Management Of Attention-deficit/hyperactivity Disorder In Adults Research Articles

Update on Identifying and Evaluating Quality Measures for Adult Attention-Deficit/Hyperactivity Disorder

The limited recognition and treatment of attention-deficit/hyperactivity disorder (ADHD) in adults has been studied in the research setting and addressed in the clinical education setting during recent years. Despite these efforts, health care professionals continue to struggle with the management of adult ADHD in everyday practice. To better evaluate and measure meaningful practice metrics, a set of 10 key quality measures (QMs) that can help improve health care outcomes in adult ADHD was identified using a combination of evidence-based literature reviews and expert consensus. Subsequently, these QMs were field-tested in a sample of 71,310 adult ADHD patients in the primary care setting and behavioral health clinics over the course of a decade to assess whether these measures were attained. The results allowed us to understand how the clinician approach to diagnosing and treating ADHD has evolved in the past few years and highlighted the ongoing challenges in practice variation by clinicians caring for patients with adult ADHD. In turn, this information also guides our understanding of the next steps needed to improve the quality of care provided to adults with ADHD in different care settings. Accordingly, the American Professional Society of ADHD and Related Disorders (APSARD) assembled a guidelines committee to create a set of clinical practice guidelines to provide practitioners with a standardized, evidence-based approach to diagnosing and treating ADHD in adults. [ Psychiatr Ann . 2023;53(10):444–448.]

Biological Predictors of Treatment Response in Adult Attention Deficit Hyperactivity Disorder (ADHD): A Systematic Review.

Background: Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent condition with onset in childhood and in many cases persisting into adulthood. Even though an increasing number of studies have investigated the efficacy of pharmacotherapy in the management of adult ADHD, few authors have tried to identify the biological predictors of treatment response. Objectives: To summarize the available data about the biological markers of treatment response in adults affected by ADHD. Methods: A search on the main biomedical and psychological archives (PubMed, Embase, Scopus, and PsycINFO) was performed. Manuscripts in English, published up to May 2022 and having the biological predictors of treatment response in adults with ADHD as their main topic, were included. Results: A total of 3855 articles was screened. Twenty-two articles were finally included. Most of the manuscripts studied neuroimaging and electrophysiological factors as potential predictors of treatment response in adult ADHD patients. No reliable markers were identified until now. Promising findings on this topic regard genetic polymorphisms in snap receptor (SNARE) proteins and default mode network-striatum connectivity. Conclusions: Even though some biological markers seem promising for the prediction of treatment response in adults affected by ADHD, further studies are needed to confirm the available data in the context of precision medicine.

Patterns of comorbidity and psychopharmacology in adults with intellectual disability and attention deficit hyperactivity disorder: an UK national cross-sectional audit

ABSTRACT Background: Attention-deficit hyperactivity disorder (ADHD) is higher in people with intellectual disability (ID) compared to the general population. Available limited evidence suggests this population has increased psychological problems, diagnostic overshadowing and psychotropic prescribing. This audit Identifies and analyzes real-world characteristics, diagnostic practices, treatment, and management of ADHD in adults with ID. Research Design and Methods: Pooled retrospective case note data for people with ID and ADHD, collected from 30 organizations across the UK, were analyzed. Patients were classified into mild and moderate-profound ID groups. Associated mental health and neurodevelopmental co-morbidity, Demographics, concomitant psychotropics, and mental and behavioral concerns were collected. Group differences were reported using logistic regression models. Results: Of 445 participants, 73% had co-occurring autism spectrum disorder (ASD) and 65% were prescribed ADHD medications. Those on ADHD medication were less likely to be prescribed antipsychotics (p < 0.001) and antidepressants (p < 0.001). Multiple significant differences were found in ADHD medication response between ID groups and those with/without co-morbid ASD but not associated with challenging behavior reduction. Conclusions: High levels of neurodevelopmental and psychiatric comorbidity were found. ID severity and the presence of ASD appear to influence the use of certain psychotropic medications. Appropriate use of ADHD medication appears to reduce psychotropic polypharmacy.

Adult Attention-Deficit/Hyperactivity Disorder Diagnosis, Management, and Treatment in the DSM-5 Era.

