2009, Number S1
Algoritmo de Tratamiento Multimodal para Adultos Latinoamericanos con Trastorno por Déficit de Atención con Hiperactividad (TDAH)
Ortiz LS, Lichinsky A, Rivera L, Sentíes CH, Grevet E, Jaimes MA
Full text
Language: Spanish
References: 38
Page: 45-53
PDF size: 125.29 Kb.
ABSTRACT
Introduction: The First Latin American Consensus on ADHD, held in June 2007, resulted that same year in the publication of a pharmacological treatment algorithm for adult ADHD. Methylphenidate (MPD) and atomoxetine were identified as first line medications for this age group. Following the Second Latin American Consensus on ADHD in Mendoza, Argentina, in October 2008, it was deemed necessary to complement the pharmacological algorithm with psychosocial treatment as part of the Latin American algorithms. In the combined and interdisciplinary ADHD treatments, stimulant and non-stimulant medications are used after the diagnostic evaluation, and these have proved effective reduction in the main symptoms of ADHD (attention deficit, hyperactivity and impulsivity). However, these medications do not alter the dysfunctions of adults suffering from the disorder: poor academic performance, taking longer than the general population to complete professional studies, employment problems such as leaving jobs, dismissals and disciplinary procedures, poor handling of finances, conflicts with partners and family members, poor time management and performance of tasks etc. that lead to frustration, low self-esteem and feeling unable to cope. Psychosocial interventions, combined with medications, have proved effective in tackling these dysfunctions. In regard to pharmacological treatment, we reviewed the past five years’ research into drug products approved by the USA Food and Drug Administration (FDA), stimulants and non-stimulants that have proved effective in reducing the main symptoms of adult ADHD, and bupropion/amfebutamone, fulfilling the purpose of this study, namely to summarize the scientific knowledge of adult ADHD and to create systematic guidelines for the diagnosis and treatment of adults suffering from the disorder in Latin America.Method: A group was formed of six specialists in psychiatry, child and adolescent psychiatry, neurology and clinical psychology from Argentina, Brazil and Mexico all members of the Latin American League for ADHD Research (LILAPETDAH). A review was carried out of the MEDLINE, EMBASE, OVID, Cochrane and PUB MED databases from 2003 to 2008 and a selection was made of English-language research articles on the diagnosis, prevalence, comorbidity, psychosocial impact, pharmacological and psychosocial treatment; in January 2009 tasks were apportioned and the summaries were completed in May 2009. In June 2009, the coordinator and a specialist in the group compiled the information into a final document, mainly using controlled studies, meta-analysis, etc. to propose the pharmacological treatment algorithm and psychosocial interventions for adult ADHD in 2009.
Results: One topic discussed was the prevalence of ADHD in adults up until 2005. In order to find an estimate, longitudinal studies were carried out to follow up on children who suffered from the disorder until their adulthood, showing a 3.3-3.5% prevalence rate. Some investigators estimated the prevalence of adults with ADHD in a general population sample of the USA and reported a rate of 4.4%. In this sample, most cases went untreated and the only treatment received was for the comorbid psychiatric disorders including substance abuse. A recent metaanlasis over 100 publications from every continent, reported the combined ADHD rate of 5.29%. Variations between countries were mainly due to methodological reasons. The study of ten national surveys in Europe, Latin America, the Middle East and the USA to investigate the prevalence of mental disorders, including adult ADHD, showed a global prevalence of ADHD of 3.4%, the highest rates being reported in France 7.3%, USA and Netherland 5% and the lowest being in Mexico and Colombia 1.9% and Spain 1.2%. These results on low levels of prevalence among adults are more related to bias in diagnostic criteria than actual reality.
