Understanding Treatment Options for Adult ADHD
While most people associate attention-deficit/hyperactivity disorder (ADHD) with distracted, fidgety, and misbehaving kids, in recent years, we’ve come to understand that the condition greatly impacts the lives of adults as well. In adults, ADHD is often characterized by difficulty performing daily work, managing household tasks, delaying gratification, regulating emotions, maintaining relationships, and much more. Fortunately, using a combination of medications, psychotherapy, coaching, and lifestyle modification, we can effectively control symptoms so people can live productive and fulfilling lives with adult ADHD.
Adult ADHD Medications
The mainstay of treatment for adult ADHD is medication. Oftentimes, I encounter patients who view medications negatively and resist taking them. They try to overcome their difficulties through sheer willpower, which is admirable, but unfortunately an unsustainable effort. I educate my patients that ADHD is a medical condition like diabetes or hypertension. Just as we wouldn’t expect patients suffering from these conditions to lower their blood sugar or blood pressure without the aid of meds, we need to understand that ADHD is a brain-based disorder that requires medication for effective management.
Essentially, ADHD medications work by enhancing the transmission of brain-signaling chemicals--neurotransmitters called dopamine and norepinephrine--to help the higher-level brain regions function better. These regions control the skills we need to navigate life, known collectively as executive functions. These skills include emotional regulation, self-motivation, organization, time management, working memory, and impulse control--skills often impaired in people with ADHD. In taking medications for ADHD, symptoms related to attention regulation and impulsivity can be improved to help with daily functioning, and even help rewire the brain to improve its function more permanently over time.
Finding the right medication treatment for adult ADHD can be a trial-and-error process. We may have to try several different drugs and dosages before we discover the optimal regimen.
The first-line treatment for adult ADHD is a class of medications called psychostimulants, which act on the dopamine and norepinephrine system. Psychostimulants are classified as Schedule II controlled substances, which are considered to have a high potential for abuse and misuse, and thus are tightly regulated by state and federal law. When taken appropriately at prescribed dosages, however, these medications are very safe and effective.
Stimulants come in two different families:
● Methylphenidate-based preparations (Ritalin, Concerta, Daytrana, Focalin)
● Amphetamine-based preparations (Adderall, Vyvanse, Mydayis)
Both families of stimulants are available in various pill forms using different controlled release systems to deliver the medication to your body and bloodstream, so they vary in how long they work. Short-acting forms last anywhere from 3 to 6 hours, requiring multiple doses per day (eg. 2 to 4 times a day). Some patients prefer these short-acting meds because they like the control and flexibility of deciding when to take them during the day,, like on an as-needed basis.
Over the past couple of decades, we’ve seen the development of longer-acting versions of these stimulant medications. These meds can last from 8 to 16 hours, as they are released gradually or in a delayed fashion into the body. Many of my adult patients prefer extended-release stimulants because of their once-daily dosing. Moreover, the longer-acting preparations tend to be more tolerable than their short-acting counterparts, as the shorter-acting versions may cause a more noticeable wearing-off effect, which manifests as sudden fatigue, irritability, or agitation. Extended-release medications may minimize the potential risk of this “crash” as they enter and exit our bloodstream more smoothly.
In addition to psychostimulants, there are other medications available for treating adult ADHD. These medications are generally referred to as non-stimulants, which are used either as substitutes for or in combination with stimulants. We may consider using non-stimulant meds in place of stimulants in cases when stimulants are ineffective, cause intolerable side effects, pose a potential risk for adverse effects, or create a concern for abuse and misuse. Atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor (SNRI), is the first and only non-stimulant medication for adult ADHD approved by the U.S. Food and Drug Administration (FDA). Its mechanism of action is to increase norepinephrine activity in the brain, which may also help with treating anxiety. Guanfacine (Intuniv, Tenex), which also acts on the norepinephrine system, is a relatively newer medication used to treat ADHD. It was originally used to treat hypertension, but we’ve discovered that it effectively treats ADHD as well. Although guanfacine is currently approved for ADHD use only in children and adolescents, we often use medications “off-label” for adults when we know they’re effective. Guanfacine enhances activity in the brain regions that control our executive function skills.
I often prescribe a medication “cocktail” to patients, in which they take both a stimulant and a non-stimulant; this way, we’re optimizing dopamine and norepinephrine levels to help patients not only manage symptoms more effectively, but also enhance development of their executive function skills that may not be addressed by stimulants alone.
The common side effects of psychostimulants include decreased appetite, insomnia, headaches, and irritability. With long-term use, stimulants may raise blood pressure and heart rate. Thus, monitoring vital signs is necessary. Tolerance to stimulants may also develop, especially in the initial few months of treatment, so patients may require a higher dose for the same results later on. Since there is a potential for abuse, misuse, and physical dependence with stimulants, I always address these issues with patients at the beginning of treatment.
Atomoxetine may cause upset stomach, vomiting, constipation, fatigue, appetite suppression, dry mouth, and sleep problems. It may also raise blood pressure over time. Side effects of guanfacine include drowsiness, dizziness, fatigue, dry mouth, constipation, stomach pain, or headache. In most cases, the side effects of these medications are manageable and tolerable.
In addition to medication, it is very important that adults with ADHD engage in psychotherapy and executive function training. Taking medications will help improve symptoms, but only a therapist or coach can provide patients with the proper guidance, structure, and support necessary for effectively managing this lifelong disorder. Quite often, people with ADHD experience an immense degree of shame and unfortunately do not get better until they’re able to work through their negative and destructive perceptions of themselves. It is essential that they find a clinician who is able to provide a sense of unconditional support and positive regard. Furthermore, I advise and encourage all my patients to incorporate wellness habits into their daily lives. Aerobic exercise, mindfulness meditation, sleep, and nutrition are vital aspects in managing ADHD. With this integrated approach of medication, therapy, and wellness habits, patients can learn to not only survive, but thrive with adult ADHD.