A complex condition requires a thoughtful treatment approach, and multiple diagnoses often require treatment with more than one medication. Unraveling the answers takes time, plus trial and error. Thanks to years of research, however, clinicians are now equipped with highly effective options for addressing tough-to-treat cases of ADHD plus comorbidities.

Use this evidence-based information to begin a conversation with your doctor about treating complex ADHD with combination therapy.

Is Combination Therapy Safe?

The stimulants used to treat ADHD generally have no major drug-to-drug interactions, so they don’t increase the levels of other medications you may be taking, and vice versa. They are safe to use in combination with other medications, including non-stimulants, antidepressants, and antipsychotics. However, some of the non-stimulants, such as atomoxetine (brand name Strattera) or viloxazine (brand name Qelbree), may affect the blood levels of other medications.

Which Condition Do I Treat First?

We generally recommend treating the more sever condition first. If untreated, the symptoms of severe conditions like bipolar or panic disorder can undermine or hijack ADHD treatment. If a patient has mild anxiety, for example, it makes sense to address the ADHD first and then assess any remaining anxiety. Sometimes, anxiety improves when the ADHD is addressed.

Even the most optimized treatment regimen may need to be adjusted over time. After feeling quite stable, a person with ADHD and depression, for example, may feel as though their ADHD is suddenly worse. Worsening depression may worsen the ADHD response. Treating the depression may enhanced the effectiveness of ADHD treatment. Clinicians must take time to sort out such issues when dealing with multiple diagnoses.

[Free Course: The Adult’s Guide to ADHD Treatment]

Anxiety and ADHD

Generally, stimulants don’t worsen anxiety, but they may for some patients. If ADHD symptoms are causing anxiety, stimulants may lessen the anxiety. If the anxiety is unrelated to ADHD, if won’t be improved by stimulants and may, in fact, be exacerbated. A meta-analysis of studies concluded that, in the aggregate, treatment with stimulants significantly reduced the risk of anxiety compared to a placebo.³ The first-line treatment for anxiety is a selective serotonin reuptake inhibitor (SSRI), such as Lexapro, Prozac, or Zoloft.

Atomoxetine is a selective norepinephrine reuptake inhibitor (SNRI) that can effectively treat both anxiety and ADHD with a single medication. There is a caveat: For reasons we don’t yet understand, atomoxetine is not as effective in patients who have already tried a stimulant. If you’re a new patient, talk with your doctor about trying atomoxetine first to treat both the ADHD and the anxiety.

Autism and ADHD

Addressing ADHD in autistic patients may improve functioning dramatically. However, studies show that ADHD medications may cause more side effects and be less effective for autistic people, particularly those with lower intellectual functioning.⁴ Research has found that autistic patients taking ADHD medication experienced a 50% response rate for symptoms including hyperactivity and emotional regulation, which is lower than the 70 to 80% response rate found in children with ADHD who do not have autism.⁵

Begin slowly and monitor closely when increasing the dosage of ADHD medications in autistic patients. It is not uncommon to see an autistic child or adult have a good response to a particular dose of medication, whereas a slightly higher dose may cause many side effects and lessens response. Rather than seeking the “best” ADHD treatment, doctors may aim for good treatment with manageable side effects.

[Read: Interventions for Adult Autism and ADHD]

When severe irritability, aggression, and acute outbursts occur, it may be necessary to stabilize these episodes before addressing ADHD symptoms. Second-generation antipsychotics, such as risperidone or aripiprazole, can work very well to create a calm and controlled context before introducing stimulants or non-stimulants.

OCD and ADHD

Untreated OCD can significantly impede treatment of ADHD, so most practitioners initially prescribe medication and/or psychotherapies like exposure response prevention for OCD, and then tackle the ADHD with stimulant or non-stimulant medication. Both SSRIs and SNRIs are indicated for the treatment of OCD, though SSRIs appear to be more effective. Most medications for ADHD can be used safely in combination with SSRIs/SNRIs.

Depression and ADHD

For children with depression and ADHD, treatment options are limited to an SSRI plus a stimulant or non-stimulant. Adults may benefit from bupropion (brand name Wellbutrin), an antidepressant that is used off-label for ADHD. While depression in adults is commonly treated with SSRIs/SNRIs, some patients report that tricyclic antidepressants help with symptoms of depression and are also quite effective for ADHD.

Eating Disorders and ADHD

Clinicians sometimes hesitate to prescribe ADHD medications to patients with eating disorders due to the common side effect of appetite suppression. These patients’ weight and eating patterns should be monitored closely during treatment, but fear of the side effects should not preclude ADHD treatment, which is shown to improve overall health outcomes.

Though non-stimulants like atomoxetine or viloxazine may be tried first, stimulants need not be ruled out. In fact, the stimulant lisdexamfetamine (brand name Vyvanse) is FDA-approved for the treatment of binge eating disorder as well as ADHD.

Executive Dysfunction and ADHD

The executive function deficits that come with ADHD – difficulties with organization, time management, and sequential thinking – are often burdensome and impairing. For these patients, non-stimulants such as atomoxetine or viloxazine may be used in combination with a stimulant for treating both ADHD and executive function deficits.

Adding an extended-release form of an alpha agonist, like guanfacine or clonidine, to a stimulant is another option that can be useful for executive dysfunction. These medication combinations (e.g., clonidine or guanfacine plus a stimulant) are FDA-approved for treating ADHD in children under 17. They are sometimes used off-label in adults with ADHD.

Research suggests that the Alzheimer’s medication memantine added to the stimulant methylphenidate may improve executive functioning and social cognition, or the capacity to read verbal cues.⁶ This can be especially helpful for autistic children with ADHD.

Comorbid Conditions with ADHD: Next Steps

• Free Tool: The ADDitude Symptom Checker
• Read: What Is Complex ADHD?
• Read: Stimulant, Non-Stimulant, or Both? Combination Therapy for ADHD

Timothy E. Wilens, M.D., is a professor of psychiatry at Harvard Medical School.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

²Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., Kogan, M. D., & Ghandour, R. (2024). ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 53(3), 343–360. https://doi.org/10.1080/15374416.2024.2335625

³Coughlin, C. G., Cohen, S. C., Mulqueen, J. M., Ferracioli-Oda, E., Stuckelman, Z. D., & Bloch, M. H. (2015). Meta-Analysis: Reduced Risk of Anxiety with Psychostimulant Treatment in Children with Attention-Deficit/Hyperactivity Disorder. Journal of child and adolescent psychopharmacology, 25(8), 611–617. https://doi.org/10.1089/cap.2015.0075

⁴Joshi, G., & Wilens, T. E. (2022). Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder in Individuals with Autism Spectrum Disorder. Child and adolescent psychiatric clinics of North America, 31(3), 449–468. https://doi.org/10.1016/j.chc.2022.03.012

⁵Joshi, G., Wilens, T., Firmin, E. S., Hoskova, B., & Biederman, J. (2021). Pharmacotherapy of attention deficit/hyperactivity disorder in individuals with autism spectrum disorder: A systematic review of the literature. Journal of psychopharmacology (Oxford, England), 35(3), 203–210. https://doi.org/10.1177/0269881120972336

⁶Biederman, J., Fried, R., Tarko, L., Surman, C., Spencer, T., Pope, A., Grossman, R., McDermott, K., Woodworth, K. Y., & Faraone, S. V. (2017). Memantine in the Treatment of Executive Function Deficits in Adults With ADHD. Journal of attention disorders, 21(4), 343–352. https://doi.org/10.1177/1087054714538656

Misdiagnosis is a significant barrier to care. Black children and adolescents with ADHD are more likely to be labeled with oppositional defiant disorder and to have their ADHD symptoms misunderstood as defiance. Also, cultural stigma surrounding mental health can prevent Black families from seeking care and from using ADHD medication when it is prescribed. Black parents report a preference for interventions like parent training and executive function skills training, to which their access is often limited.

One possible solution: integrated primary care, in which behavioral health services are embedded within primary care practices. When children go to a pediatrician appointment, they may also see a behavioral health care specialist for common concerns like depression, anxiety, and a range of disruptive behaviors from failing to follow caregivers’ directions to disrupting the classroom.

[Read: ADHD Clinicians Must Consider Racial Bias in Evaluation and Treatment of Black Children]

Integrated primary care can address the treatment disparities in Black youth by enabling more personalized, collaborative treatment for ADHD and its co-occurring difficulties. Parents should ask their pediatrician whether an in-office behavioral health specialist is available. Additionally, many primary care practices affiliated with academic medical centers or children’s hospitals have integrated primary care clinics.

