People often ask me, “Gina, what’s the best medication for ADHD?” No one wants to hear the answer: “It depends.” These days, they are also asking me about gene-testing to help identify the best medication for a person with ADHD. Sorry, we are not there yet.
Developing an effective approach to ADHD medication therapy is highly individualistic. We lack a way to reliably predict which ADHD medication might work best for any one individual. With the advent of genetic testing, that is beginning to change. But only that: beginning.
The tried and true approach remains the best: Identify symptoms that might respond to medication, carefully track the response over time, and try at least one choice from each stimulant class (amphetamine and methylphenidate).
Warning: ADHD Gene-Testing Is Being Widely Misused
Unfortunately, physicians and consumers alike are misusing these tests.
Why did we write this series? Because I’ve heard too many parents say, “Genetic testing said my child could not take a stimulant.” That is absolutely untrue—and extremely alarming.
Stimulants are the first-line treatment for ADHD. Yet they often show up in the third “extreme caution” column of this testing report. In this series, we explain why this tends to happen. But for now, please know this: We cannot eliminate the entire category of medications on the basis of misreading a test. Too much is at stake.
To repeat: This testing cannot predict which medication will work best for an individual. It can indicate if some medications will be especially problematic, given the individual’s gene mutations. And it can tell you if you should take an extra-low or extra-high dose of a medication. It should be used as one tool, however, and perhaps only after a methodical treatment approach has failed.
My husband and I share our gene reports later. While we went through a company that is no longer offering the testing, the same information applies. It seems the dominant player in this field now is Genesight.
Introducing A 7-Part Series
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.
My husband (“Dr. Goat”) and I wrote the series. 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. Because 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. I have a knack for translating complex ideas into simpler, layperson’s terms.
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, with Arthur L. Robin, PhD. 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
- Trying to obtain brand over generic (because who needs an extra wild card in all this, especially in the beginning?),
- 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.
Pin The Tail On the Donkey?
Let’s be honest: 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 another prescribing physician) know much more than you do after reading a few good articles or books. Trust me on this: Self-education and self-advocacy are mandatory.
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.
We could call this adaptation Pin the Rx on the ADHDer.
ADHD Meds An “Easy Fix”? HA!
Perhaps the biggest ADHD myth floating around is this: ADHD medication treatment is an “easy fix.” Yes, a minority of people do luck out: They quickly find a medication that works well for them or they find a skilled prescriber. I’m glad for them—but concerned for the rest.
There’s a reason my first book (Is It You, Me, or Adult A.D.D.?) includes a detailed section on medication. The goal? I empowering ADHD-challenged individuals and couples to work pro-actively with their physicians.
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). Prescribing physicians often have only a few minutes with clients. This means they know very little about their patients, especially if they aren’t using rating scales and getting feedback from a loved one.
Therapists, however, have more time to help target behaviors that might be addressed by medication and to track progress over time. Therapists cannot specifically offer medication guidance, but they are well within their “wheelhouse” in performing this function.
The evidence that medication is the singlemost powerful tool in the ADHD toolbox is there—and has been for years.
If you choose to include medication in your treatment plans, 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.
Here goes. 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 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. 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 make it suddenly 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—including 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 seven-part weekly series. Dr. Goat and I will help you to make sense of this new information.
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All the Posts in This Series
Part 1 (this post) of this series provides an overview of 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 personal test results.