When ADHD Medications Let You Down

While much is being made of how many people do take ADHD medications, and pundits weigh in on how many should, I’d like to focus attention on a group of people rather forgotten in the cross-talk–people who do have ADHD, did try medication, and it went badly.

My ADHD practice is sometimes the last stop for people who have “tried everything”, so I hear many stories of disappointment.  The stories fall into just a few broad categories: a) little or no effect, b) intolerable side effects, c) worked initially, then stopped, d) too expensive and e) “I can’t remember why I stopped, but I’ve never done anything else consistently either.”

Rather than address each category, I’d like to share two stories of success.  The common theme in these stories is that ‘failure’ is the rule, rather than the exception when selecting medications.

People hope that docs know what medicine they need when they come to us, but we don’t. Research to help us predict what works and what doesn’t for an individual has been entirely fruitless. Learning from the failures and determining what to do next is all that ADHD experts can offer.

Tim, the freshman

Tim was a very bright, 19 year old college freshman with ADD and anxiety who was barely passing when we met. He took Concerta 54 mg daily, but still had 4 of the core symptoms of inattention.  His anxiety had slowly worsened. He had a few trials under his belt already:

Concerta 18 and 36 mg had not helped inattention as well as 54 mg.  :

Adderall XR 10 mg and 20 mg: increased anxiety, very little improvement in attention.

Our first step working together was to decrease the Concerta which seemed to be driving his anxiety. The anxiety decreased somewhat, but inattention did not improve.

A trial of Vyvanse failed much like the Adderall XR trials.

Next step: begin a trial of Strattera–a non-stimulant that can be helpful with combined ADHD and anxiety. This was added to the Concerta 36 mg.  He started at 10 mg and increased to 40 mg.  I prefer to go slowly when combining medications.

After 6 weeks of combination therapy, his anxiety and inattention were virtually gone, but he had developed some mood irritability, enough for friends to notice.  We decreased the Strattera to 25 mg, and the irritability resolved. He has been taking the low-dose combination for several years with no side effects and no residual inattention.  He has been very diligent and will graduate with honors this spring.

If you kept score, Tim failed six trials before he found a good treatment for ADHD. As much as I wish for this to be a story about my brilliance and expertise, it’s not.  It’s really a story about Tim’s persistence.

Bob, the Manager

Bob was diagnosed with ADHD in his 50’s. He was unusual in that typical medications did literally nothing for him. His trials went like this:

Strattera 25, 40, 60, 80 mg: Fail, Fail, Fail, Fail.

Concerta 18, 36, 54, 72, 90, 108 mg: Fail, Fail, Fail, Fail, Fail, Fail.

Adderall XR: 10, 20, 30, 40, 60 mg: Fail, Fail, Fail, Fail, Fail.

Focalin XR: 10, 20, 30, 40 mg: Fail, glimmer of response, partial response, Success!!

For the record, this process lasted less than 4 months.  Failed Strattera trials take about 2 months.  Failed stimulant trials are more like 2-4 weeks.

Happily for Bob, who had been at the same job for 10 years before treatment, he has been promoted twice in the last two years since. He doesn’t refer to those four months as a failure.

Patience.  Persistence.  

The success rate for short trials of long-acting stimulants is about 70-80%, Strattera 60-70%, Intuniv, Kapvay, Wellbutrin, 50-60%.  Knock about 10% off those numbers for adults.  Side effects cause  another 10-15% to discontinue each trial.  The likelihood that the first medication a person tries will be a great fit is not that good.  Multiple trials are the rule.

Medications for ADHD are not a “Quick, Quick Fix”.  But for people who are willing to stick with the drudge work of finding the right medications, they can be a part of a long, long success.

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

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Posted in ADD, ADHD, medications
8 comments on “When ADHD Medications Let You Down
  1. doug puryear says:

    good post! thank you. will link on my blog
    doug

    Liked by 1 person

  2. gina says:

    Wonderful, Oren. Very clear and great examples.

    Persistence and method!

    Gina

    Liked by 1 person

  3. Amelia says:

    Great Post! Lots of useful information ! Thank You!

    Liked by 1 person

  4. Christophe Kaufmann says:

    Thank you for this very interesting comment. Is the second example frequent in your experience ? I almost never try so high doses and prefer to switch to neurofeedback when medecine does n’t work or when they want to get off of it.
    C. Kaufmann, Switzerland, adult psychiatrist and psychotherapist

    Liked by 2 people

    • Dr. Kaufmann, Thank you for your question and for sharing your experience. It is my practice to continue to high doses when the response to typical doses is inadequate. I have very few patients who are prescribed the highest doses mentioned here. If the response to a high dose of medication is incomplete, I would be more likely to use a combination of a stimulant and a non-stimulant.

      I don’t currently recommend neurofeedback. I have not found a placebo-controlled study in adults yet (using sham neurofeedback for the control). I have had dozens of patients try it either prior to medication or as an adjunct to medication therapy, but only one has responded measurably. She was able to discontinue medication.

      OM

      Like

  5. in my experience, most people who “have tried everything” haven’t tried everything.
    meds sure don’t work for everyone, but often with trial and error you can find the right med at the right dose (occasionally very high, occasionally tiny) on the right schedule and it will work well. but sometimes not.

    Liked by 1 person

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Oren Mason MD
Oren Mason MD

Oren Mason MD

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

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