Adult ADD

Summary: A study done by one of the editors of AdultADD.Info suggests that, for treating ADD in adults, amphetamine based stimulants (Adderall and others) are generally more effective than methylphenidate based medications (Ritalin and others).  They are also slightly more effective in treating hyperactivity and depression, if present.  However, the amphetamines tend to interfere with sleep a bit more than do methylphenidate medications. Short acting methylphenidate medications wear off more abruptly than do short acting amphetamines.

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Clinicians treating adult patients with ADD often have to choose between Adderall-type medications (amphetamine (AMP)) or Ritalin-type medications (methylphenidate (MPH)). Marc Schwartz, MD, one of the Editors of AdultADD.Info carried out a study comparing the effects of these medications on 41 adult patients in his practice who had obtained optimal treatment results with one or both of these medications. Optimal results were defined as those achieved by slowly increasing the dose of a medication until the patient and clinician agreed that there was definite improvement in the patient’s ADD symptoms but where a higher dose either did not achieve a better effect or caused unacceptable side effects.

Patients were between 18 and 62 years of age. A 21 item questionnaire was constructed on the basis of the author’s clinical experience treating adult ADD. Each item in the questionnaire contained a statement about the effect of the medication, for example, “helps you focus on details”, “helps with concentration”. Patients scored items on a scale from O if the medication had no effect to 3 if it had a moderate effect to 5 if it had a strong effect. Items were developed, tested, and refined with a number of patient who were not included in the study.

After an initial evaluation, patients were more or less randomly started on one or the other type medication. Those who had achieved optimal results with it were given the questionnaire. Patients who had failed to achieve optimal results were switched to the other medication. If they achieved optimal results with the second medication, they were given the questionnaire. Patients who did not achieve optimal results with either medication were not included in the study. (Since non-responders were not included, the treatment results in this study are better than would be seen in an unselected patient group.)

Results
Forty one patients completed 54 questionnaires (Table 1). Twenty eight had achieved optimal results with the first medication taken. Of these, nineteen achieved optimal results with AMP while nine did so with MPH.

The remaining 13, after having not responded optimally to the first type of medication they took were switched to the other and did achieve optimal results. One of the latter found both medications helpful but neither alone to be optimal. This patients achieved optimal treatment by taking both types of medications at the same time.

Table 1
Number of Patients In Study and Questionnaires Completed

The Effects of Stimulant Treatment
Analyses of all questionnaires were carried out. One focused on symptom reduction, the other on side effects. The symptoms most reduced by the stimulants were those which affect executive functions such as concentration, focus, and task initiation (Table 1). A weaker effect was seen on hyperactivity and impulsivity. Side effects, such as interference with of sleep, loss of appetite, and anxiety, were given lower ratings.

Table 2

Average Effect of Stimulants on ADD Symptoms
From 0 = no effect to 5 = strong effect
54 questionnaires (AMP =32, MPH =22)

Table 3

Difference Between the Effects of AMP and MPH Medications
On the ADD Symptoms of 13 Patients Who Took Both
0 = no effect to 5 = strong effect

Thirteen patients took both medications. The table below compares their scores on items measuring the effectiveness of the medications on their ADD symptoms. Only items for which the difference between medications was greater than 0.2 are included in the table.

For all of the executive functions, the beneficial effects of AMP were greater than those of MPH.

Table 4

Difference Between the Side Effects of AMP and MPH Medications
Among 13 Patients Who Took Both
0 = no effect to 5 = strong effect

The table below compares their scores on items measuring the side effects of the medications. Once again, only items for which the difference between medications was greater than 0.2 are included in the table.

Discussion
In this group of adults with ADD, AMP medications were found to be generally more effective than MPH medications for treating executive function symptoms as well for treating as hyperactivity and co-existing depressive symptoms. However, they tended to interfere with sleep more than did MPH medications.