Mental Health Stigma in ADHD Care: Next Steps

• Learn: Why We Need Clinicians of Color to Normalize ADHD in BIPOC Communities
• Read: Evaluating and Treating ADHD in African American Children: Guidance for Clinicians
• Watch: “Health Equity in ADHD: Addressing Racial Disparities in Diagnosis and Treatment” [Video Replay & Podcast #495]

Heather A. Jones, Ph.D., is an associate professor of psychology at Virginia Commonwealth University.
Alfonso L. Floyd, Ph.D., is a postdoctoral fellow in the Department of Child & Adolescent Psychiatry and Behavioral Sciences at The Children’s Hospital of Philadelphia.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Since its publication last Sunday, The New York Times Magazine article “Have We Been Thinking About ADHD All Wrong?” has been called provocative and controversial. We would like to add a few adjectives: misrepresentative, biased, and dangerous.

In his 8,800-word article, writer Paul Tough used cherry-picked bits of decades-old data, very small studies, and interviews with three patients (all men) to exhume long-debunked ideas about ADHD and its treatment with prescription stimulant medication. Tough dismissed the lifelong work of esteemed ADHD researcher Russell Barkley, Ph.D., and suggested that the diagnosis of ADHD was unreliable or subjective because it relies not on a biomarkers or genetic tests, but on a trained clinician’s careful review of patients’ self-reported and observed symptoms in several settings.

To be clear, identifiable biomarkers do not yet exist for many psychiatric, neurodevelopmental, and neurodegenerative disorders. In the case of ADHD, medical experts use rating scales, neuroimaging studies, and/or criteria in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) to assess whether patients meet the threshold for a diagnosis.

“There’s no genetic marker for most psychiatric illness, but there is very clear heritability, as Dr. Russell Barkley has pointed out for years,” says Wes Crenshaw, Ph.D., a licensed psychologist and author. “I wonder if the Times author doubts depression? Or autism? Or anxiety? Or bipolar disorder?”

Though he was also quoted in the Times article, Crenshaw says he was never interviewed by the reporter, who pulled quotes out of context from his ADDitude articles.

ADHD Biases Divorced from Fact

Tough cited findings from the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) Study to suggest that the benefits of stimulant medication wear off after 36 months. In arguing that Ritalin’s “advantage had completely faded,” Tough failed to report that long-term medication adherence among the MTA subjects was inconsistent — an important fact that undermines the author’s contradictory argument that stimulant medication is somehow both ineffective and “powerfully addictive,” as he claims in the article. (If it were addictive, wouldn’t the MTA subjects have taken it every day without fail? We know that half of teens and adults with ADHD stop taking stimulant medication within one year of starting it, suggesting that it is not addictive and shining a light on how woefully irresponsible it is to claim the ineffectiveness of a medication that is not taken consistently.)

Tough was guilty of biased reporting, or a deep misunderstanding of the subject he was covering, when he suggested that the increase in ADHD diagnosis rates — from 3 percent nearly 40 years ago to up to 11.4 percent of American children today, according to the CDC — represents a medical crisis or evidence of overdiagnosis. In truth, this uptick is is due, in large part, to a revised set of diagnostic criteria for ADHD in the DSM-5, a dramatic improvement in both clinician and patient understanding of ADHD, and critical research on its manifestations, especially in girls, women, and people of color — populations that have been historically overlooked and underserved, with serious consequences.

Perhaps the Times reporter was unaware of the basic fact that, 40 years ago, the scientific community screened almost exclusively only boys for symptoms of ADHD. It did not acknowledge the inattentive subtype of ADHD that many girls and women exhibit. And it insisted that symptoms only caused impairment in school settings. We now know much better.

Sloppy Reporting, Inaccurate Conclusions

Tough did Times readers a disservice by choosing not to interview more esteemed physicians, researchers, and clinical psychologists at the forefront of ADHD care. Instead, he plucked their quotes from the pages of ADDitude, stripped them of context, and did not pursue conversations with authors, like Crenshaw, or patients they suggested. [Crenshaw told ADDitude that, prior to the article’s publication, he offered “the author (through fact checker) a chance to interview an almost infinite number of ADHD people whose lives have been radically changed by integrative treatment.” No interviews were granted.]

For example, Tough quoted a feature from the Fall 2021 issue of ADDitude magazine in which Crenshaw addressed parents’ top concerns regarding ADHD medication. In the article, Crenshaw used established, evidence-based research to suggest that, if your child has ADHD, then stimulant medication paired with behavioral parent training and/or cognitive behavior therapy is shown to produce the greatest results in symptom management. Tough took Crenshaw’s words out of context to make it seem that he was arguing that ADHD exists as a binary, on-off diagnosis without any heterogeneity or symptom fluctuation. This is contrary to Crenshaw’s views and contradicts ADDitude‘s own recent reporting.

In its Spring 2025 issue, ADDitude magazine published a cover story titled “ADHD’s Vanishing (and Reappearing) Act,” in which author Maggie Sibley, Ph.D., explained her recent research into the sometimes unpredictable ebbs and flows of ADHD symptoms over a lifetime. Rather than acknowledge ADDitude‘s work to cover the scientific community’s evolving understanding of ADHD, Tough’s reporting painted ADDitude and its contributors as outdated. This is an unfair depiction.

He manipulated ADDitude content again in quoting an article published in 2020 and written by Roberto Olivardia, Ph.D., a clinical psychologist and Harvard Medical School lecturer. Tough did not interview Olivardia. Instead, he pulled a quote from Olivardia regarding the ways in which stimulant medication may quell a child’s social impulsivity. Tough deliberately omitted this vital precursor to the quoted statement in the ADDitude article: “Clinicians should assure parents that any medication that appears to mute the child’s positive aspects and core personality is indicative of an unsuccessful medical trial. Another medication should be tried.”

Olivardia didn’t mince words in his response to the Times article. “The suggestion that I and other ADHD clinicians would uniformly placate parental concerns with a canned response is insulting,” he says. “This is not the first time this has happened within the ADHD community, and it’s so frustrating. Some things in the article are accurate, but they are mixed in with very inaccurate, overly simplistic information.”

Unraveling a Dangerous Narrative About Medication

Of perhaps greatest concern is Tough’s inaccurate and harmful portrayal of stimulant medication as an ineffective Band-Aid that fails to improve students’ academic test scores and, therefore, must be unnecessary. He cited limited research casting doubt on ADHD medication’s ability to make kids score higher on timed tests, sort specific puzzles more efficiently, or excel in summer school. “If these studies are accurate, stimulant medications don’t do much to improve cognitive ability or academic performance,” Tough wrote. “And yet millions of young Americans (and their parents) feel that the pills are essential to their success in school. Why?”

Inexplicably, Tough did not report that ADHD medication has been shown to reduce impulsivity and, by extension, the risks of car accidents, substance abuse, unplanned pregnancy, comorbid depression and anxiety, incarceration, self-harm, and suicide. In fact, research has found that stimulant medication use among individuals with ADHD reduces the risk of premature death by a staggering 19%.

In a study published in The British Journal of Psychiatry in 2025, the life expectancy for adults with ADHD was found to be 7.5 years shorter than it was for those without the condition. Women with ADHD live 8.6 years fewer years than women without ADHD, while the life expectancy of men with ADHD was 6.8 years shorter than that of their peers. ADHD is a serious condition, and to willfully misrepresent its proven treatments is dangerous at best.

Research has documented the positive impact of ADHD treatment on life expectancy. A Swedish study, published in JAMA Network Open, followed nearly 150,000 adults and adolescents for two years after they received their ADHD diagnoses. The researchers shared the following insights about the use of stimulant medication — amphetamine or methylphenidate — which is effective for roughly 70% of patients with ADHD:

• ADHD medication use reduced overall risk of death by 19%. Among people with ADHD who did not receive medication, there were 48 deaths for every 10,000 people, contrasted with 39 deaths per 10,000 people within the medicated cohort.
• ADHD medication use reduced the risk of overdose by 50%. Medication use also reduced the risk of death from other unnatural causes, including accidental injuries, accidental poisoning such as drug overdoses, and suicide.
• ADHD medication use reduced the risk of death from natural causes, such as medical conditions, for women.

