Guidelines for the Treatment of

Adult ADHD with Psychostimulants

This guideline covers the diagnosis and management of social and/or educational or occupational impairment
Introduction

attention deficit hyperactivity disorder (ADHD) in adults in multiple settings should be diagnosed with ADHD.
(>18 years old). Determining the severity of ADHD is a matter for clinical
judgement, taking into account severity of impairment,
ADHD is a heterogeneous behavioural syndrome pervasiveness, individual factors and familial and social
characterised by the core symptoms of inattention, context.
hyperactivity and impulsivity. Not every person with
ADHD has all of these symptoms – some people are Symptoms of ADHD can overlap with those of
predominantly hyperactive and impulsive; others are other disorders, and ADHD cannot be considered a
mainly inattentive. categorical diagnosis. Therefore care in differential
diagnosis is needed. ADHD is also persistent and many
Symptoms of ADHD are distributed throughout the young people with ADHD will go on to have significant
population and vary in severity; only those people difficulties in adult life.
with at least a moderate degree of psychological,

Person-centred care
Treatment and care should take into account peoples’ individual needs and preferences. Good communication is
essential, supported by evidence-based information, to allow people to reach informed decisions about their care.

Diagnosis of ADHD Diagnosis should be made when symptoms of

hyperactivity/impulsivity and/or inattention:
Diagnosis should only be made by an adult
• meet the criteria in DSM-IV or ICD-10
psychiatrist, particularly one with an interest or
(hyperkinetic disorder), and
expertise in managing adult ADHD. A diagnosis
of ADHD in adulthood should not be made in the • are associated with at least moderate
absence of evidence of symptoms in childhood. This psychological, social and/or educational or
could include collateral history from a parent or school occupational impairment based on interview and/or
reports. In the absence of this neuropsychological observation in multiple settings, and
testing should be considered to determine if the • are pervasive, occurring in at least two settings and
patients cognitive profile is consistent with ADHD. • are not better explained by another disorder such as
depression, anxiety or a substance use disorder and
Diagnosis should be based on:
• corroborating evidence (if possible) is available of
• a full clinical and psychosocial assessment. Discuss symptomatology in childhood.
behaviour and symptoms in the different domains
and settings of the person’s everyday life As part of the diagnostic process, include an
assessment of needs, coexisting conditions, social,
• a full developmental and psychiatric history, and
familial, educational or occupational circumstances
• observer reports and an assessment of mental state. and physical health.

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ADHD in adults

Care Pathways in Adults

Adults with previously

Adults with suspected diagnosed ADHD (as
ADHD – not previously a child) and ongoing
diagnosed symptoms of ADHD

Referral to adult psychiatrist Referral to an adult

for assessment, diagnosis psychiatrist for secondary
and treatment assessment
(ensure no other mental (ensure no other mental
health diagnosis) health diagnosis

Treatment Options: Treatment Options:

• Psychological • Psychological
• Drug treatment • Drug treatment
( Note State regulations) ( Note State regulations)

Identification and referral to ongoing care

Refer adults with ADHD symptoms and moderate/ Refer adults who have been treated for ADHD
severe impairment that have persisted from childhood in childhood/adolescence and have symptoms
and are not explained by other psychiatric diagnoses suggestive of continuing ADHD associated with
(although other psychiatric conditions may coexist) to moderate or severe impairment to adult psychiatric
an adult psychiatrist for assessment, diagnosis and services for ongoing assessment and management.
ongoing managment.

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Treatment
It is important to note that many adults with ADHD • heart rate and blood pressure
will also suffer with a co-morbid mental health • weight
or substance use disorders. As a result of their
ADHD they may also have vocational, educational • family history of cardiac disease and
and social problems. Treatment needs to address examination of the cardiovascular system
these issues in a holistic way as simply providing • an electrocardiogram (ECG) if there is past
treatment for their ADHD may not improve their medical or family history of serious cardiac
overall function. disease, a history of sudden death in young
Prior to any prescribing of medication, a full family members or abnormal findings on cardiac
psychiatric assessment must be conducted. This examination (especially in patients prescribed
should include: dexamphetamine)
• risk assessment for substance misuse and
• a full mental health and social assessment
drug diversion. Information about history of
• a full medical history and physical examination, drug dependence is available from the Drugs of
including:
Dependence Unit – Ph 3328 9890
• assessment of history of exercise syncope,
undue breathlessness and other cardiovascular
symptoms

Drug treatment should be:

• started only under the guidance of an adult psychiatrist
• part of a comprehensive treatment program addressing psychological,
behavioural and educational or occupational needs

