An ADHD treatment algorithm intended for prescibing psychiatrists.
I'm going to keep this brief and to the point. Because you probably have ADHD if you're on this page in the first place.
ADHD is essentially a reward deficiency syndrome [^1]. Most people get a dopamine squirt every time they finish a task. But if you've got ADHD, your reward system is a little less sensitive.
Why ADHD Sucks in the 21st Century
Back in the day, distractibility could be an asset. Example: maybe being a little inattentive would help you focus on really salient or important stuff. Or maybe being able to work on multiple projects simultaneously could be an advantage.
But the current socioeconomic environment rewards people with supercharged executive function. If you can sit in front of a computer for hours, diligently answer emails, and tick things off on to-do lists, you're most likely to advance.
If you have ADHD, how can we succeed in the current occupational landscape?
Here's what's helped me:
- Better habits + compensation strategies
- Supportive peers and family
I'm actually a big believer in medication. If you're super inattentive and scattered, I think trying to overhaul your habits will have limited value by itself.
It also helps to be honest with yourself. Even if you're high-functioning with ADHD, it might be a bad idea to choose a profession where sustained attention/executive function are really important.
If you're chronically overwhelmed and distracted, maybe trying to execute on new habits will be too much to tackle.
Getting on the right medicine - at the right dose - makes it easier to start developing a strategy to compensate for poor attention.
Finding The Right ADHD Drug
People tend to give up on medication too early or bail on a particular medication too late.
Psychiatrists also tend to prescribe too high of a dose starting out.
As a low-dose responder, I benefit most from taking 5mg Adderall every 4-6 hours.
But my psychiatrist started me off on 20mg twice daily (40mg/day). That's way too high of a dose if you're a low-dose responder!
The take-home message: your psychiatrist won't be able to divine the best dosage for you. If you're experiencing intolerable side effects, play with the dosage (under your doctor's supervision).
Adderall is not the only ADHD drug in the psychopharmacologists' repertoire. If Adderall isn't a good fit for you , there are lots of options.
- Nonstimulants like clonidine, guanfacine, or atomoxetine
- Off-label drugs like Wellbutrin (bupropion), Provigil (modafinil), Selegiline or Rasagiline
- Nootropics and supplements (e.g. l-tyrosine)
- Choosing a career/lifestyle where focus isn't important (half-joking here)
Here's a list of common complaints/issues I've encountered, and how to address them.
1) Psychostimulants make me overstimulated, anxious, or insomnia-prone
Try a lower dose or switch to non-stimulants. You can also try combining a low-dose stimulant with relaxation-promoting supplements. Examples include:
- Melatonin (at night)
- Sleepy time tea
- Lavender (Calm-Aid)
To beat a dead horse, exercise and meditation are also helpful when it comes to stress relief.
At the end of the day, I frequently experience an "Adderall crash." This can be combatted by making sure that you stay hydrated during the day, eat something even if you're not hungry, get plenty of rest, and take supplements that will help restore your neurotransmitters.
2) Stimulants improve my focus, but only for trivial tasks
Stimulants aren't a magic bullet. If you go into things with a get shit done (GSD) mentality before taking medication in the morning, it can help. It's important to start trying to be productive before medicine kicks in.
Self-awareness is about knowing your limitations. For example, I have an insane Reddit and Gmail addiction. So I use tools to block these sites during chunks of time I'm determined to be productive.
There are literally hundreds of strategies you can use to decrease time-wasting behaviors. But all of them revolve around having the foresight to know how you tend to waste time.
It's much easier to manage self-control issues if you're honest and upfront with yourself about the habits and temptations that lead you astray.
3) Stimulants turn me into an automaton
But there are things that you can do to mitigate these undesirable effects.
Ritalin (methylphenidate) is short-acting. It has a half-life of about 3.5 hours. You can exploit its brief duration by taking it only when you absolutely need it, and spend the rest of the time drug-free.
Many non-stimulant ADHD medications are less likely to make you feel robotic (e.g. atomoxetine).
What are the best ADHD medications for all-day coverage?
You have a couple of options.
Vyvanse is a derivative of amphetamine (lisdexamfetamine) that's slowly metabolized to d-amphetamine in your body. This produces a gradual onset and offset of effects.
Further reading on Vyvanse verses Adderall:
- Vyvanse vs Adderall General Comparison
- How Vyvanse and Adderall Affect Blood Pressure
- Vyvanse vs Adderall Strength
- Recreational Use of Stimulants
Extended-release Adderall is just like instant-release Adderall - except that half of the payload is delivered instantly and the other half is delivered 4 hours later.
Since both Adderall XR and Vyvanse are extended release, you're probably wondering: what's the difference?
Vyvanse delivers d-amphetamine. Adderall delivers both d-amphetamine and l-amphetamine. You can read more about this difference here.
I have difficulty sleeping and ADHD
You might consider a drug like clonidine. Clonidine is a centrally active alpha2 adrenergic receptor activator. But in addition to being used for ADHD - it treats high blood pressure, anxiety, and migraines.
Clonidine probably isn't as effective by itself as psychostimulants for ADHD. But clonidine has some key advantages: a low side effect burden and some sleep-promoting effects.
So taking clonidine at night is a great way to control both ADHD symptoms and insomnia.
Often hyperactivity and insomnia go hand-in-hand. That's why people with ADHD tend to be "relaxed" by ADHD medications - whereas individuals without ADHD are more likely to feel overstimulated.
[^1]: Blum K, Braverman ER, Holder JM, et al. Reward deficiency syndrome: a biogenetic model for the diagnosis and treatment of impulsive, addictive, and compulsive behaviors. J Psychoactive Drugs. 2000;32 Suppl:i-iv, 1-112.