To increase awareness of adult attention-deficit/hyperactivity disorder (ADHD) in the primary care community and to provide guidance for the management of this condition. Despite its increasing prevalence, adult ADHD largely remains underdiagnosed and inappropriately treated in the United States. The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has provided more clear diagnostic criteria for adult ADHD, but a solid framework supporting the transition of ADHD management from pediatric to adult primary care is lacking. We searched PubMed and MEDLINE databases (January 1, 1984-June 1, 2016) using combinations of keywords, including ADHD, adult, diagnosis, prevalence, symptoms, treatment, comorbidity, compliance, and guidelines; international treatment guidelines; and the Diagnostic Interview for Adult ADHD websites to identify relevant clinical studies, reviews, meta-analyses, guidelines, and web-based resources describing updates to the DSM. In total, 143 citations were selected based on their relevance to adult ADHD diagnosis, treatment, major issues, and practice guidelines. The update on diagnostic criteria in the DSM-5 may increase the diagnosis of adult ADHD. There are critical differences between childhood and adult ADHD, and specific considerations should be taken with an adult ADHD diagnosis. Adult ADHD is primarily treated with pharmacotherapy assisted by behavior interventions. Caution should be exercised when using stimulants during pregnancy and the postpartum period. Adult ADHD patients often suffer from unemployment, financial difficulties, and an unsuccessful personal life. Adult-specific guidelines may improve adult ADHD treatment. The successful diagnosis and management of adult ADHD require consideration of many facets including prior medical history and comorbid conditions and use of an individualized, evidence-based treatment approach.

Attention-deficit hyperactivity disorder in adults

Attention-deficit hyperactivity disorder (ADHD) is one of the most-common psychiatric disorders; it is highly comorbid with many other psychiatric disorders and associated with substantial role impairment. Untreated ADHD results in psychiatric comorbidity, relationship and parenting problems, underachievement, frequent job losses, and opportunistic delinquency. Nevertheless, ADHD remains the most under-recognised and undertreated mental health condition in adults. This article discusses the clinical presentation of ADHD in adulthood with a particular focus on recognition, assessment and management of ADHD in adults in primary care.

The efficacy of atomoxetine in treating adult attention deficit hyperactivity disorder (ADHD): A meta-analysis of controlled trials.

Atomoxetine, a non-stimulant, is FDA approved drug used in the management of adult ADHD. Since the presentation of adult ADHD is different from the childhood onset condition, there is an urgent need to study the efficacy of atomoxetine on the different symptom domains of adult ADHD. To study the efficacy of atomoxetine in treating adult ADHD compared to placebo, we performed a Medline search for English language publications of Randomized Controlled Trials (RCTs) comparing atomoxetine to placebo for adult ADHD using the keywords "adult ADHD", "atomoxetine" and "placebo". A total of 41 RCTs were returned of which we included 13 relevant RCTs reporting data on 1824 patients with adult ADHD in the analysis. Standardized mean difference between atomoxetine and placebo for the mean baseline-to-endpoint change in total ADHD scores, impulsivity/hyperactivity and inattention scores was calculated, with a 95% confidence limit. Atomoxetine had superior efficacy than placebo on overall adult ADHD scores [-0.45; 95% CI -0.54, -0.35; overall effect p<0.00001]. Atomoxetine was superior to placebo on the domains of both inattention [-0.42; 95% CI -0.49, -0.35; overall effect p<0.00001] and impulsivity/hyperactivity [-0.36; 95% CI -0.44, -0.29; overall effect p<0.00001]. Atomoxetine was significantly more efficacious (p<0.00001) in treating inattention than hyperactivity/impulsivity. Atomoxetine is efficacious in treating adult ADHD compared to placebo, though the efficacy is significantly superior for inattention than hyperactivity/impulsivity.

Expert Opinion and Recommendations for the Management of Attention-Deficit/Hyperactivity Disorder in Correctional Facilities.

There has been considerably less research on the management of adult attention-deficit/hyperactivity disorder (ADHD) among the inmates of correctional facilities than in the general community. While the successful identification and management of ADHD in the adult correctional setting offer potential benefits to the individuals themselves, to institutional staff, and to wider society, their implementation represents significant challenges. These include high prevalence rates, the low level of ADHD recognition, the high incidence of comorbid psychiatric disorders, and the high risk of abuse and diversion of prescribed medications. Here, the authors provide an overview of current recommendations for the identification and management of adults with ADHD in correctional settings and discuss possible strategies for their further development.