Psychological Drug treatment –

treatment choice of drug
Consider group or individual CBT for adults who: If a stimulant is considered appropriate, then
methylphenidate or dexamphetamine* are the
• are stabilised on medication but have persisting choices available. However, atomoxetine can also
functional impairment associated with ADHD be considered a first line drug if there are concerns
• have co-morbid symptoms of anxiety or depression about drug misuse or the patient would prefer a non
• have partial or no response to drug treatment or stimulant medication. It can also be useful if the
who are intolerant to it patient has co-morbid anxiety.
• have made an informed choice not to have drug Consider changing to the alternative drug if symptoms
treatment do not respond to the first choice or the person is
• have difficulty accepting the diagnosis of ADHD and intolerant to it after an adequate trial (usually about 6
accepting and adhering to drug treatment weeks). Exercise caution if prescribing dexamphetamine
• have remitting symptoms and psychological to people at risk of stimulant misuse or diversion.
treatment is considered sufficient to treat mild to
Drug treatment for people who misuse other
moderate residual functional impairment.
substances should be carefully monitored. Discussion
• Offer group therapy first because it is the most with, or referral to an Addiction Medicine specialist or
cost effective. Alcohol and Drug Service, for a second opinion would
be strongly recommended. If the patient is receiving
other treatment for drug dependence then close
liaison between the health professionals treating the
ADHD and the drug dependence is essential.

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 diagnosis and
management of ADHD

Side effects
Monitor adults starting drug treatment for side effects.

Closely observe adults taking atomoxetine for

agitation, irritability, suicidal thinking and self-harming
behaviour, and unusual changes in behaviour,
particularly during the initial months of treatment,
or after a dose change.

With atomoxetine, warn the patient about the potential

for increased agitation, anxiety, suicidal thinking and
self-harming behaviour (in some adults, especially
aged 30 years or younger), notably during the first few
weeks of treatment and the possibility of liver damage
During titration
in rare cases (usually presenting as abdominal pain, Gradually increase the dose until there is no further
unexplained nausea, malaise, darkening of the urine improvement in symptoms, behaviour, education and/
or jaundice). or relationships and side effects are tolerable.

Methylphenidate and dexamphetamine should be

titrated over 4–6 weeks. In adults, record symptoms
How to use drug and side effects at each dose change, after discussion
treatment in adults with the patient and if possible, a spouse, parent,
close friend or carer.
Prescribers should be familiar with:
Review progress regularly (for example, by weekly
1. The pharmacokinetic profiles of all ADHD telephone contact and at each dose change).
preparations in order to tailor treatment to individual
Dose titration should be slower if tics or seizures are
needs
present.
2. Controlled drug legislation governing prescription
and supply of psychostimulant medication. Routinely monitor and record side effects of drug
Under the Health (Drugs and Poisons) Regulation treatment.
1996 Medical Practitioners are required to seek
Consider dose reduction if side effects become
approval from the Chief Executive (through
troublesome.
the Drugs of Dependence Unit) to prescribe
psychostimulants (methylphenidate and After titration and dose stabilisation, referral to the
dexamphetamine) to patients 18 years and over. patient’s General Practitioner maybe appropriate,
however, ongoing monitoring and review should be
Information regarding confirmation of the diagnosis
in a shared care model.
by an adult psychiatrist and history of drug misuse
is required prior to approval being granted. For details of initial, titration and maximum doses,
see table on the next page.

Contact the Drugs of Dependence Unit

for further information on: 

Ph: 3328 9890,

Fax: 3328 9821 or
email: [email protected]

(Please note that Atomoxetine does not require an approval

under the Health (Drugs and Poisons) Regulation 1996)

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Initial, titration and recommended
maximum doses for adults
Drug Initial treatment Titration and dose

Methylphenidate Begin with low doses – 5mg (half a Increase doses weekly according to response up to
scored tablet) two or three times a a maximum of 60mg daily
day (with food for better absorption) Immediate release preparations should be given
of the immediate release medication. 2-3 times a day, with the last dose given prior to
Dosage should be standardised in 6pm. If symptoms donot improve after dose titration
relation to food to ensure consistency over a one month period, the drug should be
of effect (due to faster absorption/ discontinued.
onset of action with food for Long acting preparations may increase compliance
immediate release – and high fat and be preferred if there are concerns about misuse
content slowing absorption of long or diversion. Morning dosing is recommended (with
acting). no more than twice daily dosing). Dosage may be
adjusted at weekly intervals in 10mg increments

Dexamphetamine Begin with a low dose of 5mg twice Increase dose according to response to 40mg daily
a day in increments of 10mg at weekly intervals. (There
is no strong evidence that higher doses have been
shown to increase effectiveness)
Divided doses – up to 2 to 6 times a day.

