This superb summary of ADHD is likely to be of interest to several different types of reader. First, the physician who wants a brief (the entire book, including index, is 125 pages) overview; second, the therapist whose patients have ADHD and wants to learn more about it; third, the parent who wonders if their child has ADHD, and whether they should treat it, and how; fourth, the curious layperson.
Dr. McGough, a professor of psychiatry at UCLA, and one of the top researchers in the ADHD field, is a forceful lecturer, and his book is also pithy and powerful. Every sentence counts; there is not a wasted word. The person who likes to highlight the text will often be confronted with entire pages of yellow.
His book, the first in a new series, the “Oxford American Psychiatric Library”, by Oxford University Press (other volumes are bipolar disorder by Stephen Strawkowski, MD and Schizophrenia, by Stephen Marder, MD) captures the state of the art of ADHD knowledge and treatment in 2014.
Let’s take a brief tour through this book.
In the Introduction, Dr. McGough notes that ADHD “is a frequently occurring, brain-based, neurodevelopmental disorder with substantial negative consequences for individual and public health. Once viewed as a childhood condition, , it is now recognized that a majority of cases persist throughout adolescence and adulthood.”
“The high community prevalence of ADHD suggests that there are affected patients in virtually every clinical practice in every medical specialty. Nevertheless, comprehensive education about ADHD is largely limited to specialized programs in child and adolescent psychiatry and behavioral pediatrics.”
“MIsinformation about ADHD abounds. Some assert that ADHD is not real….that childhood inattention and hyperactivity are normal, the diagnosis is subjective….older student fake symptoms to obtain academic advantages….adults are similarly drug seeking….or that the condition represents a conspiracy by pharmaceutical companies and organized psychiatry to increase medication sales.”
“ADHD…is among the most scientifically validated psychiatric disorders”, with diagnostic reliability “on par with many conditions in general medicine”,and well demonstrated biological underpinnings….”the accumulated evidence base for its clinical management is of the strongest in mental health. Medications for ADHD have been used for over 70 years in millions of patients annually, creating an indisputable record of real-world safety and positive benefit….Treatment effect sizes are double those typically seen with more widely prescribed medications for depression and schizophrenia.”
Chapter 2, Historical Perspectives, reviews the history of ADHD (first mentioned in an 18th century medical text) and follows it through the various iterations of the DSM, including the DSM-5.
Chapter 3, Epidemiology and Burden, notes how common the condition is, with an estimated 5.3% worldwide mean. Male/female ratios, 9/1 in school age clinic samples, are 1/1 in adult clinic samples. This implies that boys are treated as children because they are more likely to disrupt the classroom, while quietly inattentive girls are ignored. The late Dennis Cantwell, MD, one of my best teachers, used to describe boys as having “garlic symptoms” (which bother the environment), while girls have “onion symptoms”, and suffer internally.
Chapter 3 also notes the extensive co-morbidity of ADHD, Mood disorders and anxiety disorders are quite common, and often the underlying ADHD is missed. Chapter 4 reviews etiology and neurobiology. Chapter 5 reviews diagnostic criteria, especially the different forms the criteria take in children and adults.
Chapter 6 reviews the various aspects of a thorough assessment. “ADHD is a clinical syndrome….ADHD is not diagnosed on the basis of any distinct neuropsychological profile. There is no scientific justification for claiming to diagnose ADHD on the basis of other laboratory studies, computerized tests of attention, electroencephalography (EEG), or other brain imaging methods.” A careful reading of this chapter could save a parent thousands of dollars, and spare a child needless radiation exposure.
Chapter 7 and 8 review Treatment Planning in Children and Adolescents, and in Adults.
Chapter 9 reviews basic pharmacology.Here are a few of the pearls strewn though its pages. “It is commonly stated that 70% of patients respond favorably to stimulants. In fact, approximately 70% respond favorably to the first stimulant prescribed, whether a methylphenidate or amphetamine. Of those who fail, an additional 70% respond favorably to the alternative class. As such, more that 90% of patient have satisfactory clinical improvement with stimulants, at least during acute treatment.”
Is my child/spouse/partner being overmedicated by their physician? Tables 9-2, 9-3, and 9-4 and the associated text show the reader how the meds are commonly used, ie what are the usual standards of care.
OK, so should I start my ADHD patients on amphetamine or methyphenidate? “Some patients respond preferentially to one or another stimulant class, but there is no method other than clinical trial and error to predict whether MPH or AMPH is the optimal choice.”
OK, so what is the difference between how methyphenidate and amphetamine work at the cellular level? “Both AMPH and MPH inhibit catecholamine reuptake into presynaptic neurons by blocking norepinephrine and dopamine transporters. AMPH further directly displaces norepinephrine and dopamine from presynaptic storage vesicles, and it inhibits monoamine oxidase and subsequent neurotransmitter breakdown.”
OK, so how do these drugs work at the level of brain circuits? This is fascinating, and a little complicated, and still being worked out, but here goes (pages 74-75): “Recent research suggests that ADHD treatment response is not a direct effect of increased catecholamine release, but that increased levels of norepinephrine and dopamine have indirect modulating effects on glutaminergic signaling in the the prefrontal cortex (PFC).”
PFC circuits regulate lots of stuff (attention, executive functioning, etc, etc). “One subset .. mediates active attention to “preferred” inputs or “signals”, while another subset mediates attention to “nonpreferred” inputs or noise.”
so “ADHD treatment can be viewed as a rebalancing of “signal” to “noise” ratios….Ideally, individuals should appropriately focus on important tasks (signal), while retaining some awareness of background activity (noise) and the ability to shift attention flexibly when required. Optimal balancing of signal to noise ratios in the PFC is dependent on a narrow range of catecholaminergic activity. If catecholamine levels are excessively elevated, perhaps from too high medication doses or stress, PFC networks collapse with concomitant deteriorations in cognitive or motor control. Dopamine increases that might be useful for tasks requiring highly focused attention could also cause problems with overfocus, cognitive rigidity, and a loss of personality and spontaneity.”
