Let’s get this out of the way: Prescription Adderall works very well for some people with ADHD. For others, however, Adderall effects can create more problems than it solves—exacerbating anxiety, irritability, anger, grandiosity, and even rage.
That’s why 20 years ago I started calling it Madderall.
Here’s what you won’t hear from your prescriber: Adderall can ruin lives and ruin relationships.
What’s worse, the people experiencing poor results often don’t realize it. They assume it’s the price of focus—and then develop a cannabis habit to “come down”. Or, they love the intense focus that simultaneously reduces self-awareness. In other words, they assume that everyone else is being annoying, not them.
How many physicians know this? Pitifully few, it seems. I’ve encountered the casualties daily for far too long.
The truly tragic part? There are so many better options to try first. I cannot fathom why so many doctors insist on prescribing Adderall to newly diagnosed patients—and with little guidance. It seems they are misreading a meta-analysis, which I will write about in a future post.
Bottom line: Treating ADHD is not simple. It requires expertise and method.
To further complicate matters: Adderall is also a popular drug of abuse. Yet, even the story of “Adderall Abuse” is complicated.
Please Don’t Look Here for Tips for Adderall-Abuse Tips
Thanks to “Google keywords,” many people find this article while seeking to illegally procure or “hack” stronger effects from Adderall. You will not learn about that here.
Moreover, when you leave after 5 seconds—your goal not accomplished—that increases my blog’s “bounce” rate. Not a good thing.
I leave this post here anyway. Why? You won’t find what you’re looking for, but you might find something better.
I’ll be blunt: Chances are good that you actually have ADHD and are attempting to “self-medicate” it. Please know: That never ends well.
Mostly, readers find this post legitimately, using terms such as these (to name only a few):
- Adderall makes my spouse angry
- Can Adderall make you irritable?
- Why is Adderall making my ADHD worse?
- Depression and anxiety from Adderall?
- Anger outbursts and Adderall
- Does Adderall change your personality?
- Irritable after Adderall
- Can Adderall cause bipolar?
- My husband started Adderall and is an angry jerk now
- Adderall causing aggression and sexual behaviors in elderly
- Adderall is spiking my blood pressure
My Message Here is Fourfold:
- Warning that The New York Times (the initial catalyst for my writing this post) has a long history of anti-psychiatry reporting.
- Explaining the very good reasons to consider Adderall not as a first try but rather a last-stop in stimulant medications.
- Alerting readers to the fact that many (if not most) prescribers are incompetently treating ADHD. This is having devastating consequences.
- Emphasizing the importance of ADHD self-education and self-advocacy—for yourself or on behalf of your loved ones.
- Offering an excerpt from my first book’s chapters on medication—self-education is self-empowerment!
I wrote those three chapters on ADHD medications so patients can be smarter mental health care consumers. So they can avoid negative and even tragic outcomes.
The book also contains also a sidebar on the important distinctions between the two classes of stimulants: 1) methylphenidate (MPH) and 2) amphetamine (AMP).
It’s hard to imagine, but I was the first person to write about that in a consumer book on ADHD, published in 2008. Still relevant.
Eight years later, Arthur L. Robin, PhD, and I created a basic and license-appropriate protocol for couple therapists to help guide medication treatment. We included it in our professional guide: Adult ADHD-Focused Couple Therapy: Clinical Interventions.
It takes a critical mass of mental-health care consumers to seriously turn this tide. That means consumers must be educated and must self-advocate. Educating on this topic is a huge focus of my training in development: ADHD Success Training.
Now, back to the story.
More ClickBait From The New York Times?
A back-channel tip came to me yesterday. I steeled myself for the next anti-ADHD screed from The New York Times. What did I expect? The next in a long and vicious pattern: a stigma-producing attack on the diagnosis itself, not to mention the medications so often successful in treating it.
Many reporters seem to think this is an original angle. We who are knowledgeable see it as transparently traffic-boosting clickbait, not honest journalism.
As a young journalist many years ago, I was taught to respect The New York Times as an exemplar of journalism. That has changed.
The paper still has respectable reporters and sections. Yet, whichever editor is in charge of mental-health coverage seems to have some personal problems with neuroscience. That or, the publisher issues orders based on the website’s analytics. Any piece stigmatizing ADHD tends to draw lots of readers—and therefore ad dollars.
