How to Choose a Medicine for Adult ADHD
by Richard Rubin, MD
Clinical Associate Professor, University of Vermont College of Medicine

At a recent Baptist Hospital of South Florida Continuing Medical Education program, I presented a systematic approach for applying newer knowledge to the treatment of adults. Three variables should be considered:

• characteristics of each patient,
• differences among medicines, and
• findings from research studies.

Characteristics of Each Patient
People bring multiple questions, concerns, preferences, and experiences to their ADHD treatment expectations. It is valuable to initially review these for a clear, up to date planning start. Social, cultural, and family attitudes can influence acceptance of any and all medicines. Prior exposure to medicine can introduce adverse experiences, such as side effects to be avoided. A certain type of benefit may be anticipated, such as the immediate effects typical of the stimulants, versus gradual onset as with the non-stimulants. People taking medicine for the first time may respond differently from those with prior exposure, both positive with greater benefit, and negative with more side effects. Sometimes people have had beneficial but only partial response, and would benefit from addition of another medicine with complementary actions. The goals for each person’s treatment plan influence medicine choice. Is rapid rescue from behavioral problems needed, or ongoing maintenance? Is performance strengthening for limited duration each day required, or continuous symptom stabilizing? Does the patient have other medical or mental health problems that specific medicines may improve or worsen? There are different effects on blood pressure and anxiety, for example. Substance abuse/misuse is another consideration.

Differences Among Medicines
While adult medicine guidance used to be derived from childhood practice, we now have an adult ADHD FDA approved choice in each major category:

• the norepinephrine non-stimulant atomoxetine (Strattera),
• extended release mixed amphetamine salts (Adderall XR), and
• dexmethylphenidate (Focalin XR).

Research Findings
The evidence base for each medicine varies, including both the clinical trials for FDA approval and other published research studies. While useful information is provided, the limitations of trials and studies should be recognized in applying the results to patient treatment practice. Assessing the amount of change, sometimes expressed by the statistic called effect size, requires the same measurement instrument for valid comparison. While efficacy approval is based on significant change compared to placebo, this does not necessarily mean all symptoms will be improved to remission in practice. Studies may be limited to core symptom measurement only, while treatment in practice requires consideration of impairments also. The population included in a study will greatly influence both the effectiveness and safety conclusions. Clinical trials tend to limit co-existing psychiatric disorders, medical risk factors, and social problems that complicate the outcomes seen in community practice. Lastly, head to head comparison studies should be interpreted carefully, due to differences from practice in dosing, duration, and patient risk exclusions. RL Rubin MD, 2006

Dr. Rubin practices Child and Adult Psychiatry, directs The Clinical Study Center in Burlington Vermont, and serves as Clinical Associate Professor at the University of Vermont College of Medicine.

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Treatment tools in myADHD.com can help students develop better study strategies to more effectively manage their work in school. We have provided links to a few samples below.

1. Organizing School Supplies
2. Homework Pass
3. Home Token Economy Program
4. Bedtime Jobs List

myADHD.com and Addvisors.com offer a free ADHD related teleconference on the second Wednesday of each month.

Chris A. Dendy, MS, noted author and speaker, will be the guest speaker at our September 13th teleconference from 8:30-9:30 pm.

Call (646) 519-5883 Pin 2648 at 8:30 pm on Sept. 13th and join the teleconference.