We asked our participants for their insights and opinions on the impact of social and emotional impairments associated with ADHD, considerations for the patient, consequences for the payer, and cost implications across the life span. Strattera® (atomoxetine HCl) is indicated for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children age 6 and older, adolescents, and adults.

Given that many psychiatric disorders are characterized by overlapping symptoms, how important is it to consider all potential diagnoses when evaluating a patient?

 Outpatients seeking mental health services may present with several common chief complaints. They may be anxious,

depressed, substance abusing, personality disordered, psychotic, or be suffering from dementia, attentional, or behavioral problems. It is essential for clinicians to be able to diagnose and treat all of these conditions. Many clinicians are comfortable

with SSRIs and have a tendency to over diagnose anxiety and depressive conditions, sometimes to the exclusion of other diagnoses. Many times adolescent and adult patients with ADHD have been diagnosed as having a mood disorder. The reverse is also true, but happens far less commonly.

 Co-morbidity is fairly common in children with ADHD, even more so in adults with ADHD. There are also many overlapping symptoms. Sometimes there may be true co-morbidity and sometimes the symptoms so strongly overlap that from

screening tools, the patient will be positive for both disorders. As practitioners, we need to take the symptoms and screen for all the related disorders to find the right diagnosis or we won’t get the maximum response to treatment. If true co-morbid disease exists, then prioritize treatment. ADHD and bipolar is a prime example. There are often clues to which is the right diagnosis even if both the Conners and the MDQ are positive. Early age of onset and consistent symptoms are more likely signs of ADHD, as opposed to intermittent symptoms or onset of symptoms later in life.

 The diagnosis of ADHD involves first and foremost documentation that the patient meets DSM-IV-TR criteria for the disorder. However, because many children with ADHD eventually develop at least one co-morbid psychiatric disorder, evaluation must include consideration of additional symptoms (oppositional behavior, depressed mood, anxiety, learning disabilities, sleep problems, etc) both at initial presentation and on an ongoing basis.

Why do you think so many clinicians infrequently consider ADHD in their differential diagnosis when evaluating a patient with a psychiatric disorder? How can we educate physicians to change this?

 There seems to be a schism among clinicians with regard to the diagnosis and treatment of ADHD. Clinicians trained from

a developmental perspective such as pediatricians, child psychiatrists, and psychologists are quite sensitive to this condition,

whereas adult psychiatrists and neurologists are not exposed to ADHD in their residency training and as a result, they are far

less comfortable treating this disorder. I have been disappointed that many residencies have not added training about adolescent

and adult ADHD to their curriculum. Nearly 9% of American school-age children have ADHD; 50-70% persist into adulthood

with ADHD having impairments such as lower educational achievement, higher rates of unemployment, more tumultuous

interpersonal relationships and higher rates of co-morbid psychiatric conditions. From a basic clinical presentation and natural

history to treatment options, mood disorders are entirely different from ADHD and we need to differentiate them from one

another for these patients to be optimally served.

 Many practitioners still have a stereotype of ADHD patients having poor school performance with difficulty concentrating.

There is a pattern of recognition that needs to be taught to physicians in order to pick up those socially and emotionally

impaired ADHD patients. Physicians often do not associate the disturbed child or the troubled and addicted teen or the anxious

adult with ADHD. I think a campaign to educate practitioners on these patterns of recognition is essential. Keywords like

“impulsive,” “risk takers,” “drug dependant,” “defiant,” “frustrated,” and “anxious” are needed to go along with the keywords

now in use like “hyperactive” or “distracted.”

 Most clinicians recognize the cardinal symptoms of deficits in attention and focusing, distractibility, impulsivity, and motoric hyperactivity (when present) as essential features of ADHD. However, they are less aware that children with ADHD frequently have difficulty regulating emotion, just as they do attention and behavior. Furthermore, clinicians may not always be skilled in recognizing the manifestations of ADHD in children at different developmental levels; for example, observable behavioral hyperactivity in a five-yearold may appear quite different from the internal sense of restlessness that is the developmental equivalent in an adolescent.

What tools/screeners do you find helpful in your practice for evaluating patient for possible ADHD?

