with Joseph Biederman, MD, Rona S. Fried, EdD, and Maura DiSalvo, MPH

“Stimulants for ADHD are some of the most successful medications we have in psychiatry,” said Joseph Biederman, MD, professor of psychiatry at Harvard Medical School, in his AACAP 2020 presentation Adherence to Stimulant Medication Among Children and Youths with ADHD: An Electronic Health Records Study.“ Persistent ADHD alters the intrinsic functional organization of the brain and has a profound impact on the development of comorbid disorders.” Yet, despite data documenting that stimulants are safe and highly effective in the treatment of ADHD and could help mitigate many of its adverse complications, adherence to stimulant treatment is quite low.

Assessing Adherence to Stimulant Medication

In a 2019 study, Biederman, Fried, and DiSalvo, randomly selected 75% of the subjects to be in a discovery set (n=1,662) and 25% (n=544) to be in a replication set. All analyses were performed in the discovery set; the accuracy of the predictions was assessed in the replication set. Only 46% of children in the discovery set had their first prescription renewed within 90 days. The replication set did only slightly better at 48%. A multivariate logistic regression model indicated that these results were only modestly better than chance.1

Rates of medication adherence were worse in primary care than in the mental health setting, in older patients, and in female patients, and did not appear to be influenced by ethnicity, social class, stimulant type, or drug formulation (short- or long-acting).

The reasons for low adherence remain unclear. A newly published study led by Dr. Biederman and team of 2,689 adult patients with ADHD from the same organization showed that only 42% renewed their prescriptions in a timely fashion.2  His team theorized that such low adherence rates may be due in part to the symptoms of ADHD themselves, such as forgetfulness, difficulties in follow-through, and deficits in planning and organization. Because stimulants are classified as Schedule II medications, there may be issues in scheduling the monthly recontact with the prescriber for prescription renewal. Finally, there are ongoing misconceptions and biases about ADHD and stimulants that could also influence compliance.

 

Why Do We Treat ADHD with Stimulants?

Employment & Life Satisfaction

In an earlier community-based survey conducted by Dr. Biederman, adults with ADHD reported they were significantly less likely to have graduated high school or college or be currently employed than adults without ADHD. They were also significantly more likely to change jobs more frequently, have been arrested, have been divorced, and to be less satisfied with their family, social, and professional lives than those without ADHD.3

At the workplace, those with ADHD reported difficulties in concentrating on work, handling large workloads, paying attention for long periods of time, and being organized, with consequent losses in income.3

A national study of nearly 2 million Danish residents indicated that ADHD was associated with significantly increased mortality rates, particularly in girls and women and in those diagnosed in adulthood. The excess mortality in ADHD was driven mainly by deaths from unnatural causes.4 However, “studies show that many ADHD-associated poor outcomes can be mitigated by treatment with stimulants,” Dr.Biederman said.

Daily Function

Other studies show that pharmacologic-based treatment of ADHD can improve functional outcomes, which translates to lower rates of substance abuse, automobile violations and accidents, injuries, suicidal behavior, and ER visits. For instance, in a related AACAP presentation, Rona S. Fried, EdD, of Massachusetts General Hospital, shared a review and analysis of the literature which suggested a protective effect of ADHD medication on mood disorders, suicidality, criminality, substance abuse disorders, accidents and injuries, traumatic brain injuries, motor vehicle crashes, and educational outcomes. Her AACAP talk was titled A Systematic Literature Review and Meta-Analysis Examining the Effects of Medications for ADHD on Functional Outcomes Using Data from Registry-Based and Large Datasets-Based Studies. These findings support efforts aimed at early diagnosis and treatment of individuals with ADHD, she noted.

Disruptive Behavior and Anxiety Disorder Prevention

Further support of the crucial importance of early identification and treatment of children with ADHD was provided by Maura DiSalvo, MPH, of Massachusetts General Hospital. In her presentation, Quantifying the Protective Effects of Stimulants on Functional Outcomes in ADHD: A Focus on Number-Needed-to-Treat Statistic and Sex Effects, DiSalvo quantified the protective effects of stimulant treatment on important functional outcomes over a 10-year follow-up period. Results showed that the number-needed-to-treat (NNT) statistic in children for a long-term protective effect against disruptive behavior and anxiety disorder was calculated to be 3. For substance use disorders, the NNT statistic was 10.

The Importance of Stimulants in Treating Functional Impairments

The clinical implications of ADHD indicate a need to educate patients and families/caregivers about the full range of the condition’s core and associated impairments, and not just the narrow definition of the condition provided in the DSM-5. The patient assessment should be broad and include all relevant areas of possible impairment, and treatment should be targeted to achieve an optimal response, advised Dr. Biederman.

Functional impairments are not just symptoms. It is important to understand the ultimate targets of treatment, Dr. Biederman explained. Stimulants treat ADHD symptoms but, as noted above, they can also prevent other psychiatric outcomes, giving patients a chance at having a good life.

For example, stimulants do not address executive function, per se, but when used to manage ADHD, they may allow a child who also has dyslexia to reach out at school to access help for the learning difference. ADHD treatment may prevent the initiation of smoking or prevent an automobile accident. And it may prevent the depression experienced by someone who has felt like a failure in life or engages in substance abuse.

“The idea that you can intervene and change the course of someone’s life is extraordinary in many ways,” said Dr. Biederman. “They can be compared to the use of statins in preventing cardiovascular outcomes,” he added.

While it is important to treat ADHD to achieve an optimal response, it is also necessary to set up appropriate expectations for treatment. According to Dr. Biederman, “There is a great deal of ambivalence regarding psychiatric treatment in general, and intense bias about ADHD.”

We need to educate families that functional impairments associated with ADHD, such as disruptive behavior and anxiety, are broader than just the symptoms, such as fidgeting and short attention span. It’s also important to share with patients and caregivers how (and how long) the medications work and to ensure they understand the “hidden benefits” of medication in long-term functional outcomes. Otherwise, parents, for instance, may not appreciate that treatment improves a child’s functioning in school when they only see them at home after the medications have begun to wear off.  “The meds are not there during homework, so they think the meds are not working,” Dr. Biederman explained.

 

How Can We Do a Better Job?

“Identifying predictors of poor adherence is as important as predicting factors of poor response,” said Dr. Biederman. Studying methods of improving adherence should be a priority. Digital technology offers one option for educating patients on medication adherence and the consequences of nonadherence. In a program at his institution, for example, text messaging reminders about taking medication and renewing prescriptions on time has shown an increase in patient adherence.

 

Related Resource: ADHD and Addiction recovery program.

 

References
Last Updated: Nov 23, 2020