Attention Deficit Disorder in Adults

DIFFICULTY concentrating? Getting along with your spouse? Weaning yourself from the Internet or that computer game to get your work done? Or thinking about all those things you have to do instead of focusing on what you’re reading right now?

Pharmaceutical giant Eli Lilly & Co. thinks its new blue, gold and white pills might help.

The Indianapolis drug maker has been heavily marketing the drug Strattera, also known as atomoxetine, for attention deficit/hyperactivity disorder. It’s the first drug approved for ADHD in adults as well as children, and a surprising number of adults -- including doctors, lawyers and chief executives -- may benefit.

The roll-out includes Lilly-sponsored informational sessions with psychiatrists and physicians nationwide to educate them about the condition and, of course, encourage them to prescribe the drug. And it promises to draw attention to a syndrome that is largely undiagnosed, but possibly endemic, in adults. In fact, the drug could do for ADHD what Prozac, another Lilly drug introduced in the late 1980s, did to highlight an epidemic of low-grade depression across the country.

The new spotlight on ADHD, however, also promises to dredge up skepticism about whether such a syndrome actually exists and whether society -- which has come to expect chemical relief for everything from anxiety to sexual dysfunction -- is simply looking for a quick fix to smooth out personality quirks and discipline problems and improve concentration.

Critics charge that society has tilted too far toward helping people who say they have ADHD. Patients under treatment can get extra time to take their college entrance and professional boards and win protection from being fired -- even if they’re disorganized or can’t complete projects on time -- under the Americans With Disabilities Act.

Meanwhile, Lilly and many psychiatrists claim that as many as 4% of American adults -- about 8 million people in the U.S. -- suffer from ADHD.

Adults whom psychiatrists say have ADHD might charitably be described as “organizationally challenged.” They have lightning-short attention spans and perhaps a propensity to engage their mouths before their brains. They might fidget and daydream much of the day and find boring and passive activities particularly challenging. Few people like to balance their checkbooks, but those with ADHD just can’t seem to make themselves do it.

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Equal-opportunity disability

Though they might be good at conceptualizing ideas and adept at socializing, when it comes to the details, they often just can’t execute until the last minute, if at all, says Dr. David Feifel, director of the Adult ADHD Clinic at UC San Diego School of Medicine.

Though there are many criminals and chronic job-hoppers who are said to suffer from it, ADHD is an equal-opportunity disability, according to several psychiatrists interviewed for this article. Patients include every sex, race, age and socioeconomic status, and surprisingly many successful professionals, such as chief executives, doctors and lawyers. (Despite its name, it doesn’t necessarily involve hyperactivity, a symptom often seen in young boys with the diagnosis, but that often isn’t present in girls or adults.)

“They are people who ... have the No. 1 qualifying factor: underachievement,” says Dr. David Comings, director of medical genetics at City of Hope National Medical Center in Duarte. “They are not as successful as their motivation, efforts, intellects and abilities would seem to indicate.”

Some people compensate by gravitating toward professions that are less detail-oriented, provide constant variety, and require short bursts of attention rather than sustained day-in-and-day-out concentration and organization. For instance, if they become doctors, they might choose to work in an emergency room -- where constant activity provides plenty of stimulation and isn’t boring -- rather than doing cancer research. Others cope by surrounding themselves with efficient secretaries, assistants and spouses, or simply work or study longer to compensate for their lack of concentration.

Lew Mills, a San Francisco psychotherapist who works with ADHD patients, says he was 40 when he realized he’d had the disorder since childhood. He might have three projects going on a certain day, he says, and might do one and forget the other two. “It feels like there are always a lot of balls in the air and I’m trying to catch as many as I can.”

But the ADHD diagnosis in both children and adults itself is controversial. After all, couldn’t most of us be more successful? Don’t we all have personality traits that make some of us more detail-oriented and organized and others perhaps more gregarious and better at envisioning the big picture?

With life becoming so much more complex, with so many distractions, many people feel more overwhelmed than ever and may be prone to seeking chemical relief.

Some doctors dismiss ADHD as a concoction of drug makers out to make money.

