Pros and Cons of ADHD Medication
To Take or Not to Take, that is the question?
If you are considering a costly private ADHD assessment or ADHD testing given the ever-growing NHS waiting list, the first consideration would be if you want the long-term medication, the ‘first line of treatment’? This blog may help you make that decision.
The decision to go on Attention Deficit Hyperactivity Disorder (ADHD) medication should be made in consultation with qualified professional such as a psychiatrist or a general practitioner with experience in diagnosing and treating ADHD. Needless to say, that before starting medication, it’s imperative to hold a thorough discussion about the treatment options with a mental health care practitioner.
The psychiatrist would provide you with the basic factual information and leave the decision to you. Weighing up the risks and benefits can be challenging given that everyone’s circumstances, physical make up and feelings about being on long term medication differs widely.
This decision about treatment is even harder when deciding about if it’s worth your while to go through the assessment, post 2 or more years wait on the NHS or pay significant amount of money for an ADHD testing with a private psychiatrist or psychologists. It would not be wise to go for a long and expensive assessment if you have reservations about taking stimulant medication.
To add to the complicated scenario, we now (since October 2023) face a severe shortage of ADHD medication (ADHD Medication/ Treatment) including Lisdexamfetamine, also known as Adderall/ Elvanse/ Vyvanse one of the main long acting (once daily dose) drug used for ADHD treatment. This further caused the of loss of trust in consistent supply of medicine.
It is worth discussing about what happens when severe symptoms of ADHD including lack of concentration, impulsivity, and hyperactivity remain undiagnosed and untreated. Effects of the other less talked about but equally common and troublesome ADHD features of emotional instability (ups and downs of mood, irritability and anger issues) and executive function difficulties (disorganisation, lower ability for planning and prioritisation skills) will also be considered as these hinder the ability to take on work and personal responsibilities.
This may help with your ability to make a decision about your assessment and treatment options
Untreated ADHD and Work
Adults with ADHD may experience difficulties in the workplace. Imagine a work colleague, who misses meetings or is constantly late or fidgets through them, not taking in any instructions, struggles to keep even the crucial deadlines, gets up from the desk every 15 minutes for a ‘chat’ or ‘little break’. They find reading through reports and completing simple administrative work an unsurmountable challenge and anything that’s not thrilling may bore them to tears with little patience to wait for anything. This is when they are trying.
It’s not surprising then that people with this neurodivergent disorder would not be the most popular workers with a reputation for reliable, consistent hard work even when they try their hardest. And are 60% more likely to be fired, as per the World Mental Health Survey Initiative published in the British Medical Journal, that is if they do not leave on an impulse themselves.
Impact of ADHD at work, including Loss of household income, Poor productivity, loss of employment, stress-induced illness, stigma that you will perhaps definitely have suffered is widely observed and described in detail. ADHD is a disability which is not recognised as such in spite of the law, by many employers.
Social and Interpersonal Challenges with ADHD
The struggles and challenges are pervasive, in other words present in every facet of the ADHD sufferer’s life. People with ADHD would often be described as the ‘class clown’, good entertainment but with few or no close friends. They maybe known for their ‘out of sight, out of mind’ tendencies as they find keeping in touch hard with an over-stimulated mind.
Understanding social cues can be a challenge and it does not help that their mind works at a ‘100 miles an hour speed’ so keeping tab of the conversation which is not at the same speed may end up in bouts of oversharing, interrupting or talking in tangents or zoning out altogether, not making for the delightful company. As expected leading to difficulties in forming and maintaining friendships and relationships.
The forgetfulness, difficulty in organising everyday life, not being attentive, impulsive over-spending or risk taking are also not factors that would maintain a long-term relationship with ADHD sufferers.
If you have ADHD, you may feel over-criticised, being treated like a child and micromanaged. Doing things to your partner’s liking may seem like immense hard work but not achievable. Or you may feel constantly guilty about letting your parents or partner down, pronouncing yourself lazy or useless or like an imposter when you do well. Your partner on the other hand may feel unheard, like they were ‘walking on eggshells’ around you and generally dissatisfied with your contribution to consistent housework, taking on parental responsibilities etc.
The mood swings, low frustration threshold (emotional dysregulation) and difficulties in managing anger and impulsive outbursts would add further fuel to the fire.
