To give one example, in 2009 a “study of studies” on medication treatment of ADHD was performed. This “meta-analysis” considered only research that used the gold standard of design for clinical research: double-blind, parallel-group studies. (Pharmacotherapy of adult attention deficit hyperactivity disorder (ADHD): a meta-analysis. Mészáros A, Czobor P, Bálint S, Komlósi S, Simon V, Bitter I Int J Neuropsychopharmacol. 2009 Sep;12(8):1137-47. Epub 2009 Jul 7.)
Mészáros et. al concluded that, taken as a whole, the established medications for ADHD have an effectiveness that in statistical terms is categorized as “medium-to-high.” Although this may sound like a fancy way of saying “pretty good,” in the worlds of medicine and psychiatry it is spectacular, as it places ADHD treatments in the most rarefied category, far above used for the other major psychiatric disorders, specifically depression, bipolar disorder, obsessive compulsive disorder and panic disorder. (Leucht, S., Hierl, S., Kissling, W., Dold, M., & Davis, J. (2012). Putting the efficacy of psychiatric and general medicine medication into perspective: Review of meta-analyses. British Journal of Psychiatry, 200(2), 97-106. doi:10.1192/bjp.bp.111.096594).
Despite the relatively excellent efficacy of ADHD medication treatment, it has become clear that not all ADHD medications are created equal. The effect size of the stimulant class of medications (essentially comprised of amphetamines and methylphenidate) has consistently been found to be higher than the non-stimulants (comprising atomoxetine [Strattera], bupropion [Wellbutrin], and less commonly, tricyclic antidepressants such as nortriptyline.) [Bukstein, O. Pharmacotherapies for attention deficit hyperactivity disorder in adults. In: UpToDate, Brent, D. (Ed), UpToDate, Waltham, MA. (Accessed on May 02, 2022.)]
Given that there is solid evidence that stimulants are the most effective treatment for ADHD, it is not surprising that they are prescribed more frequently than other medication treatments. However, nature is not been so kind as to give us a truly “magic bullet” that will “cure” ADHD, free even of a shadow of adverse effects. Because stimulants do have an addiction potential, they are categorized as “controlled substances.” Controlled substances are regulated by the federal Drug Enforcement Agency (DEA) in a more stringent fashion than are ordinary, “noncontrolled” prescription medications.
All of Done’s clinicians are acutely aware of the risks of stimulants and of the close regulatory attention paid to this class of medications. Because of these factors, Done has a meticulous screening process for every patient. It includes assessment of that patient’s potential for addiction or diversion, a review of the patient’s prescription history that is facilitated by databases that include all controlled substances prescribed for that patient in their state. These “prescription drug monitoring program” databases offer complete details, including date of prescription, prescriber, quantity and date prescribed, and the date the medication was actually dispensed to the patient.
Useful as such information is in preventing prescription abuse, an initial assessment, if performed by a trained clinician who has specialized experience in psychiatry or psychiatric nursing, will provide even more relevant information, as well as reduction of the risk of medication misuse. Building a rapport with the patient, a process for which the initial evaluation is the foundation, results in honest communication from the patient. This, in turn, often results in initiation of treatment for problems that would be denied if such a rapport is not achieved.
Whatever the online pharmacy record says, there is no substitute for a face-to-face or voice-to-voice evaluation in which old- fashioned “signs,” such as tone of voice, facial expression and body language are assessed.
For ongoing treatment, each individual treated by Done meets with their provider on a regular schedule determined by the level of need, and if relevant, by state and federal regulations that apply to treatment with controlled substances. Due to such regulations, in many states, patients are allowed only one prescription per month, without refills. Thus, in those jurisdictions, providers and patients must communicate on a monthly basis if the medication is to be continued.
Continuity of care is a key component of Done’s “patient- first” philosophy. Barring unusual circumstances, ongoing treatment is provided by the same clinician who performed the initial assessment. Not only does this ensures the best care in terms of medication management, but it provides the beneficial component of individual supportive psychotherapy.
Many studies have shown that the ideal treatment for ADHD, as for several other psychiatric disorders, is a combination of medication and psychotherapy. In the case of ADHD, stereotypical intensive psychotherapy with weekly hour-long sessions is usually unnecessary. However, the support that monthly meetings with a medication provider who is fully conversant with psychotherapy modalities provides more effective treatment than either intervention on its own.
In Done’s combined treatment model, each clinical interaction gives the patient an opportunity to update their clinician on both the positive and negative aspects of their treatment. Their improvement may be quantified using various rating scales, or may simply be followed more subjectively. Medication side effects, although rarely severe with stimulant treatment of ADHD, must be monitored and dealt with, if necessary by dose adjustment.
As noted above, psychotherapy is a validated treatment for ADHD, and Done offers the most effective combination: medication with brief supportive psychotherapy. Beyond that, Done encourages its patients to use any and all validated tools that can optimize their functioning, whether in the career, social or recreational arenas. Examples of additional techniques include intensive psychotherapy, especially of the cognitive-behavioral variety, mobile phone apps, peer support groups, and specialized ADHD coaching.
Speaking as a clinician who treats ADHD, perhaps the most enjoyable aspects of that endeavor is to see that, as symptoms decrease, patients pursue goals that that were beyond their capacity before effective treatment was instituted.
Done’s goal is to disseminate such deeply rewarding treatment experiences as widely as possible among clinicians and patients. Our mission is urgent because ADHD remains a severely undertreated and severely disabling problem.
