4 Reasons Adults Give Up on ADHD Medication: Solving Nonadherence and Treatment Inconsistency
ADHD medications are some of the most effective treatments across medicine. Still, ADHD medication nonadherence is a widespread problem among adults. Here, understand four major barriers that lead to treatment inconsistency or abandonment, and targeted solutions.
ADHD medications work dramatically well. Still, medication nonadherence is a serious – and often unnoticed – problem among adult patients, regardless of age or prescription. According to a recent study, fewer than half of adult patients could be considered “consistently medicated” for attention deficit hyperactivity disorder (ADHD), based on prescription renewal records.1
Medication nonadherence often happens when patients misunderstand the nature of ADHD itself and how medications help, and/or when clinicians make incorrect dosing decisions and harbor negative attitudes around medication.
No matter the reason, prescribers must understand and address the following barriers to ADHD medication adherence to provide the best care possible for patients and improve long-term outcomes.
Treatment Barrier #1: Poor Psychoeducation
This is the single biggest cause of medication nonadherence. Ask a patient why they stopped taking an ADHD prescription, and you’ll hear: “I don’t know why I was taking the medication in the first place.”
Often, the motivation to start medication doesn’t come from the patient, but from another adult like a spouse or employer who is affected by the symptoms. Some patients are brought in while others have bought in. In many cases, the patient doesn’t see a problem at all, or is in denial. They think: “Everyone else has a problem with me but I think I’m fine.” As soon as the heat is off, they stop medication.
Psychoeducation can solve this problem, but it’s not enough to talk at patients about ADHD and the importance of medication. Instead, ask them following questions:
- What does it mean to have ADHD? Patients must understand that ADHD is essentially a lifelong neurological condition. The rules of their neurology are totally different from those of the neurotypical nervous system. They should know that ADHD brains don’t respond to importance and rewards like neurotypical brains do. Instead, they respond to what interests them, which results in inconsistent performance and frustration. ADHD, if anything, is a problem of engagement upon demand – and stimulants help with this pain point.
- What would it mean to ask for help? Some patients may be reluctant to ask for help, viewing it as a weakness.
- What does it mean to treat ADHD? Many patients succumb to the fantasy that a couple weeks’ worth of pills will rid them of ADHD. They stop medication or believe it isn’t for them when they realize they still have ADHD at the end of the month. Patients must come to accept that they are not wired the way neurotypical people are wired, and that they are going to have to work twice as hard as neurotypical people do. ADHD medication will give them a break as they try to adapt to the foreign neurotypical nervous system.
Medication reluctance may also signify that the patient has been able to compensate for symptoms. Eventually, impairment will overcome compensatory abilities, forcing patients to seek treatment.
Treatment Barrier #2: Suboptimal Dosing
An ADHD medication may either fail to adequately control symptoms, or it may produce intolerable side effects. The former indicates a too-low dose. Too often, clinicians raise the dose of a medication until the first sign of a positive benefit emerges, and then they stop. The latter situation is not nearly as common, but nonetheless impairing when it occurs. In either case, keep in mind the following:
- It takes time to find the right molecule and dose. It’s a fact that some patients may not respond at all to a given molecule, even at the lowest dose. A small portion may be “ultra-low dose responders,” for whom a low dose is already an overdose. Another portion may not respond to methylphenidates or amphetamines. Try stimulants first before prescribing a non-stimulant. Consider various formulations as well. (Some patients may respond to transdermal delivery, for example.)
- Ask the patient to rate the medication on a scale from one to ten. One: Awful. Ten: the best any medication can ever be. Ask the patient for the first number that comes immediately to mind. It’s a simple but powerful question. Anything below a six usually means that it’s time to try a different medication or dose.
- Is it really the medication? Patients may blame stimulants for side effects that are actually caused by caffeine, nicotine, or other substances. Be sure to ask about these items.
Treatment Barrier #3: Practical Obstacles
It’s not easy for patients to find clinicians who are knowledgeable about diagnosing and treating adult ADHD.2 Limited experience with pharmacotherapy may result in difficulty gauging a patient’s response to medication and optimizing accordingly.
But even with the optimal medication and dose, ADHD symptoms may interfere with adherence. After all, difficulty with tasks that require sustained mental effort is a DSM-5 symptom of ADHD. For many patients, medication management – everything from taking medications as directed to jumping through hoops to get refills every month (a dreadful, unnecessary barrier) – touches on this very challenge. Encourage patients to ask others in their lives, like family and friends, for help overcoming these obstacles to consistent medication use.
Treatment Barrier #4: Unsupportive Clinician Attitudes
Clinicians who discourage consistent medication use – and many do so unconsciously – do a tremendous disservice to patients. A good treatment regimen must meet a patient’s needs all throughout, lasting through mornings, evenings, weekends, and vacations. This is unfortunately not the case for many patients. Though many patients take medication as directed, they report insufficient effect duration, and thus continue to experience challenges and impairments as medication wears off.3
Successful clinicians will plan for nonadherence, and never assume that a patient is compliant. Be vigilant with all patients by doing the following:
- Provide written post-appointment notes and medication instructions (do not rely on a patient’s memory).
- Do pill counts to assess adherence.
- Encourage patients to use tools like pillbox timers and medication tracker apps to promote adherence.
- Commit to ongoing patient psychoeducation. (Share resources on ADHD support groups and websites.)
ADHD Medication Nonadherence: Next Steps
- Free Download: ADHD Medication Tracking Log
- Read: Develop a DESIRE to Manage Your ADHD
- Read: It Takes a Village (and a Plan) to Stay the ADHD Treatment Course
The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, Why Adults with ADHD Abandon Medication — And How to Improve Treatment Outcomes [Video Replay & Podcast #396], with William W. Dodson, MD, which was broadcast on April 13, 2022.
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1 Biederman, J., Fried, R., DiSalvo, M., Woodworth, K. Y., Biederman, I., Driscoll, H., Noyes, E., Faraone, S. V., & Perlis, R. H. (2020). Further evidence of low adherence to stimulant treatment in adult ADHD: an electronic medical record study examining timely renewal of a stimulant prescription. Psychopharmacology, 237(9), 2835–2843. https://doi.org/10.1007/s00213-020-05576-y
2 Goodman, D. W., Surman, C. B., Scherer, P. B., Salinas, G. D., & Brown, J. J. (2012). Assessment of physician practices in adult attention-deficit/hyperactivity disorder. The primary care companion for CNS disorders, 14(4), PCC.11m01312. https://doi.org/10.4088/PCC.11m01312
3 BrownTE, Romero B, Sarocco P, et al. The Patient Perspective: Unmet Treatment Needs in Adults with Attention-Deficit/Hyperactivity Disorder (2019) Primary Care Companion CNS Disorders;21(3):18m02397