 At their first visit, each of our outpatients receives a screening test to assess their level of anxiety, depression substance use,

and ADHD. For adults, the Adult Self Report Scale (ASRS) is a useful screening instrument. It is brief questionnaire based on

established criteria, but unlike the child focused DSM-IV-TR; the ASRS questions reflect the adult ADHD experience. Requesting collateral input about a patient from his parent or spouse is a prudent method of validating reported symptoms.

 I still leave the ASRS short version screeners in every exam room on the magazine racks for patients to use at their

discretion. When I have a red flag or suspicion about ADHD as the diagnosis I use the Conners. Before a practitioner can use

a screening test, there must first be some red flags in his mind that will trigger him to give the screener keywords or symptoms

that make him suspicious of the diagnosis. Also, when there is a family history of ADHD, or a co-morbid disorder currently

being treated that has overlapping symptoms, a screener should be given. There is a lot of depression, anxiety, and bipolar

being treated out there that is really ADHD. These should especially be considered for ADHD screening in those failing to

 There are a number of well-standardized tools (ADHD-RS, Conners questionnaires) that are helpful in gathering supportive data from a number of sources, including parents and teachers, as well as in subsequently tracking response to treatment. We use a data collection form that includes “prompts” to solicit information about domains of impairment (eg, social situations, organized sports) found frequently in children with ADHD. This form also includes a sleep screening tool we developed called the “BEARS” (B=bedtime problems, E=Excessive daytime sleepiness, A=Awakenings at night, R=Regularity

and duration of sleep, and S=Snoring), which screens for common sleep problems accompanying ADHD.

Finally, I find it quite helpful to ask the parent(s) and child to “describe a typical day”, which often elucidates issues

(difficulty getting organized in the morning, conflicts with siblings, difficulty sitting through a meal) that helps to corroborate

the diagnosis and to identify areas for further intervention.

What are some of the consequences for a patient with ADHD that can result from an incorrect or partial diagnosis? What impact can this have on the patient’s family?

 ADHD is a common diagnosis that should always be considered when evaluating distressed patients. The majority of individuals with ADHD have co-morbid conditions—often anxiety or depression&mdash;but the reverse is true as well. For instance,

15-20% of individuals with major depression will have a comorbid diagnosis of ADHD. To obtain the best outcome, both

disorders need to be identified and treated. We have found that a number of individuals diagnosed with treatment-resistant

depression ultimately respond to antidepressant treatment once their overlooked ADHD is addressed.

 One of the best ways to convince parents and kids of the importance of treatment is to explain the consequences of ADHD. High school drop-out rate; college completion rate; chances of being fired or having failed marriages; the chances

of addiction and prison; teen pregnancy rate—all are negatively affected by ADHD. These real-life consequences of ADHD in

children and adolescents strike very close to home and get their attention. Treatment includes those kids who no one used to be able to stand that now people actually like to be around, or the angry and frustrated kid that now is happy and confident. Also there is the difficulty placed in the way of the functioning adult. It is when two people have the same amount of papers in their in-box and one is done in an hour and home with the family while the ADHD person takes two hours because he has to keep focusing back on his work and fighting distraction. How much is an extra hour a day worth to a high functioning person? It is the frustration of disorganization and the extra 15 minutes spent every time he goes into a department store. It may be the numerous uncompleted tasks. The consequences of ADHD have many faces.

 Perhaps the most obvious consequence of an incorrect ADHD diagnosis is the failure to obtain appropriate treatment.

This applies both to children with other conditions (eg, obstructive sleep apnea) who are “misdiagnosed” with ADHD and thus do not receive appropriate intervention, as well as to children who do have ADHD but are labeled instead as “lazy” or “spacey.” These scenarios not only have a clear impact on the self-esteem and quality of life of these children, but result in considerable frustration for caregivers and can erode the relationship with their child’s healthcare provider. 

From a payer perspective, how might an incorrect or partial diagnosis affect the cost of treating a patient who has ADHD?

 The failure to identify ADHD has a significant impact on the cost of treatment both emotionally and economically. Individuals with ADHD have higher absenteeism, lower productivity, and greater conflict with their employers. Inevitably, they develop impaired self-esteem and are viewed unfavorably by their family. Treatment of their ADHD including both pharmacological and psychosocial interventions seems to mitigate this effect.

