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Concerta vs Adderall XR for ADHD

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Sunday, February 28th, 2010
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Concerta vs Adderall XR

Concerta and Adderall XR are two very common and popular treatments for ADHD.

How well do they work?  And how do they compare?

Concerta

Concerta is a long acting form of Ritalin.  Ritalin is chemically known as methylphenidate, and acts on dopamine and norepinephrine receptors.  It temporarily blocks their ability to remove those neurotransmitters from the space in between cells.

And since dopamine and norepinephrine stay around for a longer time, they have a stronger effect.  This leads to better focus concentration and motivation.

Adderall XR

Adderall XR is a long acting form of Adderall.  Adderall is a mix of different amphetamines, including both the l and the d form.  Amphetamines, like Ritalin, also act to prevent the removal of dopamine and norepinephrine from the space inbetween cells.

Unlike Ritalin, however, Adderall may also cause the cell to pump out dopamine.

Efficacy: Concerta vs Adderall XR

About the same percentage of people will get benefit from Concerta as will from Adderall XR.  They work at almost the exact same rates.  Around 70% of those who use either medication along with therapy will have very significant improvement in ADHD symptoms.

That said, it is possible that someone will respond better to Concerta than to Adderall.  Dr. Tuckman, a clinician with significant ADHD experience, reports that roughly 1/3 of patients will respond best to a Ritalin type medication, 1/3 best to an amphetamine, and 1/3 will respond equally to both.

Long lasting form

It is important to note that both Concerta and Adderall XR are long lasting forms of stimulant medication.  They both last for an extended period of time, roughly 10-12 hours.

This is important because clinicians report superior treatment results with long lasting forms as opposed to the instant release.  Studies are also starting to strongly support the superiority of long lasting treatment versus short lasting.

In one study of 70 patients, for instance, 97% preferred the long acting form of Ritalin over the short acting.  In another, 44% of those on long lasting form of medication had ADHD symptom remission, as opposed to only 16% of those on short acting.

Side Effects

Both Concerta and Adderall XR have similar rates and similar types of side effects.

The most common side effects from both include anxiety, insomnia, and trouble eating.  Some studies have indicated that side effects for the medications tend to diminish over time.  This may be due to the body becoming used to the med.  It may also be because those for whom it is a significant issue, discontinue use.

It is possible that long term use of either medication is associated with slight decreases in weight and/or height in children.

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Dr. Tuckman Answers Questions About Adult ADHD

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Tuesday, February 9th, 2010
Dr. Ari Tuckman

Dr. Ari Tuckman is the author of “More Attention, Less Deficit: Success Strategies for Adults with ADHD” and “Integrative Treatment for Adult ADHD: A Practical, Easy-to-Use Guide for Clinicians”.

He has treated hundreds, if not thousands, of adults with ADHD.  He generously took the time to answer questions that readers of mine have submitted over time.

What attracted you to ADHD?

I actually fell into it around 1998/99.  I was starting out and was approached about working with some patients who were adults and had ADHD.  They needed help dealing with their condition and with life management.  I took the opportunity and it was a good fit.

At that point, things were different.  If you knew three things about ADHD – than you were an expert on it.  It’s better now, but still not good enough.

What kind of experience do you have with adult ADHD?

I’ve been focused on that area for 10 years now and a significant percentage of my clients have ADHD.  If I had to put a number, I’d say I’ve treated hundreds if not thousands of patients with adult ADHD.

Why do we not know enough about Adult ADHD?

The problem is that doctors, especially primary care physicians, aren’t good at recognizing it.  And even if they are, they’re not in a good position to do something about it because they simply don’t have the time for a thorough evaluation, which can take a couple hours.

Very often people have ADHD and their doctor just doesn’t notice.  It’s tough for the doctor, of course, because clinicians have to know a million things.  But when it’s your life, you expect them to get things right.

Why is this a problem?

Very often a doctor will notice that someone with ADHD has anxiety or depression and treats only that.  They are then surprised when there isn’t such a good response and think “I guess this person just doesn’t respond well to treatment.”

And it’s unfortunate.  Untreated ADHD is a big set-up for a lot of problems.  We have hundreds of studies that show the kind of bad impact it has on your life.

Can you elaborate on the problems ADHD causes?

It’s a big misconception that having ADHD is no big deal.  It has severe consequences on people’s lives.  ADHD has measurable effects in all areas of functioning.  Everything is affected by it – social life, work performance and more.  Its effects can even go as far as your credit rating!

ADHD has the most impact of almost all psychiatric diagnoses because it is always present and always causing problems.

If you could tell a Doctor two things about ADHD, what would they be?

First, that even if someone was hyper as a kid, they don’t have to be hyper now to have ADHD.  And they might not be restless or overactive in your office.

Second, that having ADHD doesn’t mean you’re not successful.  On the contrary, there are some really successful people who have it.  But it comes at a great cost and they have to work harder to achieve their success.

Remember, I’m a psychologist.  That means that I prefer talking to people.  But for ADHD, I am a big fan of medication because it works.  And it works well.  Proper use of medication sets people up for success so that other strategies will be more successful.

Medications for ADHD like Ritalin and Adderall have their fair share of controversy.  What’s your opinion on that?

I’m certainly not advocating that everyone has ADHD or should take ADHD medications.  Everything stems from a proper diagnosis.  Once that’s done, choosing to use an ADHD medication is a lot like choosing to use painkillers.  You do it if you need to, and otherwise don’t.  I had surgery, for instance, and for a short time, needed to use strong painkillers.

It’s not a matter of good or bad, but rather how medication fits into your overall treatment plan.  Medications for ADHD tend to be very effective.

What are your thoughts on the proper use of medications like Ritalin and Adderall?

First, I’ll repeat that it’s absolutely essential that a proper diagnosis be made before using any medication. I have a saying that accurate diagnosis guides effective treatment.

It’s also important to have realistic expectations.  You can take a pound of medication and still not do any work.  The fact is, you still have to choose to put in the effort.  Medication puts you in the ballpark, but you still have to swing the bat.

How do you choose a medication?

Typically, I recommend an extended release.  That means either Adderall XR, Concerta, Vyvanse, or Focalin XR.

To choose between them, I find the rule of thirds to be quite useful.  Roughly one third of patients will respond best to Adderall or Vyvanse, one third to Ritalin/Concerta/Focalin, and one third will respond equally to both.

