Management of attention deficit hyperactivity disorder in nonpregnant adults without a substance use disorder*^¶

SSRI: selective serotonin reuptake inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor; ADHD: attention deficit hyperactivity disorder; SUD: substance use disorder; CBT: cognitive-behavioral therapy.

* This algorithm assumes the individual has neither an active SUD nor a history of an SUD. Refer to UpToDate content for treatment of ADHD in individuals with an active or history of SUD.

¶ We treat all individuals who present for treatment for ADHD with combined treatment including pharmacologic management and CBT addressing executive dysfunction. However, for individuals who prefer not to engage in both treatments, despite our recommendation, we treat with the patient preferred treatment as monotherapy. For individuals beginning with monotherapy, if symptoms persist, we encourage the addition the other modality at any time during the treatment.

Δ Refer to UpToDate content for discussion of initiation, titration, and monitoring of bupropion in adults with ADHD.

◊ We work closely with the patient to establish what constitutes adequate treatment of symptoms of ADHD. Examples may include improvement in attention, decreased impulsivity, decreased hyperactivity, or improvement in overall functioning (eg, work, psychosocial). In all medication trials, unless limited by side effects, we allow sufficient time within the target range prior to making further medication decisions. This time period may very between patients but generally ranges from four to six weeks.

§ Refer to UpToDate content for discussion of choice, initiation, titration, and monitoring of stimulants (ie, amphetamine, methylphenidate) in adults with ADHD.

¥ Refer to UpToDate content for discussion of choice, initiation, titration, and monitoring of SSRI/SNRI in adults with ADHD.

‡ Some individuals may need stimulants for a limited period of time while others may need them indefinitely. We advocate shared decision making in treatment decisions concerning length of treatment and tapering of medications for ADHD.

† Refer to UpToDate content for discussion of choice, initiation, titration, and monitoring of tricyclic antidepressants in adults with ADHD.