 I know the data on bipolar diagnosis is 10 years and at least four misdiagnosis before someone finally is diagnosed for bipolar. I don’t know the data for ADHD, but I know it is missed a lot. The cost to the healthcare industry is multiple visits and misdiagnosis. The cost to society is poor work performance, addiction, unemployment, crime, etc. But the greatest cost is to the patient not reaching their potential, losing jobs, all the trouble they may have been in, family problems, disorganization, etc. This applies to both dysfunctional and high-functioning patients.

 Pharmacologic treatment of children with ADHD often involves a certain amount of “trial and error,” a process that

can be frustrating, time-consuming, and expensive for both caregivers and clinicians. An incorrect diagnosis, or the failure

to appreciate and target symptoms of co-morbid mood and behavioral conditions, frequently results in a further substantial

outlay of time and money spent on ineffective treatments.

How do you incorporate factors such as a patient’s behavioral symptoms, emotional and social needs, and/or co-morbid conditions into your treatment decision-making process?

 ADHD comes in three basic variants. The least common is ADHD, predominately-hyperactive impulsive subtype. This is

most frequently diagnosed in younger male children and disruptive behavioral symptoms are the hallmark feature. More

recently, ADHD, predominately inattentive subtype has been identified. This is frequently referred to as ADD, as inattention

and distractibility are predominant, rather than hyperactivity. Girls and women are represented in the subtype. By far the

most common is ADHD, combined type and this is characterized by a mixed state of hyperactivity, impulsivity and inattention.

Although the presentation is different and they seem to afflict different groups almost all individuals with ADHD benefit

from medications and psychosocial interventions such as counseling or coaching.

 Those with social and emotional issues need to be screened more closely for the correct diagnosis, co-morbid disorders and overlapping symptoms. Keep following symptoms and don’t accept just improvement in some areas.

 It is important for clinicians to take a “big picture” approach to designing and implementing treatment strategies for children

with ADHD. This means that ADHD symptoms in a variety of settings (eg, school, home, after-school daycare, social settings)

should be considered, and that behavioral, cognitive, and affective impairments and the impact on quality of life must all be explored and addressed. Most children with ADHD benefit from a “treatment package” approach, that includes behavioral interventions; educational accommodations; social skills development programs; study, time management, and organizational skills coaching; and individual and family therapy, as well as medication.

What are some of the considerations you take into account when selecting ADHD medications?

 The number and quality of medications available to treat ADHD patients grew significantly over the past decade and the

future looks bright for further development. Stimulant medications have long been the mainstay of ADHD pharmacology. In

the marketplace there are a number of variants of methylphenidate some short others longer acting. Commonly prescribed

methylphenidate products include Concerta

, and the skin patch, Daytrana™. A popular isomer of methylphenidate is Focalin

 XR.1 The other major stimulants are the amphetamines (Vyvanse™1 and dextroamphetamine1) and mixed amphetamine salts (Adderall

 XR1) which also are manufactured in short and long acting preparations. Stimulants work quickly and are effective for a full range of ADHD patients. Stimulants are controlled substances and physicians and parents may worry about diversion and misuse. The only non-stimulant currently available is atomoxetine. Atomoxetine is long-acting and has no abuse potential. As a selective norepinephrine reuptake inhibitor, it does not affect striatal dopamine and as such does not exacerbate tics. Strattera

 (atomoxetine HCl) is particularly useful in individuals with ADHD and a co-morbid anxiety, and it is important to note that Strattera is not contraindicated with anxiety. Strattera often takes 4-6 weeks to work, so it may not be a first choice in patients with acute needs or who come in with an urgent behavioral need.

How do you select medications for your patients with ADHD? What criteria do you use to match the right medication to the right patient?

 Although treatment of ADHD does involve some element of educated guesswork, consideration of factors such as the

child’s age and developmental level (eg, ability to swallow pills), specific needs (eg, onset of treatment effect, duration of action

sufficient to cover evening homework hours), symptom constellation (eg, primarily hyperactive/impulsive vs inattentive),

drug treatment side effects (eg, somnolence, GI effect, appetite suppression, increase in anxiety), ancillary symptoms (eg, difficulty with sleep initiation), patient preference (eg, stimulant vs non-stimulant), and avoidance of specific risks associated with

medication treatment (eg, diversion) helps to highlight certain drug choices and eliminate others less likely to fit the individual

How do you evaluate whether a medication is “working? What benchmarks and/or milestones do you use when assessing treatment efficacy?

