Long-term treatment of adult ADHD in a naturalistic setting: Clinical predictors of attrition, medication choice, improvement, and response

Abstract

Objectives

The aim of this study was to identify clinical predictors of treatment attrition, medication choice, improvement and response to pharmacotherapy in adult attention-deficit/hyperactivity disorder (ADHD).

Methods

150 ADHD patients were enrolled and naturalistically followed-up for at least 4 months. Conners’ Adult ADHD Rating Scales–Observer: Screening Version (CAARS-O:SV) were used to measure ADHD severity.

Results

58 subjects (38.7%) were lost at follow-up, while 75 (50%) completed follow-up assessment, on average after 26.05 ± 11.99 weeks; 35 were treated with atomoxetine (ATX) and 40 with methylphenidate (MPH). Treatments were moderately effective (d = 0.72) and 37 patients (49.3%) were responders (≥30% CAARS-O:SV decrease). Patients lost at follow-up had lower inattentive symptoms, less generalised anxiety and family history of bipolar disorder, more amphetamine use disorder than follow-up completers. Compared to ATX-treated subjects, MPH-treated patients had greater severity of hyperactivity/impulsivity and were more frequently diagnosed with alcohol use disorder. While MPH and ATX showed similar efficacy, more pronounced improvements were observed in patients with combined ADHD, anxiety and substance use disorders. ADHD severity and comorbid substance use positively predicted response.

Conclusions

Consensus-based hierarchical treatment of ADHD comorbidity is not consistently supported. Comorbid anxiety, mood and substance use disorders should not discourage the treatment of adult ADHD.

Keywords:

• Attention-deficit/hyperactivity disorder
• methylphenidate
• atomoxetine
• substance use disorders
• anxiety disorders

Acknowledgements

None.

Statement of interest

GP has acted as consultant of Lundbeck, Angelini, FB-Health. He received grant/research support from Lundbeck and Angelini. He is on the speaker/advisory board of Sanofi-Aventis, Lundbeck, FB-Health, Angelini. All other authors declare that they have no conflicts of interest.

Data availability statement

Data are available on reasonable request from the corresponding author.