Lisdexamfetamine for the management of ADHD in adults

Lisdexamfetamine is now licensed for use in adults with attention deficit hyperactivity disorder (ADHD) under the brand name Elvanse Adult. This article summarises its indications and adverse effects and discusses clinical trial evidence for its efficacy in adults.

Attention deficit hyperactivity disorder and dual disorders. Educational needs for an underdiagnosed condition

A wide range of comorbid psychiatric disorders overlap with attention-deficit hyperactivity disorder (ADHD) across the life span. There is a robust and complex link between ADHD and substance use disorders (SUD). The aim of this report was to review the neurobiological and other vulnerability factors explaining the comorbidity of ADHD and an addictive disorder, as well as the key aspects of the assessment and diagnosis of dually diagnosed ADHD patients. A comprehensive and systematic search of relevant databases (PubMed, Embase, and PsychINFO) was conducted to identify studies published in peer-reviewed journals until July 31, 2012, with the aim of exploring the association of ADHD and SUD with postgraduate training and residency education. Across the life span, ADHD is associated with significant impairment and comorbidity. Data from epidemiological, clinical and epidemiological studies show a very solid link between ADHD and SUD. Therefore, it is very important to carefully and systematically assess for any substance use in patients with suspected ADHD coming to initial assessment, and vice versa. While there are various valid and reliable rating and screening scales, diagnosis cannot solely rely on any of the instruments available for both SUD and ADHD in adult patients with dual pathology. The most important and effective tool in the assessment of dually diagnosed patients with ADHD and SUD is a full and comprehensive clinical and psychosocial assessment. Hence, it is essential to actively incorporate training opportunities on the assessment, diagnosis, and management of adult ADHD and dually diagnosed ADHD patients during postgraduate education residency or specialist training.

Attention-Deficit/Hyperactivity Disorder in a Chronic Care Paradigm

The prevalence and disease burden of adult attention-deficit/hyperactivity disorder (ADHD) suggests that primary care physicians (PCPs) have an opportunity to improve the functioning and quality of life of a significant number of adult patients. The American Academy of Pediatrics provides evidence-based clinical practice guidelines that recognize ADHD as a chronic condition, and a large proportion of children with ADHD continue to meet diagnostic criteria as adults. Therefore, the management of ADHD should incorporate principles common to the management of other chronic conditions, including proactive planning for continuity of treatment across the life span and integrated, multidisciplinary health care teams for optimal disease management. This article describes a clinical approach whereby adult ADHD is treated within a chronic care paradigm that prominently features the involvement of the PCP If PCPs envision ADHD as a chronic illness, similar to asthma or diabetes, they may be less likely to refer individuals to be managed by specialists, and more likely to see their role in coordinating and monitoring adult ADHD care, knowing when and how to bring other resources into play, and when and how to educate patients.

ADHD with comorbid substance use disorder: review of treatment

SummarySubstance use disorders are a frequent comorbidity in adult attention-deficit hyperactivity disorder (ADHD). This review discusses the relationship between adult ADHD and substance use disorder, including use of licit and illicit substances such as nicotine, alcohol, cocaine and cannabis. We discuss treatment studies in this area and provide a treatment algorithm to guide clinicians in the management of adult ADHD comorbid with different forms and severities of substance use disorder.

Adult attention-deficit hyperactivity disorder and bipolar disorder

SummaryIncreasing attention is being paid to the concept of attention-deficit hyperactivity disorder (ADHD) in adults, in concord with evidence that suggests a proportion of children with ADHD continue to manifest symptoms into adulthood. Attention-deficit hyperactivity disorder has some symptoms in common with hypomania, and can co-occur with bipolar disorder. The diagnosis and management of ADHD in adults with bipolar disorder can be complicated, owing to challenges resulting from symptom overlap, questions of diagnostic validity and a paucity of empirical evidence to guide treatment. This article addresses comorbid ADHD and bipolar disorder, and provides practical suggestions for diagnosis and management.