 Patients prescribed ADHD medications should be evaluated routinely. At these regular meetings, the physician should

inquire about how the patient is feeling and how he is functioning. Specific evaluation of the patient’s focus, concentration,

productivity and energy level is in order. Ideally, the patient’s family member should have input as well. The Conners Global

Index Progress Tracking Form can be employed to help patients quantify their baseline symptoms and level of improvement.

I advise physicians never to become complacent when treating their ADHD patients. Always strive to reach a higher level

of improvement, use the medications at recommended dosages, and urge patient compliance. Some agents, particularly atomoxetine and methylphenidate, tend to be under-dosed which results in a suboptimal level of clinical benefit.

 To follow efficacy and determine “remission” I do the following: I have the patient list the three or four targets of treatment. These are the ADHD symptoms that are causing the most dysfunction and warrant medication. When they come back, we review those targets and I ask that they tell what percentage improvement they have had in each of the targets: 25%, 50%, 75%, or 90%. Remission to me is when all their targets are 75% or better improved.

 Targeting of specific symptoms, appropriate goal setting of measurable target behaviors, designation of tracking methods,

and frequent follow-up are key elements of treatment efficacy assessment. Treatment goals should be discussed and decided

upon in cooperation with the child and caregivers (eg, “what are the three things you would most like to change about your child’s behavior?”). In addition, information should be obtained from multiple sources to complete a “total picture.” For example, one goal might be that “Matt will sit at the kitchen table and complete his homework between 5 and 6PM, Monday-Thursday, without prompting; homework completion will be confirmed by his mother reviewing his assignment book, which is also checked daily by his teacher at the end of the school day.”

What are the most important factors that affect patient’s medication compliance?

 Patients tend to benefit from simple medication regimens. Once a day medications are preferable to multiple doses. In

general, the medication should be titrated up slowly to avoid initial adverse events like delayed onset of action, dyspepsia, or

insomnia. These adverse events are usually transient and it is unfortunate to dismiss prematurely a medication that might be

 If it is parents giving it to kids it seems to be related to efficacy. Tolerability is a big issue especially initially. Dosing is

an issue when trying to use short acting stimulants. Cost and formulary is always an issue but seems to be less so in ADHD

 A given treatment may be “effective” but ultimately lack “efficacy” if certain factors interfere with the patient’s willingness

to adhere to that treatment. Compliance in ADHD treatment necessarily involves a “team” relationship, and ongoing education

of and dialog with both the patient and caregivers. In particular, children should have medication use explained to them (“this pill

will help your engine speed up and slow down when you need it to”) and should be engaged in the treatment process in developmentally appropriate ways (eg, “would you rather take your medicine before or after breakfast?”). It is important to be proactive in discussing issues that may affect compliance, such as dosing schedules, method of administration, potential side effects, and expectations regarding onset and duration of treatment effect. Caregivers may also have unrealistic expectations about what a medication can and cannot do, which must be addressed up front. Finally, patients and caregivers should be encouraged to be open with providers regarding compliance issues in a non-judgmental atmosphere that is focused on creative problem-solving.

Do you factor cost implications into your medication selection process? How does noncompliance increase long-term cost of treatment?

 Cost factors permeate many medical decisions and it is unfortunate that many of the best medications are unavailable to many Americans. In my estimation, the treatment of ADHD is so vital to the well-being and productivity of a patient, that

compliance, safety and efficacy along with cost consideration need to be part of the medications selection process. Many of

the generic preparations need to be taken three times a day and in my clinical experience, patients have a difficulty keeping

up with this schedule. ADHD is a chronic condition and convenience may be an essential factor in choosing a medication.

Short-acting stimulants will last three to four hours, which means that if the patient takes the medication once or twice

Articles

DIALOGS ADHD

We asked our participants for their insights and opinions on the impact of social and emotional impairments associated with ADHD, considerations for the patient, consequences for the payer, and cost implications across the life span. Strattera® (atomoxetine HCl) is indicated for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children age 6 and older, adolescents, and adults.


