Adult ADHD: Pippi is growing up

20. December 2011
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Attention Deficit-Hyperactivity Disorder (ADHD), a problem of  Fidgety Philip or Pippi Longstocking? For some time now psychiatrists have classified this ailment as an illness of children. Help is also needed by adult patients, yet it does not always need to be drug-based.

Four to six percent of all children suffer from the triad: inattention, hyperactivity and impulsivity. “ADHD does not end at eighteen years of age”, Professor Dr. Wolfgang Retz from the University Hospital of Saarland, Homburg, makes clear. He estimates that for up to 60 percent of those with ADHD the condition persists from childhood into adulthood – albeit with some symptoms significantly altered. “The physical restlessness of children and adolescents in many cases gives way to an inner restlessness and anxiety in adults”, says the psychiatrist. Avoided, for example, are things such as visits to the theatre or queues – due to sheer impatience. In many cases, patients also complain of frequent changes of mood – particularly pronounced in private-life or occupational stress situations. Then there is the risk of socially incompatible overreactions, which is especially dangerous in traffic situations.

A life full of dangers

Some patients stick out due to their – to put it mildly – daring driving style, which includes ending up in traffic accidents and aggressive behaviour behind the steering wheel. Anxiety disorders and depression appear increasingly in their everyday life, and those affected are more likely to reach for drugs or consume risky amounts of alcohol. The job can also be at the centre of problems, because a chaotic lifestyle is difficult to reconcile with the demands of most jobs. And ADHD patients, regardless of proven aptitude, often only achieve low levels in their careers, they have difficulty finding a place for themselves in the hierarchical structures of working life; they err more often and – unsurpringly – are more frequently dismissed from their jobs. Yet what is exactly happening inside their bodies is something researchers are trying to decipher step by step.

Mysterious restlessness

Genetic factors are a very popular causal account; studies of twins already yielded some years ago such indications. Now a large epidemiological study has shown associations with a number of genes. The mutations involved alter functional structures in the brain, such as transporters or receptors. Metabolism-related enzymes are also affected. This in turn probably leads to a lack of dopamine as well as norepinephrine in the frontal lobe of the cerebral cortex, which is something remediable using drugs such as methylphenidate.

Environmental factors, however, appear not to play a role, clues here only exist for toxic substances such as alcohol, drugs or chemicals during pregnancy. Scientists refrain from offering other theories given in the past. “The conditions under which a child grows up can indeed strongly affect the course and severity of ADHD. ADHD is nonetheless not a disease which can be explained by bad parenting, poor diet or excessive media consumption,” Retz makes clear.

Between fiction and dysfunction

Countless articles in the past have presented ADHD as a mass affliction, a fashionable illness, as a disturbance made up by the pharmaceutical industry or (simply) as a non-treatable variant of human behaviour. Patient numbers were revised up or down accordingly. Going beyond this debate, psychiatrists established the Wender Utah criteria particularly aimed at adults as part of the diagnosis process: experts speak of ADHD as attention deficit plus hyperactivity. Additionally, at least two of the following criteria must be met: emotional lability, disorganised behavior, problems with emotional control, impulsivity or emotional over-reactions.

However specialists do not in every case advise having therapy. If, as it may be, psychiatric and social consequences strongly restrict the quality of life, it’s then high time to act – by way of multimodal concepts including psychotherapy and pharmacotherapy. This combination, according to the guidelines of the German Society for Psychiatry, Psychotherapy and Neurology (DGPPN), can be useful, it allows symptoms such as poor-organisation behaviours (mostly via psychotherapy) and symptoms such as anxiety or emotional instability (via pharmacotherapy) to be challenged.

In search of the best drug

The authors of the DGPPN guidelines therefore mention, among other things, stimulants, antidepressants and individual substances such as phenylalanine or nicotine. Professor Michael Rösler from the University of Saarland.” According to expert opinion and evidence-based guidelines, methylphenidate is, in the treatment of adults with ADHD, the undisputed medication of first choice.” To date however things have looked bad for adults – there was medication with this agent only available in “off-label” form – without reimbursement through health insurance schemes, but with risk of liability for medical staff. The German Federal Institute for Drugs and Medical Devices (BfArM) has now also given the green light for patients of at least 18 years of age. “The broadened range of indications for methylphenidate with adults means a very substantial expansion of treatment options for patients with ADHD”, says BfArM President Professor Dr. Walter Schwerdtfeger. As a basis for his reasoning he refers primarily to two studies.

EMMA and QUEMA

As part of the EMMA-study, a phase III study of multicentric, randomised, double-blind design, 359 adults with ADHD took part. Of these, 241 received a verum for six months of up to 60 milligrams methlyphenidate administered by sustained-release and 118 received a placebo. Hereby there were benefits shown for the drug as an adjunct to psychotherapy. Good outcomes have also been produced by a follow-up study named QUEMA of 162 patients, whereby 84 received the active treatment, one milligram per kilogram of body weight. Compared to the placebo, with methylphenidate there was significant improvement in many functional as well as psychopathological variables. Another aspect to note: even after prolonged treatment, the effect did not diminish. Nevertheless pharmacologists advise, after more than twelve months of treatment, that use of the product be interrupted as part of a test process. Since methylphenidate acts as a sympathomimetic, maintainance checks of the heart rate and blood pressure are essential.

Will a wave of prescriptions come?

Following approval, reimbursement via statutory health insurance has been decided: it is here that the German Joint Federal Committee (G-BA) adapted the appropriate guidelines. Nevertheless, the panel will consider to what extent “restrictions and regulations for the protection of patients” are required – as the G-BA fears a dramatic increase in prescriptions to adults. Practitioners however criticise the fact that there are too few specialists in ADHD diagnosis and therapy. While it’s true that family physicians might be able to undertake care of the patients (alongside) experts, a specialist medical opinion is first and foremost supposed to be sought for first diagnosis.

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