Adult ADD

A Guide to the Diagnosis and Treatment of Adult ADD

Treatment

Carrying Out ADD Treatment (From the Clinician’s Point of View)

There is no single right way to conduct treatment.  What follows is a rough approximation of how the editors of AdultADD.Info carry out their treatment.

This section of AdultADD.Info is too long for most people to read at one sitting.   Readers may wish to browse, or use it as a reference as their own treatment progresses.

Contents

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Make the Diagnosis, Start Deciding on Treatment
Most of this page is about medication treatment, since it is the most effective treatment for most people with ADD.  Coaching and some kinds of psychotherapy can also be useful, but they work best when the patient’s symptoms have been reduced or controlled with medication.

Have a General Discussion with the Patient about ADD Medications
After we have made the diagnosis of ADD and discussed it with the patient, we describe and discuss treatment.  In our experience one or another of the stimulant medications helps about 80% of adults with ADD thought it may require trying two or three to find the right one.  With the stimulant medications, it is usually clear within two weeks two (sometimes within a day or two) whether the medication will help. However, with the non-stimulant medications, it may take three to six week to be certain whether they work. It activates or normalizes brain functions that carry out planning, organizing, remembering, and other ADD-related functions.  It also helps the brain filter out unnecessary stimuli like unimportant noises, visual images, and ideas.  This reduces the clutter in the brain and lets people function more smoothly.  In addition, it increases alertness though if they activate the nervous system too much, they will make a person taking them feel jittery or have difficulty sleeping.

We let the patient know that if the first medication we try does not work, we can try others. If no one medication works alone, we may occasionally use a combination of medications. Since it can take up to six weeks to be sure that a particular medication will not work, in unusual cases it may take up to a few months to find the right dose or combination. Patience and perseverance may be required.

Check To Be Sure There Are No Medical Reasons the Patient Should Not Take Stimulants
Before we prescribe medication, we make sure there are no medical or psychological contraindications to the patient’s taking it and that the patient is likely to use the medication responsibly.

Discuss Mild and Potentially Serious Side Effects
Stimulants have side effects, including some which are serious. Most people have few or no side effects, even on higher doses, but some have them even with fairly low doses. Common side effects include dryness of the mouth, jitteriness, difficulties with sleep, and teeth clenching.  For a more extensive description of side effects and adverse effects, click here.

It is impossible to predict any individual’s response, side effects, and dosage needed, so a slow and careful trial with any stimulant is usually the best approach. For a more thorough discussion of the use of stimulants, click here.

Blood Pressure and Stimulants
Some people develop an increase in blood pressure and pulse while taking stimulant medication.  For this reason, we take their blood pressure and pulse before they start to be sure that there are no obvious heart problems that may make it unwise for them to take it.  The baseline information  also allows us to track how it the medication is affecting their heart functions. If…

  • there is a history of heart disease at an early age in the patient’s siblings or parents
  • the patient is over 65 or is not in excellent health
  • has a known heart condition

we refer the patient to a cardiologist or to their PCP for a cardiac assessment before starting stimulants.  We do this because such problems may have a genetic basis and therefore be more likely to be present in the patient.

Uncommonly, people have a serious increase in blood pressure after starting stimulants, and the medication must be stopped. Others choose to receive anti-hypertensive medication from their  physicians so they can continue the treatment of their ADD.

Deal with Coexisting Anxiety and/or Depression If They Are Present
But it is important to realize that many patients with ADD become anxious about the effects of their symptoms on the day to day functioning.  Very often their depression or anxiety improves dramatically after their ADD symptoms are brought under control.

A very small number of patients taking Strattera have developed severe liver problems. Patients taking Strattera should be aware of the early symptoms of liver damage such as jaundice, pain inside the lower right rib cage (where the liver is), flu-like symptoms, and dark urine. (For information from the manufacturer, go to www.Strattera.com.)  If you are being treated with Strattera, consult your physician about this development to get more information and to determine what course of action to take if you develop symptoms.

Behavioral Issues
There are certain basic skills that all people with ADD need to master.  They relate to the common problems caused by ADD symptoms like difficulty with memory, procrastinating, not finishing tasks.  People with ADD usually need to find ways to compensate for their weakness in these areas.  They need to learn how to effectively use a day planner, how to manage a to-do list, how to use an automated reminder system (cell phone, wrist watch, internet calendar, etc), how to make and work towards achieving goals, how to set priorities and keep them.   Other skills that may be needed are time management, keeping focused on conversations, being on time, study skills, keeping an orderly work place, etec.  Often an important skill is negotiating with others on how shared tasks can be carried out together without the relationship being injured by ADD symptoms.