People with childhood ADHD are nearly twice as likely to develop a substance use disorder as are individuals without childhood ADHD. However, research suggests that patients with ADHD treated with stimulant medications experience a 60% reduction in substance use disorders compared to those who are not treated with stimulant medication. Considerable evidence also suggests that children taking ADHD medication experience improvements in academic and social functioning, which translates to improved self-esteem, lower rates of self-medication with drugs or alcohol, and decreased risk of substance abuse.

What’s more, researchers at the University of Michigan and Massachussets General Hospital studied 40,000 high school seniors, more than 4,000 of whom had ADHD. The research team compared the risk for marijuana abuse — the most common drug misused by this age group—among teens with ADHD to the overall population. They found that the students with the lowest incidence of substance abuse started ADHD treatment with stimulants before 9 years of age. When treatment began between ages 10 and 14, it was helpful, but the students still had a significantly higher likelihood of smoking marijuana. The highest risk of marijuana use was found among students with ADHD who started medication after age 15.

The late Joseph Biederman, M.D., the former Chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital, along with researchers at the hospital and at Massachusetts Institute of Technology, conducted a study in which teens with ADHD were separated into two groups, then tasked with driving through a virtual roadway featuring surprise events, including oncoming traffic. The teens in the first group received stimulant medication (lisdexamfetamine: brand name Vyvanse) while the teens in the second group did not. Compared with the group of non-medicated ADHD teens, the medicated group was 67% less likely to have a collision during these events.

“For families that stop ADHD treatment on weekends and during ‘downtime,’ I emphasize the importance of driving only while medication is active,” Dr. Biederman had said. “A short-acting medication taken about half an hour before hitting the road may just be lifesaving.”

Why Ignore Patients’ Real-World Experiences?

Indeed, ADHD treatment with medication is lifesaving for many children, adolescents, and adults with ADHD for many reasons beyond the decreased risks for car accidents, illegal drug use, unprotected sex, and the other dangers outlined above.

ADDitude readers write to us daily about the social, emotional, professional, and psychological benefits they experience while using prescription stimulant medication to treat their ADHD symptoms. By excluding these patient perspectives, Tough’s reporting could place lives at risk by telling a story that may scare caregivers and adult patients away from the ADHD treatments that are shown to safely, effectively improve and protect lives.

On that note, let us leave you with a few quotes from ADDitude readers explaining, in their own words, the benefits of stimulant medication and the threats they feel in 2025.

“Adderall is literally the difference between crippling depression due to executive function disorder and not. If my access to my much-needed medication goes away, the impact will be exponential.”

“If they mess with my stimulants or access to stimulants, I could lose my job and even my marriage. I rely on it to maintain focus as a design engineer. It also helps communication with my wife when I have my stimulants.”

“ADHD medication has huge benefits. It’s frustrating that the discourse is being steered from the top by someone so willfully ignorant, bringing out everyone who has totally misinformed ‘reckons’ about ADHD.”

Rebuttal from Russell Barkley, Ph.D.

More NYTimes Rebuttals

• 4-Part Video Response from Russell Barkley, Ph.D.
• The Child Mind Institute
• The ADHD Evidence Project

ADHD Article Corrections: Next Steps

• Free Download: The Ultimate Guide to ADHD Medication
• Reader Reactions: MAHA Commission Means Fear, Stigma, Health Threats for Two-Thirds of ADDitude Readers
• Read: Is ADHD Real? Yes — and Still Heavily Stigmatized

Corrections

This article was updated on April 25, 2025, to reflect the following:

• Wes Crenshaw, Ph.D., reported to ADDitude that he invited the author to interview several ADHD patients, not himself, and that invitation was not accepted
• The CDC’s 2022 estimate for the prevalence of ADHD in American children aged 3-17 years, which is 11.4 percent, not 5 to 7 percent
• Author Paul Tough did not directly describe the ADHD diagnosis process as “arbitrary,” but rather his quoted source, Edmund Sonuga-Barke, did. This quotation was removed.
• The full quote from Tough’s text was included: “If these studies are accurate, stimulant medications don’t do much to improve cognitive ability or academic performance. And yet millions of young Americans (and their parents) feel that the pills are essential to their success in school. Why?”
• This phrase was removed, “…and then questioned why American parents and students would accept the ‘risks inherent in taking prescription stimulants.'” The original article stated: “Researchers acknowledge that there are other risks inherent in taking prescription stimulants.”

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Should your student continue to receive ADHD care from a longtime clinician or join a new practice closer to campus? Here are some factors to help you decide.

Continuity of Care vs. New Support

One benefit of your teen continuing care with their existing clinician: Because of their personal knowledge of and history with your teen, that clinician can quickly recognize and respond to worsening symptoms. Familiarity can also have a downside, however. Some young adults have told me their clinicians feel comfortable regularly re-prescribing medications over text without an evaluation, which can lead to inaccurate clinical decisions.

[Get This Free Download: How to Get ADHD Accommodations in College]

If your student wants to continue care with the clinician they had in high school, ask the clinician for their perspective. If your teen is attending college out of state, ask whether the clinician is licensed in that state. You should also keep in mind that it might be less convenient for your student to regularly attend appointments in another state. Fewer face-to-face appointments can mean that worsening ADHD symptoms go undetected and untreated. Have this conversation several months before the transition so your teen has time to find a new care team, if needed.

Finding a New Clinician

Roughly one in four students with ADHD is receiving a prescription for stimulants from a psychiatrist in the local community around their college, even though finding a psychiatrist who is affordable and taking new patients can be difficult. Some students have the financial means to pay cash and take their pick of available psychiatrists. Most do not.

To identify medical professionals in the community around your student’s new school who accept your insurance, consult your student’s insurance website. Call early. Insurance network lists can be outdated with clinicians who are no longer taking new patients.

If identifying a psychiatrist proves difficult, find a primary care clinician who is willing to prescribe ADHD medications. This might be less desirable if your teen has multiple psychiatric conditions or needs frequent or more complicated medication adjustments, however.

[Read: 13 Survival Tips from College Graduates with ADHD]

Some students use campus mental health services. Our research has shown that almost all U.S. colleges and universities offer mental health services, but few provide clinical services for ADHD. Check the institution’s website or call its health clinic to determine whether ADHD services are offered. The advantages of these clinics: They are on campus and are usually cheap or free. Your student may need to provide documents to verify their diagnosis and transition their care.

College can be a rewarding time for students with ADHD. Choosing who will manage your teen’s professional mental health care during these formative years requires planning, conversations, and careful thought about what will maximize their chance of appropriate care.

ADHD Therapist and Medication Changes: Next Steps

• Free Download: Who Can Treat ADHD?
• Read: ADHD and College: Survival Guide for Teens on Their Own
• Read: The College Survival Guide for Students with ADHD

James Aluri, M.D., is an associate professor of psychiatry at the Johns Hopkins University School of Medicine.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

That study, published in the Journal of the American Medical Association, did not show a causal relationship. Patients in that study may have had conditions like diabetes or obesity, in addition to ADHD, that raised their risk of cardiovascular disease.

This is what I say to parents of my patients: ADHD causes all kinds of problems if it’s untreated. School failure, substance use, and, as an adult, poor job performance or getting fired, breakups in marriages — these are known risks when ADHD is not well managed.

In older populations, the risk for cardiovascular disease generally increases, but even then, I say to patients, “How are your diet, exercise, sleep, and other health habits?” These are the predictors of cardiovascular disease as best as we know. The study didn’t look at these factors.

Q: Does research show that nutrition plays a role in ADHD symptoms or symptom management?

We have every reason to think that healthy diets may lead to general benefits in mood and behavior. Large population-based studies suggest that food additives may have a relatively small negative effect on behavior. However, many parents report that children have hyperactive responses to sugar.

[Free Guide to ADHD Brain Food: What to Eat, What to Avoid]

New research is beginning to teach us more about the importance of a healthy diet and healthy gut biome. We know that too much processed food leads to the generation of unhealthy bacteria in the gut, which can create chemicals that pass through the blood-brain barrier and lead to problems, such as depression, anxiety, and possibly even ADHD. So, a healthy diet (along with adequate sleep and regular exercise) is likely to benefit people with ADHD.

Q: Does screen addiction over a period of several years affect a young adult’s brain development?

Very good studies have shown that screen time can lead to brain changes. A number of neuroimaging studies have proven this even in randomized controlled trials. Specifically, violent video games, such as first-person shooter games, have been found to lead to decreased empathy and social connections, increased negative and hostile thoughts, and possibly harmful actions.

