Dr Hank is a Bristol based Consultant Psychiatrist with expertise in Adult ADHD. He kindly spent some time answering some questions about ADHD medication for adults.
1. Who can prescribe medication for adults with ADHD?
ADHD medications can be prescribed by a medical or non-medical prescriber (nurse, pharmacist) with training and expertise in the management of ADHD. This applies particularly when starting someone on ADHD medication. Many GPs will prescribe ADHD medications, under an arrangement called shared care, once the medication regime is stable, effective, and well tolerated.
2. Are there any patients with ADHD who cannot take this medication?
There are cautions and contraindications for the therapeutic use of ADHD medications, and these include some heart conditions, stroke, high blood pressure, poorly controlled epilepsy, some types of glaucoma, some thyroid diseases, florid psychosis, severe depression or mania, and severe eating disorder, to name a few. ADHD medications should be avoided alongside some other medications due to potential interactions.
3. What symptoms of ADHD might medication improve? Are there any symptoms of ADHD which you would not generally expect to improve?
I don’t think there is any one symptom/symptoms that never improve. In my experience, well established behaviour patterns which have likely come about because of ADHD related difficulties, can take time and effort to change.
4. How successful is medication as a treatment for ADHD e.g. in terms of the percentage of patients with a positive outcome?
About ¾ of people with a diagnosis of ADHD respond well to the first medication prescribed. About 90% of people get a response to medication. ADHD medications are amongst the most effective we have in the field of Psychiatry.
5. Is medication ever the whole solution for patients with ADHD?
Non-medication or so-called psycho-social intervention are crucially important in the management of ADHD. In my experience, people who combine medical and non-medical treatment tend to have the best outcomes, particularly in the longer-term.
6. What are the main types of medication that are prescribed?
Broadly speaking, there are two classes/types of medications: stimulant and non-stimulant medications. The stimulants come as immediate release and slow-release medications, i.e., they differ in how long they work for and how often they have to be taken.
7. How do you choose which medication to prescribe?
NICE guidance for the medication treatment of ADHD recommends stimulant medications as the first line approach and this is what I tend to follow, unless there are co-existing mental health or physical health problems that are likely to be negatively affected by stimulant medications.
8. Can you say a little about the titration process?
It is not recommended to increase the dose of ADHD medication at less than weekly intervals. Personally, I tend to go slower since most people with a recent diagnosis of ADHD take time to adjust to the changes that happen during medication treatment and coming to terms with the new reality of ADHD, more generally. In my experience, rapid titration can lead to people feeling overwhelmed or over-stimulated.
9. What do you do if you find that medication is not effective or if there are unpleasant side effects?
When a medication is not effective, other medications can be tried, even within the same medication group. An alternative stimulant medication can sometimes work much better. Non-stimulant medications are usually third line.
The same is true for adverse effects. If a medication is effective but associated with adverse effects, then a different release profile of the medication can be explored, such as immediate release as compared to slow release. Sometimes going back to a lower dose for a longer period of time can help the person to get used to the medication better. The dose can be increased again at a later stage and is possibly better tolerated than before.
10. What side effects might a patient experience?
The most common side effects reported by adults are sleep problems, appetite suppression, headache, dry mouth, nausea, mildly raised heart rate and blood pressure. There is a long list of other, less common adverse effects as with all prescription medications and, if in doubt, I recommend to seek advice from the prescriber rather than soldiering on with potential, troubling adverse effects.
11. What happens at the end of the titration process?
The ADHD medication titration is usually undertaken by an ADHD specialist. Following stability of the treatment regime for 3 months, the great majority of GPs will take over the prescribing of ADHD medication under a shared care protocol. This means the GP has certain monitoring responsibilities and a specialist/ADHD clinic will see the patient once a year and is available for advice if required.
12. What would you say to someone who is considering using stimulant medication which has not been prescribed to them to help them to concentrate on their studies, for example?
There is growing concern over the use of so-called cognitive enhancers, including non-prescribed ADHD medications, for academic and/or occupational performance improvement. We lack firm evidence for the benefit of these medications in people without a diagnosis of ADHD. It has been shown that individuals without a diagnosis of ADHD who use ADHD medications were less likely to achieve a bachelor’s degree. The majority individuals using non-prescribed ADHD medication had a history of prior illegal substance use or other non-medical use of prescription medication. Non-prescribed medication use can lead to adverse effects and dependence. To supply prescription medications without a prescription is illegal. Prescription stimulant medications are controlled medications and the unauthorised distribution is an offence.
13. What happens to 18-year-old patients who are transferring from children to adult services?
Ideally, a young person should get referred to the Adult ADHD service at the age of 17.5 years and the referral documentation should detail the person’s ADHD diagnosis and treatment history. Provided treatment and medication are stable, an initial consultation at the Adult ADHD service will orientate the young person to Adult ADHD services and the GP will be asked to continue prescribing ADHD medication under shared care. If required, treatment/ medication adjustments can be made. The young person will be offered annual reviews at the clinic. At the clinic, we can advise regarding education or vocational challenges and reasonable adjustments.
14. Are there any changes that you would like to see in the way that ADHD medication for adults is prescribed?
I would like to see improvements with the delivery of prescriptions, from postal to electronic. Currently we are required to send the prescriptions in the post, and this can mean delays of prescriptions getting to pharmacies, particularly in times of a pandemic when the Royal Mail experiences staff shortages. It would be useful for more prescribing of ADHD medication to take place in primary care, but this will require additional resources in terms of training, prescribing capacity and supportive input from ADHD specialists.