You can’t point at a hundred people and say that for everyone Adderall or Ritalin would work best, but for any one person there may be a better or worse response.

For my patients, it can be hard, but they have to realize that it can take some time to figure out the right dose.  It’s not a magic pill, and you have to be somewhat lucky to get the right dose on the first try.

Doctors sometimes are too cautious and might use a child-sized dose in an adult.  Then they’re surprised when they don’t get good results.  That’s like wondering why half an aspirin doesn’t help an adult with a headache. It doesn’t mean that a larger dose wouldn’t be more effective–up to a point, obviously.

What are some issues you see in treating adults?

Adults who are diagnosed or deal with ADHD are different from kids because they’ve been dealing with their situation undiagnosed for most of their lives.  They’ve had to come up with explanations for why things are not going so well in their lives.  And they’ve constantly been telling themselves, “Now it’s going to be different.  I’m going to get that report in on time, listen more when people talk, spend my money better, etc.”

They’ve had a lot of failures.

For a kid, there aren’t those years and years of struggle.

Most adults when diagnosed have a tremendous sense of relief.  It puts things in place.  And it’s an explanation that isn’t pejorative or judges them badly.  They’ve probably heard way too many times things like, “you’re irresponsible,” or, “you’re lazy.” A diagnosis of ADHD is much better than that.

How do you diagnose ADHD?

I typically do a 2 hour interview.  If possible, I have a parent or romantic partner come along to give additional input.  I try to get as much data as possible, including old report cards which can be particularly telling.  Of course doing so is often hard in someone over 25.

We look at how the person is doing now and at prior points across a broad range of situations.  Looking at just one area can be misleading – how are they performing overall?  And does ADHD fit the pattern of data?

How would you respond to critics of diagnosing ADHD?

For most psychiatric – and even a lot of medical – diagnoses you look at symptoms and history.  Blood tests can’t tell you everything.  The best diagnosis, of course, has to be thorough.  If you do a good job, you’ll look for the right things while not asking leading questions.

Some symptoms are more obviously associated with ADHD.  What are some of the more unusual or harder to notice things?

A lot of people with ADHD have difficulty retaining what they’ve read, and may not actually read books that often.  Magazines and websites are easier to digest.  It’s common to have to reread things.

Other areas include careless mistakes in math.  They know how to do something, but mess up on the small details.  Everyone has brain glitches like that but they are more common in people with ADHD.

A really interesting phenomenon I see is that sometimes people with ADHD will have done homework assignments but forget to hand them in.  This is particularly telling because there isn’t an alternative explanation.  If someone doesn’t do their homework, for instance, you could say that they just don’t want to do it.  Blame it on motivation.  But there’s really no reason you’d choose not to hand in an assignment that you did.

Another area is losing things, both in the house and out in the world.  There’s really no advantage to losing your cell phone, for instance, so doing so is an indication that ADHD may be an issue.

Some psychoanalysts might say losing your phone is a sign of subconscious conflict?

That just doesn’t seem very likely.  Remember, that psychoanalytically based treatments have not been shown to work that well for treating ADHD.  That’s not to say it can’t help with other issues that folks with ADHD or other people might have, but it won’t change the underlying condition.

Some research has shown that low levels of iron in the blood has been associated with ADHD.  What do you have to say to that, or claims that bad diet causes ADHD?

I’ve heard things like that often.  Parts of those claims may be true, but you have to remember that correlation does not mean causation.  While it is true that men in general are taller than women in general, being tall, for instance, doesn’t make you a man.

A possible explanation, however, could be that people with ADHD may not have as healthy diets.  It’s important to remember, however, that dietary treatments have not been shown to a valid treatment for ADHD.

How do you decide to use a medication or not?

It’s a question of weighing the demands of things going on in your life against your abilities to manage them without medication.  What other strategies, for instance, could you useto handle your life?  If the demands of your life outweigh your ability to handle them, that’s an indication that medication might help.

Of course, if someone shows up in my office, they’re probably not doing as well as they would like!

And of course there are different situations.  You may need to take medication during the week but not so much over the weekend.

One of the biggest fears people have is that their ADHD medication will stop working.  In your experience, does tolerance to, say, Ritalin or Adderall develop?

Not usually.  It is my experience that, once you find the right dose, you can keep taking it for years, even on a daily basis.

That said, there are some factors that may change the right dose.  Sometimes there is significant weight change which can change how effective a dose is.  Also, someone may find that their lives require them to perform at a higher level when  they might get a promotion with more responsibility and really have to be on their game.  Or when they have a new baby.

What are some thoughts you have on ADHD in general?

Getting diagnosed with ADHD can be really life changing.  Suddenly things make sense.  I have to tell my clients that I understand how hard things have been in the past.  But now they’re in a new situation.

With medication, things can be quite different.  And, although they’ve already heard a million suggestions, in therapy we look at new strategies that are based on a solid understanding of how people with ADHD tend to process information, so we can create strategies that are more likely to be helpful.

Anything else?

Today I’m having a client who is living out of the country and coming back home here in America to visit his family.  He’s driving four and a half hours here and another four and a half hours back, a total of nine hours driving, just so we can spend two hours to officially diagnose him with ADHD.

You might like:

A Full List of Medications for ADHD

Our articles on ADHD

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Strattera: Side Effects, Use for ADHD

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Thursday, January 14th, 2010
Bottle of Strattera

Strattera or Atomoxetine is a new treatment for ADHD that was approved in 2002 and the first medication approved for treating ADHD in adults.

It is a norepinephrine reuptake inhibitor, which means that, like Ritalin and the stimulants, Strattera increases the level of norepinephrine that cells are exposed to.

This hopefully results in increased attention, focus and motivation – reducing the symptoms of ADHD.

Unlike the stimulants, however, Strattera takes up to 8 weeks to work.  The exact reason for this delay is unclear, but it is reminiscent of behavior more typical of an antidepressant.

The main benefits: Strattera provides full day coverage with one or two doses, is not a stimulant, and is hard to abuse.  May work when stimulants don’t or are not a good idea.

The main disadvantages: Strattera isn’t as effective as the stimulants, is expensive, and takes a while to start working.  Plus it has its own array of side effects.

Efficacy:

Strattera is definitely better than placebo at treating the symptoms of ADHD.  Beyond that, however, the studies have been modestly positive.  In one study, for instance, of several hundred people treated for 10 weeks, scores on the AISR scale went from an average of 38.5 to 24.5 for those treated with Strattera.

