Defining and Treating Attention Deficit/Hyperactivity Disorder (ADHD)

What is ADHD?

Few medical specialties are as closely scrutinized by the general public as psychiatry. While psychiatrists must be accountable for our diagnostic decisions, it can seem like ADHD is still more of a punchline than the very real, and often debilitating, mental illness that it is. In my practice, we only treat adolescents and adults, but it is evident that ADHD, once thought to be only a juvenile disorder, extends long into the lifespan. Further, we are learning more and more about the under-appreciated symptoms of ADHD and the fact that, for example, it affects women very differently than men. The classical ADHD presentation involves symptoms like constantly losing things, being completely incapable of arriving punctually, being able to focus only on things that interest the patient, and then only briefly. NIMH describes a diagnostic triad of inattention, hyperactivity, and impulsivity. People who genuinely suffer from ADHD benefit immensely from medication, but it can be a long road to the proper individual diagnosis and successful treatment. A great starting point for understanding ADHD/ADD, and for appreciating the struggles of our loved ones who suffer from it, is Gabor Maté’s Scattered.

Stimulants

As far back as 1958, researchers were using methylphenidate (Ritalin) to treat children with what we would now call ADHD. Methylphenidate’s more popular cousin, mixed amphetamine salts, is commonly known by its brand name, Adderall. Adderall, like alprazolam, is a controlled substance, which means its use and how much a provider can prescribe to a given patient are overseen by the Drug Enforcement Agency. This regulatory information is largely irrelevant to patients taking ordinary doses of Adderall or similar drugs. What is relevant is the fact that, like the benzodiazepines, stimulants are very frequently misused and can pose severe danger to the user if not taken according to the provider’s instructions.

But how do they work? It seems illogical (scientists use the term “paradoxical”) that a powerful stimulant in a controlled dose makes people (initially research focused only on children) who are prone to severe hyperactivity less hyperactive and more able to focus. It was described as a paradox for many years until, in the past decade, scientists discovered the mechanism (apparently involving dopamine) by which stimulants calm hyperactive minds. There remain several safety concerns at work when considering the use of stimulants in psychiatric practice. Aside from their potential for misuse (“diversion” in DEA parlance), stimulants increase blood pressure and have other physiological effects that disqualify certain patients, especially older individuals, from taking them. This is why it is critical that a patient’s physical health be fully evaluated before treatment, and that physical health continue to be monitored. When a patient is a good candidate for stimulants and responds favorably, we often see not just an improvement in the symptoms bringing them to the clinic, but the beginning of deeper insights into how the disorder—which usually goes undiagnosed in adults—has changed the course of their life. Getting better with the help of medication is often a helpful, even necessary, component of successful psychotherapy and greater personal understanding. The medicine is like fixing an important part on your car: the thing giving you trouble on the freeway may have improved, but it’s up to you to steer to new and better vistas.

Atomoxetine

Atomoxetine (Strattera) was approved for use to treat ADHD by the United States FDA in 2002. Studies have shown that atomoxetine is less effective than the extended release formulation of generic Adderall in treating ADHD in children. The bulk of serious clinical research into the efficacy of pharmaceutical treatments for ADHD has so far been focused on children, which is unfortunate given the significant differences between adult and pediatric presentations of ADHD. Atomoxetine does have one major universal benefit compared to the stimulant drugs: it is not addictive or liable to abuse. This welcome feature has borne out from early research through a now extensive longitudinal body of evidence. ADHD is most commonly treated with stimulants, when deemed appropriate by the prescriber, however having an option that is more effective than placebo (if less effective than standard stimulant treatment) can be very helpful for people who wish to avoid potentially habit-forming drugs.