ADHD Symptom Management: Next Steps

• Download: Lifestyle Changes for Adults with ADHD
• Read: 5 Smart Screen Rules for Teens with ADHD
• Read: Your ADHD Treatment Options — Medication, Diet, Therapy & More
• Find: ADHD Specialists and Clinics Near You

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Earlier this month, the Justice Department charged two top officers at the telehealth company Done Global with allegedly distributing Adderall and other stimulants for ADHD to patients who officials said did not merit a proper diagnosis. While health officials warned that the “disruption” to Done could affect as many as 50,000 adult patients¹, many of whom were already impacted by the ongoing ADHD medication shortage, this criminal action highlights another important issue: the limited access to clinical care for people with ADHD in the United States.

“When a company such as Done is held legally responsible and their policies are investigated, patients under clinicians’ care may lose their prescriber, leaving them abandoned without medical care,” says David Goodman, M.D., an assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine.

“The immediate need for medication is not easily resolved because changing providers typically involves a delay. Without effective medication, patients’ daily performance is compromised and may lead to conflicts at home or reduced work productivity,” Goodman says. “The negative consequences mount the longer they are off their medication.”

Rise and Fall of ADHD Telehealth

Done and other ADHD telehealth services surged in popularity during the COVID pandemic as Americans in lockdown were unable to schedule in-person doctor visits. At the same time, the Drug Enforcement Administration (DEA) loosened telemedicine rules regulating the prescription and distribution of controlled substances, including stimulants to treat ADHD.

“Done came out of real patient pain points, including access and wait times” for clinical care, says Jacob Behrens, M.D., CEO of Envision ADHD Clinic. “They expanded as they did for a number of reasons, including how poorly our health care system met the needs of this particular population. This issue is and has been real since well before the pandemic.”

Of the 30,000 to 50,000 patients who used Done and may be seeking new providers, Behrens said: “I can’t begin to imagine how the existing health care system will absorb this population. I’m just hoping that we can use this as an educational opportunity for a deeper dive/postmortem analysis of in what ways did this improve patient care and where did it go wrong?”

Maggie Sibley, Ph.D., a psychologist, researcher, and author, suggested that the Done investigation into fraudulent stimulant prescription practices might actually help alleviate the stimulant shortage for patients with ADHD.

“If many Done clients were filling Adderall prescriptions for non-medical reasons, then presumably they were taking medications that should have gone to people with ADHD,” she says. “Eliminating the non-legitimate use of stimulants might hopefully help with the demand side of the stimulant shortage. People will be able to get their medications more easily because they are reserved for people who truly have ADHD.”

ADHD Treatment Alternatives

Greg Mattingly, M.D., an associate clinical professor at Washington University School of Medicine, says he is hopeful that improved ADHD awareness and education, overall, will mean that patients ask their providers about new medications like Xelstrym, Jornay PM, and Azstarys, which are not experiencing the shortfalls that have dogged Adderall and Vyvanse. Patients who understand the full spectrum of ADHD treatment options may be more likely to access care during the ongoing stimulant shortage.

“The rising number of prescriptions during the past several years² has caught the DEA’s attention,” says Ann Childress, past president of the American Professional Society of ADHD and Related Disorders (APSARD). The DEA sets quotas for the production of controlled substances in the United States and is widely criticized for failing to allow enough production of stimulant medication to keep pace with new diagnoses.

“We are still dealing with a stimulant shortage, and I am still having to switch patients’ medications because their regular medication is not available,” Childress says. “Most clinicians that I speak with are having the same difficulties. Several medications that are not controlled substances are approved for the treatment of ADHD by the FDA. Patients may want to discuss these medications with their providers.”

Goodman advised that some hospital pharmacies may fill prescriptions for hard-to-find stimulant medications if those stimulants are ordered by an affiliated provider. He suggested that patients inquire with their providers about this option, as hospital pharmacies may experience less patient demand than neighborhood or chain pharmacies like CVS or Walgreens.

“Hospitals that have public community pharmacies can typically fill the same prescriptions that any other community pharmacy can fill,” says Aretha L. Hankinson, J.D., director of media relations for the American Society of Health-System Pharmacists. “They generally also experience the same allocations and shortages as other community pharmacies.”

Sources

¹ CDC. Disrupted Access to Prescription Stimulant Medications Could Increase Risk of Injury and Overdose. June 13, 2024. https://emergency.cdc.gov/han/2024/han00510.asp

² Danielson ML, Bohm MK, Newsome K, et al. Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults — United States, 2016–2021. MMWR Morb Mortal Wkly Rep 2023;72:327–332. DOI: http://dx.doi.org/10.15585/mmwr.mm7213a1

The ADHD medication shortage just got worse.

That’s according to the Centers for Disease Control and Prevention (CDC), which warned of likely ADHD treatment disruptions for thousands of Americans after two executives from Done, the telehealth provider, were arrested last week for alleged health care fraud. The CDC estimates that up to 50,000 patients who rely on Done or similar subscription-based telehealth platforms for ADHD medication may be impacted, plunging into crisis a system already massively strained by a two-year drug shortage.

The Department of Justice accuses Done of conspiring to illegally distribute Adderall and other stimulants for financial gain. It claims that Done pressured employees to prescribe the drugs to users even if they did not meet diagnostic criteria for ADHD and discouraged prescribers from following up with users after initial consultations, among other practices that allegedly allowed for “easy access” to stimulants.

In a statement, Done rejected the DOJ’s accusations and claimed it would continue to operate and work to ensure that its patients do not lose access to mental health care. “During these current proceedings, Done continues normal operations and is doing everything we can to ensure stable care for our patients,” reads part of the statement.

The CDC’s advisory warned of the far-reaching risks of untreated ADHD — risks that ADDitude readers know too well, especially amid ongoing shortages. From frustration over inadequate supplies of much-needed treatment (and hopelessness over government agencies’ failure to enact meaningful relief) to hopes that better regulation of ADHD medication and care may be forthcoming, reader reactions* to the telehealth indictment and its compounding effects on the ADHD medication shortage are varied.

“This is absolutely going to make our lives even harder. I have an AuDHD child. I have to ration her medication, which means I have to decide which days she’ll spend in a heap of despair and anguish, and which days she can participate in her childhood. Today she cannot participate in her childhood because next week is swim lessons and camp. We will run out of medicine if we don’t skip today.” —@laurapeles

[Read: How to Weather the Persistent Adderall Shortage]

“This is super frustrating. They make us jump through hoops every other day to get our meds when we literally have a hoop-jumping disability. But Done is a scam. I hope this facilitates the creation of better telehealth ADHD treatment in the future.” —@danimarie1029

“The DEA failed to act during the opioid crisis, so they’re manufacturing a stimulant crisis so they can get a win. They’ve been systematically fining and shutting down pharma companies who manufacture stimulants and literally creating this shortage. People with ADHD are not criminals but we are being treated that way because the DEA has lost the War on Drugs and sees us as an easy victim to use to make themselves look like the heroes. It’s gross and sad and, so far as I can tell, they will not be held to account. Meanwhile our lives and our kids’ lives are in shambles because it’s nearly impossible to get the medications we need to keep up with the rest of society. The inequity is staggering.” —@wordsmith610

“I know it’s frustrating, but stimulant medication needs to be better regulated for those of us that need it. It will help break the stigma surrounding ADHD medication. I have to see my doctor once a month to get my meds and med management check-ins. Everyone should have to do the same, at least at first.” —@homiekates

“We deal with [refilling medication] twice per month in our family. As someone who needs [ADHD medication] myself to get my frontal lobe to function more efficiently, this could not be a more arduous task. I’m always the first to roll my eyes when people in comments jump to conspiracies on an issue, but I don’t buy the ‘dishonest practitioner’ scapegoat.” —@thatmarvelmom

[Read: “Stop Treating Us Like We’re Addicts!”]