The AISR scale consists of 18 questions each rated on a scale of 0-3, where 3 is most severe and 0 is not significant.  The max score is 54.  As such, a reduction from 38.5 to 24.5 is fairly impressive.

Unfortunately, the placebo treated group went from an average of around 39.2 to 28.9.

The difference between Strattera and placebo of 4.4 means that a few questions were answered as less severe than originally.  So there is an effect, and it is positive, but it is not as significant as with the stimulants.  Strattera shows similar if slightly better efficacy in other studies.

Roughly 25% of people who use Strattera stop specifically because they feel it does not work well.

Dosing:

Strattera is typically started at .5mg/kg and raised to 1.2mg/kg for a maximum of 100mg per day in adults.

As it is digested by the CP 450 system, medications such as Prozac may interfere with Strattera.

Strattera Side effects:

Anywhere from 10-25% of people report side effects as a reason for stopping Strattera.  They are mostly mild.  That said, over several years of use, the risk of having some sort of serious side effect becomes not insignificant.

People who use Strattera typically lose a small amount of weight.

Most common:

>50% report headaches, some issues with digestion, nausea or upset stomach, and sleepiness

~13% report abdominal pain

Some studies report increased rates of vomiting and constipation on Strattera.

~5% report dry mouth, urinary hesitation, erectile dysfunction

Less common side effects:

Low but possibly increased rates of sinusitis, impaired digestion,

Depression, thoughts of suicide (in one study, 11/714 had suicidal thoughts, or 1.5%), appendicitis.  New aggression or irritability is not common but not uncommon side effect of Strattera.

Rarest side effects:

Heart murmur, prolonged QT on ECG, liver issues, upper abdominal pain, diabetic ketoacidosis

This list is not complete; see manufacturers insert for more.

Use:

Most people who use Strattera have tried stimulants in the past and had adverse reactions or preferred to try a different medication.  Stimulants generally don’t work in about 30% of people with ADHD who try them.  Additionally, in some groups, stimulants are contraindicated.

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adhd, medication

Long term Adderall effects

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Friday, January 8th, 2010
Blue Adderall XR Pill

What happens when you take Adderall for a long time? Does it keep on working, do you develop tolerance if you’re taking it for ADHD?  As follows, is a quick summary; read on to get a little explanation.

Summary of long term effects of Adderall

Mental: Increased focus, attention, motivation.  Reduction of ADHD symptoms.

Heart: Use of Adderall or related stimulants for more than a year increases your diastolic blood pressure by ~ 3-5mm HG, systolic blood pressure by ~ 2-5mm HG and your heart rate ~3-5 beats per minute.  Additionally, it is possible that ECG testing will show slight electrical activiy differences.

This is almost always not good (except possible in someone with initial low blood pressure), but is it bad?  Some argue that these increases don’t have any direct health implications, while others argue that they can show a 20% increase in emergency room use for heart issues in kids who use stimulants.

Before using stimulants, it may make sense to get some basic cardiac testing.

Brain: Some studies have shown that stimulant use in people with ADHD may increase the size of certain parts related to controlling focus, motivation and attention.  This is very positive.  On the other hand, some animal models have shown some neurotoxicity from stimulant use.

Appeptite/weight: Amphetamines like Adderall are among the best appetite suppressers.  This led to their wide abuse as diet pills and may cause unwanted weight reduction in people who use them.  Long term use in kids has been shown to be associated with slight weight loss and even possibly slight height reduction.

ADHD Treatment Effect: Researcher Doctor Biederman reports that in a study of several hundred patients over 1-2 years, for most, stimulant medications continued to work well at a steady dose.  Noted Doctor Halloway, coauther of Driven to Distraction, reports that in almost all cases, tolerance to ADHD medication does not develop, but is possible.  Dr. Paul Wender, a noted researcher into ADHD, reports that tolerance is rare, and most patients can take stimulants for many years without problem.

Of the dozens of research papers reviewed, not one mentioned that developing long term tolerance was a limiting factor in treating ADHD.

That said, there is not enough data in this area.

What does that mean?

With the increasing use of amphetamines to treat ADHD and as recreational drugs, more and more people want to know – are they safe for long term use?  What potential side effects come with use over time?  And, this is exceptionally important, do they continue to treat ADHD over time or does drug tolerance develop?

There have not been that many studies into the long term effects of Adderall.  One thing we know is that stimulants do have some cardiovascular effects which can be serious for at risk people.  That said, one study of several hundred people over 2 years of mixed amphetamine salt treatment (the generic for Adderall), showed no clinically relevant heart effects – at least according to the doctors and researchers who did the trial.  A few people did drop out because of heart related concerns like palpitations and excessive heart rate.

Additionally, a retrospective analysis of about 2,000,000 kids treated over time with stimulant medications showed that 456 went to the emergency room with heart related issues.  When you control for how many kids would normally go to the ER in a sample that large, this represents a 20% increase in risk for heart problems.

Remember, there is a black box warning on stimulants because of their potential for heart complications.

In terms of developing tolerance to the therapeutic effect in treating ADD/ADHD: the data seems to very strongly suggest that tolerance does not develop over a year or two year period, and that use of extended release formulations may increase efficacy due to smoother release.

Attenuation of side effects?

It is possible that with time, the side effects of stimulants become attenuated, or less significant.  For instance, one study showed that a significant amount of people experienced insomnia, depression or weight loss at start of use of stimulant medication.

But near the end of a year, only 1% still had a reduction in appetite that would lead to weight loss, and no one reported insomnia (which sounds a little over-optimistic.  Everyone has insomnia sometimes.)  This may be, however, because those who had serious difficulty with those issues stopped using the medication.

Neurotoxicity?

Some studies in monkeys have shown that amphetamines can cause neurotoxicity even at therapeutic doses.  This effect is likely caused by the effect of amphetamines to reverse dopamine transport channels – because it was not shown to happen with Ritalin, which doesn’t do that.  The neurotoxicity data is not clear, however, especially considering that other animal models did not show this problem.

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The 4 Secrets to Success with ADHD

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Thursday, January 7th, 2010
A head of gears

If you think or know you have ADHD, you’re probably a little confused.  You may not feel like you have a “deficit” but you may not be entirely happy with how things are going in your life.

Let’s be honest.  Here’s some stuff that you just have to know.