“ADHD is the paradigm of the way the pharmaceutical industry has influenced the way we think,” says Dr. Lawrence Diller, a behavioral pediatrician in Walnut Creek and author of “Running on Ritalin.” “Suddenly, everybody’s got panic and phobic disorders,” Diller adds. “It’s an astonishing phenomenon -- when we have this much money, everybody’s going to have something.”

These days, the number of children taking Ritalin and related stimulants for ADHD has surged: Drug makers sold about $1.3 billion worth of the stimulants last year, according to Datamonitor Healthcare PLC, a health care intelligence and consulting firm

Concurs fellow skeptic Dr. Peter Breggin, a psychiatrist and author of “Toxic Psychiatry” and several other books: “Any of us who are creative and interesting, we’re all diagnosable with a lot of things. It’s become a farce.”

Breggin scoffs at the criteria for ADHD outlined in the American Psychiatric Assn.’s diagnostic manual. They include failing to give close attention to details or making careless mistakes; difficulty sustaining attention in tasks or play; not seeming to listen when spoken to directly; not following through on instructions and failing to finish schoolwork, chores, or duties in the workplace.

“Any ordinary person knows this is nonsense,” Breggin says.

Both Diller and Breggin think society has gone overboard in administering drugs to allegedly hyperactive children, who are taking Ritalin and its sister stimulants, Adderall and Concerta. They believe that Strattera could become a fad with adults as more people hear about it and identify with it. Resnick, who runs an ADHD clinic at Randolph-Macon College in Ashland, Va., agrees that Ritalin has become a quick fix for many who don’t need it. “The scary part is that mostly parents come in and say ‘Johnny got a C in chemistry, so he must need Ritalin.’ ”

But he and most other doctors these days accept that the condition does exist. Whether those with it should take drugs to alleviate their symptoms involves determining how much of an impairment it is in the patient’s life -- whether they have learned to cope or whether it is wreaking havoc with their lives, work and relationships.

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‘Not just a bad hair day’

Dr. Lenard Adler, a psychiatrist who teaches at New York University and directs its ADHD program, says patients who seek treatment are often in their 40s. Frequently, since the disorder appears to be hereditary, they recognize the same symptoms in themselves when their child is diagnosed.

“It’s not just a bad hair day,” says Dr. Timothy Wilens, a clinical researcher at Massachusetts General Hospital who has run clinical trials and done consulting for Lilly. “It must be chronic.... Everyone has walked into a room and wondered, why did I do this? It might happen once or twice a month.... For someone with ADHD, it might happen 10 or 20 times a day.” Often, there are other compounding problems such as depression or bipolar disorder.

In the past, even if they recognized and accepted it in adults, physicians may have been reluctant to prescribe stimulants, which are strictly controlled to prevent abuse. Students use them to improve concentration and consequently their grades. In many states including California, regulators must be informed of who is given them; prescriptions have to be written out by the doctor, they cannot be called into the pharmacy; and doctors cannot hand out samples.

Strattera, however, is not a controlled substance and will be much easier for physicians to prescribe.

Some patients who’ve taken Strattera in Lilly’s clinical trials say it does help. About 60% reported dramatic improvements in concentration and impulsiveness control, Lilly says. Side effects tended to be few in adults -- loss of appetite, nausea, dizziness and some decrease in sexual function in men.

Lilly says Strattera reduces ADHD symptoms by blocking or slowing reabsorption of norepinephrine, a brain chemical, or “neurotransmitter” considered important in regulating attention, impulsivity and activity levels. This keeps more norepinephrine at work in small gaps between neurons in the brain, which helps pass impulses from one neuron to another. Feifel says some patients find it “phenomenal” while others found it not so effective compared to stimulants.

Victor, a 24-year-old from Chula Vista who asked that his last name not be revealed, says Strattera helped improve his focus when he took it as part of the clinical trials.

In high school and before dropping out of college, he had to reread material over and over for it to sink in and had difficulty completing a book. It took a while for the drug to kick in, but slowly, he realized he was much more focused. He could finish books and get through even the driest material without getting distracted. It helped him successfully complete Emergency Medical Technician training, and now he’s working in a hospital and continuing his education.

He says, “I stopped interrupting -- I could listen and take things in.”