Aiming for remission in adults with attention-deficit/hyperactivity disorder: The primary care goal

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is often undiagnosed and undertreated in adults, resulting in wide-ranging problems and functional deficits in patients’ lives. In addition, psychiatric comorbidities unrelated to symptom severity may be present. However, effective treatment that can alleviate symptoms and bring about meaningful improvements in functionality is available. Primary care providers can play a crucial role in recognizing and diagnosing ADHD, initiating and monitoring treatment, and obtaining consultations or arranging referrals when necessary, all with the goal of achieving and maintaining remission. Fulfillment of this role requires a practical understanding of the diverse clinical manifestations of ADHD in patients stratified by age and sex, and familiarity with current treatment guidelines. Although there is no absolute consensus on the criteria by which remission is defined, treatment response may be guided by objective ratings of global symptom severity and patients’ self-reports of changes in their ability to cope with routine daily tasks, academic and vocational responsibilities, and social relationships. Although there has been much research into the genetic and neurophysiologic basis of ADHD, it is more important for primary care providers to appreciate that ADHD is a chronic condition requiring lifelong follow-up and that clinical presentation and response to treatment can vary widely among patients and over time in the same patients. Such variability makes the management of ADHD challenging, but the opportunity to bring about dramatic improvement in patients’ lives makes it imperative for primary care providers to be competent in this area. This review provides primary care clinicians with a practical definition of remission in adults with ADHD, to emphasize that symptom reduction does not necessarily mean intact functionality, and to suggest a multidisciplinary approach aimed at achieving the greatest possible reduction of symptoms and normalization of functionality.

Keywords:

• Attention-deficit/hyperactivity disorder
• primary care
• adults, remission

Acknowledegments

Financial support for writing and editing portions of this manuscript was provided by Shire Development LLC (Wayne, PA) to SCI Scientific Communications & Information (SCI, Parsippany, NJ) and Complete Healthcare Communications, Inc. (CHC, Chadds Ford, PA). Under the direction of the authors, writing assistance was provided by Michael L. Pucci, PhD, an employee of SCI, and by Craig Slawecki, PhD, an employee of CHC. Editorial assistance in the form of proofreading and copyediting was also provided by SCI and CHC. The authors exercised full editorial control and had final approval of the manuscript for submission to Postgraduate Medicine.

Declaration of interest

Greg Mattingly, MD, declares a relationship with Shire, Sunovion, Alcobra, and Noven as a recipient of research funds and with Shire, Sunovion, and Noven as a consultant and speaker. Larry Culpepper, MD, MPH, declares an advisory relationship with Boehringer Ingelheim, Forest Labs, Janssen, Jazz, H. Lundbeck, Merck & Co., Pfizer, Reckitt Benckiser, Sunovion, and Takeda. He is also a member of Merck’s speakers’ bureau and a stockholder in M3. Thomas Babcock, DO, is an employee and stockholder in Shire. Valerie Arnold, MD, has no conflicts of interest to declare.