[Music] Welcome to the Australian Prescriber Podcast. An
independent, no-nonsense podcast for busy health professionals.

Hi, and welcome to this Australian Prescriber Podcast. I’m Dr
Justin Coleman, a GP at Inala Indigenous Health in Brisbane. And with me today,
I have a fellow Queenslander, Professor Shuichi Suetani, who works at the
Institute for Urban Indigenous Health in Brisbane, amongst his other hats.
Welcome, Shuichi.

Well, thank you so much for having me, Justin. It’s such a
privilege to be here.

Wonderful. We’re talking today about the pharmacological
management of ADHD [attention deficit hyperactivity disorder] in adults, which
you were mentioning to me, Shuichi, was not really much of a thing when you
trained in medical school, but has now become a majority of your current
psychiatric practices.

That’s exactly right, Justin. I would even say when I started
training in psychiatry 10 years ago, as an adult psychiatrist, I never had
any formal training in ADHD. But in the last 5 years, like most listeners,
I suspect, everyone is talking about ADHD and probably 80% of my patients are
coming in with ADHD-related concerns.

I’m very glad you’re a quick learner, Shuichi. At the start of
your article, which is in Australian Prescriber, you do state that ADHD affects
around 3 to 5% of adults. As I often caution with these podcasts, the
prevalence studies tend to cast a wide net, whereas the therapeutic
intervention studies are usually not done on the 3 to 5%. They’re far more
likely to be done on the most severe 1%.

So, the therapeutic interventions don’t necessarily apply to the
entire 5% if you have wide diagnostic criteria. I only mentioned that as a
caution because, of course, every GP and pharmacist would be seeing in the last
couple of years, a very large increase in people who have ADHD or who may have
ADHD and are looking for treatment. Talking of which, so someone comes into
your practice and they may have symptoms of ADHD, I was wondering if you could
talk us through the initial psychiatric assessment that you would make and
whether you do this quickly or over a period of time.

Yeah. I think that’s a really good question and a very timely one
in Queensland, given that since December last year, GPs can now diagnose and
treat ADHD in adults. And I suspect that a lot of other states and territories
will do the same in coming time. I think if there’s one take-home message in
terms of assessment of ADHD, that would be there’s nothing special about ADHD
as such.

And the really important thing not to fall into is that thing
about if you’ve got a hammer, everything looks like a nail. So if you go in
thinking we are assessing ADHD, you probably are going to find ADHD. And that’s
just the nature of how diagnostic criteria in psychiatry are written. We wrote in
the paper something like 17 different psychiatric diagnoses have
inattentiveness as one of the main features for the condition, and I think it’s
number 3 in the DSM [Diagnostic and Statistical Manual of Mental Disorders]
list of most common conditions.

And if you think about number one, difficulty sleeping. Again,
people’s ADHD come with symptoms like that. When someone asks you, ‘Do I have
ADHD?’ the psychiatric assessment is all about making sure that you’re looking
at other things that may cause the symptoms. Some studies will tell you about
80% of people with ADHD will have some kind of a comorbid psychiatric condition
in addition to ADHD. So, it’s a huge number.

In my clinical practice, I can honestly say that it’s very unusual
for me to see an adult with just ADHD, straightforward ADHD. So it’s always
good to assume that there’s something else going on when someone comes in
requesting ADHD assessment.

I think that is sage advice. I recently did a podcast on childhood
ADHD and I’m interested in your take on how adults differ. You’ve mentioned the
first one is that there’s much more likely to be other things going on, and
that can be often in a negative way in the sense that they may have substance
issues or various other mental health diagnoses, and I guess a physical way in
that their bodies are older, their cardiovascular systems are older.

And another way they differ, you point out in the article is that
a lot of adults will have had time to develop strategies, either at home or at
work, in order to try to deal with their symptoms, and they have more chance at
modifying their life accordingly than children have.

Yeah, and I think your brain matures as you get older. The
comorbidities are interesting ones because for kids, you’re probably looking at
things like learning difficulties or intellectual impairment or autistic
spectrum disorder. Whereas I think for adults, we probably don’t look at those
things as much as paediatrician would do, but I’ll be thinking more about
anxiety, depression.

So physical conditions, things like anaemia and low
hypothyroidism, easily reversible causes of inattention. I also think
obstructive sleep apnoea is something that gets missed quite a bit, especially
people who are kind of middle-aged and up. And what we meant by people learning
to adjust to their challenges better is even though we kind of think of ADHD as
a brain disorder, the environment you are in impacts your behaviour so much.
And it’s much like any other mental illness.

I start seeing people, probably aged 15 or 16 when they go
out of paediatric care. And I often see young people who come to me doing
really well, but then leave school when he’s, let’s say 16, gets into some kind
of trade work where there’s a structure, but not in the same way, classroom
structure, school and stuff like that. And the function disappears because the environment’s
changed and some of them may decide to stop taking medication because they
don’t need to because they can focus on what they want to do at the times that
they want.

