Seminal research findings, such as those from the (MTA) Multimodal Treatment of ADHD study, which included nearly 600 subjects, have shown that while non-pharmacological interventions improve ADHD by approximately 30%; pharmacological interventions improve ADHD symptoms by more than 70% and the combination of both kinds of interventions improves symptoms by 85%. So, it's not "this OR that", it's "this AND that".
There are four non-stimulant medications that would be considered in the treatment of ADHD. (Not all of these have been approved by the FDA or HPB for ADHD, so consider these off-label suggestions)
Wellbutrin XL® is an extended release noradrenaline and dopamine re-uptake inhibitor (NDRI). As such in increases the synaptic concentrations of both noradrenaline and dopamine. It is officially marketed as an antidepressant, but it would be more accurate to call it a hybrid between an antidepressant and a stimulant.
It increases motivation and energy, through noradrenaline. And, it improves increases focus, impulse control and reward through dopamine. That's why it works well as an anti-smoking drug.
It does not particularly improve sadness or anxiety like the selective serotonin re-uptake inhibitors (SSRIs) do and that's why it's not really first line when someone has severe depression.
It's not a first line ADHD drug, because the magnitude of dopamine stimulation is smaller than that of the stimulants. But it works like a charm for someone who has both mild ADHD and mild depression. It's best feature is that it improves mood generally, without the sexual dysfunction and cognitive dulling that is commonly associated with the SSRIs.
Strattera® is a noradrenaline re-uptake inhibitor (NRI). It turns on noradrenaline and some dopamine circuits in the part of the brain that regulates focus and attention. It can be as effective as a stimulant, but it does not work as quickly or consistently.
It is most helpful in situations where stimulants cannot be used; such as in a patient who has tics or seizures or has recently been abusing stimulants. Common Strattera side effects include fatigue and upset stomach. These can be minimized by starting the medication at low doses, taking it in the evening rather than the morning, and taking it with food.
Modafinil - There is not enough data supporting the use of this medication in adults with ADHD.
Guanfacine - This medication is currently not available in Canada, so despite evidence of its efficacy, we have not had any experience with it, and therefore cannot comment on its usefulness in managing ADHD.
Dex-amphetamine and Methylphenidate are the most popular treatment for ADHD.
In Canada, Dex- amphetamine is available in four different formats, in order from fastest to slowest acting: Dexedrine IR®, Dexedrine SR®, Adderall XR® and Vyvanse®.
Methylphenidate is available in four different formats as well, in order from fastest to slowest acting: Ritalin IR®, Ritalin SR®, Biphentin® and Concerta®.
Psychostimulant medications have been reported to reduce the problematic hyperactive symptoms in ap- proximately 60-70% of children with ADHD. Research and clinical findings indicate that the ability to sustain attention increases; that social behaviours improve, and that hyperactivity and impulsivity decrease with the use of psychostimulants ].
Swanson and fifteen co-authors conducted a comprehensive examination of 341 reviews of the effects of stimulant medication on children with attention deficit disorders. Their review found that stimulant medication was ineffective for 25 to 40 percent of children with ADHD. A large proportion of those responding to stimulants also showed im- provements on a placebo (a harmless sugar pill).
Swanson found that amongst those that responded to stimulant medication, temporary management of over activity, inattention and impulsivity could be expected, as well as temporary improvement in compliance. Hyperactivity and aggression may be reduced, and consequently the amount of academic work completed may increase in the short term (months). However contrary to the hopes of parents and practitioners, there was no evidence of long term sig- nificant improvement in reading, athletic or game skills, proactive social skills, learning and achievement other then improved attending.
Stimulant medication allows many children with ADHD to spend a near-normal day at school, and gives teachers and parents a welcome relief from their disruptive or inattentive behaviours. However medication does not treat the causes of ADHD, only some of its symptoms.
Stimulant Medications only work when in the system, and since they clear the system in about 4 hours, up to three doses may be required each day. When medication is stopped, even if after extended periods, many of the undesir- able behaviours reappear. Clinical experience indicates that a common complaint of parents whose children take medication for ADHD is that while the child is less hyperactive and is more on task at school, the same child has difficulties getting started in doing homework at home, continues to experience difficulties following rules, and cannot understand why certain behaviours are inappropriate.
A review of the literature reported by Barkley revealed that between 79% to 90% of children on these medications experienced undesirable side effects. Side effects reported in clinical studies are: loss of appetite, headaches, sleep problems, gastrointestinal disturbances, increased tic disorders, mood instability and growth reduction. A small but significant number of children show negative physiological side effects that do not diminish or resolve over time despite cessation of the medication.
Psychostimulants are not appropriate for all children with ADHD. According to the manufacturer of Ritalin, it is not recommended for children with anxiety or motor tics or Tourette's Syndrome due to the risk of exacerbating these conditions.
Barkley, R.A., Diagnosis and assessment of attention deficit-hyperactivity disorder. Comprehensive Mental Health Care, 1991. 1(1): p. 27-43. 10.Barkley, R., Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. 1990, New York: Guilford Press. 11.Swanson, J.M., et al., Effect of stimulant medication on children with Attention Deficit Disorder: a "review of reviews". Exceptional Children, 1993. 60(2): p. 154-162. 12.Lubar, J.F., Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders. Biofeedback and Self Regulation, 1991. 16(3): p. 201-225.
Lamotrigine is a mood stabilizer. It has traditionally been used in Epilepsy and Bipolar Disorder to stabilize the erratic brain activity that leads to seizures and mania. Lamotrigine is not used for treating ADHD per se, but Lamotrigine can make it safer to use stimulant treatment in High Risk ADHD.
High Risk ADHD starts with what we call "co-morbidity". That means that besides ADHD, about 2/3 patients with severe ADHD also have other symptoms that are impairing their function in life.
Mood and and behavioral instability (MBI) is a relatvely common co-morbidity in ADHD. It occurs in about 1/3 patients with ADHD. It can make treatment with stimulants very tricky and for most physicians, this would be the kind of concern that would trigger a referral to an ADHD specialist.
Mood and Behavioral Instability is sometimes called "Affect Dysregulation". However, that term does not say anything about behaviour.
When we use Lamotrigine in High Risk ADHD, we are aiming, not only at stabilizing mood, but also at stabilizing behaviour, specifically, decreasing the craving, impulsivity and relapses that are seen in addiction and impulse control disorder.
If you give Lamotrigine to people with ADHD plus mood and behavioral instability (MBI), you substantially decrease the likelyhood that stimulant medication is going to cause major side effects (See the poster presented at the 3rd International Congress on ADHD in the Recent Presentations section).
When we use software to analyze the responses of people on Lamotrigine, the usual response from about 80% of patients is as follows:
I feel more stable.
I feel more on an even keel.
I am less irritable and agitated.
I am less impulsive.
People with Addictions will also say:
I don't have as many cravings.
When I do have cravings, I can put them out of my mind more easily.
When I give in to cravings, I use less and less often.