Special Feature: Q&A

DHD is a common presentation in all clinical settings.

However, data shows that ADHD is underrecognized in adults.1 Why is this? Remember the old adage, “Out of sight, out of mind?” If ADHD is not thought of as a possibility in adult patients, is it more likely to be missed? When ADHD in adults presents with co-morbidities, does the disorder become a “diagnostic chameleon”?

The answer to both questions, based on our reading of the literature, and our combined four decades of clinical experience, is a resounding yes. ADHD is indeed quite frequently missed, and there is a clear and pressing need for clinicians to openly discuss differential diagnosis difficulties and come up with a game plan to meet the needs of patients with ADHD. This tutorial is designed to provide a scientific as well as a practical grounding in the issues germane to ADHD in adult patients, particularly if these patients present with one of these common co-morbidities:

• Mood disorders (major depression and bipolar disorder)

• Anxiety disorders (generalized anxiety disorder, social anxiety disorder, etc)

• Alcohol and substance abuse disorders

Differential diagnosis is important to ensuring good outcomes. The topic of co-morbidities is very important to the issue of differential diagnosis. In clinical practice, most agree that co-morbidities tend to be the rule, not the exception. We strongly recommend you appreciate the importance of co-morbidities in ADHD because many patients tend to present with “masked” ADHD, with the co-morbidity (such as an anxiety or mood disorder) taking center stage and making it easy to miss the ADHD if a systematic diagnostic approach is not undertaken.  To substantiate this point, figure 1 highlights several conditions that are frequently co-morbid with adult ADHD.

Clinicians must continue to screen for ADHD if a patient presents with co-morbidities (eg, major depression, anxiety disorders, alcohol and substance abuse disorders). If a patient presents with major depression or anxiety difficulties, even upon remission of symptoms, clinicians must maintain a high degree of suspicion and routinely screen for ADHD. Our job is somewhat like that of an archeologist, continually sifting through sand searching for objects of importance.

Remaining vigilant in our search for symptoms of ADHD is clinical wisdom and is worth repeating. Consider the lifetime prevalence of co-morbid conditions in adult populations with ADHD highlighted in figure 2.

Anxiety disorders are the most common conditions affecting the United States population.2 In our practice, we most frequently see generalized anxiety disorder, social anxiety disorder and PTSD. As figure 2 illustrates (previoius page), adult ADHD is quite co-morbid with anxiety disorders. To get a more accurate clinical picture, let’s broaden the boundaries beyond anxiety disorders and take into consideration other co-morbidities outlined in figure 3.

We must not stop short when taking care of patients. Based on this data, we must screen for ADHD. These graphics illustrate the urgent need to proactively and routinely screen patients for the presence of ADHD. Complicating ADHD’s clinical picture is the fact that as many as 50% of individuals with the disorder will meet the criteria for at least one co-morbid psychiatric condition.3-5 In children, these co-existing conditions include learning disabilities, anxiety disorders, mood disorders, autism spectrum disorders, and other disruptive behavioral disorders, such as oppositional defiant disorder and conduct disorder. These disorders have an obvious impact on children’s abilities to function adequately in their academic, social, and family environments and, in combination with ADHD symptoms, often lead to adverse life outcomes and increased utilization of mental health, academic, and criminal justice system resources.

In adolescents and adults, mood and anxiety disorders, as well as substance abuse disorders, commonly co-exist with ADHD.6 Mood disorders, anxiety, substance use, and intermittent explosive disorder have been found to be 1.5 to 8 times more likely in adults with ADHD than in those without, and associated problems of frequent job changes, unemployment, and criminal arrests were found to be more common in this population as well.3,7 Studies of driving behavior also indicate that adults with ADHD incur higher rates of accidents on the highway and motor vehicle—associated injuries.8 The fact that ADHD is likely to occur with other psychiatric disorders adds to the clinical complexity of both diagnosing and treating the disorder and amplifies the potential for adverse life outcomes.

