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Medication Treatment for Adults with ADHD
The Journal of Clinical Psychiatry recently published a special issue on Attention Deficit Disorder (Volume 69, 1998). One very nice review article in this issue summarizes what is known about the medication treatment of ADD/ADHD in adults. The article is written by Dr. Paul Wender, who has been one of the leaders in the study of ADD in adult populations.
Dr. Wender begins by summarizing the guidelines he uses for establishing the diagnosis of ADHD in adults. First, as required by DSM-IV, ADHD symptoms must have been present during childhood. Next, he looks for the presence of certain characteristics in adulthood that he feels are how ADHD is manifested in adults. These characteristics include: motor hyperactivity, attention deficits, affective lability (i.e. moodiness), hot temper, emotional over reactivity, disorganization and an inability to complete tasks, and impulsivity.
In Dr. Wender's treatment research, he has evaluated the response of over 300 adults diagnosed with ADHD using his diagnostic criteria. These studies all used placebo-controlled, double blind procedures that are so essential for realistically assessing the effectiveness of medication on ADHD symptoms. (Remember, in this type of study a subjects' response to medication is compared to how they respond to a placebo. If the medication is really helpful, you would see greater improvement than that produced by a placebo alone.)
As with children, the medication studied most frequently (i.e. 176 patients) has been methylphenidate (i.e. the generic name for Ritalin.) In Dr. Wender's research about 60% of adults treated with methylphenidate showed "moderate to marked" improvement compared with only 10% of patients who showed comparable improvement on placebo. Comparable response rates were reported for adults who received Pemoline (i.e. the generic version of Cylert) and Dexedrine.
It is interesting to note that although these results suggest that stimulant medications that are helpful to children with ADHD are also helpful to adults, the response rate reported for adults is substantially lower than has been found for children. For children, the rate of positive response to stimulant medication ion has been consistently found to be approximately 80%, with some authors reporting that over 90% of children with ADHD will derive substantial benefit from medication if a sufficient number of alternatives are carefully tried. In terms of the clinical effects of these medications in adults, Dr. Wender reports the following:
- fidgeting and restlessness decrease;
- patients report an increased ability to concentrate and feel that they have greater control over their concentration;
- both high and low mood swings decrease; overall mood feels more stable;
- angry outbursts become less frequent and less extreme;
- patients report feeling less disorganized and better able to develop plans to complete tasks;
- patients report greater ability to tolerate stress;
- impulsivity decreases; become less likely to interrupt others and feel their communication skills improve.
(remember, These Changes Are Reported By Patients Who Do Not Know Whether They Are Receiving Real Medication Or Placebo, So They Reflect Real Benefits Of Medication Above And Beyond The "placebo Effect".)
Dosages
A very important issue in the use of medication for children and adults is arriving at the best dose for the individual. Dr. Wender reports that the majority of the adults with ADHD that he has studied and treated require a 10-15 mg dose of methylphenidate every 2-3 hours for a total of 40-90 mg. per day. In general, he has found that the sustained release version of methylphenidate does not control symptoms as well for many adult patients. Dr. Wender also advises that pulse and blood pressure should be carefully monitored in all adults who take stimulant medications, which would be an important issue to discuss with your physician.
For adults who are treated with Pemoline, doses range from 75 to 150 mg/day, and the medication is generally administered once a day. (This one dose per day administration is an advantage over the multiple doses that may be required for adults taking methylphenidate). As with children, however, an important disadvantage- advantage of Pemoline is the possible adverse effect it can have on liver functioning (see Volume 10 of ADHD RESEARCH UPDATE.) For this reason, ongoing monitoring of liver functioning is essential.
Dr. Wender has also investigated several other medications for treating ADHD in adults, although he indicates that these results are much more preliminary. Preliminary results suggest that Bupropion and selegilene may also be effective treatments for many adults with ADHD/ADD. Additional research on the efficacy of these medications, as well as several others, is ongoing and I will include results of these studies in ADHD RESEARCH UPDATE as they become available Tricyclic antidepressants- ants, in contrast, have not been found by Dr. Wender to be useful even though they are known to have documented efficacy in children.
There are several other important points made in this excellent review article. As with children, there is really no way to predict in advance which will be the most effective medication for an individual or what will be the most effective dose. Some patients will do better on one type of medication while others will derive greater benefit from another. It is thus important to carefully and systematically monitor an adults response to the initial medication and dose prescribed. Information in this regard can be collected from the patient him or herself as well as from significant others who are in a good position to monitor and observe the patient's behavior. If an initial medication is not providing the full benefits that are hoped for, trying another type of medication may often yield better results.
Dr. Wender also emphasizes the importance of ongoing education for patients with adult ADHD so that individuals can better understand how ADHD has effected, and may continue to effect, their develop- development. He stresses that psychological treatment should be com- bined with pharmacological treatment, and that medication by itself will rarely if ever be a sufficient form of intervention.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.