1) First, if you have ADHD, you’re different.  Your brain works differently.  You can’t do anything about it directly (as far as I know, there isn’t a brain exchange program – yet), and, whether you like it or not, it has a major impact on your life.  Most people aren’t like you.

There’s a reason you’ve been having all the issues you’ve been having – it’s not your fault.

2) There are amazing things about you that you don’t appreciate.  Other people simply aren’t as energetic, friendly, interested in biofuels or spontaneous as you.  By focusing on your strengths, you will achieve great success and the respect, admiration and even envy of other people (“why can’t I start my own art agency/legal practice?” and, “why can’t I get that promotion?”)

3) Life will make it near impossible for you to focus on your strengths.

You will instead focus on the fact that you can’t sit still.  That you have trouble having “normal” conversations about small, boring things.  That you drive really fast, blasting music.  Whatever the symptoms the ADHD causes – those are the things that will hurt and depress you.

And when you focus on the bad things, other people will too.  People instinctively look to other people for social guidance, how to judge things, even more so than you might think.  (People with ADHD can be quite resistant to group think because they can’t ignore that nasty voice inside of them saying, “this is stupid!”)

If you are down and unhappy about your flaws, other people will see and judge them the same way you do.  They’ll think, “wow, that guy’s not normal.”

If you focus all your energy on doing things that you feel you have to, but are excruciatingly hard, you’ll never be happy.  And you won’t do them that well anyways!

Your gift is in certain areas, certain things, certain strengths.  You are AMAZING at those things but don’t realize it.  And trying to do the things you can’t, that people without ADHD can do easily, is a sure fire way to fail and be unhappy.

Would you expect a great and passionate painter to spend his time filling tax forms?  Or the CEO of the company to mop the floor?

The Hunter/Farmer model proposed by Hartmann is very empowering and just makes sense to a lot of people.  What it says, basically, is that people with ADHD are more like hunters – they need constant stimulation, variety, excitement and change.  Other people are like farmers – focused, able to do boring things for long times, and conventional.

Now, remember, ADHD isn’t just a matter of feeling, or personality types, or lifestyle.  (Although based on how many executives I know have ADHD, it can actually be an advantage at some jobs).  It’s a neurological condition that we have pretty much proven is a physical condition.

If you have ADHD, your brain has different wave patterns and activity than people without it.  Your basic energy processing system is different, as well as the way that you respond to stimulation.  For you to maintain focus on something, it has to be very, very interesting.

We’re starting to be able to prove that by pointing at specific brain activity and abnormalities.

4) If you have ADHD, you are still fully responsible for your life.  But treatment can change everything.  That’s not just hyperbole.  We’re talking about a complete change in everything – for the better.  Even so, and even though ADHD is a real problem that can make your life hell at times, you’re still responsible for everything you do.

If you have ADHD and you run a traffic light – you still get a ticket.  If you don’t do your homework and miss the final, you’ll get an F.

Remember, most other people are simply too busy to care about whether or not you have ADHD.  They care about what you do, whether they enjoy spending time with you, doing business, or whatever.  You are the only one ultimately responsible for your life.

And, ADHD or not – how can you make it great?

If you found this article useful, we have some news that might shock you.  There’s more!

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How to use qEEG to Diagnose ADHD

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Friday, January 1st, 2010
Electroencephalograph

Some people who don’t believe ADHD exists argue that there is no physical signs or tests for it.  Such a claim, while popular, ignores the strong and compelling evidence from PET and fMRI scans that show things like smaller brain size in people with ADHD as well as dopamine irregularities.

But recent innovations in brain wave monitoring may put that claim to rest for good.  There is now a physical test that may be able to diagnose ADHD  up to 90% of the time, the qEEG.

Sounds too good to be true.  That said, the science behind this test does seem to be valid, and a recent test of qEEG ability to diagnose real people was breathtakingly impressive.  In a mix of 500 people, the qEEG tests diagnosed 96% of non-ADHD people correctly (as not having ADHD), and diagnosed correctly 86% of the people with ADHD.

Very impressive.  Let’s go a little more into the details.

What the heck is a qEEG?

A qEEG is the weird sounding abbreviation (“We’re going to have to run a queeg on your son”) for “quantitative electroenchalogram.”  Basically, a qEEG is an EEG that has been converted to a digital format – a computer stores the EEG data which is “quantified.” This is important because the computer can perform a higher level of analysis and check for minute differences that might not be noticed by a person alone.

And an EEG is that test when you wear a cap covered in electrodes.  What the test basically does is detect the electrical activity going on up in your skull.  The best thing about it is that it is non-invasive, not too expensive, and can be done fairly quickly.  That said, they are not yet very common and may be hard to obtain.

We’ve had EEGs for a while, but only recently have we improved our ability, especially by using computers, to analyze them.  With better analytical capabilities, we are increasingly able to develop a model of differences in brain wave behavior between people with ADHD and people without.

One analysis, for instance, showed that up to 80% of people diagnosed with ADHD and tested with an EEG show some signs of brain electrical difference.

Now, some electrical difference is not entirely uncommon. 24.6% of kids with learning disabilities may also have qEEG differences, but possibly of a different nature, and that’s not to mention that some of the kids used to get that number could have had ADHD as well.  After all, a great deal of kids with ADHD also have learning disabilities.  And in “normal” kids (who is really normal?), only 3.3% have EEG irregularities.

Lots of numbers.  What do they mean?

Recently, 176 people with inattentive ADD, 221 people with hyperactive ADHD and 85 people without ADHD were given qEEG tests.  The researchers didn’t have anything else to look at besides the data taken directly from measuring brain waves.

The result?  An astonishing 86% of the people with ADHD were diagnosed – and 96% of those without ADHD were correctly identified.

The next time someone tells you there isn’t a physical cause or aspect of ADHD, tell them that.

Do Medications “Fix” qEEG Differences?

To top it off – and this is like finding a $20 bill in the pockets of a returned pair of lost jeans – medications like Ritalin may actually change the very same brain patterns that can be used to blindly diagnose someone with ADHD!  Not only does the qEEG seem to show clearly that there are brain wave differences, it may also show that medications change those brain waves to something more normal.

It all makes an extremely compelling story.  That said, as always, healthy skepticism is called for, and the word is still out on this new method.