Adult attention deficit hyperactivity disorder: translating research into practice

Attention deficit hyperactivity disorder (ADHD) in adults is a prevalent, yet under-appreciated, under-researched and poorly understood condition. Given this, it is imperative that information and awareness regarding this condition are made more widespread, both amongst the general public and amongst healthcare professionals. Further, given our poor understanding of the aetiology of the condition, meaningful translational research that migrates into and better informs clinical practice must be a priority. In this brief review we highlight areas regarding the clinical diagnosis and management of ADHD in adults (guidelines, rating scales, pharmacotherapy, psychotherapy) as well as areas of promising translational research (genetics, neuroimaging, sleep and circadian rhythms, animal models of ADHD). We address some of the challenges presented for both clinicians and healthcare providers and research scientists working to improve the lives of those adults with ADHD.

OROS methylphenidate hydrochloride for adult patients with attention deficit/hyperactivity disorder

Introduction: Attention deficit/hyperactivity disorder (ADHD) is estimated to affect 4 – 5% of adults. Impairment across multiple domains of daily living can be mild to serious. OROS methylphenidate (MPH) was evaluated in two large adult clinical trials, and in 2008 it was approved in the USA to treat ADHD in adults aged up to 65 years.Areas covered: Products approved for adult ADHD; chemistry, pharmacodynamics, pharmacokinetics, metabolism, efficacy, safety, tolerability, abuse liability, regulatory affairs, and relative merits and limitations associated with OROS MPH; and complexities associated with diagnosis and treatment of ADHD are discussed in this review. The reader will gain an introduction to the epidemiology, features and special issues regarding clinical management of ADHD in adults. Key features and development of OROS MPH are presented, and unique characteristics of the delivery system and their implications for clinical use of the drug are discussed.Expert opinion: The OROS system delivers MPH in a highly consistent manner using osmotic pressure at a controlled rate over a 12-h duration of effect. Compared with immediate-release MPH, it provides a smoother pharmacokinetic curve, and it may show greater patient compliance, fewer missed doses and reduced abuse liability.

Challenges in Identifying and Managing Attention-Deficit/Hyperactivity Disorder in Adults in the Primary Care Setting

To examine how to screen for and establish a correct diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults and to identify the outcomes associated with untreated ADHD. PubMed was searched using the key words ADHD, adult, diagnosis, and primary care from the years 1999 to 2009. This search produced 50 publications. Publications were screened for data specific to the diagnosis or management of adult patients with ADHD in the primary care setting. The estimated prevalence of ADHD in adults throughout the United States is 4.4% or approximately 10 million adults. Adults with ADHD by definition must experience impairment from the symptoms of ADHD in at least 2 areas of their life. Despite significant impairment, only 1 in 10 adults with ADHD have received ADHD treatment within the past year. Given the high rates of undertreatment, primary care physicians, who provide much of the general adult mental health care in the United States, are increasingly charged with making the diagnosis of ADHD in adults. ADHD symptoms are often masked by comorbid psychiatric conditions or patient adaptations such as choice of occupation. One of the ADHD assessment tools, a short 6-item screener, can simplify identification and management of ADHD in adults and help identify which patients may require further evaluation. Primary care physicians should consult with other members of the health care community such as psychiatrists and psychologists when necessary, but should also develop a level of comfort with diagnosing and treating ADHD.

Management of attention-deficit hyperactivity disorder in adults: focus on methylphenidate hydrochloride

Attention-deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in young adults and causes significant psychosocial impairment and economic burden to society. Because of the paucity of long-term evidence and lack of national guidelines for diagnosis and management of adult ADHD, most of the data are based on experience derived from management of childhood ADHD. This article reviews the current evidence for the diagnosis and management of adult ADHD with special emphasis on the role of methylphenidate hydrochloride preparations in its treatment. Methylphenidate hydrochloride, a stimulant that acts through the dopaminergic and adrenergic pathways, has shown more than 75% efficacy in controlling the symptoms of adult ADHD. Although concern for diversion of the drug exists, recent data have shown benefits in preventing substance use disorders in patients with adult ADHD.

