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Can a Single Study Have Such Influence Over ADHD Treatment?

Imagine that in a world where thousands of new studies are published every year, and hundreds of studies are conducted on any one condition, that one gleaming, gold-standard study has the ability to completely determine the course of treatment for one condition. For decades.

If you find that hypothetical situation difficult to swallow, you’re not alone. Experts and specialists of a condition such as attention deficit hyperactivity disorder (ADHD) rarely rely on a single study’s results to help guide their treatment decisions. And even when they do, it’s nearly always done within the context of a specific patient’s individualized needs.

So can a single study have such influence over the choice of treatments in ADHD? Let’s find out.

3 Comments to
Can a Single Study Have Such Influence Over ADHD Treatment?

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  1. I posted about Adult ADD just before coming here, and I advise readers to seek out the source of that post, the Jan/Feb 2014 issue of Scientific American Mind, the article entitled “ADHD Grows Up” by Bilkey, Surman, and Weintraub. I’d offer the link but the publication only gives you a preview, well, here it is anyway:

    I did a cut and paste of the meat of the article, how to utilize skills and not just depend on pills.

    Just remember this, from a provider who has watched the drug seeking of stimulants literally explode in number the past 4 or so years, at least in the areas I have worked in around Washington DC: stimulants are NOT benign medications, and certainly have ceiling dosage limits. But, you can always find someone to give you what you want.

    However, is it really what you need?…

    Nice post by the way Dr G!

  2. Many people cannot afford therapy, or can’t take off work to go to or to take a child to therapy. Medication copays are often just $10 a month and the medications can be prescribed by a family doctor.

    I suppose these factors are just as important to consider when making treatment recommendations.

  3. Dear Dr. Grohol and All: Kudos to Dr. Grohol for an excellent scientific analysis of the NYTimes article written by Alan Schwarz. And, kudos, for keeping it scientific.

    There are many rational and scientific weaknesses in Mr. Schwarz’s series of articles on ADD dating back to mid-2012 and a pattern of biased analysis and logic that cannot be ignored. Clearly, after making his mark by being the foremost journalist to inform the public about the truth of sports-related concussions through New York Times articles, he has decided to push an agenda at the New York Times that is so transparently biased for the purpose of scaring readers about “stimulants” that it would be scientifically laughable if it wasn’t so serious.

    Dr. Grohol is way too kind to Mr. Schwarz, not only in this post but in Dr. Grohol’s earlier posts about the “overdiagnosis” of ADD.

    I have sent my book to Mr. Schwarz and talked with him briefly on the phone, and it is clear that he does not want to know the truth about traditional ADD medications that consist of mostly controlled substances classified as Schedule 2 drugs by laws passed in and around 1971. This kind of fear-mongering sponsored by one of the traditional giants in journalism, the New York Times, is unforgiveable.

    A few bullet points because there is no way I can discuss the nuances here. 1. Since 2008, the literature is clear about both the downside and the upside of the ADD brain. 2. Both the downside and the upside are produced by the same common-denominator, dopamine dysfunctions. 3. The dopamine system of bridges (neurotransmitters) is very complex with ten significant genes controlling all aspects of the dopamine bridge system. 4. The downside of the ADD brain is poor working memory (working memory is almost entirely dopamine function dependent). 5. The upside is more difficult to understand because many terms have missed the target in describing it so far — terms like risk taking, thrill seeking, adventurous, etc. The two terms I use are emergency capability and threat tolerance. 6. Threat treats ADD — it percolates dopamine in the emotional brain (which I call the Threat Monitor Center) and the dopamine spilling out due to threat optimizes poor working memory.

    Thus, the ADDer gets “better” in threat, conflict, competitive, defensive, and disgusting environments. Better means increased working memory (calmer, better judgment, “in the zone”) and faster reaction times. The non-ADDer baseline dopamine optimal brain is decidedly problematic in the same threat environments, with dopamine presence exceeding optimum and creating poor cognitive function (confusion and inefficient data processing due to data “detours”), “overamping,” and longer reaction times. In other words, too many dopamine bridges (above optimal) is just as bad as too few dopamine bridges.

    So, what’s my point? My point is this. The medications available are literally targeting different aspects of the dopamine system. We do not yet know exactly what they are doing in the intact human brain, but we know they are not the same and CANNOT be compared head-to-head, unless you genotype subjects and figure out what kind of ADD they have from their genotype.

    Different problematic genotypes exist but poor working memory and behavior is typically similar no matter what problematic genotype is present. This means that the best method for finding the correct medication is to aggressively do trial doses of the different medications that are available looking for the one that has no significant side effects, and is either neutral on sleep or fixes sleep problems. (90% of ADDers have significant sleep problems and sleep quality.)

    Adderal is particularly problematic for many reasons and many more bona fide ADDers are taking it than should be taking it. It is a longer story, but in essence, the problem lies in the fact that it contains two different amphetamines which have very different properties and likely target different aspects of the dopamine system. In other words, one of them might be right, and the other completely wrong. Unless you know that, you don’t know what to look for and what to do about it.

    Significant side effects are always due to the wrong medication or too much of the right medication and are 90% of the time the same side effects that above optimal dopamine produces — upset stomach, nausea, increased anxiety, over-amping, more irritable rather than less, jitteriness, muscle tension of many kinds, increased heart rate, increased blood pressure, a buzz, worse sleep, a crash. In other words, those Vyvanse commercials on television that are 3/4 about side effects, should end by saying, “if you get these side effects talk to your doctor, there may be a better medication for you.” As if pharmaceutical companies would say that, right? But, that is the truth.

    So, in that regard there have been no significant studies of medications that have investigated subjects taking the same medications and dividing them into at least two groups, those experiencing significant side effects and “adapting” to them, and those experiencing no significant side effects, including neutral or positive on sleep.

    The New York Times does an injustice by not telling its readers why Adderall is particularly problematic and by using worst case scenarios to fearmonger about all ADD medications. The single study Dr. Grohol refers to in this post is fatally flawed from the outset since it makes no attempt to separate out the two general groups of medication users, those with significant side effects, and those without. It is garbage in, garbage out, and literally none of the head-to-head medication response (efficacy) studies I know of have any scientific credibility.

    Most medication studies have concluded that medications are a wash, with no significant upside or downside. Well, yah, when you group side-effectors with non-side-effectors in a single study, guess what? A wash.



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