Untreated Severe ADHD and Risky Behaviours
One in four prisoners in Britain have features of ADHD, according to a new report published by The Guardian. This makes the prevalence of ADHD 5 to 10 times higher than its 2% to 4% in the general population. These numbers however are not an indication that people with ADHD have some form of ‘criminal genes’ and need careful consideration and understanding of the different factors that may contribute to this association:
The impulsivity and thrill seeking behaviour which is often part of the ADHD complex is mostly attributable. Many patients who suffer from ADHD would report that they act before considering the consequences. The other issues are associated with their struggle to stick to the societal norms and rules, which they may find tedious or cannot adhere to due to lack of organisation.
We often find that they would sign documents without reading through or promise to commit to activities without getting into the nitty gritty of what the activity is about.
It’s important to emphasise that majority of individuals with ADHD do not engage in criminal behaviour, and there is no criminality gene associated with ADHD. It can be attributed to the factors above. That makes an early diagnosis of ADHD with appropriate treatment and support vital for prevention.
So do the stimulant medicines for ADHD work, are they worth it?
Medication used as the first line treatment of ADHD, including Elvanse (Lisdexamfetamine), Concerta, Ritalin (methylphenidate), do they help improve your performance at work or school? What about your social life, is the medication effective in improving your ability to make and maintain friendships and relationships? Below are some scientific facts and observations about the effectiveness of stimulants in treatment of ADHD.
Pros / Advantages of ADHD Medication
The evidence from research shows that improvement in the ADHD symptoms related to concentration, attention and memory with medication is significant. There are hundreds of studies that show, improved academic performance in exams, better recall of events and instructions, higher exam scores are some of the findings which prove the above at least in the short to intermediate term. One of the methodical and high value scientific study by Daniel Cox added to the evidence that long-acting methylphenidate (Concerta XL, Medikinet MR etc.) reduce collision rates of young adult drivers with ADHD. with improved concentration and less likelihood of acting impulsively.
Other research, including that by Matthijssen and associates found discontinuation of the stimulant medication ended up in worsening of the symptoms of ADHD sand overall functioning at home, school and work.
An essay ‘Blame it on the Brain’ published by the Royal college of psychiatrists explores criminal behaviours in people with ADHD and if these can be prevented through treatment intervention. Put succinctly this report explores and confirms that treatment helps reduce impulsivity thus reducing offending behaviour across the population that suffers from ADHD.
In relation to efficacy, the positive effects of the medication in clinical practice, anecdotally from patient stories and revies as well as the results of several studies (meta-analysis and randomised control trials) convincingly demonstrate that all the stimulant medication, that is, Dexamphetamine, Lisdexamfetamine, Methylphenidate were better than placebo*
Cons / Disadvantages of ADHD Medication
Most significantly the concerns about side effects need to be considered here. Decreased appetite with unwanted loss of significant amount of weight, initial insomnia and dry mouth are the commonest. Understandably, Irritability developing on starting these may occur, increased heart rate and blood pressure are uncommon but most concerning adverse effects from the medical point of view.
These side effects can be prevented, modulated or treated with monitoring and early non-medical and behavioural methods or less often medically. These include taking medication earlier in the day, eat and drink regularly with daily exercise.
Stringent physical health monitoring of pulse rate and blood pressure when starting and increasing the medication is essential. In a small number of patients, treatment with high BP medication may be required, when the benefits outweigh the risks significantly.
Medication effect may reduce over time, also called tolerance. This is a very real problem, managed by a ‘treatment holiday’ at your psychiatrist’s advice. This is a a few weeks’ break from your medication intake may ‘reset’ the body so it recognises the medication as a new one when recommenced. A change in the type of stimulant can also help overcome this problem.
Another consideration is that although very effective in controlling inattention, hyperactivity and impulsivity related symptoms, the ADHD medicines are less effective with improving social behaviours and mood symptoms. This means the medicine is not as useful in case of people who deal with mood dysregulation. Psychological therapy should be used alongside medication.
Summary
In a nutshell generally speaking, the common consensus is that given the scientific evidence and patient experience taking medical treatment for ADHD is usually beneficial. Most researchers have concluded that this medication works as cognitive enhancers, and apart from this well-known ability, can improve memory and recall and help reduce impulsivity. Secondary to these core effects the above translate into better performance at work, enhancement of relationships, less risk taking or criminal behaviours.
However, medication cannot and should not replace psychological and behavioural interventions. Therapy alongside support from health workers, family and friends is essential. Medication and these psychological and social aspects of treatment and support together would make for optimal care with the best outcome.
Author: Dr Meetu Singh
Dr Singh is the consultant psychiatrist with a special interest in neuropsychiatry. Having seen and treated hundreds of patients with ADHD, in London and Birmingham and with masters in Neuropsychiatry, she is well known as an expert in this field.
