Adult ADD

Many patients wonder whether they might develop tolerance to the stimulant medications. That is, they are concerned that the medications may become less effective over time or lose their benefit altogether. have observed a number of tolerance patterns that seem to occur as people stay on these medications.

Medication Not as Strong After a Week or Two of Use
Most patients who have a positive response to the stimulants find that within the first month they are not only more effective and better focused but have a mild sense of euphoria and optimism that they had not experienced before. This is a common, but temporary effect. Almost all patients lose this after about a month or so. Luckily, they retain the benefit of increased focus, decreased distractibility, and less tendency to procrastinate. It is important for patients to understand that this initial euphoria will likely not be an enduring phenomenon. Often patients can run into trouble if they seek to maintain this aspect of the response. The effort to do so will often be fruitless and in many cases will lead to their taking higher and higher doses of medication with no benefit. If patients happen to find that this good feeling remains with them over time, all the better. But the thrust of treatment should be toward relief of ADD symptoms.

It is worth noting that the stimulants can sometimes be effective in treating depression or enhancing the effects of other anti-depressant medications. Some patients who were depressed before starting the stimulants feel a sense of relief bordering on euphoria as their depression clears. The euphoric feeling usually disappears as they get used to not being depressed.

Sometimes the medication seems less effective after only a week or so. There are a few reasons this may be so:

1. there’s often a placebo effect at first that makes the real medication effect appear stronger. It tend to wear off after a week or two and you’re left with just the medication effect.

2. some people’s bodies adjust not only to the side effects but to some of the beneficial effects of the medication after a week or two.

3. delight about the changes people see make them more excited and excitement itself can for a week or so reduce the effects of ADD.

If the medication does not continue to work as well after a week or so, I often suggest patients increase their dose a bit and see if that helps. But it’s important to check with your doctor before making any dosing changes.

Medication Not As Effective After a Year or Two of Use
Another way that patients commonly experience a change in their response to medication is in the need for a slightly higher dose as their first year of treatment progresses. Often patients will find that they need to bump up their dose by about 25% sometime between their first few months of treatment and the one-year mark. Again, this is normal and should not be construed as medication losing its potency.

Medication Not as Effective During Stressful Periods
A third pattern is sometimes seen when ADD patients taking a stable dose of stimulants face a situation when dramatically more focus and concentration is demanded of them. This might be true for a patient taking a three week intensive continuing education program or for a patient completing a major project that has a deadline. Patients in these circumstances may find that their usual medication dose is not working as well – not only during the hours they are working on their project but during the rest of the day as well. Perhaps their brains are metabolizing the medication more quickly. Often a temporary increase in the dose worked out in collaboration with their care provider can be very helpful. Once the pressing project is over, patients almost always find the new higher dose they have been taking makes them a bit anxious or interferes with their sleep, and they resume their usual dose.

Repeated Increases in Dose Needed to Maintain Effectiveness
There is a fourth pattern seen in a small minority of patients. Most people tend to stay with whatever dose was originally optimal for them with only slight adjustments required thereafter. However, some patients do indeed lose the benefit of the medication over time. Each increase to a higher and higher dose produces only a temporary benefit, and within a short period of time the patient finds that his or her symptoms have returned again. This is unfortunate, but does not mean that there is no hope for this patient’s symptoms to be relieved. Rather, it means that the patient and physician will need to work harder and more closely to develop an effective treatment strategy. This might involve the patient taking “medication holidays” (for instance, taking the medication Monday through Friday, but taking weekends off), rotating medications (2 months of a methylphenidate medication alternated with 2 months of a dextroamphetamine medication) or adding other medications.

Medication Not as Effective When a Person Gets Depressed or Anxious
There is another pattern that can look like tolerance, but is actually quite different. ADD and depression have some symptoms in common, like memory problems and difficulties with concentration. For this reason, when patients with ADD taking a stable dose of stimulants develops a depression, it may appear their ADD symptoms are getting worse or that the medication is not as effective. Both patient and clinician should keep the possibility in mind that depression may be causing this since psychotherapy, counseling, or anti-depressant medications may be more helpful in these circumstances than increasing the stimulant dose.

Medication Not as Effective When Medication is Made by Different Manufacturers
While brand and generic medications must, by law, contain the same therapeutic medication, there are differences in filler that might affect absorption.  In addition, the law does not require that the generic contain 100% of the brand medication but rather that is can contain between 80% and 120%.   If a person switches from a generic that contains 120% to one that contains 80%, then there will likely be a significant decrease in effectiveness.  It is best to stick with the medication manufacturer whose pills have proven themselves.  For more details, see the page on Brand vs Generic Stimulants.

It is important to bear in mind that people’s dosage requirements do vary over time as a result of life circumstances, stress, mood and anxiety difficulties, and metabolism. Some people will need to spend more time and effort than others with their doctor to make sure their dosage is optimized. This is an unfortunate reality of almost all medical conditions. However, provided that the doctor is well-trained in caring for ADD patients, and both doctor and patient keep lines of communication open, most patients will be able to get good symptom relief indefinitely.