When Can I Stop Them?
There are no hard and fast rules about the duration of medication treatment for ADHD.
In essence, you can take these medications for as long as they are effective, and you can stop them at any time provided you discuss this decision with your prescribing clinician.
Stimulants and ATX can be discontinued quickly, whereas the alpha adrenergic ago-nists should be weaned gradually to avoid “rebound hypertension.” But there is no single algorithm for deciding to stop medication treatment. In some cases, it makes sense to discontinue pharmacotherapy for a defined period of time so as to see what happens and to figure out if life is manageable without it. In other cases, it is better to take the medi-cation continuously—most of the time, there is no “wearing off ” of efficacy. In those cases where it seems that the medication is no longer working properly, it’s advisable to discuss this with the clinician and determine if it’s time either to increase the dose or to try a different medication.
What If I Also Have Depression or Anxiety?
Many if not most adults with ADHD also suffer from coexisting conditions like depres-sive disorder, bipolar disorder, anxiety disorder, or other disorders for which they are taking a medication. Most of the time, it isn’t necessary to modify these treatments when considering a medication for ADHD. Clinical prescribers should be able to look up any potential interactions among medications and caution you about potential problems
that might develop. For example, there is very little concern about combining an SSRI (for depression or anxiety) with a stimulant medication, but caution should be used when combining an SSRI with ATX because they may interfere with each other in terms of liver enzyme activity, which might alter the rate at which the body clears the medications from the bloodstream. If a patient is taking bupropion (Wellbutrin®) for depression, it is important to use caution when adding a stimulant medication, since the combination can cause “overactivation” and even agitation. And if a patient suffers from bipolar disorder as well as ADHD, it is critical that mood stabilization be achieved before starting a stimulant. It is also advisable to avoid using ATX because it is known to cause overactivation of patients with bipolar illness.
What If I Have Problems with Substance Abuse?
Substance abuse is very common in patients with ADHD, and it poses unique challenges to everyone concerned. For the patient, the possibility that an ADHD medication might induce craving for an illicit substance is a great challenge. It is very important to share any important clinical information with your prescriber so that she or he can choose the medication with the least potential for abuse (e.g. long-acting instead of short-acting stimulants, or nonstimulants instead of stimulants). For many clinicians, the presence of active substance abuse will lead them to avoid using stimulant medications for fear of worsening the abuse. The remedy for this dilemma is to make reduction of problematic substance use or of abuse a treatment goal, along with that of reducing the ADHD symp-toms. In this fashion, the patient and clinician can work to address the challenges head on and to build a working alliance built on mutual respect and accountability.
Additional Advice and Information
There is growing public concern about the rise in rates of stimulant misuse, diversion, and abuse. Misuse is the use of a controlled substance for reason other than that for which it was prescribed or in dosage different than that prescribed; here, the pattern of misuse does not lead to disability or dysfunction. Diversion involves giving or selling a controlled substance to someone else. Abuse is the use of a controlled substance outside normally accepted standards of use (e.g., to achieve euphoric effects, to enhance alcohol or other substances), which results in disability or dysfunction (including the notion of “problematic use”). The catastrophic use of a controlled substance involves illegal activity and places the patient at risk for immediate harm (e.g., snorting or intravenous usage of stimulants). In view of these serious health concerns, it is important that there be full disclosure between patient and clinician about expectations regarding appropri-ate stimulant use and that ground rules are established for scheduling appointments, for monitoring usage, and for refilling prescriptions. The occurrence of lost or misplaced prescriptions is always considered a red flag that signals the possibility of medication misuse, diversion, or abuse.
It is common for patients to experience discomfort with the prospect of taking a medication because of deep seated negative attitudes and/or unconscious biases toward the concept of being “on drugs.” For some people, medications are a necessary evil that undermines individual autonomy and achievement. This is clearly a distortion of the
170 The Role of Medications
facts. In actuality, medications for ADHD can enhance patient autonomy by helping them to overcome the limitations and impairments that result from this disabling con-dition. Moreover, the improved ability to complete tasks and to finish projects, or to achieve desired goals and outcomes, is never the result of medication alone. Rather, it is the individual’s efforts (aided in part by a medication) that make it possible for him or her to succeed (or at least to persist for a longer period of time before stopping). Indi-vidual agency (i.e., self-directed activity) can be drastically diminished by ADHD; by the same token, it can be enhanced (but not determined) by any intervention that reduces the symptoms of ADHD, including a medication.
On the other hand, based on their history of effectiveness and on compelling accounts of the “life-changing” effects of ADHD medications, some patients run the risk of engag-ing in the cognitive error of magical thinkengag-ing about medications. That is, people may pin their hopes on finding the right medication that will turn their lives around. Indeed, for most adults with ADHD, pharmacotherapy is an essential part of a treatment plan that provides vital benefits. However, the danger is that there are unrealistic expectations that medications will address issues that are better handled through the use of cognitive-behavioral coping strategies, such as a college student with ADHD who took extra doses of his or her stimulant medication to engage in a marathon study session rather than planning out a more realistic (and more effective and healthier) study schedule. Although medications may help to reduce symptoms and open up an opportunity for improved functioning, in and of themselves, they cannot ensure that you will complete a paper or pass an exam in class, receive improved work performance ratings, or arrive on time for appointments. These and other important objectives require follow-through on various other strategies to attain.
In this vein, it is important to keep in mind the role that medications play in the over-all treatment plan. More often than not, a combined treatment approach is optimal to pursue. Medications are simply tools for enhancing the learning that takes place during treatment (“pills don’t teach skills”), and for sustaining the effort that individuals need to exert in order to achieve their goals. Medications represent an important tool for most adults with ADHD, but it is still important to have a well-stocked tool kit.
