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Treating ADHD with Non-Stimulant Drugs

Margaret V. Austin, Ph.D., edited by C. E. Zupanick, Psy.D.

Stimulant medication is the primary treatment for ADHD, especially with regard to improving concentration. However, other medications are often prescribed along with stimulants to help control side effects or to treat associated symptoms. Additional medications are also necessary to treat co-occurring disorders such as depression, or when stimulants are not working.

Commonly prescribed non-stimulant medications in ADHD treatment

pillsBefore we discuss single, specific, non-stimulant drugs, it is important to remember that most people will take some combination of medications. Furthermore, medication requirements may change over time. Each person must arrive at the right combination in conjunction with their healthcare professional. This list is intended for educational purposes only.

Antidepressants

Antidepressants are the next most commonly prescribed category of drugs for ADHD. However, they are not FDA-approved for this purpose. Antidepressants may be used in combination with stimulants in order to maintain treatment effects throughout the night, and to reduce depression. Antidepressant drugs are less effective than stimulant drugs in improving concentration. However, they can be quite effective in reducing impulsivity and enhancing social skills. Typically, antidepressants take several weeks to reach an optimal level in the body. Therefore, symptom improvement may not be immediately evident.

Bupropion (Wellbutrin®) This medication is called an atypical antidepressant. This simply means it is dissimilar to other medication categories. Buproprion (Wellbutrin®) can be very helpful in reducing irritability associated with ADHD in both adults and children. The appropriate pediatric dosage has not been established. Nonetheless, Wellbutrin is frequently prescribed "off label" or beyond the recommended label instructions with children. It is generally well-tolerated. Side effects may include weight loss, anxiety, headaches, dry mouth, and confusion.

Tricyclics (Pamelor®, Aventyl®, Tofranil®, and Norpramin®) - Tricyclic antidepressants are helpful for both children and adults with ADHD. The dose to treat ADHD is usually lower than the dose for depression. They have a quicker onset of action than most other non-stimulant medications. Tricyclics block norepinephrine and dopamine receptors in the brain. This causes the brain to produce higher levels of these neurotransmitters. The increased availability of these brain chemicals appears to decrease impulsivity, inattention, and poor concentration. There may be some unpleasant side effects such as urinary problems, constipation, and dry mouth. The risk versus the benefit must be carefully weighed for each individual.

Long-acting Non-Stimulants

Non-stimulant medications affect the brain differently than do stimulants. They do not change the dopamine levels. Three, long-acting, non-stimulant medications have been approved by the FDA for ADHD treatment. They are used alone or combined with a stimulant medication.

Atomoxetine (Strattera®) - This was the first non-stimulant, ADHD medication approved by the FDA. This medication seems to block the norepinephrine receptors in the brain. This causes the brain to increase norepinephrine production. The result is improved attention and better controlled hyperactivity and impulsivity. Although Strattera is used frequently to treat ADHD, it is generally considered less effective than stimulants. Strattera came under fire in 2006 with a warning that children may have increased suicidal thoughts early in the treatment process. The increased rate of suicidality is low (less than a 1% out of 1,357 patients studied (Watkins, 2012). Nonetheless, children just starting treatment with Strattera should be closely monitored for suicidal or other unusual thoughts. Likewise, clinical worsening of ADHD symptoms, or unusual behaviors, should be promptly reported to the healthcare provider. All suicidal comments should be taken seriously. Caregivers must maintain close observation and communication with the prescriber.

Intuniv is approved by the FDA for use with ADHD. It is an extended release medication that contains the same active ingredient as a blood pressure drug called Tenex. Intuniv is thought to affect the part of the brain that controls working memory, attention, and impulsivity. It may lessen ADHD-related symptoms such as argumentativeness, disruptive behavior, hyperactivity, and anger or irritability.

Kapvay contains Clonidine. This is the same active ingredient used in Catapress, a high blood pressure medication. For many years it has been prescribed off-label for ADHD. It reportedly improves frustration tolerance. Therefore, it is helpful to reduce angry outbursts and/or violent behavior. Clonidine is often prescribed for children with ADHD and tics. Tics are spontaneous, purposeless, often repetitive, movements or vocalizations, such as eye blinking, throat clearing, and verbal or non-verbal sounds. Kapvay can be particularly helpful for children with tendencies to over-focus, or otherwise become overly absorbed in a specific activity. This medication is thought to work by inhibiting the release of the neurotransmitter norepinephrine in certain parts of the brain. People with heart disease should not take drugs containing Clonidine because the lowered blood pressure can present additional risks. The medication can also exacerbate depressive symptoms.

Anticonvulsants

Another type of medication prescribed for ADHD are anticonvulsants (anti-seizure). One such medication is Tegretol®. Tegretol can be especially helpful for children with both ADHD and seizure disorders. Having a seizure disorder can complicate ADHD treatment. This is because the usual stimulant drugs often worsen seizures disorders. Some children with ADHD have seizures accompanied by angry outbursts and aggressive behavior rather than the more usual loss of consciousness. Anticonvulsant medications can have a calming and soothing effect on these children. Other children may require a combination of stimulant medication and anticonvulsants.

 




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