Comprehensive pharmacoeconomic data are lacking on

ADHD’s impact in adulthood, but indirect indicators—such as the

increased rates of criminal involvement, substance abuse, and psychiatric

co-morbidities, along with driving data—would suggest

that ADHD is a costly disorder. Numerous studies have documented

the high societal costs of depression, anxiety, and substance use

disorders but have ignored the impact of co-morbid ADHD.9-11

Increased or Unnecessary Cost to Patients and Society

Data for healthcare use and cost-of-illness in adults with ADHD is lacking.12-14 The persistent nature of ADHD wouldsuggest,

however, that adults with the disorder, like children, have higher healthcare use and costs than people without the disorder. Little, too, is known about the social cost of ADHD, but if left untreated, the effect of the disorder may be substantial. For example, the prevalence of ADHD in male prisoners has been estimated to be 25%, which is five times that of the

Functional Impairments (Work, Academic, Family, and Social)

Overlooked or misdiagnosed ADHD can result in serious functional impairments for the patient. Barkley and colleagues have found that people with ADHD frequently get fired, change jobs, and have lower job performance evaluations than people without ADHD.16 No clinician or patient is immune from the consequences of missing a diagnosis of adult ADHD.

Diagnostic Issues and Challenges in Adult ADHD

Diagnosing co-morbid ADHD in adult patients with anxiety disorders, mood disorders, and/or alcohol/substance abuse disorders is challenging due to the lack of systematic screening for all patients as part of routine care, and failing to consider ADHD as a possible diagnosis. Distractibility as a stand-alone symptom may alert clinicians to a variety of different DSM-IV-TR diagnoses or distractibility may mean absolutely nothing. Figure 4 (previous page) provides an illustration of distractibility as a roadmap to multiple disorders.  Clinicians who do not currently screen patients may find it difficult to change existing practice habits. Nevertheless, incorporating screening into routine clinical practice is a necessity and screening tools for adult ADHD are available.

One of the most striking, and useful developments in the field of screening has been the development of the six-item instrument called the Adult ADHD Self Report Scale (ASRS), version 1.1 (figure 5, previous page). It was developed under the auspices of a WHO work group and is designed to screen for adult (18 years and older) ADHD in community samples. The screener takes less than five minutes to complete and can provide very useful supplemental information as we screen all our patients for adult ADHD.  The ASRS is, in our opinion, an efficient and effective screener for adult ADHD. In our clinical practice, we feel the sensitivity and specificity of ASRS has been quite good. The only cautionary note regarding screeners is to be watchful for false positives. With that said, screeners are a great safety net to help capture important clinical information. Screeners serve as red flags to alert clinicians to the possibility that something is going on. We strongly recommend the use of ASRS in all patients, even if the presenting symptoms initially suggest an anxiety disorder, mood disorder, or alcohol or other substance abuse disorder. Remember: screeners work best if we routinely use them in all patients. Because ADHD in adults is quite common, we confidently recommend the routine use of ASRS in all clinical settings.

A Systematic Approach to Discovering Co-Morbid ADHD

It is important to create a step-by-step paradigm to accurately assess patients. One such paradigm that we use in our clinical practices is illustrated in figure 6 (previous page). This decision tree offers clinicians a systematic pathway to identifying diagnoses. Consider the decision tree as a roadmap to discovering co-morbid ADHD.  Clinicians must remember to screen ALL patients for ADHD who present with a diagnosis of any mood disorder, anxiety disorder, or alcohol/substance abuse disorder. As discussed in the previous section, the ASRS is an excellent screener for adult ADHD. If the ASRS is negative, ADHD is an unlikely co-morbidity.  However, if the ASRS is positive, the clinician must determine the following:

• Has the patient met 6 of 9 of the DSM-IV-TR criteria for either or both inattentive or hyperactive/impulsive symptoms?

• Is impairment present in at least two settings?

If yes, ADHD is a likely diagnosis. This type of systematic approach offers clinicians a great safety net against missing critically important pieces of information. As a footnote, screeners are not diagnostic but their suggested use as an addition to routine clinical practice is strongly recommended.

ADHD does indeed qualify as a “diagnostic chameleon.” However, the clinician who employs a systemic approach to routine screening and co-morbidity detection, will surely be successful in improving patient outcomes. Indeed, the diagnosis of ADHD is not always clear at first, but the rewards for patients when an accurate diagnosis is made are so great that we feel compelled to urge all our colleagues to strive to maximize their screening efforts and to utilize the decision tree we and others recommend. While it is true that overlapping symptoms between many psychiatric co-morbidities can lead to confusion, utilizing the “pyramid of information” illustrated in figure 7 can lead to enhanced detection and outcomes for patients with adult ADHD. If all of these seven steps are undertaken in a systematic and deliberate fashion, you can rest assured that you have offered your patient the very best of clinical services.