Now, it’s important to note that the research on the effects of stimulants on resting EEG behavior are mixed but generally show little effect.  Which goes against what we just said.  Emerging data, however, seems to show that stimulants do have a significant effect on the EEG behavior of people who aren’t resting – which is how we spend the vast majority of our waking time.

Using qEEG, for instance, Winsberg and his colleagues reported higher amplitude and peak on certain brain waves while performing a task in ADHD kids who took Ritalin as compared to ADHD kids who didn’t.  That activity could indicate better focus and concentration.  Another recent study of 20 kids showed similar positive effects of stimulant treatment, with a lowered theta and somewhat lowered delta brain wave activity.  Both the theta and delta areas seem to be elevated in ADHD people.

The models aren’t perfect, and the exact brain wave patterns that are different in ADHD people still not fully established.  The most consistent finding seems to be an elevation in delta and theta action, with lower levels of alpha and beta waves.  And some EEG studies have shown a decrease in activity in the frontal brain region, while others show an increase.

That the details aren’t worked out makes sense.  This is a revolutionary, break through idea.  And the inconsistencies may be due to different test situations, as well as possibly indicating different types of ADHD.  Amazingly enough, studies which measured brain activity of kids resting have been compared to the activity of kids watching television – which only makes sense that there would be a difference! (Probably for the worse.  I mean, they’re watching TV, right?)

There are other interesting findings from these tests.  2-3% of normal children have an abnormal wave pattern known as epileptiform, for instance, while a much higher 6% of ADHD do.  That specific pattern is important because it may hint at an underlying pattern that only overtly expresses itself in 6% of ADHD kids, but is really present behind the scenes in a much higher number.  Additionally, for those specific kids, it offers a potential drug target.

So far, the qEEG seems to be 80-90% accurate at diagnosing ADHD.  Which is pretty darn impressive for a test that doesn’t ask a single question – just looks at what’s going on in the brain.

We at Health and Life feel this article discusses a fascinating breakthrough – if you agree, please share this article and help fight the popular myth that there is no physical aspect to ADHD.

Sources:

Epileptiform abnormalities and quantitative EEG in children with attention-deficit / hyperactivity disorder
Effects of methylphenidate on quantitative eeg of boys with attention-deficit hyperactivity disorder in continous performance test
The Clinical Role of Computerized EEG in the Evaluation and Treatment of Learning and Attention Disorders in Children and Adolescents

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A Full List of Medications for ADHD

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Sunday, December 27th, 2009
One Ritalin Pill

This is a full list of medications that are currently used for treating ADHD.  We wrote it because we were horrified that there was not much like it, and how hard it is for people with ADHD to figure out what their treatment options are.

This list is written to be informative and even entertaining while still being scientifically valid. If you find it useful, we’d really appreciate your helping getting the word out by sharing this page’s link with someone.

#1) Ritalin

Extremely popular – almost a synonym for ADHD – Ritalin has been a star since it was made in the 1940s and named after a chemist’s love, “Rita.”

Ritalin’s technical name is methylphenidate, and chemically it is a close relative to the amphetamines.

Ritalin acts on dopamine and norepinephrine, to block reuptake from the space in between cells.  This increases the amount of time they stay there, which means that they activate signaling pathways for longer periods of time.

And that means greater focus, motivation and attention.

With therapy, up to 70% of people with ADHD experience significant benefit from Ritalin.  The effects can be amazing, allowing normal living for some – it is a powerful medication that can make normal living possible for some people.

One of the biggest downsides to Ritalin – and all the stimulants – is that the benefits only last a matter of hours, at best 12.  This can mean you have to take several doses a day, which can be inconvenient.

While the most effective treatment for ADHD, stimulants like Ritalin have their fair share of side effects, however, including anxiety, weight loss, and potentially even psychiatric issues like triggering mania or psychosis.  Additionally, they can cause heart problems in at risk people.

Because Ritalin has a high potential for addiction and abuse, it has the highest restriction possible while still being widely used – it’s a Schedule II drug.

Pros: With Adderall, Vyvanse and so on, the most effective chemical treatment for ADHD

Cons: Serious side effects, schedule II, dosing can be a pain

Variants: Concerta, Focalin, Metadate, Daytrana

Blue Adderall XR Pill

#2) Adderall

Adderall has become extremely popular for treating ADHD since its introduction in 1996.  It is a mix of several amphetamine salts and like Ritalin is a highly effective treatment.

Some studies have shown that Adderall may be slightly more effective than Ritalin at treating some of the ADHD symptoms.  This advantage is not established, but probably has to do with a slightly different mechanism of action.  One dose of instant release Adderall, however, may last as long as two doses of instant release Ritalin.

Adderall may also have a slightly different side effect profile than Ritalin.

In terms of chemical action – Adderall not only blocks the reuptake of dopamine and norepinephrine through cellular pumps, it also goes inside the cells and reverses the pumps.  So instead of letting those chemicals in, and taking them away from “outside” the cells, it kicks them out.

Reversing the pumps may lead to the build up of free radicals, but no major study has analyzed whether this happens or has a clinical impact.

Adderall has the same downsides as Ritalin, and is also schedule II.

Pros: Among most effective treatment for ADHD

Cons: Serious side effects, schedule II, dosing can be a pain

Variants: Adderall XR

Bottle of Strattera

#3) Strattera

Strattera used to be “the only non-stimulant treatment approved for ADHD” until Intuniv came onto the market in 2009.

Like Ritalin, Strattera also works on the norepinephrine chemical and prevents its removal from the space in between cells.  Despite a similar mechanism of action, it does not have work immediately, however.  It can take up to 8 weeks for Strattera to show its full benefit.

Strattera is supposed to provide all day coverage taken just once, but one study showed that taking a dose in the morning and at night provides the best release.  This is still a significant advantage over the stimulants.

The history of Strattera is somewhat interesting – it was initially tested for use in depression, but didn’t seem to do much.  Researchers thought that its effects on norepinephrine might have benefit in treating ADHD, and they were right.

Similar to the antidepressants, Strattera does increase your risk of becoming suicidal, which is why it has a black box warning.

The studies show that Strattera works, some say even as well as Ritalin.  But those claims to efficacy seem somewhat overstated, with many people saying that Strattera is not so effective.

Strattera is worth a try when stimulants fail or are not a good idea (say you have serious anxiety or past psychosis), yet it also has some of their nasty side effects.