It was only when I became an expert on ADHD that I realized that The New York Times is incredibly anti-science and pro-stigma when it comes to psychiatric conditions. Over the years, I’ve written several posts:
This Time: More Grief But Tiny Relief
Grief —that yet another person fell victim to the stimulant Adderall, a medication that, even though helpful for many people, can create severe reactions in many others.
Relief—that finally The New York Times’ grandstanding front page finally got something right about ADHD. At least in tiny part.
The tiny part is this: The manner in which many prescribers treat ADHD largely resembles a giant game of “Pin the Rx on the ADDer.” Or even worse — a “test the spaghetti” equivalent of throwing chemicals at someone’s brain and seeing what sticks.
All else in the story, unfortunately, is sensation and assumptions. And it wasn’t the last story in Alan Schwarz’s campaign to win a Pulitzer. (He didn’t, and he’s no longer at the paper. Nor is he still a reporter. But during the time he was, he inflicted immense, perhaps lasting damage.)
Core Problem: Poor Prescribing
In the early days of my advocacy, the early 2000s, I heard story after story repeated in my Adult ADHD monthly discussion group in Palo Alto—as well as my online group for the partners of adults with ADHD (ADHD partner): Very reckless prescribing patterns around Adderall. “Adderall anger” doesn’t begin to describe it.
It’s hard to explain why, even today, so many prescribing physicians consider Adderall the “most effective” medication for ADHD. Where did they get that? Pharma reps with cleavage? There is no published evidence to support this practice. [Update 1/20/20; still it continues, unabated.]
What does the research say? A meta-analysis of studies examining stimulant efficacy in children and adults found methylphenidate (the medication in Ritalin, Concerta, etc.) more effective for children and Adderall more effective for adults. Yet, the number and quality of studies being considered for adults were paltry and poor. Moreover, Vyvanse did not exist at the time the studies were conducted. In other words, that finding does not sit on very solid ground.
Prescribers who fail to understand anything beyond one line in a published paper are not practicing good medicine. They can cite “evidence” all they want, but it doesn’t make them right.
To understand the essential problem, we have to start with poor prescribing protocols for ADHD overall.
—Prescribing physicians should have a method for tracking progress.
They should be using a checklist of symptoms that helps them monitor how well the medication is working—and what side effects it might be creating.
—Physicians should gather reports from family or close friends.
That’s because sometimes folks with ADHD lack accurate self-observation. Typically, this improves with medication, but the wrong medication can further cloud self-observation.
—Too many physicians most don’t bother with either method.
Instead, they rely on a casual, “So, how is that working for you?”
Has Poor Prescribing Contributed to ADHD Backlash?
To summarize the points above: The prescribing of any stimulant is often done badly. Moreover, little attention is paid to rebound or co-existing conditions such as anxiety or depression. But the problems with Adderall are an order of magnitude more serious.
In fact, I credit slipshod prescribing patterns for much of the blowback against ADHD, especially the first-line medications used to treat it.
The fact that I publicly predicted and warned about this years ago brings me no pleasure in being right. Every day, I help to educate and steer in a better direction. But I am just one person—without an “authoritative” MD after my name. I am, however, a journalist with dyed-in-the-wool respect for accuracy.
When it comes to ADHD medications, lives truly do hang in the balance.
Caveat: Prescription Adderall Works Great Sometimes
Make no mistake: For some people, prescription Adderall works well and with few side effects. It is the best choice for them.
Yet, Adderall has a higher side-effect profile. So, individuals with ADHD just beginning treatment might consider a conservative route. That is, try Adderall only after trying the methylphenidate class stimulants (Ritalin, Focalin, Concerta, Daytrana, etc.) and some newer delivery systems in the amphetamine class (such as Vyvanse).
Ideally, a trial should be given of both the amphetamine and methylphenidate classes, as I explain in my book. (Based on interviews with preeminent ADHD experts.) That way, you can judge which works best. There is no way to predict beforehand how a person will respond to either class of stimulant. It all depends on genetics and their unique neurochemistry.
Yet, so many physicians routinely start new patients with Adderall, and at too high a dose.
It makes no sense! Adderall is an old option, in many ways outdated given the superior delivery systems available today. These systems release the medication more evenly and over a longer period of time, creating less of a “rollercoaster” for neurotransmitters.