Efficacy and Safety of OROS Methylphenidate in Adults With Attention-Deficit/Hyperactivity Disorder

To assess the efficacy and safety of OROS methylphenidate (Concerta; McNeil Pediatrics Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc, Titusville, NJ) in the management of attention-deficit/hyperactivity disorder (ADHD) in adults. A randomized, 7-week, double-blind, placebo-controlled, dose-escalation, parallel-group study of OROS methylphenidate 36, 54, 72, 90, or 108 mg/d versus placebo was conducted in adults with ADHD. The primary end point was the Adult ADHD Investigator Symptom Report Scale. Other assessments included the Clinical Global Impressions-Improvement scale, a post hoc responder analysis, adverse events, and vital signs. Two hundred twenty-six subjects (56.2% male; mean age, 39.0 years; range, 18-65 years) were included in the intention-to-treat population (110 subjects on OROS methylphenidate; 116 subjects on placebo). OROS methylphenidate resulted in greater ADHD symptom improvement than placebo as demonstrated by a statistically significantly lower least squares mean change from baseline in Adult ADHD Investigator Symptom Report Scale total score at the final visit (last observation carried forward [LOCF]; P = 0.012). Subjects on OROS methylphenidate also had a significantly lower least squares mean Clinical Global Impressions-Improvement score at the final visit (LOCF; P = 0.008). A significantly greater proportion of subjects on OROS methylphenidate (36.9%, 38/103 subjects) were responders at the final visit (LOCF) compared with placebo (20.9%, 24/115 subjects; P = 0.009). OROS methylphenidate was well tolerated. Adverse events were reported by 93 (84.5%) of the 110 OROS methylphenidate-treated subjects versus 74 (63.8%) of the 116 placebo-treated subjects. No serious treatment-emergent adverse events and no deaths were reported. Similar mean changes from baseline to final visit (LOCF) for systolic and diastolic blood pressures for the OROS methylphenidate and placebo groups were observed. In a dose escalation ranging from 36 to 108 mg/d, OROS methylphenidate is effective and well tolerated in the management of ADHD in adults.

Once-daily medications for the pharmacological management of ADHD in adults

Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric disorder in children and adolescents. Symptoms of ADHD often persist beyond childhood and present significant challenges to adults. Pharmacotherapy is a first-line treatment option for ADHD across all age groups. The current review's goals are (a) to critically examine the current state of knowledge regarding once-daily formulations of pharmacotherapies for treatment of adults with ADHD and (b) to provide clinicians with evidence-based information regarding the safety, efficacy and tolerability of once-daily medications for adult ADHD. The reviewed body of evidence strongly supports the use of pharmacotherapy as a first-line therapeutic option for the treatment of adults with ADHD. The once-daily pharmacological agents are effective therapeutic options for the treatment of adults with ADHD. In the US, based on the available evidence, once-daily medications are currently underutilized in adults with ADHD compared to pediatric population.