“I am not surprised, but I am thrilled this company is facing up to its shady practices. I used them (but do qualify) and the entire experience was an absolute mess. I canceled immediately because it was so horrid. I am not happy about what this might mean for refills for my son (or myself) and having to physically see a doctor every three to six months now.” —@laramccask

“This is infuriating. It only makes things harder for those of us with actual diagnosed ADHD to get the meds we need that save our lives.” —@bluestategirl

“It worries me a lot as my husband and I both depend on telehealth for our meds. We each see our psychiatrist monthly on Zoom for a good 30 to 45 minutes to discuss how we are doing and reacting to the meds we are on. My doctor is two hours away from me and my executive functioning difficulties would mean I’d never manage to go in anything close to monthly.” —@jennifernishizaki

“Those of us with REAL ADHD are suffering due to a large group of people with no real diagnosis who are getting scripts for fun from a random doctor who has not performed adequate testing.” —@okram82

“This makes me so worried! There are already so many hoops for those of us with an actual diagnosis. It’s infuriating that people like this and neurotypicals make it even harder for us to get medication to function. It’s even more frustrating because medication helps but certainly doesn’t ‘cure’ us like people think. I have a baby and need to function for him and us.” —@jacquelinedufour872

“It’s crazy to me that this is allowed to happen. ADHD is a disability and medication is a disability aid, no different than someone needing glasses to see or a cane to walk. The world constantly shits on the disabled.” —@alexandrahahnfeld

“I haven’t been able to have my medication since January. I have no executive functioning and when I finally do make myself do something I get extremely overwhelmed bouncing from thing to thing. People who don’t need these medications to actually function (e.g., cook, clean, bathe, work a job to survive) should not be taking them from those of us who do.” —@wnpersson

Done ADHD Medication Shortage: Next Steps

• Join the Conversation on Instagram
• Investigation: The Tattered Promise of ADHD Telehealth
• On the ADHD Drug Shortage: “This Cannot Be the Price We Pay to Function.”
• Opinion: “The DEA’s Manufactured Crisis”
• Call to Action! Speak Up to End the ADHD Drug Shortage
• Resource Center: Adderall Shortage

*comments edited for brevity and clarity

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

In other words, it’s critical for college students and others who recently moved out on their own to develop reliable medication management routines without parental scaffolding — and to advocate for their own health care needs at the doctor’s office.

[Free Resource: 2024 Scorecard of ADHD Treatments]

Here is the advice I give to my young adult patients:

• Incorporate medication administration into your daily routine. Use alarms or reminders on your phone, or associate medication with specific daily activities (e.g., breakfast or brushing teeth). Use a pill organizer to keep track of doses.
• Understand the expected effects and potential side effects of ADHD medication, and the likelihood that ADHD symptoms will return if doses are skipped. Also know that ADHD medication reduces the risk of substance use and improves productivity at work and in school.
• With your provider, brainstorm ways to adjust your routine to better support medication maintenance. Discuss different medication options, such as long-acting versus short-acting formulations.
• Regularly monitor medication effectiveness and side effects. Keep track of changes in symptoms or adverse reactions. Talk to your doctor about these and any other challenges with your medication regimen, concerns about mixing your ADHD medication with other medications or substances, difficulties adhering to the prescribed schedule, or struggles with getting timely refills from your pharmacy.
• If you experience significant side effects, worsening symptoms, or recognize a change or deterioration in your work performance, relationships, sleep, exercise routines, task management, or overall executive functioning skills, it’s important to tell your health care provider.

ADHD Medication Management: Next Steps

• Download: Get Control of Your Life and Schedule
• Q&A: ADHD Medication — Side Effects, Dosages, Precautions & More
• Read: How to Treat a Teen Self-Medicating ADHD

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Health Insurance Plans: High-Deductible vs. Low-Deductible

Employer-sponsored health plans generally include high-deductible plans and low-deductible plans. With the former, you pay less in premiums but more out-of-pocket for medical care and prescriptions before your insurance kicks in to cover eligible costs.

In traditional low-deductible plans, you pay higher premiums, but the carrier covers a copay or coinsurance on your office visits and certain prescriptions. Your deductible is tapped only for services like surgery, emergency room visits, MRIs, and so on. Under these plans, you typically copay for medication and therapy sessions.

[Free Download: What to Ask Before Starting ADHD Medication]

Drawbacks of High-Deductible Plans for ADHD Patients

The higher your deductible, the lower your premiums. For people with ADHD, this is usually not the best option. (However, if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA), a high-deductible plan may be worthwhile because it will let you set aside pre-tax dollars for certain health care costs. More on that below.) Generally, high-deductible plans are not advised for these reasons:

• You’re unlikely to put the money saved from lower premiums toward your health care. Also, many folks with ADHD are reluctant to seek routine health care. If they must pay out-of-pocket to see a provider, their motivation won’t improve.
• You may avoid preventive care and end up spending more in the long run. A copay-based system generally helps you to spend less on medical care and keeps you healthier.

HSA vs. FSA

Many employer-based insurance plans offer these options. HSAs are attached to high-deductible plans. If you contribute more than you spend on health care costs in a year, you can roll those funds over year after year and build a sizable nest egg.

FSAs, on the other hand, do not typically roll over to the next year; you must spend the funds during the policy year or lose them. But if you have a sudden expense early in the year, you can typically pay for it with an FSA because these accounts are usually fully funded at the beginning of the policy year (then paid back over the next 12 months through an employee’s pre-tax payroll deduction). By contrast, the HSA can pay only what has been saved.

[Free Resource: Treatment Strategies You Haven’t Tried]

Prescription Discount Programs and Medication Discount Cards

Before you start any brand name medication for ADHD (or anything else), go to the manufacturer’s website and see if they offer a discount program (find a list at additu.de/medsavings). This is not the same as an after-market coupon, like GoodRx. Those can be helpful too, but typically only for generics.

How Does Health Insurance Work: Next Steps

• Free Webinar: How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle
• <Read: Doing Battle with Your Insurance Company
• Read: Can Insurance Companies Discriminate Because of ADHD?
• Find: ADDitude Directory — Affordable Care Near You

Wes Crenshaw, Ph.D., is a licensed psychologist in Kansas and co-author of ADD and Zombies: Fearless Medication Management for ADD and ADHD.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

The ongoing shortages of generic ADHD medications and chemotherapy drugs are addressed in new draft legislative proposal released on May 3 by Senate Finance Committee Ranking Member Mike Crapo (R-Idaho) and Chair Ron Wyden (D-Oregon), who said the proposed legislation would “tear down regulatory barriers that are preventing families from accessing critical drugs like those needed to combat ADHD.”

The draft legislation was announced on the same day the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP), and Children’s Hospital Association (CHA) sent a letter to the U.S. Department of Health and Human Services and Drug Enforcement Administration expressing their continued concern about the ongoing stimulant medication shortages.

“Families that rely on generic stimulant medications have been disproportionately affected by the ongoing stimulant shortages,” the letter said. “This situation only exacerbates existing health disparities among economically disadvantaged families who are enrolled in Medicaid and CHIP.”

The proposed legislation establishes a Medicare Drug Shortage Prevention and Mitigation Program, wherein hospitals, healthcare providers, group purchasing organizations, drug manufacturers, and others could earn payment incentives for improving their purchasing and contracting practices across the supply chain for generic drugs, including generic versions of ADHD medications such as Adderall and Vyvanse. The proposed legislation would also limit inflationary rebates under the Medicaid Drug Rebate Program (MDRP) for certain generic drugs susceptible to shortages.

“It is unacceptable that America is consistently running out of affordable and essential generic medicines,” Wyden said in a press release. “Once again, monopolistic middlemen have put market power and profit over families’ healthcare.”

Associations Urge Government to Address ADHD Medication Shortage

In their letter on ADHD medication shortages, the AAP, AACAP, and CHA call on the federal government to “convene all relevant stakeholders for a forum to discuss the impact these shortages are having on patients, families, and their providers and identify actionable solutions that will alleviate these shortages.”

“Pediatric providers, including child and adolescent psychiatrists, pediatricians, and children’s hospitals, along with the patients and families they serve, face an insurmountable struggle with stimulant medication shortages,” the letter said. “Untreated ADHD can contribute to worsening mental and behavioral health disorders, including mood and substance-use disorders, unintended injuries resulting from ADHD-related impulsivity and long-term impacts on relationships-building, educational achievement, and professional success. Parents and families may also be negatively impacted by the disruption that untreated ADHD can cause in the home, school, and work environments.”

According to the American Society of Health-System Pharmacists (ASHP), 323 medicines are currently in short supply, the highest number of ongoing and active drug shortages since the organization began tracking data in 2021.

ASHP reported that “new DEA quota changes, along with allocation practices established after opioid legal settlements, are exacerbating shortages of controlled substances (12% of all active shortages).” The Drug Enforcement Agency (DEA) classifies stimulant ADHD medications, such as Adderall and Vyvanse, as “Schedule I,” which indicates drugs with a high potential for abuse.