Probably the most important thing many people with ADD can learn is how to find someone who can help them stay organized and get things done on schedule.  This can be a significant other, a good friend, or, if finances permit, an administrative assistant.  Some people already have a secretary but do not take full advantage of the assistance that person could be to them. Many secretaries, if asked to be more helpful with reminders and organization, are very happy to do so because it can make their work easier and more satisfying.

Consider Short Acting vs Long Acting Medications
Short acting stimulants work for about four hours for most people.  Most long acting ones last about eight hours though Vyvanse lasts a few hours longer.

We generally start with either short acting mixed amphetamine salts or (long acting) Vyvanse.  The advantage of the short acting medications are the greater control and sense of safeness some patients feel they provide to apprehensive patients who are just starting a new medication.  They are also the least expensive option where price is a consideration. The advantage of the Vyvanse is that is long and smooth acting.

least expensive stimulants (short acting – 3 to 4 hours per dose)

  • generic short acting methylphenidate (generic Ritalin)
  • generic short acting dextroamphetamine (generic Dexedrine)
  • generic short acting mixed amphetamine salts (generic Adderall)

more expensive (short acting – 3 to 4 hours per dose)

  • brand short acting methylphenidate (Ritalin, Focalin)
  • brand short acting dextroamphetamine (Dexedrine)
  • brand mixed amphetamine salts (Adderall)

yet more expensive (long acting – 6 to 9 hours)

  • brand long acting methylphenidate (Concerta, Focalin XR)
  • brand long acting dextroamphetamine (Dexedrine SR)
  • brand x generic long acting mixed amphetamine salts (Adderall XR)

most expensive (long acting – 7 to 10 hours)

  • long acting lisdexamfetaine (Vyvanse)
  • brand long acting mixed amphetamine salts (Adderall XR)

Consider What Medication To Start With
When considering medication treatment for patients, we review whether they have taken medications for ADD in the past and with what effect.  If the patient (or a blood relative) has achieved a good response from a particular medication, we are likely to prescribe that medication.

Otherwise we usually start with an amphetamine (either dextroamphetamine (Dexedrine or generic) or mixed amphetamine salts (Adderall or generic) or  lisdexamfetamine (Vyvanse).  The latter offers two major benefits for most people.  It is the longest acting and has the smoothest effect.  Some patients prefer a shorter acting (4 hour) medication because, for example, they work mornings and evenings and want to nap in the afternoon.  For others, especially those without prescription insurance, price is an important consideration.

Choose Between Ritalin (methylphenidate) vs Adderall (amphetamine)
A small study we carried out suggested that the amphetamines may, on average, be superior to the methylphenidates for many people. The difference, if there is one, is not very great, and some people repsond to one better and others to the other.  If one medication doesn’t work, or if the patient, for some reason, prefers a methylpheniate, we will try it first.  Its advantages are that it may intefere with sleep less when taken within four hours of bed time and is less likely to make people jittery. It does cause some patients to get irritable especially as it wears off.

Second Line Medications
If, as sometimes happens, the stimulants don’t work, our second line treatment for ADD is Strattera and rarely buproprion (Wellbutrin) or modafanil (Provigil). These are generally not nearly as effective as the first line treatment of ADD, if they work at all.  We use second line treatments only when the first line medications have not worked.

We Give the Patient Instructions on How to Take the Medication
If the patient is taking a stimulant medication, we have the patient start the medication at a low dose and slowly increase it every three days or so until he/she achieves a satisfactory response or it is found not helpful.  During the time the patient is slowly increasing the dose, we remain in contact by visit or phone every week or two. we encourage the patient call me between sessions if there is a pressing question.

We tell the patient when to take the medication, what foods or other medications might affect its metabolism, what side effects are typical, what side effects should prompt the patient to call me, and what drug interactions to avoid. With the patient, we draw up a list of “target symptoms” for which the medication is being prescribed. we discuss how to (and how not to) judge whether the medication is working. we discuss what changes to look for when starting the medication or increasing the dose.

We give the patient a print-out of the side effects of the medication prescribed and of the dosing schedule.

Refill Instructions
If we have prescribed a federally controlled (pop up) medication like Vyvanse, Adderall, Ritalin, or Dexedrine, we explain the legal issues regarding prescriptions and refills for such medications.  Some of these differ from state to state but all require that prescriptions be written, not called in.  Some states permit clinicians to call in a five day supply to hold the patient over until a written prescription arrives by mail.