You’re not really just looking at the symptoms here. You’re
looking at the impairment the symptoms cause. And in adults, there’s a lot more
flexibility in terms of how you cope with the environment to manage the
behaviour.

I am always fascinated by that background to any of these
conditions that we talk about in Australian Prescriber. So you’ve mentioned
some of the things we look for, anaemia and thyroid, and essentially
cardiovascular health, which takes into account blood pressure, heart rate, and
liver, kidney, cardiometabolic status.

For those we’re considering putting on medication, what sort of
cardiovascular risks are we particularly concerned about?

There’s clear guidelines from the Bi-national ADHD Association in
terms of when to refer to cardiologists, and I think it’s really handy. So we
know that at least in the short-term when we put people on most ADHD
medications, except for maybe guanfacine, your blood pressure and your heart
rates will go up.

And at the populational-level, it doesn’t look like clinically, a
significant increase, but I’m sure in individuals, you will get people whose
blood pressure will go up and that might concern you. I think we just need to
be mindful that when we talk about evidence in ADHD, often we are mixing up
different age groups. So someone in the 40s might have different risk profile
compared to a 5-year-old who gets started on psychostimulant medication.

The specific cardiac examples that the guidelines suggest are
things like actual active cardiac symptoms, like shortness of breath, fainting,
palpitation, chest pain, and also heart murmur. Mainly, you’re worried about
things like QTc prolongation and make sure that there’s no undetected cardiac
structural abnormalities. And I think I’m a psychiatrist, Justin, so I’ll
probably have a very low threshold getting cardiology input.

I think otherwise a good GP with a stethoscope is an alternative
sometimes. Yes.

I’m very mindful that GPs probably feel a lot more comfortable
dealing with the cardiac side effects of ADHD medications than we do.

Sure.

The other thing that we worry about is the appetite suppressant
side effect of psychostimulant medication and atomoxetine to some extent. For
adults, I don’t actually worry about it as much because most people, when I
talk about this side effect of, ‘Oh, you might lose weight,’ people are
actually quite happy about it. So again, it’s not like kids where you have to
worry about the height and all that kind of stuff.

I also tell people about the risk of seizure. I think the evidence
is a little bit mixed, but again, just as information, there’s a chance that it
might lower your seizure threshold. If anything like that happens, stop the
medication straightaway and let us know, that kind of stuff. Your heart, your
seizure risk, and your appetite are the 3 main things that I always talk to my
adult patients about before starting medication.

So Shuichi, just moving from where you’re perhaps less
comfortable, which is the things at the other end of the stethoscope to where
you’re very comfortable, pharmacology itself, could you briefly run us through
the psychostimulants and the non-psychostimulants for ADHD?

Yep. It’s pretty simple because you’ve only got really, 4
medications that you’re playing with.

Yep.

So the way that I think about it is you’ve got 2 different types
of ADHD medications. So you’ve got psychostimulants and non-psychostimulants.
Psychostimulants gets divided into 2 different subtypes, methylphenidate and
amphetamines.

So methylphenidate, I’m going to use the trade name just because
that’s how the different formulations are structured. So you’ve got your
short-acting (SA) formulation, Ritalin SA is the main one that we use. For the
long-acting methylphenidate, you’ve got your Concerta and Ritalin LA
[long-acting]. It’s something like Ritalin LA is 50-50 short-acting and
long-acting, and Concerta’s something like 75-25 long-acting, short-acting. So
Concerta actually lasts a little bit longer in the system.

With amphetamines, you’ve got the short-acting ones, your
dexamfetamine, and the long-acting one is your lisdexamfetamine, which is
Vyvanse is the trade name for that. In terms of non-psychostimulant
medications, we’ve got options like atomoxetine and guanfacine, and sometimes
clonidine gets used as well. But I think in practice for adults, we often end
up using atomoxetine as a non-stimulant choice for ADHD pharmacological
treatment for adults.

So in practice, psychostimulants seem to have better evidence for
efficacy. So if there’s no contraindication or no concerns about any particular
medication, I usually start with the psychostimulants, so either Vyvanse,
Ritalin (or methylphenidate). And if that doesn’t work, I’ll try other
psychostimulants, so that’ll be step 2. And if that doesn’t work, you can
always go for non-psychostimulants. And in practice, the majority of time, I
end up using atomoxetine as a number 3 choice for most people.

Thank you. And in terms of side effects to watch out for, I think
we’ve covered the blood pressure going up and the pulse rate going up, and we
need to keep an eye on the cardiovascular side. Also, it does increase the risk
of serotonin syndrome if combined with other medication.

Yeah. I think serotonin syndrome is something that most
psychiatrists are overcautious about because we probably have seen the cases
where things have gone quite bad. But again, going back to a lot of
comorbidities, most of these patients probably would be on some kind of other
antidepressant medications or psychotropic medications even before they come
and see you for ADHD treatment.

And I find that for most people, you need to be mindful of
coexisting antidepressant medication such as SSRIs [selective serotonin
reuptake inhibitors] and SNRIs [serotonin noradrenaline reuptake inhibitors],
but most people can use ADHD medication quite safely as long as you monitor for
symptoms and side effects, and start low and go slow. Like anything else, if
you’ve got other medications in place already, just take your time, starting,
going up slowly.

