Medications for Adults with ADHD
It had long appeared that the medication situation for AD/HD was reversed from that of other psychiatric conditions. For other conditions, psychiatrists who treated children and adolescents had relatively fewer medications that had actually been tested on children. We had to extrapolate from adult data, make do with fewer medications, and base our prescribing practices on less research data. Child psychopharmacology seemed like the stepchild of adult psychopharmacology. The exception was AD/HD. This was the condition child psychiatrists could call their own. Although medication choices were still more limited than they are today, clinicians still had more information on how the medications affected AD/HD children than they did on how the same medications affected adults. The tables were turned. The adults were the ones with less data and fewer medication options. It used to be quite controversial to give stimulant medication to older adolescents, let alone adults. However, some adults did get stimulant medication for AD/HD. Usually it involved adolescents who simply continued treatment after they turned 18. Second opinions or special permission from the Drug Enforcement Agency were necessary if one wanted to prescribe stimulants to an adult with AD/HD. Tricyclic antidepressants could be a less controversial choice.
Over the past 20 years, it has become easier and much less controversial to diagnose and treat adult AD/HD. Medication options have expanded, but stimulant medications, usually methylphenidate (Ritalin) and dextroamphetamine compounds (Dextrostat, Dexedrine Spansules and Adderall) are still a frequent starting place in the pharmacological treatment of AD/HD.
Adults and children may have different medical considerations:
Although there is still more information on pediatric AD/HD, there is an emerging body of knowledge specific to medication for adult AD/HD. Many of the medications are the same as those used for children and adolescents. However, when treating adults, there are several general differences to consider. Although adults are generally larger, their liver and kidney function may not be as robust as children. Thus an adult may need less of a particular medication per pound of body weight. A given dose of medication may hang around longer in the adult’s system.
Adults are more likely to be taking medications for other medical conditions such as high blood pressure or diabetes. These may interact with the AD/HD medication. Conversely, some of these other medications may cause inattention and thus exacerbate or mimic AD/HD. For example, a clinician from another state referred me a patient with possible AD/HD. It turned out that an anxiety disorder, along with two medications she was taking, caused her inattention.
Stimulants can cause modest increases in blood pressure and heart rate. Thus there has been some concern that widespread
use of stimulant medications in adults might lead to an increase in heart attacks, strokes and other cardiovascular problems.
Stimulants may cause increases in blood pressure or pulse. This is usually not significant at normal doses in most people. However occasionally, the blood pressure effects can be significant. Individuals on very high doses of stimulants or individuals at risk for blood pressure problems should be monitored more closely. Some adults may opt to continue the stimulant and add a blood pressure medication. A small open study suggested that adults who were well controlled on their blood pressure medications could take amphetamine without significant increases in blood pressure. Individuals with blood pressure changes need to discuss the risks and benefits with their physicians.
In late 2011 a large retrospective study of adults aged 25-64 reported that individuals who were taking amphetamine, methylphenidate or atomoxetine did not have a higher incidence of heart attack, stroke or sudden cardiac death than matched individuals who were not taking stimulants. (citation)
Polypharmacy, (prescribing several psychiatric medications at the same time) has become more common. Adult AD/HD by itself often requires more than one medication to control all of the AD/HD symptoms. If the individual has another disorder, such as depression, one may need to medicate this too. I have mixed feelings about the trend towards polypharmacy. When done carefully and systematically, it can bring relief to individuals who have experienced distressing symptoms. However, if done in a rapid or cavalier fashion, it can lead to medical side effects, or it can exacerbate the very symptoms it was meant to treat.
The stimulants, including methylphenidate (Ritalin) and amphetamine (Dexedrine and others) along with some tricyclics (such as Desipramine), have demonstrated efficacy in the treatment of adult and childhood AD/HD. The stimulants have a 60 to 80% response rate. However, some individuals respond partially or not at all. Others develop uncomfortable side effects. Atomoxetine (see below) is a non-stimulant medication approved for the treatment of AD/HD in adults and children. The following is a brief overview of some of the emerging developments in the field.
Food can affect the way stimulants are absorbed. The amphetamines are more likely to be affected. A meal high in fat can slow the absorption of amphetamines. High dose Vitamin C can lower the effect of amphetamines. Grapefruit juice and delay excretion of amphetamines.
Current Second and Third-Line Medications: Alphaagonists, bupropion, (Wellbutrin) and the tricyclic antidepressants. Other medications often used for comorbid disorders or ADHD-related symptoms: SSRIs (eg. Prozac, Zoloft and others) mood stabilizers (Lithium, Depakote, Tegretol) and the atypical antipsychotics. Other than two of the
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