Saundra Jain, PsyD, is the Executive Director of Mental Health Educational Initiative, an organization that provides educational services to mental health professionals and patients. She also maintains a fulltime private psychotherapy practice, offering services for a wide range of mental health issues.

Rakesh Jain, MD, MPH, is Assistant Clinical Professor of Psychiatry at the University of Texas Medical School in Houston. He is also Director of Psychiatric Drug Research for R/D Clinical Research at Lake Jackson, TX.

ADHD is a common presentation in all clinical settings. However, data shows that ADHD is underrecognized in adults.1 Why is this? Remember the old adage, "Out of sight, out of mind?" If ADHD is not thought of as a possibility in adult patients, is it more likely to be missed? 

ADHD as a Diagnostic Chameleon: Developing a Systematic Approach to Differential Diagnosis

This article provides answers to several common questions associated with the use of Strattera® (atomoxetine HCl) to treat patients with ADHD. Strattera is indicated for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children

age 6 and older, adolescents, and adults.

Is atomoxetine an efficacious medication for ADHD?

There have been more than a dozen double-blind, randomized

controlled ADHD trials of atomoxetine in children, adolescents,

and adults with ADHD and all clinical studies have had a positive

efficacy outcome. Each of these studies demonstrates a very

clear statistically significant and clinically meaningful advantage

Why do many clinicians report not having the same clinical success with atomoxetine that they might with stimulants or other medications?

A number of factors may be contributing to the differential perception

of efficacy between stimulants and atomoxetine. The most

basic explanation is that the magnitude of benefit for many patients

may be greater with stimulants and there is some research to support

this from head-to-head studies.8,9 However, other factors can

also contribute to the perception of an efficacy gap. Central to these

factors, I believe, is the fact that atomoxotine works via a different

mechanism of action compared to the stimulants, and therefore

exhibits a different therapeutic time-course. Atomoxetine is a selective

norepinephrine reuptake inhibitor. ADHD symptom reduction

begins early but accrues slowly and steadily over many weeks

before marked benefits are achieved.1 In fact, data suggests that it

may require 4-6 weeks before marked benefits are seen. As a result,

changes in patients are gradual and subtle and therefore can be

more easily overlooked by patients compared to the rapid symptomatic

improvement experienced by some patients taking stimulant

medications every morning. In essence, patients may report that

atomoxetine is not having any effect, when indeed it may be. This

could be because it produces symptom improvement that grows

slowly and steadily over time in contrast to the more apparent daily

One possible explanation for a perceived less apparent response

with atomoxetine is that patients who had experienced the more

dramatic response to stimulants previously may be less able to

recognize the more subtle therapeutic benefits of atomoxetine.

What can clinicians do to help patients recognize the therapeutic effects of atomoxetine?

A potential gap in perceived versus actual benefit of atomoxetine

may often be mitigated if clinicians take a more rigorous approach

to evaluating the therapeutic effects of atomoxetine. This means

not relying solely on nebulous, open-ended questions to assess a

patient’s response to the medication (eg, “how are you doing?” or

“do you think the medication is working?”). Given the extremely

subtle course of atomoxetine’s therapeutic effects, patients will,

not infrequently, answer in the negative to such questions. The

clinician must, in those cases, pursue a more meticulous line of

questioning aimed at a patient’s specific target symptoms. Prior to

starting treatment, the clinician and patient should create a short

list of frequently occurring and debilitating ADHD target symptoms.

If a treatment is successful, these target symptoms would

decrease noticably. By doing this, clinicians and patients themselves

may be surprised how often an apparent lack of effect by

This article provides answers to several common questions associated with the use of Strattera® (atomoxetine HCl) to treat patients with ADHD. Strattera is indicated for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in children age 6 and older, adolescents, and adults.

December 2007

Special Feature: Q&A

ADHD as a Diagnostic Chameleon: Developing a Systematic Approach to Differential Diagnosis

Perspectives on Efficacy: An Atomoxetine Tutorial

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