In my last Health Tip, we discussed Claire, a woman in her thirties with attention deficit disorder (ADD), reviewing lifestyle and non-medication approaches. This week, I’ll go over the conventional medications used for this very common condition (estimated at 5% of the population).
Let me start by saying that untreated ADD, in both children and adults, can prevent very (very!!) bright people from living up to their potential. Also, it’s important to know that with most ADD meds, there’s no “lifetime commitment”. Some kids really outgrow their ADD issues and stop their meds. Many ADD medication users find they don’t need a pill every day. Students (and adults) often skip their meds over summer vacation or on weekends when there’s no homework. Many adults with mild ADD use the meds on an as-needed basis.
By far the largest group of medications for ADD are the stimulants (accounting for 99% of ADD meds). These literally “wake up” the inefficient ADD brain by boosting levels of neurotransmitters dopamine, norepinephrine and serotonin. Because of this effect, psychiatrists often prescribe small doses of ADD meds for clinical depression, even when actual ADD may not be present.
The two stimulants are the amphetamines (Adderall, Vyvanse and Mydayis) and methylphenidates (Ritalin, Focalin, Concerta), and they’re all available in both immediate release and extended-release form, the latter developed to last a little longer than a school day. When the ADD meds first came out as “Immediate Release” only, classroom teachers had to send their ADD kids to the school nurse for a noontime dose.
If you open a capsule of any of the time release amphetamines, you’ll see it’s filled with tiny beads of different colors. Actually, the beads are all the same medication. It’s the coating that makes the difference. Adderall XR lasts to about 3 or 4 PM. Vyvanse was developed for adults and lasts until about 5 PM. Mydayis is even longer lasting, 7 PM or so. Since Mydayis is new (and expensive around $330 a month) insurance companies balk at coverage. ADD patients can get pretty much the same effect as Mydayis by taking an Adderall XR in the morning (generic, inexpensive) and an Adderall immediate release tablet (ditto) at about 3 PM.
One of the genuinely annoying aspects about the stimulant medications is they’ve been classed as ‘controlled medications’, meaning you can only get a 30 day supply and a new prescription is needed each month. Some states and some insurers allow 90 day supplies, but Illinois and Blue Cross are not among these.
By the way, if you have anxieties about starting a low dose of a stimulant med for your diagnosed ADD, keep in mind that the average age of the people taking any of these meds is about 11 years old.
All the stimulants, taken in the morning, begin to work within an hour and start fading in the afternoon. As I mentioned before, people with more severe ADD often take a second dose mid-afternoon to last them until about 8 PM. The main side effects are jitteriness (resolved by reducing the dose), insomnia (ditto), and appetite suppression (goes away in about two weeks).
If you’re wondering why I haven’t discussed the methyphenidate group, it’s mainly because I’ve never had much reason to use them. I think pediatricians prescribe them a lot, but most internists prefer the Adderall family. Both groups are very effective.
I reserve the single non-stimulant ADD medication, Strattera, for patients who report not feeling well on the stimulants, or those with a history of anxiety whose symptoms might worsen if stimulated.
The best description of Strattera is “subtle”. There’s no epiphany like that experienced by someone with ADD given one of the stimulant drugs for the first time. But there’s such a difference between that effect and the non-stimulant effect of Straterra that when patients switch from the first to the second, they’re often convinced it isn’t working.
Strattera requires patience, and I confess to never having been impressed by it. Strattera was developed as an antidepressant and withdrawn when clinical studies showed it didn’t work particularly well. Some users reported improved focus, so Big Pharma got FDA approval for clinical trials treating ADD. Patients report perhaps 25% improvement in their ADD symptoms (which I am even skeptical about that number), and it has the same side effects of the SNRI antidepressants, like duloxetine. In fact Strattera’s chemical name is similar: atomoxetine. Since duloxetine is Cymbalta which some patients nickname Cymbarfta, you can guess the side effects of Strattera.
Strattera works by slowly increasing the brain’s level of norepinephrine, which, like dopamine, can enhance focus and concentration. It usually takes a month to appreciate Strattera’s effect, but once in place, its two main advantages are: no stimulant symptoms (some people just feel physically uncomfortable taking stimulants) and it works around the clock. You’re just as focused at 8 AM as at 8 PM with one capsule a day. The main side effect, stomach upset, can be completely prevented by taking Strattera with food.
The natural therapies Claire had been using were helping a little, she told me, but she was curious about how she’d feel without any ADD symptoms at all. So, after some discussion about the options, Claire chose Vyvanse. I also recommended two books: Scattered Minds (for her) and Is It You, Me, or Adult ADD? (for her husband). The second is an excellent book about living with someone who has ADD.
Claire was back in a week to talk about what she’d experienced. “It’s amazing” she began, “I now know what people talk about when they describe ‘memorizing something’. I can read lists and two hours later, recite the list. I actually read a whole book, cover to cover, and can tell you what it was about. It was miraculous, like my mind was given a pair of eyeglasses.”
The big test, she said, would be the following month when she’d be re-taking her real estate license exam, which she’d failed twice in the past and had just about given up as a lost cause.
Although she kept in touch by e-mail regarding some minor Vyvanse dose adjustments, it wasn’t until one of her e-mails held photos of a condo she “thought I might be interested in” that I learned the ultimate results of her treatment. No, I didn’t need the condo, but I was thrilled she had passed her license exam.
I now see her ads regularly.
David Edelberg, MD