FTC, HHS Seeks Public Input on ADHD Medication Shortage

The Federal Trade Commission (FTC) and U.S. Department of Health and Human Services (HHS) are seeking public input to understand how the practices of pharmaceutical middlemen contribute to drug shortages and impact patients, hospitals, healthcare providers (including small healthcare providers and rural hospitals), pharmacies, generic manufacturers, and other suppliers.

Sixty-three percent of the more than 6,200 public comments already submitted mention ADHD.

The deadline to submit public comments is May 30, 2024. Add your testimony at Regulations.gov.

The public can also demand an end to the ADHD medication shortage by writing letters to representatives, the DEA, and the FDA using templates provided by ADDitude.

When administered at carefully selected dosages in clinical settings, and combined with therapy before and after treatment, psychedelics have been found to provide rapid relief from some of the most painful and difficult-to-treat mental health conditions. Ketamine is being used for depression and suicidality in clinical trials. MDMA is treating severe post-traumatic stress disorder (PTSD), and psilocybin is being used for treatment-resistant depression, alcohol use disorder, and more.

However, important questions remain about the long-term efficacy and safety of psychedelics, as well as patient suitability. Several large-scale studies are now under way to address these concerns, including the first-ever phase 3 clinical trial on psilocybin-assisted therapy — the largest randomized, controlled, double-blind study on the drug, with more than 800 participants. Initial results are expected this summer.

How Do Psychedelics Work?

Research shows that psychedelics improve many neuropsychiatric disorders, but the way they work is less clear. Functional MRIs and laboratory studies offer possible explanations:

• Ketamine binds to NMDA receptors in the brain, increasing levels of a mood-regulating neurotransmitter called glutamate.¹
• MDMA increases oxytocin, dopamine, and other chemical messengers related to positive emotions.²
• Psilocybin stimulates the brain’s serotonin 2A receptors, appearing to decrease activity across the default mode network.³

But these biochemical explanations don’t tell the full story, says Gül Dölen, M.D., Ph.D., professor of psychology and researcher at University of California Berkeley’s Center for the Science of Psychedelics. Psychedelics only reliably improve psychiatric conditions when administered with therapy. “Therapy is the context to get the cure,” Dölen explains. “You can’t take MDMA and go to a rave and expect it to cure your PTSD.”

Indeed, when taken on their own, psychedelics aren’t hugely effective, according to studies; therapy unlocks the drugs’ enduring benefits. Also, there are serious risks to taking the drugs without medical supervision.

[Read: The Truth About Lion’s Mane, Psychedelics & Caffeine]

A Brand-New Framework

Most psychiatric medications must be taken daily, often for a lifetime. By contrast, a single dose of certain psychedelics paired with therapy can result in full-blown remission. This claim appears too good to be true when viewed through the traditional “biochemical imbalance” model of neuropsychological disease that has dominated the field for the past 50 years. “The idea is that depression, for example, is a biochemical imbalance in serotonin,” Dölen says. “So, we’ll restore serotonin levels with a pill, and you’ll get better.”

But what if there were an approach that treated depression by restoring the fundamental ability to learn (and unlearn) behaviors and ways of thinking, and not by raising serotonin levels? It’s an entirely different framework for understanding neuropsychiatric disorders — the learning model — and Dölen says it’s the best way to comprehend how psychedelics work.

Psychedelics act like master keys unlocking what scientists call “critical periods” of learning—specific times when individuals have a heightened ability to soak in new information. During brain development, these are the critical windows in which we acquire vision, language, motor development, and more. And after these critical windows close, they remain locked.

Or so we thought.

Psychedelics Restore Child-Like Learning

In a study that involved giving mice MDMA, Dölen found that the drug unlocks a critical period for social reward learning, restoring adult mice to child-like levels of openness for social development.⁴ Dölen’s next study uncovered the potential of all psychedelics—including LSD, psilocybin, ketamine, and ibogaine—to open these critical periods.⁵

[Watch: “Psychedelic Therapy for Mood Disorders: Research & Potential”]

“This is a big deal,” says Dölen. “And if it’s true, it’s going to revolutionize things, but only if we understand what a critical period is. It’s not that you take a pill and you speak Japanese. It’s that you take a pill and you restore the ability to learn Japanese.”

The drugs open the mind to learning. The therapy provides the learning itself.

“Patients talk about how they had an epiphany, how the trip enabled them to see how they’d built their lives around a foundational myth that wasn’t true, whether about their relationship to other people, their personality, their deserving to be in the world,” Dölen says. The post-trip therapy, in turn, allowed them to identify how that myth led to maladaptive ways of interacting with the world, and understand how to integrate that knowledge into their daily lives.

The potential of psychedelics to re-open critical periods has far-reaching implications. Dölen’s lab is exploring the possibilities of treating conditions like stroke and blindness with psychedelics through a project called PHATHOM (Psychedelic Healing: Adjunct Therapy Harnessing Opened Malleability).

“Psychedelics are not going to be the magic bullet that fixes everything, but we’re excited about the possibilities,” Dölen says. “Being able to restore child-like learning is a major therapeutic opportunity.”

Psychedelics Therapy and Mental Health: Next Steps

• Self-Test: Symptoms of Depression in Adults
• Free Download: Signs of Depression That May Surprise You
• Read: Real Stories of Using Ketamine for Depression, Anxiety, PTSD

Nicole C. Kear is Consumer Health Editor at ADDitude.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Matveychuk D, Thomas RK, Swainson J, Khullar A, MacKay MA, Baker GB, Dursun SM. Ketamine as an antidepressant: overview of its mechanisms of action and potential predictive biomarkers. Ther Adv Psychopharmacol. 2020 May 11;10:2045125320916657. doi: 10.1177/2045125320916657. PMID: 32440333; PMCID: PMC7225830.

² Mitchell, J.M., Bogenschutz, M., Lilienstein, A. et al. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nat Med 27, 1025–1033 (2021). https://doi.org/10.1038/s41591-021-01336-

³ Smausz R, Neill J, Gigg J. Neural mechanisms underlying psilocybin’s therapeutic potential – the need for preclinical in vivo electrophysiology. J Psychopharmacol. 2022 Jul;36(7):781-793. doi: 10.1177/02698811221092508. Epub 2022 May 30. PMID: 35638159; PMCID: PMC9247433.

⁴ Nardou, R., Lewis, E.M., Rothhaas, R. et al. Oxytocin-dependent reopening of a social reward learning critical period with MDMA. Nature 569, 116–120 (2019). https://doi.org/10.1038/s41586-019-1075-9

⁵ Nardou, R., Sawyer, E., Song, Y.J. et al. Psychedelics reopen the social reward learning critical period. Nature 618, 790–798 (2023). https://doi.org/10.1038/s41586-023-06204-3

Despite highly esteemed and plentiful literature on the use of stimulant and nonstimulant medication to treat ADHD, relatively little information is available on the treatment of complex ADHD — that is, attention deficit disorder plus at least one comorbid condition like anxiety, depression, or an eating disorder. Few studies address the treatment of comorbid conditions, the order of treatment, or the treatment of cognitive deficits and/or hard-to-treat ADHD symptoms.

This presentation will integrate data from controlled and open trials to highlight strategies for illustrative cases of complex ADHD. Participants will learn:

• About new medications approved for ADHD and their use for complex and hard-to-treat ADHD
• About strategies to manage ADHD comorbidities
• About approaches for treating cognitive executive function deficits in ADHD

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the  symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Audacy; Spotify; Amazon Music; iHeartRADIO; YouTube 

Treating Complex ADHD: More Resources

• Download: 2024 Scorecard of ADHD Treatments
• Sign Up: The Clinicians’ Guide to Treating Complex ADHD
• Read: Treatment Troubleshooting Guide for Patients
• Replay: Substance Use Disorder and ADHD: Safe, Effective Treatment Options with Dr. Timothy Wilens

Obtain a Certificate of Attendance

If you attended the live webinar on June 4, 2024, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker

Timothy E. Wilens, M.D., is the Chief of Child and Adolescent Psychiatry, and (Co) Director of the Center for Addiction Medicine at the Massachusetts General Hospital. He is a Professor of Psychiatry at Harvard Medical School. Dr. Wilens specializes in the diagnosis and treatment of ADHD, substance use disorders, and bipolar disorder. Widely published, Dr. Wilens has more than 350 original articles, reviews, chapters, books and editorials to his credit. Dr. Wilens is a consultant to the National Football League, Major/Minor League Baseball, Bay Cove Human Services and Phoenix/Gavin House and is consistently named one of the Best Doctors in Boston and in America for psychiatry.