Varenicline and Adult ADHD

Back to table of contents Previous article Next article LETTERFull AccessVarenicline and Adult ADHDJames A. Cocores M.D.,Mark S. Gold M.D.,James A. Cocores M.D.Search for more papers by this author,Mark S. Gold M.D.Search for more papers by this author,Published Online:1 Oct 2008AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Nicotine dependence is perpetuated by biobehavioral rewards generated as the result of nicotine’s interaction with the brain’s neurochemical systems. 1 Nicotine’s memory-enhancing reward is believed to result from its effects on specific nicotinic acetylcholine receptors. 2 Nicotine’s attentional, antidepressant, and antianxiety rewards are thought to be due to pathways between nicotinic acetylcholine receptors and noncholinergic neuronal subtypes that selectively traffic dopamine, norepinephrine, 5-hydroxytryptamine, and gamma-aminobutyric acid. 3 Varenicline is a new treatment for nicotine dependence and a member of the selective alpha4beta2 nicotinic acetylcholine receptor partial agonist class. 4 Central nicotinic acetylcholine receptors have been implicated in attention deficit hyperactivity disorder (ADHD), 5 and an alpha4beta2 antagonist counteracted nicotine-induced improvement in an animal model of ADHD. 6The first case of adult ADHD that responded to the addition of varenicline is reported here.Case ReportMs. A, a 26-year-old white woman, was self-referred in 2007 for difficulties staying focused, staying on task, and with reading comprehension. She fulfilled DSM-IV-TR criteria for ADHD, but was against the initial recommendation to begin taking a prescription stimulant. The administration of the antidepressants bupropion (150 mg) and venlafaxine (up to 150 mg), each alone or in combination with valproic acid, was met with either side effects or undesirable results. The medicine selected was based on office sample availability at Ms. A’s request because of financial problems. A wealthier patient had previously donated a barely used varenicline prescription that she had abandoned due to nausea. Ms. A agreed to undergo a trial of varenicline taking 0.5 mg in the morning, after eating a low-acid breakfast, with an 8-oz glass of water. Her reading comprehension and ability to focus improved substantially after reaching 1 mg b.i.d. Her mild hyperactivity improved marginally. She complained of no side effects as she completed 6 weeks, including weekends, of the clinic’s subsidized varenicline treatment trial. Her problematic ADHD symptoms fully resurfaced about 2 days after she ran out of varenicline. Ms. A agreed to continue medicine trials using affordable antidepressant, dopamine agonist, or nicotine replacement generics.CommentAlthough this report does not rule out the placebo effect, and a therapeutic connection between varenicline and ADHD cannot be established with certainty, this case does suggest that the new selective alpha4beta2 nicotinic acetylcholine receptor partial agonist class of medicines is useful in the management of adult ADHD. In particular, the varenicline-ADHD interface warrants further investigation using larger groups of subjects, more sophisticated study designs, and a variety of memory deficits such as depression and mild cognitive impairment.Nutritional Neuropsychiatry, Southcoast Psychotherapy and Education Associates, Boca Raton, Florida; Visiting Clinical Assistant Professor, University of Florida College of Medicine and McKnight Brain Institute, Gainesville, FloridaEminent Scholar, Distinguished Professor and Chairman, Department of Psychiatry, McKnight Brain Institute; College of Medicine, University of Florida, Gainesville, FloridaReferences1 . Rosecrans JA: The biobehavioral effects of nicotine: interaction with brain neurochemical systems, in The Clinical Management of Nicotine Dependence. Edited by Cocores JA. New York, Springer-Verlag, 1991, pp 53–65Google Scholar2 . Mansvelder HD, van Aerde KI, Couey JJ, et al: Nicotinic modulation of neuronal networks: from receptors to cognition. Psychopharmacology (Berl) 2006; 184:292–305Google Scholar3 . Rosecrans JA, Krynock GM, Newlon PG, et al: Central mechanisms of drugs as discriminative stimuli: involvement of serotonin pathways, in Stimulus Properties: Ten Years of Progress. Edited by Colapaert FC, Rosecrans JA. Amsterdam, Elsevier/North-Holland Press, 1978, pp 83–98Google Scholar4 . Lam S, Patel PN: Varenicline: a selective alpha4beta2 nicotinic acetylcholine receptor partial agonist approved for cessation. Cardiol Rev 2007; 15:154–161Google Scholar5 . Potter AS, Newhouse PA, Bucci DJ: Central nicotinic cholinergic systems: a role in the cognitive dysfunction in attention-deficit/hyperactivity disorder? Behav Brain Res 2006; 175:201–211Google Scholar6 . Ueno K, Togashi H, Matsumoto M: Alpha4beta2 nicotinic acetylcholine receptor activation ameliorates impairment of spontaneous alternation behavior in stroke-prone spontaneously hypertensive rats, an animal model of attention deficit hyperactivity disorder. J Pharmacol Exp Ther 2002; 302:95–100Google Scholar FiguresReferencesCited byDetailsCited ByNeuropsychopharmacology, Vol. 38, No. 3Expert Opinion on Drug Safety, Vol. 9, No. 3 Volume 20Issue 4 Fall, 2008Pages 494-495 Metrics PDF download History Published online 1 October 2008 Published in print 1 October 2008