20 Conclusions
Attention-Deficit/Hyperactivity Disorder (ADHD) and its corresponding executive dys-function and motivational deficits are associated with some of the most wide-ranging and severe difficulties that are seen among individuals seeking outpatient psychologi-cal and/or psychiatric treatment. There is a range of severity that includes relatively mild and limited symptoms, so not everyone who receives a diagnosis of ADHD should immediately think the situation is a dire one (although even mild ADHD may require special attention and effort to manage).
On the other end of the severity continuum are complex and significant presenta-tions of ADHD that may have extensive, negative effects on employment, relapresenta-tionships, and financial and physical well-being. It is all too easy for skeptics to minimize its effects by building up and tearing down the straw man argument that ADHD is a collection of nuisance symptoms (e.g., “If your attention ever drifts or you misplace your cell phone, you, too, could be diagnosed with ADHD”) and perpetrating the “everyone has ADHD”
myth. This line of reasoning is often used to call into question the need for interventions despite the fact that ADHD has been shown to have corrosive and cascading effects on the lives, outlooks, and well-being of ADHD adults.
The chapters of this handbook represent the topics we cover and approaches we use with adults with ADHD who seek treatment through our Adult ADHD Treatment and Research Program at the University of Pennsylvania, but they are personalized to each person. Any one of these chapters, however, could have been expanded into a book-length discussion in order to deal with the nuances of someone’s unique situation. That being said, the issues and coping strategies covered here offer a pretty thorough overview and representation of the essential skills, strategies, and tactics that provide a foundation for coping with and managing the effects of adult ADHD. These skills and strategies are representative of those offered within the cognitive behavioral therapy (CBT) frameworks for adult ADHD that have empirical support, be it through our program or those of our colleagues who special-ize in the psychosocial treatment of adult ADHD, many of whom are listed in Appendix D.
In order to get the most out of treatment for adult ADHD, the first step is to make sure that, in fact, ADHD is the source of the difficulties that have led you to consider treatment. Because the symptoms of ADHD, such as poor concentration, are also seen in other conditions, it is important to obtain a comprehensive and competent assessment that includes evaluation for ADHD as well as other diagnoses that often coexist with ADHD or, in some cases, may better explain your symptoms—all that glitters is not gold;
all that is inattentive is not ADHD.
172 Conclusions
Much of the existing controversy about ADHD and its treatment stems from cerns about misdiagnosis, most often focused on overdiagnosis. This is an obvious con-cern and there are steps to follow to administer a “gold standard” evaluation that will increase diagnostic accuracy and reduce overdiagnosis. On the other hand, underdiag-nosis of adult ADHD is a problem because this error delays the opportunity for people to understand the source of their difficulties and to consider treatment options, many of which are quite effective.
Once it has been determined that adult ADHD is the appropriate diagnosis and target for treatment, you will need to consider a treatment plan to address the areas of your life and well-being that are most impacted by ADHD. Many people find that medica-tion treatment alone and the symptom relief it provides offers sufficient benefit and improvement in functioning, but you should review the risks and benefits of this option with a psychiatrist familiar with ADHD.
Nevertheless, most adults with ADHD will benefit most from a combined treatment of medications and CBT. The coping strategies discussed throughout this tool kit have utility in most areas of life and are essential for managing ADHD. Your treatment and coping plan should be personalized to your specific circumstances.
We know that these treatments and coping skills work, based on outcome studies of CBT for adult ADHD, as well as by using common sense. It is the implementation of these coping strategies and tactics in your daily life that is the key to improving your functioning and well-being. However, as we have said before—change is difficult. Hence, most ADHD adults find it beneficial to work with a clinician, ideally one who is familiar with ADHD, to help establish good coping patterns and to address the common barriers to carrying out these plans.
There is one more point we want to make about our approach to treating and manag-ing adult ADHD. We have presented the copmanag-ing strategies and topics in a systematic way in order to help you develop a structure to your day and your endeavors. Moreover, CBT is known to be a structured psychotherapy approach insofar as it works toward delineated goals and makes a point of identifying and facing life problems head on. The focus on improving structure and follow-through on tasks is centrally relevant for handling aca-demics, occupational functioning, and other adult obligations in 21st century life. The coping tactics also are relevant for personal activities and undertakings that you pursue and which are a part of who you are. However, the emphasis on organization and struc-ture inherent in managing ADHD, executive dysfunction, and motivational deficits might be misconstrued as efforts to create conformists and automatons whose sole purpose is to add to the gross national product, or that you must judge yourself by some measure of academic attainment, income status, or some other calculation of productivity.
To our way of thinking, the reason to manage ADHD by using these coping strategies is not to make you fit a certain mold, but rather to expand your options for managing your life on your terms and for you to make informed decisions about how you “spend yourself ” as you strive for personal fulfillment. The choices you make about how you devote your time, energy, and efforts reflect your values and are the building blocks of your sense of self.
Thus, keeping track of incoming bills is, at first blush, not an existentially fulfilling chore. However, not paying attention to these bills puts you at risk for financial stress that may limit your independence and, at the very least, drains time and energy away
from other things you would rather do. Conversely, spending inordinate time on amus-ing diversions may be pleasant, but it siphons off time and energy from ventures more directly tethered to your identity. As Shakespeare wrote, “If all the year were playing holidays, to sport would be as tedious as to work” (King Henry IV, Part 1).
This is the insidiousness of ADHD—even the escape into enjoyable activities becomes exhausting and infects your sense of well-being and agency. It erodes your ability to pur-sue the opportunities and experiences that are important to you. Recalling the definition of executive functions used throughout this book, they operate to improve your long-term well-being—however you define that to be. We hope that this Adult ADHD Tool Kit provides you with some assistance as you implement your plans and pursue your goals—however you define them to be.