Offered with some concern: Stimulants are the “treatment of choice” for ADHD because a significant number of randomized, controlled trials have found a more favorable balance between benefits and risks when ADHD is treated with stimulants than when other treatments are used. Stimulants have been compared in this manner to cognitive-behavioral therapy, atomoxetine (Strattera), tricyclic antidepressants (nortriptyline, desipramine, and others), bupropion (Wellbutrin), venlafaxine (Effexor), clonidine (Catapres, Kapvay), guanfacine (Intuniv), selective serotonin reuptake inhibitor antidepressants (Paxil and others), selegiline and modafinil.
Thus, there is nothing “magical” about stimulants being awarded their first place position-it is as simple, common sense, and mundane as, “let's try out different things and carefully evaluate which works best, and that one will be our treatment of choice, all other things being equal.”
Startlingly, this is the way most, or perhaps all, “treatments of choice” in medicine are determined. With such a mundane means of selection, the question as to why the treatment of choice for ADHD generates such interest becomes even more pointed. In my opinion, it is only because the disorder is ADHD and the treatments of choice are stimulants that anyone aside from specialists cares about the “why” question.
To offer a clarifying detail:
The primary reasons there is a burning debate about ADHD treatment are twofold:
- ADHD is a so-called “mental” disorder.
- Stimulants, the treatment of choice, are potentially addictive.
It does beg the question: why does the selection of a treatment for a psychiatric disorder generate more controversy than the selection of treatments for so-called physical disorders?
Psychiatric disorders have proven a lightning rod for controversy in parallel with medicine’s evolution as a discipline. For example, in the distant past, the “insane” were thought to be possessed by supernatural powers. Although contemporary rationality now reject extreme explanations, the inability of medical science to offer explanations for psychiatric disorders that possess the rigor and clear-cut observational support of the theories that underpin cardiology or infectious disease has led to a persistence of skepticism about the treatment of psychiatric disorders. In extreme cases, their very existence is cast into doubt
Among the general public, there is a commonly held belief that “ADHD” is the medical establishment’s collusion with “lazy” but otherwise normal people. In that segment's opinion, the goal of this collusion is to enable those “lazy” people by providing them with an “easy way” to successfully execute key activities that require concentration and perseverance. Thus, the “treatment” that helps the “treated” meet life’s challenges is not really a treatment, for they believe there is no disease to treat.
Medications for ADHD are viewed not even as something as dignified as a “crutch,” but as facilitators of the pure evil of “cheating.” Among the subscribers to this view, there is significant anger towards clinicians who treat ADHD and towards patients who suffer from ADHD. The group that rejects the existence of ADHD perceives life as essentially a long, drawn-out competition. They demonize ADHD treatments, especially stimulants because they perceive such treatments as proffering an unfair advantage in the competition of life. The fact that the medication designated by the medical establishment as “treatment of choice” for ADHD is a compound also misused as a recreational drug with an addiction potential does not serve to decrease this anger and resentment!
A naïve observer would be surprised by the controversy and acrimony generated by the placement of the psychostimulant medications on the top step of the ADHD treatment of choice podium. Contrasting the contentious nature of the discussions about ADHD treatment to the relatively measured, calm and even grateful acceptance of “treatments of choice” in non-psychiatric areas of medicine can provide insights into the challenges presented to programs and platforms aimed at maximizing both psychiatric treatment efficacy and increasing access to psychiatric treatment.
For example, in diabetes treatment, the medication metformin is more or less in the same exalted position as psychostimulants in ADHD treatment. Metformin is recognized as the type 2 diabetes “treatment of choice,” yet there are few, if any, indignant diatribes about possible overprescribing of metformin, and whatever concerns have been voiced about it are directly related to its concrete pharmacologic properties, rather than to vague and global concerns such as “overuse.”
In informing the general public about the “treatment of choice” for a non-psychiatric medical disorder, there is little interest in “why” that treatment is “of choice.” The public wants to know how effective the treatment is, what are the negatives of the treatment, and most importantly, how they can get it. Even if the “why question” was asked, few people would be interested in the answer, and the intensity of whatever interest was sparked would be low. That would be for good reason, as the reason would be that the same mundane, common sense, almost boring clinical trial procedure had been followed to demonstrate the efficacy of the treatment of the non- psychiatric disorder as was followed to demonstrate the superior efficacy of stimulants as treatments for ADHD.
The “drama-free” acceptance of metformin as a basic, “go-to” diabetes drug can be contrasted with the pathetic inability of our medical system to provide even rudimentary ADHD treatment to more than a sliver of those suffering from the disorder. In 2006, the National Comorbidity Survey Replication found that only 10% of adults with ADHD in the United States received treatment during the previous year. Simple failure to diagnose ADHD was only part of the reason for this shocking neglect of a common disorder that has major morbidity and mortality. It has been demonstrated that even after an individual is diagnosed, reluctance to treat plays a crucial role.
The description of some of the reasons for this reluctance to treat are offered by James J. McGough, MD, in a 2016 article entitled “Treatment Controversies in Adult ADHD.” Dr. McGough writes, “ongoing apprehension about possible malingering, fears that medications, notably psychostimulants, will be abused or misused, and reluctance to prescribe controlled medications for individuals with past or current substance use disorders add to clinician discomfort regarding ADHD diagnosis and treatment.”*
Dr. McGough’s comments are accurate as far as they go and thus very much appreciated. Nevertheless, he significantly understates the degree of resistance in the clinical community as a whole to treating adult ADHD vigorously and with the tools that have been shown, by the well-designed studies mentioned above, to maximize success.
In my clinical career, I have seen numerous examples of this antipathy (“reluctance” is unfortunately too weak a word) to proper treatment of ADHD. Examples include complete refusal to treat ADHD by an entire county’s behavioral health division. This was effected by the simple but completely inappropriate deletion of ADHD from the category of “Serious Mental Illness.” In a different county, I observed consistent rejection of all new patients presenting on stimulants for clinic enrollment. I will also mention the arbitrary switching of patients from stimulant to non-stimulant treatments solely because prescription of stimulants was “against policy,” pharmacies refusing to honor properly submitted stimulant prescriptions, etc., etc.
The ubiquity and egregiousness of these less-than-honorable actions have convinced me that only vigorous efforts in educating clinicians, patients and the general public, combined with innovations in the delivery of assessment and treatment, will bring the treatment of adult ADHD to anything even resembling a par with less controversial non-psychiatric disorders such as diabetes and hypertension, or of less controversial psychiatric illnesses such as depression.
The achievement and that goal will certainly not be easy, but there is no doubt it is worth the effort. The toll of ADHD is far more severe, and its effects more widespread than is generally recognized. If we can overcome the ignorance and stigma surrounding this and other psychiatric disorders, a major cause of human suffering will have been alleviated.