Contributing Problems: A Larger View
Still, the ignorance around prescription Adderall remains only one piece of a very problematic and often tragic puzzle:
1. Physicians who see ADHD as a “simple condition.”
“You just throw a stimulant at it!” one psychiatrist told me. He was explaining why he didn’t find ADHD treatment interesting and therefore not worth his study.
In fact, ADHD is a highly complex condition, especially when it is diagnosed later in life. For example, other conditions—such as sleep deprivation and substance use—complicate medication response.
A thorough history must be taken, including teasing out signs of the co-existing conditions suffered by an estimated 75 percent of late-diagnosis adults with ADHD. Moreover, 50 percent of these adults will have two co-existing conditions.]
2. Physicians who believe in a “starting” or “average” dose
“There is no starting or average dose!” I’ve emphasized that in my lectures for years. Yet still, that seems the status quo.
—Some people are slow metabolizers: an “average” dose might be too high for them.
That means it might present intolerable side effects, causing them to give up a medication that might, if prescribed at a lower dose, work very well for them.
—Some people are rapid metabolizers: an “average” dose might be far too little for them.
They “burn through it” too fast. They need a higher dose in order to get an average effect.
My scientist-husband and I wrote a 7-part series explaining metabolizing issues and more:
3. Insurance companies who reimburse poorly for psychiatric treatment
Yes, insurance companies share the blame. They do not reimburse psychiatric treatment at a rate commensurate with the kind of expertise and time required. But physicians are responsible for understanding on a basic level the medications they prescribe.
4. People with ADHD who are impatient for results—would rather “feel” it than observe it objectively
If I had a dollar for each time I’ve warned about this dangerous trap.
The hard truth is, you can’t depend on a “visceral feeling” to tell you when the medication is working. In fact, sometimes you won’t realize that the medication is working—but the people around you will!
Moreover, relying on that feeling (especially if it feels like booster rockets attached to your behind) almost guarantees a bad end. Maybe not today. Maybe not tomorrow. But soon. And you might be so strung out you don’t even know it.
Often, patients (or their parents or partners) will listen to me only after the fact—after the typical crash that happens. For many people, that’s about two months into Adderall usage.
That’s when they are completely depleted:
- Typically from exhaustion (why go to sleep when for the first time in your life you have “superhuman” focus?).
- But also due to Adderall’s mechanism of action, their very supply of neurotransmitters might be depleted.
5. Parents’ and loved ones’ who are “in denial” of ADHD
Now we turn back to the NYT story. Did the poor young man featured in the piece truly not have ADHD, as his parents claim? I’ve seen no evidence of that. This was the weakest point of the story.
Reporter Alan Schwarz has made it clear that he has no understanding of ADHD’s complexity. As a former newspaper editor, I have seen the pattern: “Hot Dog” reporters who will do anything to land on the front page, above the fold. They might have had success on one topic (in his case, concussions from sports) and fancy themselves a rockstar on all topics.
Schwarz failed to comprehend that ADHD sometimes had a way of “sneaking up” on people later in life. That’s when their innate intelligence and ability to get by in school without good study habits are no longer enough to let them keep up with their goals. It might seem that these people are “abusing” stimulants when really they are seeking help.
But could it be the parents’ own denial systems about their son’s long-running ADHD-plus-related problems augmented their son’s distress? At least these doctors believed him, Richard Fee might have felt.
6. Prescribers Who Fail to Ask for Third-Party Feedback
Please understand: I feel deeply for Richard Fee’s parents. It seems they truly tried to warn the physicians of what was happening to their son.
I’ve seen the same thing for years. The partners of adults with ADHD try desperately to get through to the Adderall-prescribing physicians, to explain that their partners are turning into rageaholics. (Their partners will never report increased anger and ability to their prescribers because they don’t want to lose their life’s long-missing focus.)
Yes, there are privacy laws. But that does not mean the prescriber must not request such feedback.
Did Fee have a condition such as bipolar disorder (either instead of ADHD or co-existing to it)? That is, a condition that made him more vulnerable to abuse or become addicted to Adderall? Was he using Adderall to minimize sleep so he could study more, thus becoming sleep deprived and further deteriorating his mental function?
We’ll never know. But I am certain that there were red flags throughout his childhood and young adulthood. Red flags that if they were recognized accurately might mean Fee would still be alive.
Rest in peace, Richard.
