Can An Algorithm Help Medication Decisions in Adult ADHD?

David Neal Osser, MD

Although algorithms are often considered too “cookbook” for those who practice medicine, a group of physicians are making the case for their use in the treatment of adult attention-deficit/hyperactivity disorder (ADHD).

In a presentation at the American Psychiatric Association’s annual meeting in New York City, David Neal Osser, MD, and Bushra Awidi, MD, a psychiatrist at Harvard South Shore Psychiatry, shared with a packed room of physicians one of the medication algorithms from the Psychopharmacology Algorithm Project.

While Awidi and Osser noted the skepticism of the process, Awidi stressed that it should be used only as a tool to help the physician. “We discourage using an algorithm to make a diagnosis, only to aid in the treatment,” she said.

Osser, an associate professor of psychiatry at Harvard Medical School, opened the session by making a few things clear about the project and its benefits, noting that it can help prevent some of the mistakes that are caused by a slew of issues, from burnout at the end of a long day to overconfidence in decision-making. The algorithm, Osser noted, is meant to help prevent human error.

“It’s been a consistent finding that we think we know more than we do,” Osser said. He added that the algorithm data is supported by study findings, with each step including citations from clinical trials. The algorithm, which works like a flow chart, should ultimately allow for clinicians to take a stepwise approach to treating patients with adult ADHD based on scientific evidence, as well as to aid the clinician in decisions to modify medication choices based on the presence of possible medical and psychiatric comorbidities, he said.

ADHD impacts roughly 3% to 10% of school-aged children and often continues to manifest in adults, with up to 4% having the diagnosis globally. This growing need for a treatment guide for clinicians when choosing medications for adult ADHD led to the creation of the medication algorithm.

The algorithm recommends that after a concise diagnosis of adult ADHD is made, and all medical contraindications are accounted for, patients should be initiated on a low dose of 5-mg immediate release methylphenidate (MPH; efficacious dose, 1—1.3 mg/kg) or amphetamine (efficacious dose 0.5–0.65 mg/kg). It was then recommended that doses were titrated every 3 days until the effect took place or adverse effects were revealed.

“Non-stimulants such as atomoxetine may be tried after 2 adequate trials fail with stimulants,” Awidi said. “However, it is important to note that no evidence supports the positive effects if stimulants have failed.”

Bupropion, modafinil, guanfacine, and clonidine, among other non-stimulants, were also discussed to similar notes.

Comorbidities such as cocaine use disorder and bipolar disorder were also accounted for, with the algorithm recommending the use of extended-release stimulants (post-sobriety) for those with cocaine use disorder. Patients with bipolar disorder were recommended stimulants as well, but only after stabilization of mood was achieved.

Both Osser and Awidi stressed the importance of having data to back up the decision-making process. Osser noted that the use of data, while it cannot replace the physician’s role, will only continue to aid the prevention of human error and the development of tools such as the ADHD algorithm.

“Big data has allowed us to do many things,” Osser said. “We can see what patients do, and what physicians do.”

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