This is, in my opinion, a brilliant and succinct summary of a very complicated area, and it suggests what a delicate touch is required in adjusting a patient’s medication.
Chapter 10 is clinical medication management. Dr McGough has developed a method (which in my notes I label the McGough titration) to quickly (within 2 weeks) and efficiently (with one prescription) answer 2 questions: is this medication helpful or harmful to my patient, and what is the optimal dosage ? (pages 81-83, and table 10-1). When to use combination pharmacotherapy, and how to handle various common side effects are also discussed.
My psychiatrist wants to see me every month to give me refills. Is this really necessary? (see page 82)
Patients are often dealt more than one diagnostic card, and chapter 11 shows how to deal when a patient has comorbid diagnoses.
Chapter 12 reviews medication controversies Do ADHD meds stunt growth or cause sudden death? Should one get an EKG before starting a stimulant? What if the patient is using alcohol or marijuana? Do ADHD meds cause birth defects? Do patients fake symptoms to get stimulants? Do ADHD meds stop working?
Chapter 13, Complementary and Alternative Medicine Therapies, covers the evidence base, and the quality of the research, for restriction/elimination diets, dietary supplements, neuropsychological treatments, and mind-body therapies. Careful reading of this chapter could help parents avoid wasting a lot of money on treatments with scant evidence to support their efficacy. The treatments with the strongest evidence base are the addition of essential fatty acids, and the removal of artificial colors.
This is a book that the practicing psychiatrist will want to read from cover to cover, and then read again. It may be of even more benefit to the parent or the adult patient.
How to avoid paying too much for generic medications
The pricing of generic medications for uninsured patients is irrational and counter-intuitive.
Because of this, the uninsured patient can pay far too much for a generic drug.
One might expect that the price of a generic medication to be “low”, and to not vary much from pharmacy to pharmacy.
This is often not the case.
What inspired me to write this post is hearing from several different patients that they had paid exorbitant prices for their generic meds.
Consider lamotrigine, the generic name for Lamictal, which is increasingly admired for its ability to prevent depression in bipolar II patients.
A typical initial prescription for lamotrigine would be for 60 25 mg pills.
Without insurance, the estimated cash price would be (from the Goodrx website, accessed 5/16/15: https://www.goodrx.com/lamotrigine/price#/?distance=6&filter-location=&coords=&label=lamotrigine&form=tablet&strength=25mg&quantity=60.0&qty-custom=&language=&store-chain=
Walgreens $149
CVS $134
Rite Aid $127.
This is far too much to pay. How to pay less:
Method 1:
1. Go to the Goodrx website http://www.goodrx.com/ (It is unnecessary to sign in or register)
2. Enter the name of the drug you’re interested in.
3. At the lamotrigine page, enter your zip code (so you can see the pharmacies closest to you), the dosage of lamotrigine you’re interested in, and the number of pills you’d like to buy
4. In the example above, I’d enter 90403 (my office zipcode), lamotrigine 25 mg, quantity 60.
5. The cheapest price ($13.98) is from “membership warehouse, name cannot be shown” (presumably Costco).
6. There is no need to battle traffic in the Costco parking lot, however, because of these prices (which require printing the free coupon from the Goodrx website):
Ralph’s $13.98
Pharmaca $14.08
Walgreen’s $14.38 (a 90% savings over the cash price)
Von’s $14.63
But note, even with the coupon
CVS $79.39
Rite Aid $107.33
7. If you prefer your small, neighborhood, independently owned pharmacy (as I do), Goodrx will allow you to print out a coupon which you can take to your pharmacy. For the lamotrigine example, the cost is
independent pharmacy: $13.20
Example 2: sertraline 50 mg # 30 (generic for Zoloft, a commonly prescribed selective serotonin reuptake inhibitor, useful for anxiety and irritability)
Cash price: GoodRx coupon price
Ralph’s $42 $7.02
Vons $24 $8.45
Rite Aid $55 $9.99
Walgreens $36 $10.58
CVS $31 $24.93
Independent pharmacy $9.89
Example 3: in the above examples, the supermarket pharmacies (Von’s, Ralph’s) are often less expensive than the retail pharmacies (Walgreen’s, Rite Aid, CVS).
But this is only the case for non-controlled substances. For certain controlled substances, the retail pharmacies are less expensive
Adderall XR 20 mg # 30, in its generic form:
Cash price: GoodRx coupon price
Rite Aid $200 $81.08
CVS $175 $102.12
Walgreen’s $75.62
Von’s $132.75
Ralph’s $133
Independent pharmacy $133-133.50
Method 2:
Go to the Costco website http://www.costco.com/Pharmacy/home-deliveryb?storeId=10301&catalogId=10701&langId=-1 (You do not have to be a Costco member to use the pharmacy, due to a California state law).
Enter lamotrigine.
Notice that this website is less informative, because you cannot customize the results.
A second weakness of the Costco site is that it will not give pricing information on controlled substances, such as stimulants (commonly prescribed for ADHD) or benzodiazepines (sometimes prescribed, cautiously, for anxiety).
In our case, looking for 25 mg lamotrigine, we find only the orally disintegrating tab, not the tablet, in amounts of 30 ($10.27), 50 ($13.10), and 100 ($18.26). The price is roughly comparable to the Goodrx coupon price at Ralph’s, Pharmaca, Walgreen’s, and Von’s.