There are many limitations to the use of DSM IV criteria for the clinical diagnosis of adults, as the criteria were designed for children. The three symptoms (attention deficit, hyperactivity and impulsivity) manifest themselves differently with adults, as the criteria are not sensitive enough to detect manifestations shown in this age group. Furthermore, impulsivity in adulthood is considered as a key feature of this disorder that leads to serious behavioral and cognitive manifestations, which the DSM only evaluates with three criteria. Other investigators had discussed at what age ADHD begins, and suggests the existence of the late onset of ADHD among adult sufferers shows that it is not essential to consider it starting before the age of 7. This study indicates that the many difficulties facing adults when recalling their infancy and forgetting information must be taken into account when making the diagnosis and it therefore recommends using information from third parties to support the retroactive diagnosis. Clinimetric instruments are now available in Spanish to assist in clinical evaluation, such as the World Health Organization’s (WHO) ASRS.V.1 and ASRS.1.1 and the FASCT in Mexico with a selfadministered version and another one for the informant that uses screening tools. The Spanish-language version of the structured International Neuropsychiatric Interview (MINI PLUS) for the diagnosis, which explores principle psychiatric disorders, has a section on adult ADHD. The presence of comorbid disorders is very frequent and this makes it difficult to diagnose ADHD, given that other cognitive, social and work-related dysfunctions share the same symptoms. Studies show that 35 to 50% of depressive episodes throughout their lives. 40 to 60% of patients with the disorder manifest one or more of the diagnoses in the anxiety spectrum during their lives. 15.2% of adults suffering from ADHD have abused drugs, mainly alcohol and tobacco. Substance abuse complicates the diagnosis among adults, though it is important to point out that patients receiving pharmacological treatment with stimulants do not appear to face an increased risk of substances use disorders. Comorbidities and other pathologies shown by adults with ADHD must be diagnosed and treated promptly and independently of the specific and integral treatment of ADHD. Adults suffering from the disorder have the following symptoms: having difficulty in coping with waiting, making impulsive decisions, being easily distracted by irrelevant thoughts, having trouble remembering things and staying alert and awake in boring situations, not remembering as many childhood events compared with non-sufferers. The psychosocial impact is reflected in academic, vocational and work-related instability, conflictive relationships with partners, problems raising children and social lives. In regard to pharmacological treatment, there is a description of results of controlled studies, meta-analysis and in some cases open studies on drug products approved by the USA FDA, stimulants and non-stimulants that are effective in addressing the main adult ADHD symptoms and the bupropion/amfebutamone dopamine reuptake inhibitor. Psychosocial interventions for adults with ADHD include psychoeducation, cognitive behavioral therapy, individual and group therapy, neurocognitive strategies and social skills training. Studies show positive changes in behavior and attitude for those suffering from the disorder. The decision tree had three stages: Stage 0 – Focus on clinical assessment, diagnosis and psychoeducation. Psychoeducation involves understanding the clinical condition, and provides very precise explanations about the combined treatment and pharmacological prescriptions. There is no scientific evidence for the combination and escalation of pharmacological an psychosocial interventions, these recommendations were obtained by consensus of the authors. Stage 1 – Recommend using extend release or immediate release MPD, atomoxetine or amphetamines (in countries where available). For partial responses, proceed to stage1A. Stage 1A – Extended psychoeducation is combined with medication and cognitive strategies and social abilities. For partial responses proceed to stage 2. Stage 2 recommends a change in medication, if treatment had begun with short-acting MPH, change to long-acting MPH. If treatment began with the latter, change to the immediate release. If treatment began with amphetamines, change to immediate release or extended release MPH or atomexetine. For partial response proceed to stage 2A. In Stage 2A, combine medications with a psychoeducational refresher, review previous interventions, and behavior cognitive program. For partial responses processed to stage 3. Stages 3 recommends bupropion/amfebutamone, assess the response 4 weeks later, adjust the dose and observe continued response.
Conclusions: The adult ADHD treatment algorithm is the result of a study by a Latin American group of mental health specialists, recommends a combined treatment using stimulant and non-stimulant drug products and psychosocial interventions.
REFERENCES
Almeida Montes L, Friederichsen Alonso A, Olivo Hernández A, Rodríguez Carranza R, De la Peña F et al. Construction, validity and realiability of the screening scale «FASCT» for attention deficit hyperactivity disorder in adults (self reported and observer versions). Actas Esp Psiquiatr 2006;34:231-238.
Ferrando L, Franco-A L, Soto M, Bobes J, Soto O et al. Instituto IAP. M.I.N.I. Mini International Neuropsychiatric Interview. Versión en español 5.0.0.DSM-IV. Adaptat de: Lecrubier Y, Weiller E, Hergueta T, Amorim P, Bonora LI, Lépine JP. (Hôpital de la Salpétrière). Sheehan D, Janavs J, Baker R, Sheehan KH, Knapp E, Sheehan M. (University of South Florida). Madrid: Edit. Masson; 1998.