Back in the 1960s, when Ritalin (methylphenidate) was first approved by the US Food and Drug Administration (FDA) for treating behavioural problems, parents and teachers alike were impressed by the remarkable and immediate effects of stimulants on children’s ability to stay on task. Kids who had previously spun like a top, unable to concentrate or switch focus from one task to another, suddenly settled down and got on with their work.
“For many people, it’s like a miracle,” says Edmund Sonuga-Barke, a developmental psychologist at King’s College London.
Today, stimulants are still the front line of treatment for attention deficit hyperactivity disorder (ADHD), and they are considered to be one of the most effective medications across the board. They have “the highest effect size we have in psychiatry, and among the highest in general medicine”, says Samuele Cortese, a child psychiatrist and ADHD researcher at the University of Southampton, UK. But controversy has long surrounded these drugs, spurring a desire to find alternatives.
Nature Outlook: ADHD
In the 1970s, concern about the abuse of stimulants led to a backlash against prescribing them for children. The medical consensus is that supervised oral stimulants are safe, but the side effects — including loss of appetite, sleep problems, mood swings and stomach aches — can be problematic for some. Furthermore, many people with ADHD also have other issues, such as anxiety or a history of addiction, that make stimulants less suitable. For up to 30% of people with ADHD1, stimulants just don’t work or aren’t tolerable.
There are also broader societal issues with stimulants, says Stephen Faraone, a psychiatrist and neuroscientist at Upstate Medical University in Syracuse, New York. The increasing number of ADHD diagnoses has led to occasional shortages of these drugs, leaving people without the medications they have grown accustomed to. Because stimulants are controlled substances, they come with onerous paperwork and visits to the doctor, creating barriers to access. And some medications are being used by people without a prescription, such as students who want to stay up late studying. “There’s a small but growing problem with misuse and diversion,” says Faraone.
Fortunately, there are some non-stimulant options for ADHD, and researchers are trying to find more, based on a better understanding of the genetics, pharmacology and symptomology of the condition. Some drugs have been repurposed, from blood-pressure medications or antidepressants, and some aim for different targets, including neurotransmitters produced by gut microbes. Other research is focused on retraining the ADHD brain through talking therapy, video games, neurofeedback or brain stimulation.
Given the societal issues, and because some people will do just as well or even better on non-stimulants, it might be time to rethink the general advice on prescription, says Faraone. “All current guidelines say you should start with a stimulant medication. Maybe we should reconsider that.”
Stimulating work
More than two dozen stimulant formulations have been approved by the FDA for ADHD in the United States. The two main active ingredients are methylphenidate (as found in Ritalin) and amphetamines (as found in Adderall). These drugs, along with other similar stimulants, typically increase the amount of dopamine and noradrenaline in the brain, which are neurotransmitters that affect mood, increase alertness and focus attention. Stimulants typically start working immediately and have no residual effects if you stop taking them, making it easy to try various drugs or doses, or to target different needs on different days.
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