Janet recalls with a shudder the first time she took medication as a treatment for attention deficit hyperactivity disorder (ADHD). “I was glued to the sofa, unable to move for two days,” says the 37-year-old mother of two, and a marketing manager for a Silicon Valley software company. “I looked and felt like a zombie. It scared me off medication.” For Janet’s husband, the incident confirmed his long-held belief that giving ADHD medications to their 10-year-old son would be tantamount to drugging him.
When Janet later attended a local adult ADHD discussion group, she learned that some people who reported great results from taking medication said it took weeks for most patients to tolerate the dosage the doctor had prescribed her — and that many were taking half that amount.
“I should have educated myself first, instead of trusting the physician,” Janet says. “Now my husband gets upset if I talk about trying medication again. It created a wedge between us; I’m giving up higher functioning for myself and my son because of my husband’s fears.”
Janet’s experience is becoming less common. Increasingly, physicians are learning how to use medication to treat adults with ADHD, although many adults still encounter professionals whose knowledge of meds management is spotty, including psychiatrists who claim special expertise.
“You might call adult ADHD an ‘orphan’ disorder,” says Margaret Weiss, M.D., Ph.D., a preeminent ADHD clinician scientist, based in Vancouver, British Columbia. “That’s because most professionals with the expertise to recognize and treat ADHD work in child services; they are not working in adult centers or seeing adults.”
The bottom line for adults with ADHD is: Be a smart health-care consumer, and learn as much as you can about medication before you start taking it. The Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA), a coalition of ADHD experts, has created comprehensive treatment guidelines for patients, parents, and physicians. The practice guidelines, including charts of medications, are available as a free download on CADDRA.ca. My own book, Is It You, Me, or Adult A.D.D.? is another good source, as is the e-book “ADHD Treatments,” from ADDitudeMag.com.
In the meantime, if your prescribing physician makes any of the following 10 statements, share a copy of the CADDRA guidelines with her and talk things over, or find a new doctor.
1. “My adult ADHD patients do best on this stimulant medication.”
Physicians who “play favorites” with stimulant medications — the first-line treatment for ADHD — don’t have an empirical basis for doing so, and are gambling with your chances of success. Here’s why.
There are two major classes of stimulant medications: methylphenidate, or MPH (Ritalin, Focalin, Concerta, Daytrana, and others), and amphetamine, or AMP (Dexedrine, Adderall, Vyvanse, and others). The MPH class works best for some people who have been diagnosed with ADHD, but has no effect, or a negative effect, on others. The same is true for the AMP class. There is no way to predict how you will respond to each class until you try it.
Physician and ADHD specialist Patricia Quinn, M.D., suggests trying both classes of stimulants (MPH and AMP) before deciding that stimulants won’t work for you and moving on to a nonstimulant medication: “You might even try several meds within the same class before switching to another stimulant class.” For example, Ritalin LA and Concerta are both long-acting medications in the same class (MPH). Due to their different delivery mechanisms, however, each brings different results.
2. “For an adult of your height and weight, we start with this dosage.”
An optimal dosage is not related to a person’s height or weight.
3. “This is an average starting dose.”
There is no “average starting dose.” The choice depends on many factors, including:
- Your history of taking stimulant medications. Those who have taken stimulants in the past might be less response-sensitive than people who have not.
- Genetic differences — some people metabolize the medication more quickly than others.
- Co-existing conditions — anxiety or depression , for example, and their current treatments.
- ADHD symptom severity. “The brain is profoundly complex and results differ from person to person,” Weiss says.
4. “We’ll increase the dosage to 10 mg in two weeks.”
Just as a professional cannot predict which medication will work best, or at which starting dose, he also cannot predict an optimal dosage goal. The optimal dosage is identified by a method called titration: carefully increasing the dosage over time, until side effects outweigh benefits, and then dialing down to the previous dosage. The approach should always be “Start Low, Titrate Slow.”