Varenicline and Adult ADHD

Back to table of contents Previous article Next article LETTERFull AccessVarenicline and Adult ADHDJames A. Cocores M.D.,Mark S. Gold M.D.,James A. Cocores M.D.Search for more papers by this author,Mark S. Gold M.D.Search for more papers by this author,Published Online:1 Oct 2008AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Nicotine dependence is perpetuated by biobehavioral rewards generated as the result of nicotine’s interaction with the brain’s neurochemical systems. 1 Nicotine’s memory-enhancing reward is believed to result from its effects on specific nicotinic acetylcholine receptors. 2 Nicotine’s attentional, antidepressant, and antianxiety rewards are thought to be due to pathways between nicotinic acetylcholine receptors and noncholinergic neuronal subtypes that selectively traffic dopamine, norepinephrine, 5-hydroxytryptamine, and gamma-aminobutyric acid. 3 Varenicline is a new treatment for nicotine dependence and a member of the selective alpha4beta2 nicotinic acetylcholine receptor partial agonist class. 4 Central nicotinic acetylcholine receptors have been implicated in attention deficit hyperactivity disorder (ADHD), 5 and an alpha4beta2 antagonist counteracted nicotine-induced improvement in an animal model of ADHD. 6The first case of adult ADHD that responded to the addition of varenicline is reported here.Case ReportMs. A, a 26-year-old white woman, was self-referred in 2007 for difficulties staying focused, staying on task, and with reading comprehension. She fulfilled DSM-IV-TR criteria for ADHD, but was against the initial recommendation to begin taking a prescription stimulant. The administration of the antidepressants bupropion (150 mg) and venlafaxine (up to 150 mg), each alone or in combination with valproic acid, was met with either side effects or undesirable results. The medicine selected was based on office sample availability at Ms. A’s request because of financial problems. A wealthier patient had previously donated a barely used varenicline prescription that she had abandoned due to nausea. Ms. A agreed to undergo a trial of varenicline taking 0.5 mg in the morning, after eating a low-acid breakfast, with an 8-oz glass of water. Her reading comprehension and ability to focus improved substantially after reaching 1 mg b.i.d. Her mild hyperactivity improved marginally. She complained of no side effects as she completed 6 weeks, including weekends, of the clinic’s subsidized varenicline treatment trial. Her problematic ADHD symptoms fully resurfaced about 2 days after she ran out of varenicline. Ms. A agreed to continue medicine trials using affordable antidepressant, dopamine agonist, or nicotine replacement generics.CommentAlthough this report does not rule out the placebo effect, and a therapeutic connection between varenicline and ADHD cannot be established with certainty, this case does suggest that the new selective alpha4beta2 nicotinic acetylcholine receptor partial agonist class of medicines is useful in the management of adult ADHD. In particular, the varenicline-ADHD interface warrants further investigation using larger groups of subjects, more sophisticated study designs, and a variety of memory deficits such as depression and mild cognitive impairment.Nutritional Neuropsychiatry, Southcoast Psychotherapy and Education Associates, Boca Raton, Florida; Visiting Clinical Assistant Professor, University of Florida College of Medicine and McKnight Brain Institute, Gainesville, FloridaEminent Scholar, Distinguished Professor and Chairman, Department of Psychiatry, McKnight Brain Institute; College of Medicine, University of Florida, Gainesville, FloridaReferences1 . Rosecrans JA: The biobehavioral effects of nicotine: interaction with brain neurochemical systems, in The Clinical Management of Nicotine Dependence. Edited by Cocores JA. New York, Springer-Verlag, 1991, pp 53–65Google Scholar2 . Mansvelder HD, van Aerde KI, Couey JJ, et al: Nicotinic modulation of neuronal networks: from receptors to cognition. Psychopharmacology (Berl) 2006; 184:292–305Google Scholar3 . Rosecrans JA, Krynock GM, Newlon PG, et al: Central mechanisms of drugs as discriminative stimuli: involvement of serotonin pathways, in Stimulus Properties: Ten Years of Progress. Edited by Colapaert FC, Rosecrans JA. Amsterdam, Elsevier/North-Holland Press, 1978, pp 83–98Google Scholar4 . Lam S, Patel PN: Varenicline: a selective alpha4beta2 nicotinic acetylcholine receptor partial agonist approved for cessation. Cardiol Rev 2007; 15:154–161Google Scholar5 . Potter AS, Newhouse PA, Bucci DJ: Central nicotinic cholinergic systems: a role in the cognitive dysfunction in attention-deficit/hyperactivity disorder? Behav Brain Res 2006; 175:201–211Google Scholar6 . Ueno K, Togashi H, Matsumoto M: Alpha4beta2 nicotinic acetylcholine receptor activation ameliorates impairment of spontaneous alternation behavior in stroke-prone spontaneously hypertensive rats, an animal model of attention deficit hyperactivity disorder. J Pharmacol Exp Ther 2002; 302:95–100Google Scholar FiguresReferencesCited byDetailsCited ByNeuropsychopharmacology, Vol. 38, No. 3Expert Opinion on Drug Safety, Vol. 9, No. 3 Volume 20Issue 4 Fall, 2008Pages 494-495 Metrics PDF download History Published online 1 October 2008 Published in print 1 October 2008