In this chapter, we consider some other important mental health issues encountered in medical settings. Recognizing the signs and symptoms of these disorders can prevent misdiagnoses and medication errors, as well as help the patient to get started on an effective course of treatment early on, often by timely referral.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by age-inappropriate levels of motor hyperactivity, impulsivity, and inattention.¹ It is a common disorder of childhood and adolescence and persists into adulthood in about 50% of cases.² The prevalence of ADHD in Americans aged 18 to 44 years is estimated to be 4.4%.³ Like prescribed opioids, the stimulant drugs commonly used to treat ADHD have posed a problem of misuse, so it is important to know how to diagnose these patients so that those with true ADHD can receive the effective treatment you have at your disposal. Also, diagnosis is especially important because persistence of childhood ADHD into adulthood and adult-onset ADHD are associated with increased mental health problems and substance abuse, in addition to the diminished economic and physical health outcomes that characterize remitted childhood ADHD.⁴

Diagnosis and Screening

The differential diagnosis of ADHD in adults includes disorders that are also commonly comorbid with ADHD such as mood disorders, anxiety disorders, substance use disorders, learning disabilities, and impulse control disorders.^3,5 Medical disorders that can mimic ADHD include endocrine and metabolic disorders (thyroid disorders), neurologic disorders (including traumatic brain injury), sleep disorders (obstructive sleep apnea), and side effects of medications.¹

The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnostic criteria for ADHD (Table 8-1), originally developed to diagnose ADHD in children, need slight modifications for use with adults. Adults with ADHD present primarily with deficits in executive functioning such as memory deficits, problems with initiating and shifting tasks, and difficulty with inhibiting or monitoring themselves. This leads to problems with organizing, prioritizing, remaining focused, and following through with tasks and assignments.⁵ While these manifestations of inattention are prominent, symptoms of hyperactivity or impulsivity are less or overt in adults.

The objectives of the assessment of an adult for ADHD is to identify symptoms and behaviors consistent with DSM-5 criteria for ADHD, evaluate the patient for any impairment attributable to these symptoms, rule out other psychiatric and other comorbid disorders, and refer doubtful cases for neuropsychological testing, as described shortly. A careful history, including documenting when the symptoms started, will often help to exclude ADHD.⁵ There should almost always be a history of onset by age 12 to entertain a diagnosis of ADHD.⁵ What often is called adult-onset ADHD usually is due to a comorbid mental health disorder rather than ADHD.⁶ A new adult ADHD questionnaire has a high sensitivity and specificity for DSM-5 ADHD.⁷ It may be a useful tool in primary care for screening and evaluating treatment efficacy.

Approach to Diagnosis and Referral

If the patient has a history compatible with ADHD and if they have been treated previously, we request records from their prior physician, including medication use and doses. If this material indicates a prior history of ADHD and a response to stimulants, we continue the medications and follow the treatment plan that follows.

If this past information is not forthcoming or if the patient does not have a clear childhood history of ADHD, we recommend referral to a mental health professional skilled in ADHD diagnosis and neuropsychological testing. Neuropsychologic assessment consists of a series of tests that evaluate intellectual abilities, academic achievement, memory, language skills, visual-motor coordination, attention, reasoning abilities, executive functioning skills, and emotional dysfunction. Most testing also will evaluate possible other psychological problems that might contribute to the problem, such as learning disabilities. Such a referral can also help weed out those seeking to simulate ADHD, perhaps having reviewed the symptom criteria for it, for financial gain and other misuse.

If testing indicates a likely diagnosis of ADHD, we follow the treatment plan given next. If there is a history of substance use, we do not prescribe stimulants but offer the patient referral for addiction counseling. Use of the Prescription Drug Monitoring Program and urine drug screening is needed, as outlined in Chapter 6.⁸

Treatment

Adults with ADHD usually do not receive treatment for ADHD. This is unfortunate because untreated persons with ADHD compared with unaffected controls experience higher rates of academic failure, low occupational status, increased risk of substance use disorders (tobacco, alcohol, or drugs), accidents and delinquency, and have fewer social relationships or friends.⁹ Even with treatment, unfortunately, patients may not get to the level of non-ADHD patients.¹⁰

An approach that combines appropriate pharmacotherapy with the Mental Health Care Model (MHCM) described in Chapter 3 works best with these patients. Patients especially benefit from education about ADHD and comorbid disorders, as well as cognitive behavioral therapy, coaching and family therapy, and medications for ADHD and any comorbid disorders.⁹ Referral to a mental health professional can be helpful.