Pros: “Non”-stimulant, long term coverage

Cons: Suicidal ideation, may not be as effective, expensive, long time to take effect

Vyvanse Pills

#4) Vyvanse

Vyvanse is a miracle of advertising and repackaging.  Fundamentally, it’s nothing more than Dexedrine, which has been around for a long time and developed a bad reputation due to its over-use as a diet pill.

That said, there is something quite good about Vyvanse/Dexedrine – it’s made only from the d-type of amphetamine with none of the the l-type.  This is important because it’s quite possible that the d-type is more effective and/or has less of the side effects of the l-type.

Adderall, by contrast, is a mixture of d and l-amphetamines, which means that it more may have more of a kick as well as more or different side effects.  This mix may mean that Adderall may provide more of a “punch” so to speak.

That said, Vyvanse has its fair share of side effects, and none of the stimulants are entirely safe drugs.

The good things about Vyvanse include its quite long lasting effect, possibly up to 12 hours, and its somewhat less susceptibility to abuse.  It is as effective as Adderall and Ritalin for treating ADHD.

Pros: Among most effective treatment for ADHD

Cons: Serious side effects, schedule II, dosing can be a pain

Guanfacine or Intuniv Tablets

#5) Intuniv

Intuniv is a treatment that was initially used for lowering blood pressure and has  recently become more fashionable for treating ADHD, a use for which it was recently approved.  Intuniv is pretty much the opposite of the stimulants, which raise blood pressure and stimulate the body.

If it does the opposite of traditional treatment, why might it work?  The key is that Intuniv acts as an alpha-2 agonist.  While activation of these receptors lowers blood pressure, it may also serve to activate certain areas of the brain, especially the prefrontal cortex, meaning better focus and attention.

Intuniv is like a stronger Strattera, but hopefully avoids the problems of the stimulants, and may even be useful in combination with them.  There are problems, of course.  As this blog has noted, some of the trials which led to its approval had a shockingly high rate of people fainting – something like 5/262 participants fainted.

That is not a good side effect.  Additionally, treatment with Intuniv just falls short of sending ADHD into “remission.”

Other issues possibly include depression and blood pressure problems.

Pros: Non-stimulant, may be moderately effective

Cons: Possibly serious side effects like fainting, less effective than stimulants.  Very new and untested.

Variants: Clonidine, Guanfacine, Intuniv

Provigil Pills

#6) Provigil or Modafanil

There’s quite a buzz around Provigil, generic modafanil.  It keeps enough of the amphetamine like behavior of Adderall to provide the kick needed to treat ADHD, while having a host of other chemical behaviors that, some argue, may make it less addictive and less risky.

Provigil, for instance, is only schedule IV, as opposed to the highest restriction placed on Ritalin and Adderall.

That said, we don’t know a lot about it.  Provigil may play with the dopamine receptor like Ritalin – or it might not.  It might just increase levels of dopamine by some other mechanism.  This is important because the way it interacts with dopamine may determine its potential for addiction.

Other chemical behaviors of this drug?  Hold your breath – it possibly has GABA, serotonin, adrenergic, histaminergic and glutamanergic effects.  That’s like half of the neuro-transmitters currently in vogue, and some of them theoretically cancel each other out!  (While there are hundreds of neurotransmitters, because of how little we know, we basically pretend there are only about 10.  Hopefully, as we learn more, we will get even more effective treatments with fewer side effects.)

Provigil is used, in part, for sleep apnea, narcolepsy and has been proposed for schizophrenia, which is stunning, considering that traditional stimulants cause psychosis, not treat it.

As of now, however, Provigil is not approved for treating ADHD, although it seems to have decent efficacy in treating it.  (Some studies have shown similar efficacy to Ritalin, one – from the manufacturer itself (!) – showed no efficacy, and so on).  A major study trying to approve it for ADHD in children failed when a significant amount of children developed skin rashes.

So we don’t know how well it works.  And Provigil is also extremely expensive, so playing around with it can rack up a bill.

Expect interesting things from this drug and its half-dozen chemical actions.

Pros: May be less addictive, may be as effective as stimulants, schedule IV

Cons: Expensive, new, not-approved for ADHD, not enough long-term use data

Wellbutrin Bottle

#7) Wellbutrin

Wellbutrin is a strangely behaving antidepressant. It’s an alternative treatment for ADHD, although not approved for that use like Strattera, and has been shown to be better than placebo for treating ADHD.

That said, Wellbutrin has only a modest benefit for ADHD, with some studies showing that it works to some degree and others showing that it doesn’t really work that well.

What it does is act as an inhibitor of reuptake of norepinephrine and dopamine – to some degree.  It also mimics them somewhat, which is interesting.  Chemically, Wellbutrin is eventually converted by the body into some form of amphetamine, which might explain why it has some impact for ADHD.

So it isn’t the best treatment for ADHD, but it is used not-rarely.

Side effects can include extreme anxiety.  We’re talking potentially about really bad anxiety.  That said, in addition to making you less depressed, Wellbutrin might just help you stop smoking – which is another of its uses.

Pros: Moderately effective, full day coverage

Cons: Extreme anxiety, not as effective as stimulants, turns into amphetamines eventually – so may have similar problems

Tricyclic Antidepressant Structure

#8) The Tricyclic Antidepressants (TCA)

The tricylcic class of antidepressants has been shown to have significant benefit in treating ADHD, although not as strong as the stimulants.  They are not so often used because of their serious potential for cardiac toxicity among other side effects.

The TCA’s benefit for ADHD  is separate from their potential antidepressant effect.  This is highlighted by the fact that reduction of some ADHD symptoms, especially behavioral, may start occurring in less than a week, as opposed to the 3-4 weeks it takes for the antidepressant effect.

(It’s an important distinction to make because you could feel like the King of Morroco but still have significant ADHD symptoms.)

They are many drugs in the TCA class.  Of them, desipramine may be the best for ADHD, then imipramine.

That said, it is possible that other issues like antagonistic behavior may emerge with treatment, meaning that you exchange one set of symptoms for another.  On the other hand, treatment with TCAs may provide almost full-time coverage.  You don’t need to take 5 doses a day, for instance, as may happen with some forms of Ritalin.

Note that newer antidepressants, especially the selective serotonin reuptake inihibitors like Prozac and Zoloft have not shown similar efficacy or benefits in treating ADHD.  This may be due to their more specific behavior, and lack of effect on norepinephrine.