Listener Testimonials

“This was one of the best one-hour presentations I’ve ever heard. I love how experienced the doctor is with actual on-the-ground pharmacology. Lots of clinical nuggets to digest!”

“Great explanation about ADHD medication and co-existing conditions. Thank you so much. Now I have a much better understanding of when my son goes to his appointment to change his current medication, which is having a lot of side effects and that he has had to stop taking.”

“Really appreciated hearing from a medication expert.”

Webinar Sponsor

The sponsor of this ADDitude webinar is…

Play Attention: Empower yourself by developing strong executive function and self-regulation. Cognitive control is your Superpower. We can help you develop it! Backed by research from Tufts University School of Medicine, Play Attention empowers individuals to improve attention, emotion regulation, and overall performance. Our NASA-inspired technology ensures tailored support for every aspect of life. Take our ADHD test or schedule a consultation to start your journey toward improved executive function and emotion regulation with Play Attention. Call 828-676-2240. www.playattention.com

ADDitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

Follow ADDitude’s full ADHD Experts Podcast in your podcasts app:
Apple Podcasts | Google Podcasts | Spotify | Google Play | Amazon Music | RadioPublic | Pocket Casts | iHeartRADIO | Audacy

But if you’ve tried some of these ADHD interventions with limited success and ended up feeling like you “failed” at treatment, rest assured that you did not -— and you’re not alone in feeling this way.

In ADDitude’s recent treatment survey, we asked 11,000 readers about their experiences with 10 different kinds of treatments for ADHD, from medication to meditation. Readers shared what worked and what didn’t, plus stories of how painful the process of finding effective treatment can be, especially for those with rejection sensitive dysphoria (RSD), perfectionism, or feelings of shame.

“I felt as though I flunked mindfulness because I couldn’t pay attention for that long!” said one ADDitude reader. Another shared: “I felt like I was failing in talk therapy when I couldn’t talk in straight lines or remember what I had just said.”

Robyn, an ADDitude reader in Canada, simply said, “I always feel like I’m failing.”

[Read: ADHD and the Epidemic of Shame]

Feelings of Failure, Easily Triggered and Intense

Many people are quick to blame themselves when supplemental therapies don’t work as rapidly or as well as they’d hoped. This instinct has everything to do with the wiring of the ADHD brain, explains Tamar Rosier, Ph.D., in the ADDitude article, “Silence Your Harshest Critic — Yourself.”

“Neurotypical people have prefrontal cortexes that act like a butler. ‘Sir,’ the butler calmly says, ‘your keys are on the table.’ Or ‘Madam, you must leave now if you want to be on time,’” Rosier explains. “Instead of a tranquil butler, individuals with ADHD have an angry neighbor threatening them with his shoe. ‘If you lose your keys again,’ he yells, ‘I’ll throw this at you!’”

Zak, an ADDitude reader in Florida has experienced this first-hand: “My doctor is still working with me to get the meds correct and I feel at times it’s my fault; that I am the one whose body is not adjusting.”

[Download: 2024 Scorecard of ADHD Treatments]

For many, these feelings of falling short or failing to meet expectations are amplified by RSD, which triggers intense emotional sensitivity and pain, explains William Dodson, M.D., LF-APA in “How ADHD Ignites Rejection Sensitive Dysphoria.” “For people with RSD, these universal life experiences are much more severe than for neurotypical individuals. They are unbearable, restricting, and highly impairing.”

This description resonates with ADDitude reader Calvin in Florida. “When I have tried things like mindfulness, exercise, or therapy, I have not had success and I just felt awful,” Calvin says. “I thought mindfulness might help to end the snow-piercer-like train that lives in my head, but instead I felt like a child unable to do a simple concept.”

In addition to the neuroscientific factors that play a role in triggering feelings of failure, a long history of negative experiences exerts a powerful force, says J. Russell Ramsay, Ph.D., ABPP, clinical psychologist.

“Adults with ADHD are often more susceptible to feelings of failure and defeatism when undertaking new endeavors,” Ramsay explains. “This is likely due to past experiences with setbacks, which often result in criticisms. This, in turn, makes adults with ADHD sensitive to the first signs that something seems to not be going well.”

Clinical psychologist Sharon Saline, Psy.D., agrees, adding: “These past struggles resemble a thousand paper cuts per day and accumulate over time into larger wounds which leave sensitive scars. Feelings of shame and not measuring up haunt folks and make it tougher to try new things.”

How to Reframe Feelings of Failure

Experts agree that to optimize treatment for ADHD, trial-and-error is essential. The “error” part of that process can be demoralizing, but it is critical. To discover interventions that work, you’ll have to try ones that don’t — and knowing that from the get-go can be helpful.

“It is important to normalize setbacks as a part of the process of establishing new habits. It is rarely, if ever, a straight line,” Ramsay says. “Reframing a new habit as a challenge or as an experiment is important, as is setting up realistic expectations.”

“I have a hard time planning and sticking to a good regular habit, like exercise and mindfulness meditation. I used to get so aggravated with myself, and feel helpless,” says an ADDitude reader. “My therapist has taught me to not make a big deal of it and simply get back on track.”

Fine-tuning the therapies, lifestyle changes, and medications that best address your particular constellation of symptoms — and dealing with the emotional fallout of that process — is hard work, make no mistake. You can make that hard work a little easier by being kind to yourself, says Saline.

“Treat yourself with compassion, understanding that change usually involves forward motion along with some backsliding,” Saline urges. “Stumbling, regrouping and trying again is part of living for everybody—ADHD or not.”

 Fear of Failure & Treatment: Next Steps

• Read: You Are Worthy of Self-Compassion – How to Break the Habit of Internalized Criticism
• Read: “My Fear of Failure Becomes Paralyzing Perfectionism”
• Free Resource: Understanding Rejection Sensitive Dysphoria

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

The number of clinics offering infusions of ketamine — the only psychedelic that is legal nationwide — has exploded. Research on the drug known as ecstasy, or MDMA (3,4-methyl-enedioxymethamphetamine), has shown such promise for treating severe PTSD that pharmaceutical companies are preparing to seek FDA approval.¹ Experts say psilocybin, the psychoactive ingredient in magic mushrooms that has shown efficacy for treatment-resistant depression,² may not be far behind.

Used under medical supervision and paired with pre- and post-drug therapy, these psychedelics have been life-changing in alleviating symptoms for many patients. Bob, an ADDitude reader in Arizona, took part in a clinical trial involving psilocybin for obsessive-compulsive disorder (OCD). “I have not had OCD symptoms since I finished the trial over a year ago,” he says.

Bob has also been receiving ketamine treatments for depression, anxiety, ADHD, and complex PTSD. He says the treatments have been more effective than cognitive behavioral therapy and prescription antidepressants, and without the “difficult side effects.”

While many patients like Bob report profound benefits from psychedelics, some psychiatrists and researchers fear that the pharmaceutical industry is moving too quickly toward legalization, while important questions about long-term efficacy and safety remain.

[Read: Real Stories of Using Ketamine for Depression, Anxiety, PTSD]

Psychedelic Therapy: A Blast from the Past

Psychedelics have an ancient history of medicinal use by the Aztecs and other civilizations. In Western culture, the groundbreaking potential of psychedelics to heal disorders of the mind took root around 1950, when the first English-language paper citing their therapeutic benefits was published. By 1960, Sandoz Pharmaceuticals had begun manufacturing psilocybin and LSD, substances later popularized, in part, by iconic Harvard psychologist Timothy Leary, Ph.D.

For years, he and other therapists embraced these experimental drugs for their potential to aid patients. At the same time, LSD played a major role in the counterculture movement of the 1960s. When then-President Richard Nixon outlawed all psychedelics in 1970, the drugs became associated with criminality. That effectively ended most research into psychedelics’ therapeutic value for 30 years.

In 2000, a new era of research began when scientists from Johns Hopkins University secured regulatory approval to study the effect of psychedelics on behavior, brain function, learning and memory, and mood. In 2020, Johns Hopkins opened a psychedelics research center. Since then, most of the country’s elite universities have followed suit. Researchers at Yale, Stanford, Universities of California Berkeley and San Francisco, and New York University have conducted clinical trials investigating the therapeutic benefits of psychedelics on mental health disorders.