We review our office policies with the patient regarding refills, canceled or missed appointments, reaching us with urgent problems, billing and payment, and charges for reports for schools or lawyers that may be requested.

Coaching
Where appropriate, we make some coaching suggestions or refer patients to an experienced ADD coach.  Some are available locally and some do their coaching by phone.  To read about some coaching ideas, click here.

We Ask If the Patient Has Any Questions about the Treatment Plan and Answer Them

We Give the Patient a Prescription for the Prescribed Medication
The first prescription for a patient is usually written is for a one month supply to give the patient enough time to try it out.  Subsequent stimulant prescriptions may legally be written for up to a three month supply.  However some pharmacies and some insurance companies will only accept ones that are written for one month. On the other hand, most mail-in pharmacies usually prefer three month prescriptions.  Go figure.

Since some people abuse or misuse their stimulant medication, some physicians are very careful about writing extra prescriptions for patients who say they have lost their medications and may not write a refill dated before the time the previous prescription would have run out.

Occasionally older pharmacists view people who fill stimulant prescriptions with suspicion.  We suggest that if a patient feels the pharmacist who is taking care of them is rude or offensive, it may be helpful to deal directly with the pharmacy manager.

We Make Short Term Treatment Plan and An Appointment
We ask the patient to call us in a week or so to report on their her progress and suggest they call sooner if there are any problems.  We give the patient an appointment to see us in about two weeks.  We observe whether the patient writes down the appointment time or enters it into their cell phone.  If they do not, we discuss the importance of getting in the habit of always doing that since forgetfulness about appointment times is common in ADD.  We also discuss how they can be reminded of the appointment a day before hand.

The clinician may arrange for her secretary call the patient the day before the scheduled appointment with a reminder or use an automated telephone or text messaging reminder system to do so. Textmemo.com or 3jam.com

Appointment Cancellations
Sometimes patients realize a week or more before their appointment that they have a scheduling conflict that makes it impossible for them to keep the appointment.  And sometimes they procrastinate and don’t notify the clinician of this until the a day or two before the appointment, making it difficult or impossible for him to fill the time with another patient.  When that happens often enough, it reduced the clinician’s income and reduces the number of hour in which is beiong of help to people.

To reduce the likelihood of late notifications, many ADD clinicians charge in part or full for appointments scheduled but cancelled with less than a few days notice or missed.  Harsh though this may seem, the consistent result is that there are fewer last minute cancellations or missed appointments.

Early treatment management
We meet with the patient as scheduled and, if a positive response has been obtained, make any necessary adjustments in the dosing and timing of the medication and suggest changes that may reduce or eliminate some side effects.  We check to be sure there have been no significant change in the patient’s blood pressure or pulse.

Most patients respond adequately to a dose of stimulants of between 15 mg and 50 mg per day (Vyvanse 30 to 70 mg per day).  If the patient did not have a satisfactory response to such doses and has no disturbing side effects, we discuss further increases.   Daily doses higher than 60 mg per day have not been approved by the FDA for children but have been found helpful for many adults. The Harvard University group of ADD specialists suggest a maximum dose per day of 60 mg per day (amphetamines) to 80 mg per day (methylphenidates) per day for a 160 pound person and 75 mg per day (amphetamines) to 100 mg per day (methylphenidate) for a 200 pound person.

In a study of patients in our practice, about a third of adult patients benefit most from doses higher than that. Patients should never take such doses without the permission of their treating clinician as there may be medical or other reasons such doses may be contra-indicated.

If a lower dose has not worked, we discuss our experience and that of others using higher doses. If the use of a higher dose is acceptable to the patient, we slowly increase the dose, stopping the increase when an optimal response has been achieved or if there are unacceptable side effects. If the response is not satisfactory at the maximum dose, we stop the medication and consider starting another.

Once a satisfactory response has been achieved, we meet with the patient in two to four weeks to make any further adjustments. It may take as long as six weeks to be sure a medication works satisfactorily at a particular dose, and two or rarely three medications may need to be tried to find one (or a combination) that works best.

Keeping ADD from interfering with the treatment relationship
If you or your doctor would like some ideas about how to keep your ADD symptoms from disrupting your treatment sessions, click here.

Long term follow up
If there are no other psychiatric or therapy issues that need addressing, we schedule appointments every three months or so to check on the patient’s psychological and medical condition, on his or her response to the medication, to make sure the medication is being taken as prescribed, and to make any necessary adjustments in the dosing.

Case Examples
For a more detailed description of the course of treatment of a few patients with ADD, see the Case Reports of four patients treated with stimulants.