People often ask me, “Gina, what’s the best medication for ADHD?” The answer, unfortunately, is one that no one likes to hear: “It depends.”
Sorry, but it’s the truth: Effective ADHD medication therapy is highly individualistic. A medication that works well for one person might work poorly for another. Until now, however, we have lacked a way to predict which ADHD medication might work best for any one individual. With the advent of genetic testing, that is beginning to change.
Hence this 7-part blog series called “ADHD, DNA, and Predicting Medication Response: Or, What Your Genes Might Tell You That Your Doctor Cannot.” Look for the next six posts each Wednesday for the next six weeks.
That’s the subject of this series, co-written by my husband (“Dr. Goat”) and me. He is a molecular biologist with a strong emphasis in genomics and data mining. He also happens to take medication for ADHD. His nickname is Dr. Goat, and since he is not writing professionally here, we’ll stick with that.
I (Gina) am an ADHD expert who has heard 1,000s of medication-gone-wrong/right stories and who passionately works to improve the odds for good outcomes.
By way of background, I am the author of a bestselling book on Adult ADHD, especially as it affects relationships. It’s the first, and to my knowledge, still the only consumer book to actually detail an effective way to approach medication. It’s been translated into Turkish and Spanish. My second book will be out in January, 2016; it is one I was asked to produce by a major publisher of clinical guides—that is, books for mental-health professionals. It’s called ADHD-Focused Couple Therapy: Clinical Interventions.
The Trouble With Current Prescribing Patterns
To be clear:
- We have strong data showing the effectiveness of ADHD medications for people with ADHD in general.
- We also have common-sense methods of selecting medications for trial by an individual person, as described in my book.
But the trial-and-error process can involve weeks of
- Titration (dosage-adjusting),
- Procuring this or that medication
- Wrangling with the insurance company or poorly supplied pharmacy
- Wrangling with the insurance company for brand over generic (because who needs an extra wild card in all this?),
- Teasing out what is “side effect” and what is the medication exacerbating a co-existing condition, and
- Making several trips to the doctor, who might or might not even be a skilled prescriber.
Given that many adults try medication only when they are in crisis, this is especially problematical. When in a crisis—with a job or marriage hanging in the balance—there is little margin for error.
And, let’s face it, most prescribing physicians are just not that expert. There are exceptions, to be sure, but you simply can’t expect that the average psychiatrist (or other prescribing physician) will really know much more than you do after reading a few good articles or books.
The fact is, when it comes to predicting an individual’s response to a particular medication—stimulant, non-stimulant, one class or stimulant or the other—it’s been largely a game of what I call Meds Roulette.
Or even Pin the Tail on the Donkey. Remember how that childhood party game of is played? A blindfolded person tries to pin the tail where it should be on the donkey.
In this example, the blindfolded person is the prescribing physician, and the person with ADHD is the donkey.
We could call this adaptation Pin the Rx on the ADHDer.
This all puts the lie to the public misconception that ADHD medication treatment is “easy fix.” Of course, a minority of people do luck out: They find a medication that works for them without too much trouble, or they find a skilled prescriber. I’m glad for them! But I’m concerned for the rest.
Let’s just say there’s a reason I devoted a detailed section in my first book (Is It You, Me, or Adult A.D.D.?) to empowering ADHD-challenged individuals and couples to work pro-actively with their physicians.
There’s also a reason why Arthur Robin, PhD, and I included a full chapter in our new book for couple therapists: Adult ADHD-Focused Couple Therapy: Clinical Interventions (Routledge, January, 2016).
For 16 years now, in my public presentations and personal consultations, medication is the topic that most interests people. I suspect this is largely because the evidence is so strong that medication can be helpful, even if “real world” good results can be elusive.
Being pro-active about your own medical care, or that of a loved one, is not a luxury; it is a necessity.
I know. That’s a big mouthful of a word. Don’t worry. We’re going to walk you through it.
Now. We’ve always known that different people react differently to the same medications. Finally, we are beginning to understand why—and to benefit from new genetic testing that helps predict how a certain medication will work with our particular genes. This is one tool furthering the “personalized medicine” movement.
The topic of this blog-post series is one aspect of how we might do medication better—in particular, by using a type of genetic testing to help inform ADHD medication. The field is called pharmacogenomics, or sometimes pharmacogenetics. It’s the study of genetic differences that determine our individual responses to drugs, whether positively and negatively.
The value of such genetic testing is why the FDA has posted a table of 150 FDA-approved drugs with pharmacogenomic information in their labeling.
Pharmacogenetics. the study of
genetic differences that
determine our individual
responses to medication.
The field of pharmacogenomics has broader implications, too. For example, it is being used to identify medications that, while not shown effective in large populations, might be effective in sub-populations. This is important, because the state of drug discovery is such that we’ve already hit most of the “targets”; inroads will be made not so much by discovering new medications but by finding other uses for existing medications.
So, what’s the bottom line here? Does the advent of genetic testing suddenly mean that now it’s a snap to find an effective medication—at the right dose? Sorry, no. Human brains are like snowflakes: no two alike. Moreover, the brain’s complexity makes a snowflake look like a simple dot.
Plus, there are so many other factors that contribute to an individual’s response to a medication—weight, overall health, age, and other lifestyle factors. But, increasingly, new ways of gathering data are helping to inform treatment decisions.
Look for the next post in this six-part weekly series next Wednesday. My resident scientist and husband, Dr. Goat, will help you to make sense of this new information.
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Part 1 (this post) of this series provides an overview to the topic.
Part 2 shares testing results for my husband and I, along with my husband’s reactions.
Part 3 dives into the details of genotyping: what does the term mean?
Part 4 examines “when and why” to pursue genotyping, the real-world value and usage
Part 5 covers the limits of genotyping
Part 6 brings it all together with a closer look at our personal testing results and real-life application of the findings, beginning with Gina’s results
Part 7 …and continuing with Dr. Goat’s results.