Pros: Modest efficacy, long term coverage

Cons: Heart toxicity, overdose possibility, possible new symptoms, not as effective as stimulants

Risperdal tablets

#9) Risperdal

Risdperdal is a very popular tranquilizing antipsychotic.  It blocks dopamine receptors in the brain, reducing the activity of dopamine.  Careful readers may wonder if that is its chemical action, then how can it treat ADHD?

The answer is most likely because Rispderal and its family of medications, the antipsychotics, are tranquilizing and can induce a sense of calm.  This can be useful at night in addition to standard treatment to help fall asleep.

Use of antipsychotics as sole treatment for ADHD, however, is not a standard medical choice.  It does, however, happen, which is unfortunate.  Remember, Risperdal has been approved for treatment of agitation and aggression in autistic kids.  Its sedative effects may make it attractive for treating kids who have ADHD and are a handful.

The risks are significant.  Long term use of Risperdal may lead to permanent movement disorders, extreme weight gain, and diabetes.  And long term use of antipsychotics may make concentration and attention problems worse.

Pros: Sedating, may help fall asleep, may help gain weight

Cons: Long term side effects.  Is pretty much the exact opposite of traditional ADHD treatment

Variants: Any anti-psychotic class tranquilizer

People exercising

#10) Exercise

The best comes last.  Exercise is an incredible treatment for ADHD.  Within healthy moderation, it has no side effects – though people taking stimulants should be careful – and can honestly be said to be nature’s treatment for ADHD.  It relaxes the mind and body, increases concentration, and improves mood.

One kid used to be a handle in school, but when his teachers agreed to let him run around the schoolyard when he got restless, did OK.  That kid?  Winston Churchill, one of the greatest British leaders ever.

Now, it’s true that exercise is unlikely to provide complete relief from ADHD symptoms.  But it’s also for sure not going to make you become psychotic, manic, stunt your growth, make you faint, give you diabetes or make you suicidal.

Other Drugs of Interest: Pemoline or Cylert – a schedule IV drug with moderate ADHD efficacy.  Withdrawn in US from market due to toxicity to liver.  Desoxyn – basically methamphetamine, not used often because it is essentialy the same as the street drug “meth,” which has very bad associations

Using medications properly

At the right dose, an ADHD medication should have minimal impact on how you feel.  It changes how you experience things, how you perform, but shouldn’t change who you are or make you feel weird.  The right dose is often very subtle in its effects.

The following is not uncommon – that someone is on an ADHD medication, feels it isn’t doing anything, but when other people are asked, they see a major change.

As such, the best person to judge if a medication is working is someone who spends a lot of time with you and doesn’t have ADHD him or herself.

Because the person taking the medication might not feel it at the right dose – finding the right dose can be a bit tricky.  Doctors have different approaches, but the one that feels safest is to start at the lowest and carefully work the way up from there.

You might like:

What are the long term effects of Adderall?

What sucks and what rocks about ADHD

Our ADHD articles

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What Sucks & What Rocks About ADHD

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Tuesday, December 22nd, 2009
A businessman and woman

You’re distractable, impulsive, and constantly worried if you’re doing the right things.

But you’re unpredictable, fun, and always trying out new things.

Having ADHD can be a real pain in the butt.  Still, it gives you strengths and differences that you probably don’t appreciate.

It’s up to you to learn how to use the good and accept your limitations.

Great Success

People with ADHD can be incredibly good at focusing on what’s important to them, impatient in some ways, and able to multitask really well.  They tend to get excited by things which are new and exciting to them and can think of entirely new ideas, innovating.

Michael Phelps, one of the most admired swimmers ever, has ADHD.  He used his ability to focus on what matters to him to become the best in the world.

Paris Hilton, celebrity and businesswoman, has ADHD.  She has been on medication since a child; her ability to fit the rapidly changing and demanding stereotype of her audience while building a massive business is classic ADHD.

Seth Godin a modern marketing guru, has ADHD.  He used his out-the-box thinking to come up with marketing ideas that are ingeniously simple and effective.

I know several executives who have ADHD and they are all extremely interesting people, highly accomplished and fun to work with.  The technology business and popular music scene are always evolving, require learning new ideas constantly, and always changing – perfect for people with this condition.

Challenges

But it’s not all good.  People with ADHD can find it incredibly hard to finish tasks, to sit through meetings, or plain pay attention.  Social relationships can also be a challenge.  Friendships may be exciting at first but lose their luster, with your friends feeling unappreciated, or simply not understanding the way you show your care for them.

If you have it, you may only feel fully comfortable in certain environments.  You may, for instance, only be able to think about a subject for an extended period of time while doing something totally unrelated, like taking a walk or riding a bus.

And you may have brilliant ideas that, when you actually have to do, turn out to be a lot more boring than you thought.  Or when you pursue them, you get bored just as they start becoming successful.

You may even be confused for someone with bipolar because of the many similarities between the two conditions.

Ultimately…

ADHD is so common that it could be argued to be normal.  If you have it, then that’s what you have, and you’re different.  That doesn’t mean worse or bad, but it does mean that you have to understand your strengths and weaknesses.  And don’t downplay your strengths.

If you can’t make it through a long meeting, but can spend hours doing your own thing – that’s great.  Think of it like this: the vast majority of people can do what you can’t, which means it isn’t that special.  But, because ADHD talents tend to be really esoteric and focused, there is hardly anybody who has the ability to do what comes easily to you.

You also have to realize that you may work in a different way than other people.  And you have to take their feelings into consideration as well as realize that what may make perfect sense to you might not to them.  Don’t be overly neurotic, of course, but be smart and realize there is a difference and, sadly, it’s up to you (because it’s your life) to bridge the gap.

You might like:

Our Articles On ADHD

The 14 Weirdest Medical Facts I Know

What do you love about having ADHD?  Or what do you hate?

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Thoughts on ADHD, Diagnosis & Controversy

2 »
Sunday, December 20th, 2009
A man with glasses thinking

What is ADHD?

ADHD is an extremely common disorder that is characterized by difficulty paying attention, distractibility and hyperactivity. And some say it’s even more common than previously thought.

For one, it’s now believed to be common in adults – not just children – and that a diagnosis of ADHD doesn’t always have all the symptoms commonly associated with it.

That means you don’t have to be hyperactive to have ADHD, though what you have would then be characterized by ADD, or Attention Deficit Disorder, not Attention Deficit Hyperactive Disorder.

