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The Role of Stimulants in ADHD Treatment

October 26, 2020


In this video, psychiatrist Birgit Amann, MD, discusses the common myth that stimulants are a good treatment option for all patients with attention-deficit/hyperactivity disorder (ADHD).

Dr. Amann is medical director of the Behavioral Medical Center in Troy, Michigan. She treats ADHD in children, adolescents, and adults, and has been an investigator on numerous ADHD medication trials.

This is Part 4 of a 4-part video series marking ADHD Awareness Month, which is held in October.

Part 1: The Importance of Using Multiple Approaches When Treating Pediatric ADHD
Part 2: Dr. Theresa Cerulli Discusses the Complexity of ADHD
Part 3: Anxiety and Mood Disorders in Children and Adolescents With ADHD

Read the transcript:

Hello. My name is Dr. Birgit Amann. I'm a child, adolescent, and adult psychiatrist with a private practice in Michigan. Our office consists of physicians, nurse practitioners, and therapists. We treat all ages across the lifespan. We see many patients with ADHD but in particular, those with ADHD and comorbidities. I'd like to thank you for spending time with me today.

The topic for our discussion today relates to stimulant medications and the common myth that stimulant medications work for everybody. The fact is that stimulant medications are only one part of the ADHD treatment armamentarium. Let's take a closer look at a few considerations related to this fact.

Consideration number one: Stimulant medications are considered to be a first-line agent, but they're not right for everyone. Patients may have difficulty with sleeping or eating. They may become more anxious or develop tics. Stimulant medications are controlled substances. As such, there's a risk for abuse dependence or diversion.

Prescribers need to monitor very closely. A patient with an addictive history may not be an appropriate candidate for this type of medication. Finally, stimulants may not be efficacious for the patient.

Consideration number two: A nonstimulant medication may be a better treatment option for some of our patients. Nonstimulant medications are less likely to cause difficulty with sleep and appetite. They don't typically worsen anxiety, and they don't typically cause tics.

Nonstimulant medications are not controlled substances, and they have no addictive potential. However, at this time, we only have 3 nonstimulant options for medication treatment available to us, and all 3 of them must be swallowed whole. None of them can be opened or sprinkled. This can be difficult for some of our patients and pose a problem.

Consideration number three: ADHD patients commonly have comorbidities. In a child, these may include examples such as anxiety, tic disorder, oppositional defiant disorder. In an adult, these may include depression, bipolar affective disorder, and substance use disorder.

A presentation of ADHD alone occurs 25 percent of the time. It's the exception rather than the rule. Patients with ADHD and 1 comorbidity occur approximately 15 percent of the time, and those with 2 or more comorbidities occur 60 percent of the time. We refer to these patients as having comorbid complex ADHD.

Our comorbid complex ADHD patients have a 5‑time greater risk of mortality from all causes, as compared to a 2‑time greater risk in patients with simple ADHD. It's very important to take a look at treating both the ADHD and the comorbidities. These patients may require more than 1 medication, as well as counseling to optimize their overall level of improvement and functioning.

In summary, stimulant medications are a first‑line treatment option for many patients, but they're not right for everyone. Nonstimulant medications may be a better choice for some patients. But currently we only have 3 available. Additional nonstimulant medications are needed.

Finally, it's imperative for us to evaluate our patients with ADHD for comorbidities, as up to 75 percent of our patients can have comorbid complex ADHD and do best by more than 1 medication—one to treat the ADHD and another to treat the comorbidity along with counseling to optimize their overall functioning.

I'd like to thank you for spending time with me today.

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