ADHD Unmasked: Current ADHD Treatment Landscape

In this roundtable discussion featuring a panel of experts, Dr Gregory Mattingly, Dr Richard Price, and Dr Birgit Amann delve into the evolving landscape of ADHD treatment. The panelists discuss current treatment options, including psychostimulants and nonstimulants such as viloxazine ER, and share insights on their clinical decision-making processes. Key topics include patient-specific factors influencing treatment choices, the impact of increasing ADHD diagnoses on clinical decision-making, and recent significant advancements expected to influence ADHD management practices.

Dr Greg Mattingly: Welcome everyone, and thank you for joining us for a roundtable discussion discussing extended-release viloxazine compared with atomoxetine for ADHD. I'm Dr Greg Mattingly, an associate clinical professor at Washington University and the president-elect for the American Professional Society for ADHD and related disorders. Today I'm joined by two friends, colleagues, and a researcher who just published an article that's really going to be the topic of our discussion today. Why don't each of you just introduce yourself to the audience as we go through this discussion?

Dr Richard Price: Okay. Hello everyone. I'm Dr Richard Price, professor of psychiatry at Weill Cornell Medical College in New York, and happy to be with you today.

Dr Birgit Amann: Hi everybody. I am Dr Birgit Amann. I'm a child, adolescent, and adult psychiatrist. I'm in a private practice setting, the Behavioral Medical Center in Troy, Michigan. I'm also happy to be here with you today.

Dr Greg Mattingly: Well, let's take the audience through our main topics of the day. So number one is we want to talk about some of the treatment challenges that we've all experienced in the landscape of ADHD in the past year. Birgit, I don't know about your clinic, but every day we probably get phone calls, right?

Dr Birgit Amann: All day long.

Dr Greg Mattingly: Phone calls about “I can't find this medicine,” “This medicine isn't available,” “Is this really the right medicine?” “They tried to switch me to something else.” And so talking about some of the recent landscape of ADHD, some of the recent challenges, right? I'm assuming in New York you probably have the same challenges we've had in St. Louis, right?

Dr Richard Price: Absolutely. We actually published two articles on the topic. One was about pharmacies actually switching formulations on patients who only found out subsequently when they came in and they had all these new-onset symptoms, and then we delve in a little bit more in depth, and we found that the prescription was changed because of shortages.

Dr Greg Mattingly: Yeah.

Dr Richard Price: Another article was about how to find workarounds, requesting brands versus generics, but then insurance would say we're not covering brands. Then maybe we got an exception, nationwide shortage, 90-day authorization administered. So a couple tricks of the trade, but it's been really challenging, which is encourage people to consider other options, which is not necessarily a bad thing. Could be a silver lining.

Dr Greg Mattingly: Yeah, it's been interesting because the 3 of us who have been in the ADHD field for, in my case, several decades, probably each of us a couple of decades, we pick and choose the medicines based on duration, symptom coverage, side effects. It's not just a willy-nilly, I just pick it out of the air. It's based on what we think is best for our patients. So to have those shifted without academic discussion, without a discussion with the patients, and it puts people in harm's way. But I think I agree with you, we'll talk about this later. It has caused me in our clinic with the doctors and nurses that I work with to sit and think about are there other options that may even be even better options for the patients sometimes. So that's going to be number one, the treatment landscape. Number two, we're going to dive into your study. So your clinic, if I remember right, it was you and your son, I think, participated in a research study saying, hey, let's take a look at not just stimulant options, but nonstimulant options. One of our newer-release nonstimulants, I think the most recently released nonstimulant, viloxazine extended-release, saying, how could that play versus atomoxetine for people who maybe didn't want to be on a stimulant or, if I remember the study, and we'll talk about this, some of those people were on a stimulant but were looking for other options along with the stimulant.

Dr Richard Price: Or insurance algorithms forced you to go through certain protocols.

