How to Address Comorbid Conditions When Treating Adult ADHD

In this podcast taken from Psych Congress Elevate, Psych Congress Network ADHD Section Editor, Valdimir Maletic, MD, MS, answers questions about common challenges that arise when treating adult ADHD in patients with comorbid conditions, including psychotic disorders, depression, anxiety, and substance use. Dr Maletic is clinical professor of neuropsychiatry/behavioral Science, University of South Carolina School of Medicine, Greenville.

This Q&A session is moderated by Psych Congress Steering Committee member Andrew Penn, RN, MS, NP, CNS, APRN-BC.

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Read the Transcript:

Moderator: So a number of these have to do with comorbidities. We're reading articles that say antipsychotics and stimulants should not be used together.

Valdimir Maletic, MD, MS: Yep.

Moderator: Some articles state this is a dangerous practice due to unknown outcomes and increased chance of psychosis. Other articles show favorable outcomes. So what's your opinion?

Dr Maletic: So here's what my opinion is, and here is what well-conducted research suggests. Stimulants are not contraindicated in psychotic disorders. However, do not use it if somebody's in the midst of an acute psychotic episode. So treat psychosis, make sure it goes away, make sure that patient is stable. At that point, carefully add and titrate stimulants, meet frequently with the patient, make sure that there's no breakthrough psychosis. If one is treating ADHD-like symptoms in people with psychotic disorders, you are decreasing the risk of suicide. Paradoxically, you're actually, in the long run, decreasing the risk of destabilization. And you will have a patient with much greater likelihood of treatment adherence because they will remember to take their medicines and they're going to be better organized and they will be coming to their follow-up appointments. So two things, not a good idea during the acute psychotic episode, make sure the patient is well-stabilized, start low dose, monitor closely, respond if there are signs of emergence of psychotic symptoms. And in the long run, it seems to be beneficial.

Moderator: Okay. And I'm thinking probably similar advice for bipolar.

Dr Maletic: Similar advice for bipolar.

Moderator: Not in manic, but when ...

Dr Maletic: The group at Mass General actually has a study showing the number needed to treat in terms of reduction in bipolar six or seven. In other words, if you treat six or seven people with stimulants who have bipolar disorder, you're preventing one new onset of bipolar episode.

Moderator: Okay. Now a lot of this is flying in the face of what many people were taught.

Dr Maletic: Indeed.

Moderator: Which is that we should certainly treat substance use first.

Dr Maletic: Right.

Moderator: Treat depression and anxiety next.

Dr Maletic: Right.

Moderator: And then if there're attention problems, then we treat ADHD.

Dr Maletic: Right.

Moderator: So I'm hearing something quite different.

Dr Maletic: Yes. Co-treatment is good in terms of mania, not during acute mania and psychosis, not during acute psychosis. First stabilize, carefully introduce stimulants, closely monitor.

Moderator: Okay. So this is reminding me of 25 years ago, when people would say, "Well, you can't treat depression until somebody's substance abuse is under control."

Dr Maletic: Yeah. It's a vicious cycle.

Moderator: Now it's more of a dual-diagnosis approach.

Dr Maletic: Indeed, indeed.

Moderator: Okay. What about navigating tolerance concerns with stimulants?

Dr Maletic: There are individuals it's really hard to say how much of that tolerance are some of the factors that we have spoken. There's a lot of intercurrent stress. What appears to be tolerance is actually undiagnosed comorbidity. A scenario where the person is accumulating sleep debt, for example, stimulants seem to be less effective. And there appear to be some bonafide circumstances in which one does develop tolerance to stimulants. So all these scenarios, it's good to parse them out.

Moderator: Yeah.

Dr Maletic: So we have a better sense of what's going on, because if it's comorbidity, we need to treat it obviously.

Moderator: Yeah. Now, just sort of practical tips. I treat a lot of veterans at the VA, many of whom are trying to catch up with their lives. They've been in the military for a couple of years, they're doing college, they're trying to start a business.

Dr Maletic: Yeah.

Moderator: And they're trying to function on four hours of sleep.

Dr Maletic: Yeah.

Moderator: And they're saying, "I think I have ADHD because I'm getting Cs in school," and I say, "How much sleep are you getting?" And they say, "Four hours a night." Where would you go with that?

Dr Maletic: Well, setting appropriate goals.

