5. “So, how’s that medication working out for you?”
Judging a medication’s effectiveness requires more than a physician asking, “How are you doing?” It requires at least two steps:
- Taking careful inventory of the challenges you face (writing them down, one by one), before you started medication
- Regularly reviewing each challenge as treatment progresses, in order to track improvement (or not), worsening symptoms, or new side effects.
During this titration phase, experts recommend talking with your physician weekly. In-office visits should take place every three to four weeks, to review side effects, physical health, patient and family well-being, and other therapies, when indicated.
Many experts and patients report that not enough physicians closely monitor medications used in adults. “It’s critically important to do, but the utter paucity of clinicians doing it is shocking,” says psychologist Stephen Hinshaw, Ph.D., a leading ADD/ADHD researcher and professor of psychology at the University of California, Berkeley. “You can’t notice small improvements or side effects without a monitoring sheet.”
Weiss recommends using rating scales that measure a broad range of symptoms and functioning; in other words, a metric for tracking how you’re doing in life. The Weiss Functional Impairment rating scale is a good place to start. Having a tangible method for observing change makes the target concrete and keeps it in focus.
6. “You should see a huge improvement in symptoms right away.”
Research tells us a lot about overall stimulant efficacy, but we cannot tell how it will affect any particular individual. That’s because clinical trials are:
- Conducted in controlled settings
- Done with patients who have no co-existing conditions (a rarity among adults with ADD/ADHD)
- Very brief in duration (usually ending before side effects can develop).
The potential positive effects of medical treatment for ADD/ADHD shouldn’t be oversold, Weiss warns. “It’s true that some symptoms may improve dramatically in days, or even in hours. But it is important to wait to judge the full effect of the medication, because it can take some time for all the data to accrue.”
As you face challenging situations in your life, you can gauge how your responses differ from those in the past. “It can also take time to notice the differences in how people are reacting to you, or to evaluate changes in how efficient or how much better you’ve become at your job,” she says.
Weiss offers these guidelines:
- Symptoms tend to get better within weeks.
- Functioning improves within months.
- Developmental changes happen over years. For example, the individual who never had a friend can now make and keep them. An adult who could not keep a job can now hold onto one for a year.
7. “If the stimulant disrupts your sleep, we will have to switch you to a nonstimulant.”
The causes of sleep problems among adults with ADD/ADHD are multi-faceted, and poorly understood by most physicians. Increasingly, research is pointing to neurophysiological differences in circadian rhythm, the inner biological clock that tells us when to go to sleep. Yet there are other ADHD-related obstacles to sleep, such as being unable to “put the brakes on” a chatty brain.
In evaluating a stimulant’s apparent adverse effect on sleep, it’s important to pay attention to timing. Perhaps sleep problems are caused by the rebound from the medication’s wearing off. In that case, you should try taking the medication earlier in the day. Some people with ADD/ADHD sleep better on a stimulant; such medications stop “brain noise” and increase focus on going to sleep and staying asleep.
8. “Sure, continue consuming caffeine, if you like.”
Many adults with ADD/ADHD have lifelong love affairs with coffee or caffeinated sodas. Yet caffeine may exacerbate the effect of stimulant medications, creating anxiety and heart palpitations. You can’t determine what’s causing these side effects -- the stimulant or the caffeine -- unless you gradually wean yourself off caffeine before starting stimulants. (Try to do it a few days in advance, though, so that you don’t mistake a headache due to caffeine deprivation for a medication side effect.)
“Some people can tolerate stimulants and still have some caffeine,” Weiss says. “For others, caffeine interferes by creating or exacerbating side effects, making it impossible to increase the stimulant to therapeutic doses.”
9. “If you have high blood pressure, you can’t take stimulants.”
An adult should have a thorough physical before starting any new medication, and adults with ADD/ADHD should have their blood pressure and heart rate checked before beginning, and periodically during, treatment.
However, Weiss dashes the common myth that hypertension precludes taking ADD/ADHD medication: “I would say that it is never a contraindication. You treat the hypertension first. And, in fact, there are medications for ADD/ADHD that lower blood pressure.” These include generic guanfacine and its longer-acting brand-name formulation, Intuniv, which can lower both systolic and diastolic blood pressure. These medications are often used as an alternative to, or in conjunction with, stimulants.
10. “If you think that the stimulant has stopped working for you, maybe we should try something else.”
Perhaps the stimulant stopped working for any of several neurobiological reasons. Or could you have forgotten what life was like before you started taking the stimulant?
Adults who are diagnosed with ADD/ADHD later in life typically develop the habit of paying attention only to the exciting or new. After a few weeks of experiencing the “novelty” of improved symptoms, it’s easy to forget how far you’ve come. This is another reason for keeping written records of baseline symptoms and of the progress you’ve made. It’s the only way to know if the med is doing its job.
More on ADD/ADHD Medications
This article appeared in the Fall issue of ADDitude.
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