Types of ADHD

It turns out there are several types of ADHD each with its own criteria. There’s the typical hyperactive form and then the inattentive form, characterized by poor attention. And then there’s the combined form, which has both. That puts the total at three, but some have argued for the existence of six different types.

There are good and bad aspects to this wider approach. On the one hand, it means that effected adults will greater understand what’s going on in their life and potentially get access to treatment. On the other, it’s part of a trend that increasingly makes normal human experiences into mental disorders.

After all, it’s only human to occasionally feel restless, unable to focus, or distractible. And despite claims of some ADHD proponents, there’s still no real test for ADHD like there is for Diabetes. There are diagnostic lists, but ultimately no black and white physical signs of the condition.

That said, there is a recent test, the quantitative electroenchephalogram, that famous author Dr. Hallowell reports is 90% accurate in diagnosing ADHD.  Additionally, ADHD is perhaps the single most heritable of all the psychological conditions – if your parent has it, then you have a 60%-90% of having it.

Combined that with the consistent discovery of brain differences in people with ADHD and the evidence for its existence is almost 100% definitive.

ADHD Treatment

Treatment for ADHD is no simple matter. Although the medications seem to be safe, they are potent stimulants, all of which have been used as street drugs. Adderall, for instance, is also popular as “speed.” While medications work most of the time, especially when combined with supportive therapy, it’s not clear what that means.

Stimulant medications are, after all, also used by college studies to cram for tests. Some say that they would help anyone focus and be less impulsive. Proponents respond that stimulants seem to have a paradoxical calming effect on people with ADHD. Instead of making them hyperactive and energetic, stimulants might calm them down and help them be focused.

Ultimately, however, stimulant treatment can be a life saver.  As Dr. Wender, a famous psychiatrist, puts it, some people who have ADHD and take stimulants can, “for the first time in their lives“(!) enjoy studying, having long conversations and so on.  Instead of getting C’s and D’s in college, they work hard and get B’s and A’s.  Instead of endlessly chasing new ideas, they settle down and function better than they ever had.

The difference is remarkable, consistent, and lasts typically for as long as the medication is taken.  These are effects that are far beyond the simple high that someone who abuses a stimulant medication might get.

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Intuniv for ADHD: Efficacy, Side Effects

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Sunday, September 6th, 2009
Guanfacine or Intuniv Tablets

Intuniv for treating ADHD

The FDA approved Shire’s Intuniv medication as a once-daily treatment for ADHD on September 3, 2009. Intuniv is an extended release formulation of guanfacine, a blood pressure med that has been on the market for quite some time.

There have only been several studies done into the efficacy, safety and profile of use of Intuniv for treating ADHD.  So far, they say that Intuniv works somewhat less than the stimulants like Ritalin and Adderall and probably somewhat more than the traditional non-stimulants like Strattera.

30% of people can’t take or don’t respond to stimulants.  Parents in particular have concerns about traditional treatment for their children – so there is a lot of excitement around Intuniv.

The pros: Intuniv could possibly fill a lot of the role as a non-stimulant treatment that Strattera was supposed to play but didn’t.  It has a long duration of effect and can even be used in combination with stimulants. And the short acting form of Intuniv has been on the market for some time, so we know a little about its safety and side effects.

The cons: Intuniv is very new, and it is still unclear just how effective it works.  Some studies have hinted at potential problems such as high rates of serious side effects such as fainting and possibly even suicidal thoughts.  While the short acting form has been on the market, Intuniv is long lasting.

Remember, roughly 50% of medication side effects are discovered after it is released onto the market.

Efficacy

How well does Intuniv work?

The studies seem to show that Intuniv falls just short of sending ADHD symptoms into remission.  Roughly 55% of those on Intuniv in one study reported significant improvement compared to 30% of those on placebo.

In one major study, on one scale, people who started with an ADHD score of around 40 and took Intuniv had their score go down to around 19 on average. The accepted number for remission of ADHD symptoms is a score of 18 or less.

Those who took Intuniv along with stimulants went from about a starting score of around 29 to around 13.

There are some more interesting hints towards Intuniv’s efficacy we found in that study.  On the one hand, only 10% of participants said that they stopped specifically because they thought Intuniv wasn’t working that well.  And of those taking Intuniv with stimulants, only one person stopped specifically because it wasn’t working well.

That said, around 80% of people in total dropped from that study.  It was done over two years, but that is still a somewhat high number.

Other studies into Intuniv have had much lower drop out rates.

In another, smaller study, roughly 30% of people on placebo reported significant improvement, as compared to around 55% of those treated with Intuniv.  This difference likely means that it has some benefit and is useful but falls short of the efficacy of the stimulants, which work in roughly 70% of those treated.

Analysis of that study concluded that at low doses Intuniv is about as effective as traditional non-stimulants, and at higher doses is superior to the current non-stimulants, such as Strattera, Wellbutrin, and possibly even Provigil.

Intuniv Side effects

Different studies show different side effect profiles for Intuniv.  Some say that it has about the same rate of issues as placebo, while others show that around 10-15% stop using it because of some side effect.  As far as psychoactive drugs, a 10-15% discontinuation rate due to side effects is on the lower/medium range.

The side effects of Intuniv also depend on its particular use.  When used in combination therapy with stimulants, for instance, it has much less rates of sedation and sleepiness, and users seem to report less problems.  This is probably because its sedative effects that lower blood pressure are counteracted by the stimulants effect of raising it.

Some of its side effects take time to start showing up, with sedation in particular starting after 3 weeks of treatment.

Most common:

30-40% report sleepiness

25% report headache

17% in one study reported upper respiratory tract infection

10% report sedation

Other common side effects include dizziness, nausea, irritability and reduced salivary flow.

Concerns

In one study, 5 participants out of 262 who took Intuniv  experienced syncope, or “temporary loss of consciousness.” In layman’s terms, they fainted or blacked out.

The clinical trials dedicated to exploring safety did not have such incidences, and it’s possible that the syncope events were environmentally based. One of the sufferers, after all, had a history of such issues. And guanfacine has a long history of use. So while those numbers are alarming, they are explainable.

Other possible side effects that may be an issue: head injury, suicidal ideation.

Like with all psychoactive medications, people using Intuniv should be monitored for anything abnormal like increased feelings of depression.

Dosing

Intuniv is given typically anywhere from 1-4mg/per day.  A dose typically lasts for 12 hours, but may have some effect for up to 24 hours.

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