How is ADHD treated?

The number of people being prescribed ADHD medication has been used to determine the extent of the condition. It doesn’t, of course, tell the whole story. But how does the medication affect people who take it? Here’s Nicola Jayne Little and Tania Martin again…

Tania - If I'm really honest with you, one of the reasons why I wanted to gain a diagnosis was because I wanted to try medication. For most of my life, I've been in these bouts of depression and anxiety and I wanted something to fix my brain. I went to my GP, had a conversation with her, she was incredibly supportive. I got a diagnosis quite quickly after that.

Chris - And you mentioned managing your symptoms and wanting to try medication. What did you use?

Tania - So I actually didn't get on with it very well, so I tried both stimulant and non-stimulant medications. And unfortunately I'm not medicated now because whilst they helped some of the symptoms, they made other symptoms worse for me personally.

Chris - Was that your experience, Nicola, or have you just gone down the behavioural route knowing the problem and grappling with it that way?

Nicola - Oh no. I'm fully medicated up to my eyeballs. It's the best decision I ever made to try stimulants, you know, and for someone with ADHD, and again, the narrative is really misunderstood, a stimulant for me that might stimulate someone else to make them high, I suppose is the term. For me, the stimulants let me think in a straight line. So instead of the plate of mad spaghetti that I can never get control of, I have a better opportunity to start a thought and get to the end of the thought, to start a task and get to the end of a task to be able to rationalise in a different way. The meds for me have changed my life in a positive way. That's not to say I always wanted to take them or wanted to take them, but in doing so, has fundamentally changed my life.

That was Nicola Jayne Little and, before that, Tania Martin. I caught up with Barbara Sahakian, professor of clinical psychology at the University of Cambridge, to discuss what types of treatments people with ADHD are currently prescribed…

Barbara - Methylphenidate, it's also known as Ritalin is one of the most effective treatments for ADHD. And it is really the first line treatment that is offered to people if you have moderate to severe symptoms. Obviously if your symptoms are mild, they can be managed with more psychological treatments such as cognitive behavioural treatments and sort of structuring your activities and helping you plan and that sort of thing. But if it's more moderate to severe, you may need drug treatment. And then methylphenidate is usually the first choice.

Chris - What sort of a difference does that make? Do we have any quantitative or objective numbers we can put on this?

Barbara - Well, it's been said to be about 70% effective, and it seems to work for most people. But of course, no drugs work for everybody. And some people may have comorbidities, which means that they might have anxiety or depression along with the ADHD. And that may be that the drug doesn't work quite so well in some other groups with these comorbidities.

Chris - What do we understand about what the drug is actually doing in the brain of someone with ADHD to get them that benefit?

Barbara - So the chemicals in the brain, dopamine and noradrenaline, are both increased by methylphenidate. And what happens is their re-uptake is actually blocked. So there's more in the synaptic cleft. So that basically boosts dopamine and noradrenaline in the brain.

Chris - Do people who have ADHD have a deficit in those chemicals to start with, or is there something else wrong and boosting the levels up helps to solve another problem?

Barbara - Well, what we do know is there can be changes in the brains of people with ADHD and actually when they're on drugs chronically like methylphenidate, especially if they're children, when they start these drugs, they can actually mitigate the effects that you see in the brains. So they do do that, but we do know that methylphenidate is what we might call a cognitive enhancing drug. So for anybody who has some problems with attention, it will improve attention. Or for impulsivity it will do that as well. So it is a sort of general cognitive enhancer. And in our study that we published in Brain with Natalia Del Campo and other people, we showed that the drug is not actually acting in a different way in the brain of people with ADHD. It's the same as it would in a control group of people without ADHD. That's part of the issue because people have been suspicious sometimes. And the Care Quality Commission has said the reason for increases in prescription is because ADHD is being identified and diagnosed more in children, which is good. And now in adults too, which is also good, but there may also be circumstances where people are using it more as a cognitive enhancing drug and perhaps don't really need the drug, but want to use it because it helps with their attention as well, and other issues.

Chris - Nicola said that it helped her quite a bit. Tania on the other hand said she just couldn't get on with it. Is that normal?

Barbara - Well, there'll always be some people that the drug doesn't work for. I mean, I think the first person benefited from it and most people will benefit from it. But if you have some comorbidities, for instance, one of the side effects, sometimes people can get a bit more nervous and so if you've got anxiety, it may exacerbate that, for instance. And there's other conditions where if you have a sort of bipolar disorder it might exacerbate your mania, for instance. So you have to be careful when there's comorbidity involved. But in somebody who has only the ADHD disorder, then it should work out reasonably well for treatment.

Chris - One of the paradoxes about this is that people with ADHD struggle to stay on task and focused on doing one thing. They want to be onto the next thing before they finish the first thing. And the drugs that we're exploring to try to help them are actually sometimes abused because people want more energy and want to be more impulsive. And it seems a bit weird that we treat a condition of impulsivity with a drug that can make people impulsive.

Barbara - Yeah, I mean, I first started to study the drug because I was fascinated by the fact why would you give a stimulant drug to somebody who was hyperactive? But actually the evidence is that it helps control the behaviour. And there is this idea that there's an inverted U shape function with the arousal level. So that if you are under aroused, the drug will bring you out to an optimal level of arousal. If you're over aroused, it will bring you down again. So it may well be that it's working to get the right optimal level of arousal for whatever your behavioural circumstances might be or your cognitive circumstances, as the case is in schools and universities.

Chris - Do you think there's a difference in terms of outcomes and benefits and long-term effects, whether you are an adult who starts taking these drugs versus a child? Because as we've heard in recent weeks with people arguing about the trans debates and so on that are going on, the brain is still developing well into your twenties. And if you are taking a chemical that chronically alters the levels of various nerve transmitter chemicals in the brain, is there a danger you're in some way bending someone's brain from a young age permanently and that could have unforeseen consequences?

Barbara - Well that's why you have to be careful. You know, students often use it as a study drug, and I'm always concerned about that because if they basically don't need the drug, they don't have a diagnosis of ADHD, but they just want to use it to cognitively enhance themselves and help the study or stay awake longer.

Chris - Is that actually common though, Barbara? Are lots of people doing that?

Barbara - Certainly at universities, yeah. There's quite a percentage of people that do it. And actually it's not just university. I mean there's quite a lot of data where they've looked at surveys and they found that these drugs are used quite commonly for cognitive enhancing drugs. Actually, the most common one used in the UK is modafinil, but in the USA, they're more likely to use stimulants like Adderall or Ritalin.

Chris - And you were going to go on and tell us about what happens if you do use this from a young age without a diagnosis or even with a diagnosis of ADHD.

Barbara - Yeah, so I think that we do have evidence that there are differences in the brains of people with ADHD and that some of these differences seem to be mitigated with the use of the drug. So that could actually be beneficial. It may be that it's actually helping you get back on track as far as that goes. But I would think that if your brain is developing within the typical trajectory of normal and no problems, then introducing a drug may not be advantageous for you. And especially while your brains are still in development up until about the age of 24, 25.