We strongly recommend treatment of comorbid disorders before making a diagnosis of ADHD. Many believe a diagnosis of ADHD cannot be made until after this occurs. In addition, an approved nonstimulant medication such as bupropion should be used first with the patient’s understanding that they may take 1 to 2 weeks to exhibit an effect. Also, the serotonin noradrenaline reuptake inhibitor (SNRI) atomoxetine is approved for use in ADHD. See Table 8-2. The nonstimulant medications, however, have lower effect sizes in ADHD than the stimulants.

Stimulants (amphetamine/dextroamphetamine and lisdexamfetamine; methylphenidate) are absolutely contraindicated with a history of substance abuse; their nontherapeutic effects such as euphoria may place the patient at added risk of abuse. They are relatively contraindicated in patients with structural heart disease, hyperthyroidism, hypertension, anxiety, and glaucoma. In patients with contraindications, bupropion or atomoxetine can be used. Stimulants are generally quite safe, however, and can have a major impact on ADHD. See Table 8-2 for dosing. One caveat: contrary to popular perception, they should not be used diagnostically because neither a response nor lack of response has diagnostic value. While the different drug classes of stimulants are of equal effect in ADHD, failure to respond to one does not necessarily mean the other will also be ineffective, so switching drugs is recommended with an initial poor response. We recommend using the extended release forms from the outset and for maintenance. Unfortunately, many primary care physicians have historically been reluctant to prescribe stimulants, in part, because they are controlled substances that have the potential for abuse.¹¹

Amphetamine side effects stem from sympathetic overstimulation and can lead to agitation and delirium accompanied by hypertension, tachycardia, hyperthermia, sweating, paranoia, and dilated pupils. Symptoms can progress to violent behavior and seizures. Death usually stems from hyperthermia, arrhythmias, and cerebral hemorrhage. In contrast to alcohol or opioid withdrawal where we expect symptoms opposite those of intoxication, the symptoms of stimulant withdrawal can often at least partly mimic intoxication, for example, agitation, hyperarousal, and sleeplessness. See Table 8-3. While there is little evidence that tapering the drugs is of value or that other medications are helpful during withdrawal, because of the potentially serious nature and difficulty of withdrawal, we recommend referral of addicted patients or those showing signs of intoxication or withdrawal be referred to addiction specialists for supervised withdrawal.¹²

Introduction

In 2016, over 2.7 million people died in the United States. These deaths came in many different ways and under a variety of circumstances. Lunney et al¹³ have identified 4 trajectories of dying: (1) Sudden death is progression from normal function to death with little warning and often with little interaction with the health care system; (2) terminal illness is death after a distinct phase of terminal illness (sufferers may function relatively well for a prolonged period and then suffer a sudden decline, eg, cancer); (3) people with organ failure experience gradual decline with acute exacerbations (eg, congestive heart failure; chronic obstructive pulmonary disease), each episode of which can potentially result in death; and (4) frailty often occurs in people with long-term diseases (eg, dementia and stroke) that show a slow and gradual decline. The main sources of health care expenditures in the first 3 groups are physicians and ambulatory care, inpatient care, and long-term care and skilled nursing facilities, respectively. Sources of costs in the last category are highly variable, but use of nursing homes or other long-term care is higher than with other groups.¹⁴

The wide variability of the end-of-life (EOL) experience, coupled with current advances in medicine, has complicated the process of dying for many people. Clinicians, patients, and their families often are faced with an overwhelming number of options and decisions. Nevertheless, most people identify effective pain and symptom management, communication with their physicians, adequate preparation for death, and/or the opportunity to achieve a sense of completion as their most important value(s) at the end of their lives.¹⁵

Diagnosis and Screening

Despite national efforts to improve EOL care, troubling symptoms like dyspnea, severe fatigue, incontinence, anorexia, and frequent vomiting have remained prevalent, while pain, depression, and delirium have become more common. Debilitating symptoms increase notably beginning in the last 5 months prior to death and may be a prospective marker for the EOL period in patients with chronic conditions who appear relatively healthy.¹⁶

Primary care providers can screen for symptoms and monitor effects of treatment in appropriate patients, using simple tools like the revised Edmonton Symptom Assessment System in Table 8-4.¹⁷ Referral to palliative care at an earlier stage of an advanced disease or life-threatening illness may reduce the symptom burden of patients and better prepare them for the last stages of life.^18,19