Sure. And I guess being aware of other substances as well, both
licit and illicit, so alcohol and opioids, cannabis, and various other
substances. We won’t go on about it, but we do also need to keep an eye out for
misuse of the stimulants.

Yes. Sometimes ADHD medications, especially psychostimulants can
increase your risk of psychosis, especially when used with illicit substance.
So it’s important to be mindful of people using other things as well.

Okay. So the patient has been started on an ADHD medication. We
need to see how they’re responding. Like so many conditions, we see them often,
early on. And then if they’re stable, we don’t have to keep such a close eye.
You mentioned there’s an adult ADHD self-report scale which can be helpful.

Yeah. I find that screening for ADHD is probably not a very useful
use of your time because everyone just comes up with high symptoms anyway. But
if you keep doing the same screening tool over time, sometimes you see the
benefit of the changes in the symptoms over time. And that’s quite a useful way
of checking how things are going, the response to the medication that you’re
using.

Yes. And at the same time, we’re looking at first, side effects
and I think we’ve covered the cardiovascular ones. So we’ll look at their heart
rate, BP [blood pressure], look at their weight. You mentioned the appetite
suppression. And I guess, some psychiatric-type symptoms, anxiety, sleep
disturbance, and you certainly mentioned psychosis. They’re the sorts of things
you look out for in terms of once you start the medication?

Yeah. And you’re just looking at the benefits, side effects, both
physical and psychiatric. It’s always useful to check about compliance in terms
of missed doses. Some people decide not to take things on the weekends, and
given that psychostimulants are controlled medication, you’ll always be
checking and making sure that people are getting benefits from the treatment
that we’re providing.

And if the patient doesn’t seem to be getting any better, you
mentioned adherence, obviously is one factor. What other factors can there be
if nothing seems to be changing?

I think it’s always important to remind yourself in psychiatry,
diagnosis is always provisional or it’s always a working diagnosis. Especially
for something like ADHD in adulthood where the symptom clusters are so
nonspecific and comorbidities are so common, you need to always go back and
say, ‘Okay, is this person not getting better because we’re not treating the
right things?’

So always think about if the diagnosis is correct or not. If
someone’s not responding well, that’s probably the first thing that I think
about in terms of where to go from there.

In terms of the long-term benefits of ADHD medication, I know for
opioids in chronic pain, most of the studies are showing benefit in the first 6 weeks
and up to 12 weeks, and there’s actually very little evidence that it
makes a whole lot of difference in the longer term.

ADHD drugs in adults have been less studied, and there have been
far fewer years to study. Where do we stand in terms of the long-term efficacy
and effect on one’s life and symptoms?

Yeah. I think that’s a really good question because when I started
learning about ADHD, which would’ve been only 5 years ago, that was one of
the striking things about ADHD medications. These medications that have been
run for long, long time, and our paediatric colleagues have been using it for
years and years, but I think we don’t always remember that this big wave of
adults, people who are older than 18 using medication consistently is probably
something new that hasn’t really happened before.

So as such, we don’t really have a good body of evidence for
long-term effect, especially for older people. So for example, using
psychostimulants starting from 5 until you’re 75 is going to be quite different
from starting amphetamine when you’re 45, for example. So we don’t really know
the evidence.

I think in setting like this, you always go back to, okay, what
are the benefits? What are the side effects? Are there non-pharmacological
changes that people can make that’s going to make things better? And like I
said, ADHD is not just about symptoms, it’s the environment that’s important.
The impairment comes from the environment that you live in as much as the
symptoms that you’re experiencing.

We’re almost out of time. Professor Shuichi Suetani, what are your
top tips? What do you tell patients when you start the medication? Any hints
that you give them before they walk out the door?

I think there’s a lot of positive placebo effect to ADHD
medications, where people come in with a lot of expectation that it’s going to
change their lives. The funny thing is a lot of people tell me that it’s been a
life-changing thing, getting diagnosed and treated for ADHD. Even though the
data is reasonably short term, it’s a very effective medication for ADHD.

But what I try to explain to people is pills don’t teach skills.
It is something that’s going to help you. It’s going to give you an opportunity
to do things that you might not have been able to do because of ADHD symptoms,
but that’s your starting point. And what I often say is medication becoming
almost like a silver bullet.

So we just need to make sure that even though it’s a very
effective intervention, it should always be one part of a wide range of changes
that you make in your life to treat symptoms of ADHD. And medication’s not
going to fix everything, but it’s going to give you an opportunity to make
changes that’s going to make your life better.

Professor Shuichi Suetani, on that note of philosophical advice
for our patients, I thank you for joining us on today’s podcast.

Thank you so much, Justin.

[Music]

Shuichi Suetani received honoraria from Sage Publishing, Inside
Practice Psychiatry and groupH. He also received advisory fees from Seqirus in
relation to cariprazine.