[Read: LSD, MDMA, Magic Mushrooms Clinical Trial Guidelines Released by FDA]

“Monumental Results”

For patients diagnosed with depression and in acute distress, waiting six weeks for commonly prescribed antidepressants to begin working may not be feasible, says Gregory Barber, M.D., a psychiatrist in Bethesda, Maryland, and author of “Ethical and Practical Implications of Psychedelics in Psychiatry,” a scientific review that was published recently in the American Psychiatric Association’s Psychiatric Services journal.³ Ketamine, however, has been shown to improve mood sometimes after only one or two infusions.

“With psychedelics, there is some evidence to suggest that even single doses have medium- to long-term effects,” Barber says. “The ability to simplify treatment in this way would be a real paradigm shift.”

Karlyn, an ADDitude reader, knows this first-hand. Diagnosed with bipolar disorder and ADHD, she had been taking antidepressants for 16 years. “My psychiatrist recommended ketamine infusions in 2021 when I was acutely suicidal. It was the best drug that I have ever used for depression. By the fourth infusion, I felt relief,” she says.

Eight percent of Americans suffer from major depressive disorder (MDD). While a majority of individuals seek treatment, about 30 percent find no relief from antidepressants.⁴ This means that millions of Americans struggle with troubling symptoms like sadness, hopelessness, and suicidality.

Elizabeth Wolfson, Ph.D., a California psychotherapist who has been in practice for 30 years, says she has integrated ketamine into her therapy with “monumental” results. “It augments and deepens the work that people do in psychotherapy and accelerates the process in a way that I see as transformative,” she says.

Psychedelic Therapy: Investigating Risks

Psychedelics’ powers to heal have been heralded in countless headlines, so it’s no surprise that the drugs have recently enjoyed a surge in popularity. According to the National Survey on Drug Use and Health, 7.1 million Americans used hallucinogens in 2020. Proof of a changing public perception is apparent in Oregon and Colorado, where citizens have voted to legalize psilocybin.

The drugs, however, are not without risk. When psychedelic use takes place outside therapeutic settings, the symptoms people are trying to improve may actually worsen. The “therapy” part of psychedelic-assisted therapy is essential to positive outcomes.

In clinical trials and at carefully selected doses, ecstasy, ketamine, and psilocybin have produced generally mild side effects. When taken at higher doses, these drugs can cause disorientation, paranoia, and panic, which can lead to dangerous behavior, accidents, self-harm, and even suicidality. Other adverse effects include the potential for hallucinogen persisting perception disorder (a rare condition in which patients previously exposed to hallucinogenic drugs continue to experience distorted perceptions of the world around them months or years later), misuse, and abuse.

“The clinical trials have had very exciting results, but those results came in carefully controlled research settings with mental health professionals who have hundreds of hours of training,” Barber says. “It doesn’t mean that you will get similar benefits in other settings.”

Important Questions Remain

Experts agree that large-scale research on the long-term effects of psychedelics is needed. Many aspects of how the drugs work, their long-term outcomes, safety concerns, and patient suitability for treatment are still not known.

“I’ve seen psychedelics transform people positively very quickly, but I’ve also seen it be very challenging for people both in the moment and after the experience,” Barber says. “Psychedelics are not going to be for everyone nor solve every problem.”

Patient Suitability

People who have the following conditions or history are not considered good candidates for psychedelic-assisted therapy:

• a personal or family history of psychosis
• unstabilized bipolar disorder
• high blood pressure
• heart disease
• thyroid disease

Psychedelics Research Timeline

1943: LSD’s psychoactive effects are discovered by Swiss chemist Albert Hoffman.

1950: First English-language publication suggests LSD may aid psychotherapy.

1957: The term “psychedelic” is coined. Life magazine publishes “Seeking the Magic Mushroom.”

1960: Harvard psychologist Timothy Leary begins experiments with psilocybin.

1963: LSD is sold on the street in sugar cubes. Timothy Leary is fired by Harvard.

1965: Sandoz stops manufacturing LSD and psilocybin.

1997: Swiss scientists publish new research on the effects of psilocybin on humans.

2000: Johns Hopkins researchers secure regulatory approval to resume psychedelics research.

2017: FDA grants “breakthrough” status to MDMA and psilocybin, putting the drugs on a fast track for approval.

2023: Findings of Phase 3 clinical trials on MDMA for PTSD are published.

Psychedelic Therapy & Mental Health: Next Steps

• Self-Test: Symptoms of Depression in Adults
• Read: Treatments for Depression and ADHD-New and Forthcoming Approaches
• Read: The Relationship Between PTSD and ADHD

Nicole C. Kear is Consumer Health Editor at ADDitude.

Sources

¹Mitchell, J.M., Bogenschutz, M., Lilienstein, A. et al. MDMA-Assisted Therapy for Severe PTSD: A Randomized, Double-Blind, Placebo-Controlled Phase 3 Study. Nat Med. 2021(27),1025–1033.

²Goodwin, G., Aaronson, S., Alvarez, O. et al. Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression. N Engl J Med. 2022 Nov 3.; 387:1637-1648. DOI: 10.1056/NEJMoa2206443

³Barber GS, Dike CC. Ethical and Practical Considerations for the Use of Psychedelics in Psychiatry. Psychiatr Serv. 2023 Aug 1;74(8):838-846. doi: 10.1176/appi.ps.20220525. Epub 2023 Mar 29. PMID: 36987705.

⁴Zhdanava M, Pilon D, Ghelerter I, Chow W, Joshi K, Lefebvre P, Sheehan JJ. The Prevalence and National Burden of Treatment-Resistant Depression and Major Depressive Disorder in the United States. J Clin Psychiatry. 2021 Mar 16;82(2):20m13699. doi: 10.4088/JCP.20m13699. PMID: 33989464.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Small studies suggest that an individual with trauma may be predisposed to ADHD, just as anyone with a history of trauma is predisposed to depression, anxiety, and post-traumatic stress disorder (PTSD).

The task of a good diagnostician is to identify a patient’s current diagnoses and treat them, focusing particularly on the most pressing and problematic symptoms. If all of those appear to be symptoms of PTSD, we treat that with a different kind of therapy called trauma-focused cognitive behavioral therapy (TF-CBT). If we find that ADHD symptoms linger even after the trauma is addressed, then we add in ADHD treatment as well. The general rule is to treat the most pressing problem first, then determine whether there are other problems, such as ADHD, that also require treatment.

Q: What do you think about genetic or blood testing, and using those results to choose a prescribed medicine?

These blood tests look at the enzymes in the liver and some of the blood cells to learn how antidepressants, in particular, metabolize in an individual. Enzymes come in different variants, some of which may metabolize an antidepressant very quickly. Other variants of the same general enzymes metabolize medication very slowly.

[Read: What to Expect When You Start Depression Medication]

If someone metabolizes an antidepressant quickly, they’re going to need a higher dose. A slow metabolizer given a doctor’s standard dose will be more likely to have higher blood levels of the medication and more likely to experience side effects.

Q: Can taking certain medications during pregnancy cause ADHD in the child?

The medications people most commonly worry about during pregnancy are SSRIs taken for depression or anxiety. However, there is no evidence that taking SSRIs poses a risk. On the other hand, we do know that taking opioids or heavily abusing stimulants, such as methamphetamine or cocaine, can have a negative effect. Opioids, the top concern on my own list, have been linked to birth defects. Federal and state health agencies provide resources online about reducing the risk of birth defects through behavioral and environmental exposures.

[Read: Treating for Two – ADHD Meds in Pregnancy]

Q: What do researchers think will be different about ADHD treatment in, say, 10 years?

ADHD is a final common pathway of external symptoms. Like a bad cough, it can have many different causes. A cough might occur because of allergies, an infection such as pneumonia, or even cancer. We can find many causes using physical examinations, X-rays, blood tests, and so on.

We don’t yet have precise tools to do that for ADHD. But there is reasonable hope that advances in research will help us develop testing to identify an individual’s specific ADHD causes. And when we figure that out, we can begin to think about preventing and treating ADHD in a very person-specific way. But this is 10 to 20 years away.

PTSD Symptoms and ADHD: Next Steps

• Read: The Science of Fear – Probing the Brain Circuits That Link ADHD and PTSD
• Learn: A Playbook for Post-Traumatic Growth
• Read: Getting Meds Right – Is It in the Genes?
• Learn: The Future of ADHD Research Looks Like This