Overview of 

Medication Treatment of Adult ADD

Click for detailed information about amphetamines, methylphenidate, Vyvanse, or Strattera

The most effective treatment of ADD is stimulant medication.  Other medications, like Wellbutrin or Strattera, are used if the stimulants are contraindicated for medical reasons, if they don't work with a particular patient or if there are medication abuse problems, but they are only rarely effective.

There are two classes of stimulants: amphetamines and methylphenidates.  There is relatively little difference between the effects of the two for most people, but I prefer to prescribe the amphetamine class first.  In my experience, they are often a bit more activating, wear off more smoothly so patients don't so often "crash" as a dose wears off, and seem to cause irritability less often.   On the other hand, they are a bit more likely to interfere with sleep, cause jitteriness, and reduce appetite.  There are many patients for whom the methylphenidates are more effective and many instances where the amphetamines cause less side effects so there is no way to be sure that you are selecting the right medication.  It a matter of trial and error.  (To view the results of a study I carried out comparing the amphetamines and methylphenidate medications on a group of my patients, click here.) 

Methylphenidate medications
Short acting generic methylphenidate works, in the average person, for about four hours.  Brand named short acting products include Ritalin, Focalin, Methylin. 

Long acting methylphenidates work for up to eight hours, though not always that long.  They include Concerta and Focalin LA.  (There are no long acting-generics.)  A skin patch, Daytrana, is available, but I have never used it as I work mainly with adults and adolescents, who are generally more comfortable taking pills. 

If I want to prescribe a methylphenidate medication, I usually start with generic methylphenidate and switch to the long acting if the patient is not able to remember to take repeated doses during the day.  Drug reps will provide doctors with coupons to let patients obtain their first month's supply of Concerta and Focalin at no cost. 

For information sheets that you can give to patients about taking...

Amphetamine medications
Short acting amphetamine generics include mixed amphetamine salts and dextroamphetamine.  They generally work for about four hours or so.  

Brand brand amphetamines usually offer a delivery system that provides coverage for eight to ten hours.  They include Vyvanse, Adderall XR, Dexedrine Spansules, and others. 

For information sheets that you can give to patients about taking...

Vyvanse long acting amphetamine, click here.

Choice of stimulant
If there are no reasons do to otherwise, I generally start my patients on Vyvanse since, for most patients, it is the longest acting of the long acting amphetamines (about 10 hours for most people), has a smooth effect throughout the day, and on average works about 10% better on average than the other amphetamines, which work about 10% better on average than the methylphenidate medications.  For any individual patient, it is impossible to predict with confidence which stimulant will work best.   While the only way to find out is through trial and error, if a patient responds pretty well to the first medication tried, most often they will not want to switch to see if another one works better.

If I am not prescribing Vyvanse for patient, the choice is more complicated.  Short acting generic medications are sometimes preferred by patients because they are the least expensive.  This is often an issue for those with little or no medication insurance.   The disadvantage of the short acting medications is that they must be taken every four hours or in order to have a steady effect throughout the day, so some reminder system (wrist watch or cell phone alarm) often needs to be used to insure that doses after the first one of the day are taken regularly.

If expense is not an issue, my second choice will usually be Concerta or Adderall XR.   Concerta, a methylphenidate based stimulant, might be preferable if Vyvanse caused unacceptable side effects since Adderall and Vyvanse are both amphetamines and are likely to have the same side effects.

If patients have difficulty getting started in the morning, I will usually suggest that patients take their first dose of the day immediately upon arising or even an hour or so before wake up time.  They can do the latter by putting a dose of their medication on their bedside table, setting a alarm for an hour before awakening time, taking the medication when the alarm goes off, going back to sleep, and awakening to a second alarm an hour later with the medication fully active.