Moderator: Yeah.

Dr Maletic: Right? If there are unreasonable expectations, I don't have a hard time saying, "You know, I understand where you're coming from, but I don't think that it is a reasonable expectation."

Moderator: Yeah. Yeah.

Dr Maletic: Something's got to give.

Moderator: Right.

Dr Maletic: You can't function in all these areas in your life and sleep four hours and we'll try to make it happen because we're using high doses of stimulants. It's going to be a boomerang. It's going to come back to hurt you.

Moderator: Yeah. Yeah. It seems like stimulants are the one class of meds that our patients often are asking for by name.

Dr Maletic: Indeed.

Moderator: And as a result, we're often most resistant to give.

Dr Maletic: Yeah. Yeah. And it's interesting because it's usually considered to be a red flag if the patient has a very specific idea which stimulant they want to take. And it happens to be a short-acting because long-acting ones don't really work well for them. I would be a little bit more on alert in that scenario.

Moderator: Yeah. How about combined therapy of non-stimulant and stimulant drugs, so an atomoxetine?

Dr Maletic: Right.

Moderator: Plus a stimulant or bupropion?

Dr Maletic: And viloxazine and stimulant. There is a study with viloxazine and stimulants going on right now. Atomoxetine, there are studies. And indeed the suggestion is that some individuals who are non-responders to stimulants may be responders if there is a combination, vice versa non-responders to non-stimulant adding stimulants. My favorite approach would be try to get as far as we can with non-stimulant and then introducing a stimulant.

Moderator: Yeah. Yeah. Because I've personally found that if you've had a stimulant, atomoxetine really doesn't go well.

Dr Maletic: Right. Yeah. One has very different expectation if one is stimulant-naive, so to say. I think they have better chances of having a more favorable response to non-stimulant.

Moderator: Yeah.

Dr Maletic: If they've taken stimulant, there's a little bit of a jarring experience, especially if they've taken immediate-acting stimulants. And they anticipate that, and if it doesn't happen, then it's not working.

Moderator: Yeah.

Dr Maletic: Or if it doesn't happen the first day, which it doesn't happen with non-stimulants, it's not working.

Moderator: It's like buspirone and benzos.

Dr Maletic: Indeed.

Moderator: Last question here. This is an interesting one. I'm finding women who have been on chronic benzos, speaking of which, benefit from stimulant therapy. Did benzos cause poor processing or were they misdiagnosed?

Dr Maletic: Well, it's interesting because we do know that benzos do interfere with cognition. If you look at the processing speed of somebody who's on benzos, even appropriate therapeutic range, their processing speed is like somebody who is legally intoxicated. So definitely benzos will interfere with cognition, attention, processing speed. And I'm not a big fan of trying to fix adverse reactions of one medicine with the other medicine.

Moderator: Yes.

Dr Maletic: Right?

Moderator: Swallow the spider to catch the fly medicine.

Dr Maletic: Right, right, right.

Moderator: And chasing side effects with more meds, which cause more side effects.

Dr Maletic: With another, indeed.

Moderator: Yeah. Yeah. Well, we are up against the clock here. I want to thank you for a fantastic presentation.

Dr Maletic: Yeah. Thank you very much.

Vladimir Maletic, MD, MS, is a clinical professor of psychiatry and behavioral science at the University of South Carolina School of Medicine in Greenville, and a consulting associate in the Division of Child and Adolescent Psychiatry, Department of Psychiatry, at Duke University in Durham, North Carolina. Dr. Maletic received his medical degree in 1981 and his master’s degree in neurobiology in 1985, both from the University of Belgrade in Yugoslavia. He went on to complete a residency in psychiatry at the Medical College of Wisconsin in Milwaukee, followed by a residency in child and adolescent psychiatry at Duke University. Dr. Maletic is a member of several professional organizations, including the Southern Psychiatric Association and The American College of Psychiatrists. In 2013-2014 he has served as a program chair for the US Psychiatric and Mental Health Congress. In addition, he has published three books, including The New Mind-Body Science of Depression, numerous articles and several book chapters. Dr. Maletic has participated in various national and international meetings and congresses. His special areas of interest include the neurobiology of mood disorders, schizophrenia, pain, and the regulation of sleep and wakefulness. Dr. Maletic is board certified in psychiatry and neurology.