The use of medications to treat ADHD in adults increased 90% from 2002 to 2005 in the United States. This was a dramatic increase, and adults now receive one third of all prescriptions for ADHD medications, a pattern that is not seen in other countries. You may or may not know that the bulk of the available data on the treatment of ADHD come from studies in children, which limits the ability to make evidence-based recommendations for adults.
I am often asked by my patients who are in undergraduate or graduate school whether they should be taking these medications, since “all of their classmates are.” Many of their friends weren’t diagnosed as children but rather started on stimulant medications upon entering college or graduate school. Without making this a blog about diagnosis of Adult ADHD, understand that for primary care physicians, the number of patients who self-diagnose ADHD far exceeds the number of people who fit DSM-IV criteria for ADHD, shown in studies to be 2.5- 4% depending on which criteria you use.
Many patients read the Utah criteria for ADHD in adults and believe they fit it: hyperactivity and poor concentration along with two of the following: affective lability (mood all over the place), hot temper, inability to complete tasks and disorganization, stress intolerance and impulsivity. Remember, there is no single "gold standard" diagnostic test for ADHD in adults
Okay, so why does pharmacotherapy for ADHD, most of which is stimulant medication, make primary care doctors nervous. Well, the addicting nature of stimulants, the chronicity of ADHD (do we treat patients with stimulant medications until they are 70?), and the large number of medical conditions that arise in adults which will be worsened on stimulants are a few reasons. Not to mention the warnings issued along with Adderall, Ritalin, and Vyvanse which acknowledge that women of reproductive age should not take these stimulant medications. Use of stimulant medications during pregnancy may lead to increased risk of premature delivery and low birth weight, infants may experience symptoms of withdrawal, and birth defects have been reported with women taking Adderall during the 1st trimester.
The cardiovascular effects of these stimulants (Ritalin, Vyvanse, and Adderall) are of potentially greater concern in adults than in children. Stimulants increase heart rate and blood pressure and both need to be closely monitored, and yes there are reports of sudden death with the use of stimulants in both adults and children. Abuse potential exists and this is different for adults who require larger doses of stimulants than those prescribed to children.
Many people feel better on stimulants, so realize the difficulty of weaning someone off them. They may feel the “normal” periods of fatigue during the day, and may not feel as productive as they did while on them. Stimulants improve cognitive function in most people. For example, methylphenidate (Ritalin) has been found in studies to reduce driving errors in all adults, not just adults with ADHD. Thus, a person’s response cannot be used to confirm or exclude the diagnosis of ADHD.
When adults have been started on ADHD medications by their psychiatrist or another doctor, those of us in primary care need to wonder: what is our endpoint for treatment? Do we treat you into your 50’s and 60’s if you have high blood pressure, high cholesterol, and high blood sugar? Do we continue to treat women in their 20’s-early 40’s with stimulant medication for ADHD and warn them of known complications during 1st trimester use? Young women will need to stop them during pregnancy and breastfeeding for sure, but do we stop the medications during the reproductive years anyway?
There is currently no consensus on this in the adult medicine literature... what are your thoughts?