Clinicians

The Side Effect of Not Treating Adult ADHD is the Most Serious Side Effect of All by Jay D. Tarnow, M.D.

With many disorders, not just ADHD, patients and physicians must decide whether a particular medication is worth taking. It can be a challenging decision.

One must answer the question, is this medicine likely to provide relief. There is no point in risking any side effects if the medicine is not going to be helpful.

Consideration must be given to the individual history of a patient to determine if there are particular vulnerabilities that would heighten the likelihood or severity of any side effects. If a medicine has a small potential to cause stomach upset and a patient has a history of ulcers, that potential side effect might render the medicine inappropriate for this patient.

Finally, one must balance the potential side effects of a medication against the potential consequences of not treating the disorder at all. For example, a drug that has a 15% potential to cause liver damage would not be considered a very good choice if you were trying to cure a nagging headache. However, the same potential side effect might be considered tolerable if the disorder being treated had a 95% chance of killing the patient if left unchecked.

Consequences of untreated ADHD are underrated

There are a variety of medicines effective for treating adult ADHD. While there are some potential side effects, they are, for the most part, not severe and are easy to manage. Given these facts, it should tip the balance towards these drugs, however there is still a signifi cant number of adults with ADHD who are reluctant to treat their disorder medically and also a number of health professionals who are reluctant to recommend medical treatment for ADHD. I think the reason for this is that people underestimate the impact of leaving ADHD untreated.

In this article, I will discuss the drugs available for treating ADHD and will also examine the consequences of not treating the disorder.

Consequences of untreated ADHD: Lower educational attainment Diffi culty obtaining and maintaining employment Increased interpersonal problems Reduced earnings Increased emergency room admissions Greater healthcare utilization More likely to be divorced More likely to suffer from depression More likely to suffer from anxiety More likely to have traffic accidents Twice as likely to smoke cigarettes Six times more likely to suffer depression Twice as likely to abuse alcohol. Four times more likely to have sexually transmitted diseases.

ADHD is a serious and prevalent adult disorder

ADHD is a serious disorder and it is not likely that children will simply "grow out of it." Two thirds of children with ADHD become adults with ADHD. Often the hyperactivity diminishes, but other symptoms persist with very negative consequences. It is estimated that 4% of adults in the general population have ADHD symptomatology. Most of these people are undiagnosed. Further complicating the situation is the fact that untreated ADHD usually results in a host of comorbid disorders. This makes diagnosing the underlying ADHD that much more complicated. However, the presence of comorbid disorders also makes the consequences of untreated ADHD that much more serious.

Adults with ADHD have lower educational attainment levels, have great diffi culty obtaining and maintaining employment, have more interpersonal relationship problems, earn less, and are admitted to the medical emergency room more often than those without ADHD. They demonstrate greater healthcare utilization overall. Adults with ADHD report that they have a poor outlook on life and feel they don't fi t in with their peers. They are more likely to be divorced.

Adults with ADHD change jobs more frequently and have signifi cant differences in workplace performance than adults without ADHD. Estimates of the average loss of household income per adult with ADHD ranges from $8,900 to $15,400 per year. The aggregate loss in household income made ADHD one of the costliest medical conditions in the United States, with estimates ranging from $67 billion to $116 billion annually.

Untreated adults with ADHD have a higher incidence of car accidents. A study looking at 15-25 year olds with ADHD showed that in simulated driving tests, those who were medicated with Adderall XR or Concerta experienced fewer collisions, had improved crash avoidance ratings, demonstrated longer time to collision, had fewer drivin-outof-lane occurrences, and tailgated less. Adults with ADHD are twice as likely to be smokers, six times more likely to suffer depression and twice as likely to abuse alcohol. They are four times more likely to have sexually transmitted diseases.

Stimulants are one category of medicine approved to treat ADHD

There are essentially two categories of medicines presently approved to treat ADHD: stimulants and Strattera (a selective noreprehephrine uptake inhibitor). In this article, I will focus on the stimulants, which are the most commonly prescribed drugs for this disorder.