Atomoxetine Up to 70kg body weight: Use a Up to 70kg body weight: increase dose after a
total starting dose of approximately minimum of 3 days to 1.2mg/kg/day
0.5mg/kg.day Over 70kg body weight: Increase dose after a
Over 70kg body weight: Use a total minimum of 3 days to maximum of 100mg daily.
starting dose of 40mg/day The usual maintenance dose is 80-100mg/day in
divided doses. Trial for 6 weeks to determine the
effectiveness of the dose.

Duration of treatment and follow up

Continue treatment for as long as it is effective. • the effect of missed doses, planned dose
Adopt an individual treatment approach for adults. reductions and brief periods of no treatment
If patients are managed by their General Practitioner • coexisting conditions; treat or refer if necessary
a regular review by a psychiatrist is recommended
• the need for psychological, social and
(yearly would be considered appropriate) Include in
occupational support for the person
all reviews:
• if the patient has a history of drug misuse then
• clinical need, benefits and side effects random urine drug screens are advised to confirm
• the views of the person with ADHD, and those of the psychostimulant medication is being taken
carers, a spouse or close friend, as appropriate and that there is no continuing use of other drugs

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Monitoring side effects
Monitoring and Intervention Methylphenidate Atomoxetine Dexamphetamine

Weight:
In adults, weight loss is sometimes associated with treatment.
Consider monitoring BMI or changing drug if necessary.
Strategies to reduce weight loss:
Yes Yes Yes
• taking medication with or after food
• eating additional snacks early morning or late at night when
stimulant effects have worn off
• obtain dietary advice re high calorie foods

Cardiac function and blood pressure:

Monitor heart rate and blood pressure, check before and after
each dose change and every 3 months
Yes Yes Yes
Sustained resting tachycardia, arrhythmia or a clinically significant
increase in systolic BP measured on 2 occasions should prompt
dose reduction and referral to a physician for review.

Reproductive system and sexual function

Monitor for dysmenorrhoea, erectile dysfunction and ejaculatory Yes
dysfunction

Tics
Consider whether tics are stimulant related, and whether
tic-related impairment outweighs the benefits of ADHD treatment. Yes Yes
If stimulant-related reduce the dose or stop drug treatment
or consider using atomoxetine instead.

Psychotic symptoms (delusions, hallucinations)

Withdraw drug treatment and carry out full psychiatric assessment Yes Yes
Consider atomoxetine instead

Anxiety symptoms including panic

Where symptoms are precipitated by stimulants, particularly
if there is a history of coexisiting anxiety, use lower doses of
Yes Yes
the stimulant and/or combined treatment with an antidepressant
used to treat anxiety
Switching to atomoxetine maybe effective

Agitation, irritability, suicidal thinking and self-harm

Closely observe especially during the initial months of treatment
or after a change in dose
Warn patients and family members if relevant about the potential Yes
for suicidal thinking and self-harm with atomoxetine
Warn young adults about the possible increased agitation, anxiety,
suicidal thinking and self-harming behaviour, especially in the first
weeks of treatment

Drug Misuse and diversion

Monitor potential for misuse and diversion with regular checks
for illicit drug use (check for needle marks, urine drug screens, Yes Yes
pill counts)
Long-acting methylphenidate or atomoxetine maybe an option

* Dexamphetamine is not TGA approved for use in adult ADHD, however, it is PBS reimbursed. Using Dexamphetamine to treat adults is
therefore an “off-label” use and consent of patients should be obtained.

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 Patients presenting for
continuation of treatment
Patients who present to a medical practitioner
requesting ongoing prescribing of their medication
that are unknown to the doctor should be managed in
Ceasing
the safest way possible. It is recommended that the psychostimulants
medical practitioner:
All psychostimulant medication should be ceased over
• Contact the previous prescriber to check the dose a period of time to avoid problems associated with
and last prescribing date or withdrawal symptoms. A slow withdrawal from high
• Contact the DDU though the Enquiry service doses over several weeks is recommended.
(Phone: 3328 9890, 24-hours, 7-days a week)
to determine the last approval holder and the
prescribing history. Psychostimulant
If in doubt, arrange to give the patient a small number
of tablets for the next 1-2 days and ask them to return
prescriptions
to their normal prescriber; or make contact with the Prescriptions are valid for 6 months only.
prescriber and arrange to take over the prescribing.
The new prescriber should make contact with DDU to All prescriptions must be endorsed with the words
request approval to continue treating the patient. “specified condition” when prescribing in Queensland.

Further information
The following websites are particularly helpful:

1 Information about dexamphetamine

http://www.choiceandmedication.org/queenslandhealth/pdf/pilldexamphetamineadultau.pdf

2 Information about methylphenidate

http://www.choiceandmedication.org/queenslandhealth/pdf/pillmethylphenidateadultau.pdf

3 Handy chart comparing medications for ADHD

http://www.choiceandmedication.org/queenslandhealth/pdf/handychartadhdau.pdf

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