ADHD Medication in the Longer Term

Introduction

One condition that frequently lasts into adulthood is ADHD. Overactivity, impulsivity, and inattentiveness are the three distinguishing traits. Impaired social development can occur in people from the community who are not referred, as well as in people with severe behavioral issues who do not fit the diagnostic criteria. Although impulsivity has decreased in absolute terms, it still differs from peers in the same age group (Taylor et al., 1996).

Some kids can overcome obstacles in their growth or learn to live with them. Shaw et al. (2012) conducted a thorough investigation and discovered evidence of a wide range of adverse outcomes being more likely in people with ADHD than in people without the disorder across the lifespan. According to that review, those with ADHD who have received treatment are less likely to experience these side effects than people who have not. Although this is positive, doctors and researchers continue to face challenges in treating conditions that worsen even after obtaining the right care. This opinion piece aims to provide solutions for overcoming certain potential boundaries that may arise in long-term therapy. Table 1 lists a few potential restrictions, some of which might not apply to everyone, along with the potential fallout for clinical practice should they do.

Effect of Medication in the Long Term

A sufficiently broad and long-term follow-up of a 14-month randomised comparison of children with ADHD who had received different therapies was made possible, nevertheless, by the Multimodal Treatment Study of ADHD (MTA). Some individuals benefited from comprehensive behavioral management in addition to psychological assistance, while others were prescribed medication under strict guidelines. Once more, those in need only received the basic medical and mental health care that their community offered. Those who received the “carefully crafted” medicine showed unquestionably greater results over the course of the 14-month trial.

Moreover, the high degree of commitment to the entire therapeutic approach would not have persisted even for those who had stayed in the first assignment condition. Because of this, the follow-up was observational rather than experimental, but it nevertheless has the best data currently available for that kind of study.

What Might Be Responsible for Any Long-Term Limitation of Therapy?

Different hypotheses deserve to be examined independently since they have different long-term implications for clinical therapy.

Medication is Not Effective in Adult Life?

Most likely, this is not the reason. There is currently enough evidence from adult therapy studies to be certain that medication is still helpful and that cognitive-based therapies and the development of coping skills are promising. Cortese et al. (2018) provided a network meta-analysis comparing medicines, and the Canadian Agency for Drugs and Technologies in Health (2011) provided a systematic review. In fact, evidence points to a better response to medication-assisted ADHD treatment for those with chronic symptoms. For example, Lichtenstein et al. (2012) found that medication use was linked to less disruptive behavior than abstinence. This is a good indication of short- to medium-term adult effectiveness; it is not a good indicator of long-term efficacy. Short spurts of usage may precede some periods of abstinence; by definition, some uses will have only recently begun. Moreover, the reason for decline after abstinence can be rebound instead than persistent value.

Medication Does Not Address the Main Prognostic Factors?

The challenges that people with ADHD encounter go beyond the scope of the diagnosis. The basic features of impulsivity, hyperactivity, and inattention are not always the main characteristics of eventual disability. Numerous issues and comorbidities exist; stigma is pervasive; and unfavorable reactions from peers, school, and family are possible. Related characteristics, such as emotional dysregulation or violent behavior, may have an equal impact on unfavorable outcomes as the intensity of core symptoms (Taylor 2009).

Still, most trials use these traits as the endpoint, and most therapies center around the primary DSM5 traits. The long-term effects of medication on social and personal functioning as well as overall quality of life may be overstated or underestimated using this strategy.

Self-Selection Implies That Most People Receive the Therapy That Best Suits Them?

At the conclusion of the 14-month trial in the MTA, the original randomization of treatment assignment was abandoned. It’s possible that those who preferred medicine and those who believed that psychological counseling was helpful chose to continue getting it. It would therefore be expected that you would eventually acquire the therapy that best suits your needs and see results that are comparable if you were to receive good advice and manage to put it into practice. The therapeutic implication would be to provide continuing guidance, supervision, and experimentation with different approaches to intervention. Administrative restrictions cannot be used as a justification for denying young people access to a range of therapies or preventing them and those in charge of them from choosing and arranging the sequence in which those therapies are administered.

Continued Benefit of Interventions Might Require Very Careful Control of Therapies?

Following a 14-month trial in the MTA, the well planned behavioral and pharmaceutical interventions were no longer effective. If they had been properly implemented and regulated, they might have had some long-term benefits (Coghill & Set, 2015).

Although this would be prohibitively expensive, it would have clear therapeutic implications for the slow loss of efficacy. Furthermore, a key element of the careful monitoring of the MTA medication was the steady increase in dosage. Perhaps this is related to the fact that the treated group’s long-term findings showed a decreased rise in height and weight (Swanson et al., 2007, 2017).

The Effect of Medication Wears Off with Time?

Tolerance to psychostimulants is an anticipated feature based on their pharmacology. Clinical experience often dictates that a gradual increase in dosage is required to maintain efficacy. Neuroimaging of synaptic dopamine levels, as reported by Volkow et al. (2012), demonstrates that the increase resulting from single doses of a stimulant is substantially reduced after a year of medication compared to when the same patients were drug-naïve. High striatal dopamine transporter concentrations were formerly thought to be a diagnostic indicator for ADHD, but they have now been associated more with long-term treatment than with the condition itself (Fusar-Poli et al., 2012). This may be one of those systems that promotes tolerance.

Clinical Recommendations

We recommend using a customized approach because there is insufficient information available to determine the optimal length of medication. Patients often struggle to distinguish whether their “true self” with ADHD or what emerges when ADHD is under control, and the short-term effectiveness of the therapies creates existential problems. One of the effects is having to decide whether to take the medication every day or only when there are significant environmental demands for concentration and self-control. Most ADHD sufferers who simultaneously battle other types of disabilities and have to find a way to live with their disease while overcoming its limitations highly value a responsive consultation with a knowledgeable professional.

Cultural Attitudes

Public perceptions are influenced by the media, education, religious beliefs, political ideologies, and education. Attitudes toward therapies are sometimes influenced by perceptions of them as artificial or natural. I disagree with the notion that “psychological problems should not be treated physically” because I think problem-solving techniques shouldn’t always be centered on the underlying cause of the issue. What is really at play here is the question. Medicalization, in all its bad overtones, is not intrinsically wrong. 

What’s New?

Despite effective medication therapy, ADHD has a dismal long-term prognosis. A number of theories are put up to explain the apparent decline in medication efficacy. One possible explanation for the situation is the emergence of pharmacological tolerance.

Conclusion

It is important for scientists and medical professionals to acknowledge how medication efficacy declines with time and look for solutions.

This essay is based on a retirement speech given by Professor Dittman in Mannheim.

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