The stimulants are one of the most studied medications we have. They have been in use for over 40 years. Children have grown up on these medicines and have been followed into adulthood by child psychiatrists, pediatricians and family doctors. They have not been associated with any major negative effects.

With adults, there has been concern about that stimulants could adversely affect blood pressure. However, studies have not been able to correlate blood pressure elevations with stimulant use in patients who were not hypertensive to begin with. In addition, adult patients with hypertension requiring management with antihypertensive medication were able to tolerate stimulant treatment of their ADHD without signifi cant elevation in blood pressure. However, stimulant use can be correlated with elevated blood pressure, so I recommend that all my patients aged 18-50 monitor their blood pressure monthly. Adults over 50 should monitor their blood pressure more closely.

A recent Canadian report linked Adderal XR with sudden death. While there were signifi cant fl aws in that research, people with existing heart disease or a family history of sudden death should not take stimulant medications.

Potential for stimulant abuse in drug-users

Another concern with stimulant medication is the potential for abuse. It must be noted, that the incidence of substance abuse is greatly elevated in those with untreated ADHD, so treating the illness is likely to diminish rather than increase the rate of abuse. However, if a patient is an active substance abuser, stimulants are not the best choice of treatments for ADHD. We need to be concerned about diversion of the stimulants, i.e., the drugs being resold. We also must take into account the mentality of substance abusers, which says that if one pill is good, then more is better. And, most obviously, using stimulants to get high is a concern.

Another problem with an active substance abuser is that it is diffi cult to know whether a given medications for ADHD is having the desired effect because of the presence of other mindaltering drugs.

Past I.V. or skin popping drug abusers also require special care when prescribed stimulants. The physician needs always to evaluate these issues before starting any medication and be vigilant thereafter.

ADHD stimulant medication is taken orally. To produce a "high" stimulant medication needs to reach the brain very quickly. Oral use interferes with that, so abusers will break up medicines into powders and snort it or dissolve it and then inject. Long-acting preparations make it very diffi cult or impossible to do that, so these formulations would be preferable when a risk of abuse is present.

Likelihood of drug abuse is diminished when ADHD is treated

Patients without active or a history of stimulant abuse are not likely to develop drug problems as a result of the prescribed stimulants. Indeed, it is the untreated ADHD patient who is at heightened risk for becoming a substance abuser. Most of the long-term research shows that he use of medications that effectively treat ADHD decrease the risk of developing an abuse problem over time.

Diagnosis is challenging, dosing is, as well

There are serious challenges in diagnosing adult ADHD. As one gets older with untreated ADHD, many comorbid disorders can occur which complicate the diagnosis. Even once diagnosis is made, establishing an optimal stimulant dose is challenging. There are no rules that defi ne doses like weight or height. There is a fine line between the optimal dose at which a patient gets maximum performance with minimal side effects and a dose that is too great, making treatment intolerable. The doctor must use feedback from the patient to fi ne tune dosing. This is one of the major problems with ADHD patients – they have great difficulty in observing themselves. The physician needs to probe and teach the patient what and how to look at themselves. It can take time to reach optimal dosing.

Drugs are only part of the solution

Even once an adult ADHD patient has been successfully placed on a dosage of stimulants, the disease will not automatically resolve. Medicine will improve symptoms such as attention, focus, concentration, detailing, organization, ability to stick to things with tasks, decrease hyperactivity, fidgeting, hypertalkativeness and impulsivity. It may also improve short-term memory because patients can pay attention better. But all that isn't a cure.

Patients have likely developed many habits that are unproductive and inefficient, like rushing through things and making careless mistakes, or waiting to the last minute to do things and then being in a panic. Medicine doesn't, by itself, change bad habits, but it gives the patient the power to change.

Patients must answer the question for themselves whether medicine is worth it, but they should think about it carefully. People with ADHD have a tendency to be stubborn and oppositional. So again, they should carefully consider both the risks of medicine, the potential rewards of medicine and the consequences of doing nothing.