Excerpt: My Book’s Chapter on Medication
Now I’ll share with you now the introduction to my first book’s chapter on medication. Please share it with anyone who is thinking of seeking treatment for ADHD. You cannot rely on the average physician or even psychiatrist to be competent.
I do not want to scare people away from seeking treatment that can vastly elevate their lives. But I do want to emphasize: We consumers must be educated, we must self-advocate.
To lack vigilance is to risk a lot. Trust me on this. Please don’t let you or your loved one be another casualty. The method of identifying ADHD symptoms and medically addressing them is, for the most part, not rocket science. It’s not even brain science. It’s step-by-step logic and observation.
Chapter 21: RX Treatment Results That Last
It took Alex two grueling years to convince his wife to seek an evaluation and then treatment for her diagnosis of ADHD.
“Now, who knows how long it will take me to convince her to ditch this psychiatrist, who refuses for no logical reason to prescribe stimulants and find one who actually understands ADHD,” he complains. “My wife is skeptical that I or this support group could know something her psychiatrist doesn’t. But trust me, it’s alarming how little this guy knows.”
Looking back, Alex wishes they’d been far more careful in selecting a physician.
In Jeanette’s case, the irony is that she never found her husband’s ADHD a problem—until after he started medical treatment for it.
“I used to go to bed at night thinking I’m the luckiest wife in the world,” she recalls. “Yes, Mike is lousy at paperwork and he doesn’t remember to take out the garbage (or what day it’s collected!), but he is fun, very goodhearted, and rarely gets angry, and loves being with me and the children.”
All that changed soon after Mike learned that he might have ADHD and decided to do something about it. He had recognized in himself the traits he didn’t like in his father, including poor follow-through on promises, and wanted to do a better job with his own family. “His attitude was, ‘If treatment can help me to be a better person, why not?” Jeanette recalls.
Unfortunately, under the first physician’s care, Mike’s personality changed completely after starting medication. “Medication seemed to be a miracle worker at first, but then it ended up making him angry all the time,” Jeanette explains.
“I went from this perfect marriage to hating my life and being ready to leave him. The worst part was that he didn’t realize that things were getting worse, especially the anger, until we were in major trouble. As far as he was concerned, his focus was better so that was great. But in reality, his focus was unrelenting.”
Jeanette found the support group’s feedback critical to realizing what was happening. He was probably either on the wrong type of stimulant medication or at too high a dosage. She also learned how to find a more qualified physician and, more importantly, convince Frank that he was turning into a father far worse than his own.
Stories like this are way too common for the support group’s comfort.
As much as we might want to place our faith in our physician’s ability to navigate the increasingly complex world of medicine for us, one troubling fact remains: Many physicians, including psychiatrists, are poorly trained to treat Adult ADHD. Some know that and respect their limitations, but some don’t.
As long as you understand this going in, and as long as you take steps to be a smart healthcare consumer, the chances are good that you will avoid common pitfalls and come out a success story.
“My message to those embarking on this journey,” Jeanette says, “is don’t be afraid of medication; it can bring great changes. Just be aware.”
Indeed, lest you be scared off entirely from pursuing medication treatment, know that, for many, it is a straightforward issue. In fact, ADHD Partner Survey respondents report that when their partner started taking medication, symptoms improved significantly within:
• Hours (15 percent)
• Days (39 percent)
• Weeks (19 percent)
As Jeanette learned, however, the initial “promise” of medications to smooth out the ADHD roller coaster can soon peter out. Support-group members have agonized over this phenomenon for years.
This chapter will support you and your ADHD partner in creating your own success story by helping you to:
- Avoid common pitfalls that lead to low treatment adherence.
- Understand that treatment education and goal setting form the foundation of successful medication treatment.
- Know that each person has a unique biochemistry, which eliminates the possibility of any single medication or standard dose being the
best choice for everyone.
- Recognize that it requires a careful, methodical process to find the best fit in a medication regimen.
- Know that ADHD commonly coexists with other conditions, which must be considered in any treatment plan.
The good news is that physicians are increasingly becoming more educated, and these guidelines should help you shop for and recognize competent care when you encounter it.
For more posts related to ADHD medications, click here: archives
For more information on my book, click here: Is It You, Me, or Adult A.D.D.?
COPYRIGHT 1201 ALARM PRESS, 2008
—I welcome your comments.