyone who claims things are more precise than this is peddling a falsehood. Such is the state of modern psychiatry!
How ADHD is treated
Once you’ve received your diagnosis of ADHD, it’s time to decide what to do about it. In many cases, adult patients simply feel validated knowing that their struggles have a cause, and do not choose to pursue any further action. Others may opt for making lifestyle changes or focusing on therapy for a time. At some point, many people decide that they want to try a medication for ADHD, which is what this section will focus on.
Stimulants
By far the most common class of medications used to treat ADHD are the stimulants. These can be broadly broken up into medications based on methylphenidate (Ritalin) or amphetamines (Adderall). These are C-II controlled medications, meaning they are strictly regulated by the DEA. While largely safe, they do carry risks such as cardiovascular effects (higher heart rates, higher blood pressure), insomnia, appetite suppression and weight loss, dry mouth, paranoia and psychosis, and the potential for dependence and abuse. That said, many people do quite well with stimulants, and with careful monitoring from your psychiatrist, they can be very safe and effective.
Below is my internal algorithm for selecting a stimulant:
Methylphenidate vs. Amphetamine
Neither has been definitively proven as more effective than another.
Reasons to choose one over the other include past medication trials/failures and family history (ie a sibling or parent who does well with one type of medication).
Long-acting vs. immediate release
Most people with ADHD and “normal” 9-5 jobs do best with a long-acting medication. Dosed once daily in the morning, they offer maximum convenience.
For people with more variable schedules, or anyone particularly sensitive to effects of the longer acting medications, immediate release may be a better option.
Sometimes a combination of the two works best, such as a long-acting in the morning followed by an afternoon “booster.”
Generic vs. branded
Historically not as big of an issue.
Periodic stimulant shortages make this a consideration, as branded medications are typically more easily obtainable.
Some patients have already tried the generics and prefer to try something new.
Medication interactions
While not common, sometimes a patient is on another medication that makes choosing one stimulant more favorable than another.
As you can see, there is a lot of room here for trial-and-error. Again, the world of ADHD is hardly precision medicine.
While many psychiatrists stick to Adderall and Ritalin, I have experience prescribing many newer medications for ADHD, including:
Asztarys (combination of immediate release and longer-acting methylphenidate formulations; I think of it as the “Vyvanse of methylphenidates”)
Adzenys (great alternative when Adderall XR is out of stock)
Jornay (for those who can only remember to take meds at night)
Xelstrym (it’s a patch, not a pill)
Non-stimulants
There are many reasons someone may want to avoid a stimulant. In other cases, it may be best to avoid them due to a patient’s history, such as hypertension or panic disorder, since stimulants can worsen these conditions.
Though less commonly used, there are now a few non-stimulant options that work very well for patients. Many patients actually prefer these medications because they are not controlled, are easier to obtain, and are generally easier to manage. There are not many, so I will simply list them here:
Strattera (atomoxetine)
Probably the most common non-stimulant. Great choice for anyone also dealing with a lot of anxiety, as it has properties of norepinephrine-reuptake inhibition.
Intuniv (guanfacine XR)
Typically dosed in the evening. Tends to have a calming effect. Often not effective on its own, but can be used in combination with a stimulant or other non-stimulant for better effect.
Wellbutrin (bupropion)
Also an antidepressant, so very useful in cases of depression with worsening of ADHD or cognition generally.
Qelbree (viloxazine)
Essentially similar to Strattera, though longer acting and seemingly with less nausea as a side effect.
Starting any medication for ADHD is a big decision, and should only be done after consultation with a reputable psychiatrist. Online practices that promise quick diagnosis and treatment, or those that advertise as only treating ADHD, are likely not giving you the time and care you deserve before making such a decision. Additionally, the most effective treatment for ADHD includes not just medications, but also therapy and lifestyle changes.
Telehealth for ADHD
The use of telehealth for ADHD has been greatly expanded over the past 6 years, since the start of the pandemic. Before, in-person visits were required at least initially to be prescribed a stimulant, and often at a minumum of every three months thereafter. These requirements were largely lifted during the pandemic, but have started to come back in some states. If you are looking for ADHD treatment in New Jersey, for example, you now have to see someone in-person initially and at least every three months once again.
While studies on the topic are scant, those that we do have seem to show that there is no significant difference in outcomes for those treated via telehealth vs in-person. For many patients, especially those who live outside of major cities, this can be a great way of improving access to quality psychiatric care. Unfortunately, many companies have also realized this, and have used the more relaxed laws to advertise and provide subpar care.
To ensure the highest quality treatment of ADHD, whether you are opting for telehealth or in-person care, I recommend working with a trusted local psychiatrist rather than a large company whose only goal is to create maximum profit (read: prescribe, prescribe, prescribe).
Currently, I see patients in Philadelphia and the surrounding suburbs for diagnosis and treatment of ADHD. While in-person visits are always encouraged, if you cannot make it to one of my offices, I am happy to see you via telehealth. Reach out today to schedule your ADHD evaluation in the Philadelphia area.