Andrew J. Cutler, MD, and Rakesh Jain, MD, MPH, comment on comorbid psychiatric disorders complicating the diagnostic process for ADHD and review unmet needs.
Andrew J. Cutler, MD: There are various comorbid conditions that can complicate the diagnosis and treatment of ADHD [attention-deficit/hyperactivity disorder]. These differ from childhood to adulthood.
During childhood, the most common comorbid conditions include emotional behavioral dysregulation, for which the diagnoses that accompany that are oppositional defiant disorder and conduct disorder. Then we also have anxiety and depression, which are less common in childhood but start to become more prominent during adolescence and adulthood. You can see things like tic disorders, and learning disabilities and learning disorders are often seen in childhood ADHD.
As we move into adolescence and adulthood, we still have some behavioral issues. However, these issues become more prominent as anxiety and depression. We think up to half of adults with ADHD have anxiety, and about 40% to half of adults will have comorbid depression. This is often how they present to clinicians—with treatment-resistant anxiety and depression. That’s the tip of the iceberg, and then the ADHD is subsequently recognized.
What also comes into the picture is substance abuse, which is a common comorbid condition. Then there are medical conditions such as sexually transmitted diseases, unwanted pregnancies, and cardiovascular disease. There’s an association of smoking with ADHD. Also, ADHD is associated with traffic accidents and driving problems. These are some of the common comorbidities that can be seen.
I failed to mention bipolar disorder as a common comorbidity. It’s been estimated that anywhere from 15% to 40% of patients with ADHD will also meet criteria for bipolar disorder.
Rakesh Jain, MD, MPH: Based on my clinical experience, there are many unmet needs in the world of ADHD in children, adolescents, and adults. Perhaps I can highlight for you 4 that I run into repeatedly. First, ADHD and sometimes the treatment of ADHD can have a rather negative impact on sleep. Sleep architecture is often abnormal to begin with. Undoubtedly, many individuals with ADHD have trouble falling asleep.
Second, not everybody gets adequate, full, and necessary coverage of symptoms. That doesn’t happen. That does happen for a fairly large number of people, but I would not say it happens for everybody. So that’s an unmet need.
Third is rebounding of symptoms. By that I mean things are quite well for a certain number of hours, but once the medication fades out, instead of coming back to baseline gently, some individuals actually go above baseline in terms of their difficulties. They are often very irritable, moody, and dysphoric. That’s a rebound. That’s an unmet need.
Then with some medications we have challenges with rather slow onset of action. It may take sometimes weeks while you are engaging in the medication for it to produce full results. Those are the 4 current and often-encountered unmet needs in the world of ADHD treatment.
Transcript Edited for Clarity