Dr Greg Mattingly: Yeah. And then we want to dive into what are the current needs for our audience out there when they’re taking care of patients? What are some of the residual symptoms? What are some of the side effect barriers? And then I think there's a big push these days, there's a push across the country trying to minimize the use of short-acting stimulants, especially in college-age and adults, having worked now with the FDA and the CDC and other people, they're saying, let's see if we can't find other options. Not that short-acting stimulants don't work, but sometimes they get used for the wrong reasons. Okay. So let's talk about the treatment landscape. Birgit, if you had to say currently some of the biggest challenges in ADHD, what would you say some of the biggest challenges are in the treatment landscape?

Dr Birgit Amann: Well, I think first and foremost, we need to do a better job diagnosing. We know that especially adults, we're missing a lot of them. So many of them come in and they've been treated for depression and many different antidepressants. No one's ever asked them anything related to focus, concentration. So just right at the basics, take a good history and consider ADHD as a diagnosis. And then from there, the different treatment options that you might consider, you would discuss.

Dr Greg Mattingly: Dr Price. I don't know your practice quite as well as I know Birgit’s. Do you see children, adolescents, and adults? I'm assuming you see the entire age range, right?

Dr Richard Price: Age range and seniors.

Dr Greg Mattingly: Okay, yeah. One of the fastest growing groups is seniors with ADHD. We haven't talked much about that up until now. So that landscape about missed patients, we know that right now it's about two-thirds to three-fourths of adults that come in for an ADHD evaluation weren't being treated as a child. So about a third to a fourth of our adults were being seen as kids. They had a diagnosis, maybe they're getting treatment, but now that we know about two-thirds, and this is around the world, are coming as adults saying, “Listen, I think I was missed.” I just saw something online. I read an article. Could this be me? And that chief complaint, Birgit, what's the chief complaint when a woman with ADHD comes in your office? What are the symptoms she's usually experiencing?

Dr Birgit Amann: Most of the time it's “I'm overwhelmed.” “I'm anxious.” “I can't keep the balls in the air.” “There's too much for me to do.”

Dr Greg Mattingly: Yeah, chief complaint is “I'm stressed and distressed.”

Dr Birgit Amann: Mm-hmm.

Dr Greg Mattingly: And we've talked a lot about this, that that tends to be the chief complaint, and unless you're cued in to look for what's underneath the surface, if somebody's stressed and depressed, what do they wind up on?

Dr Richard Price: Benzos, SSRIs, which you're not going to address the core ADHD symptoms.

Dr Greg Mattingly: Yeah. So it may help to decrease the overall perceived stress, but it's not helping what's driving the stress. So I think we've talked looking beneath the surface,

Dr Birgit Amann: Absolutely.

Dr Greg Mattingly: what’s that long-term journey been like? Go back in time. Let me get to know you as a kid. Where'd you grow up? What did you like to do? Start with strengths, but then let's talk about when you started having challenges. We know that women with ADHD tend to be more often missed than men. We know that women tend to be about twice as likely to be missed when they were children versus men. And we know the inattentive group, right? That group that was just distressed and overwhelmed, but they weren't causing trouble, are more likely to be missed. There's a great study I like that was done, and it looked at IQ, it looked at IQ versus ADHD, and one of the take-homes of that slide was IQ doesn't discriminate. You can have low IQ and have ADHD, right? Kids with learning disabilities. You can have middle IQ and have ADHD. You can be bright and gifted and have ADHD. But IQ does change the age you get diagnosed. If you have 100 IQ in that study, the average age of diagnosis was age 9. If you had 120 to 130 IQ, the average age of diagnosis wasn't until about age 28, because you had enough IQ points to compensate early in that journey. How often do you guys see a professional who's gone back to maybe graduate school who all of a sudden, they've hit their ceiling when it comes to ADHD? Is that a common thing in your practice?

Dr Richard Price: Sure, because they reach a certain kind of cognitive load. The demands of their academia or their work have now superseded their capacity. But with intervention, they will be able to do it very nicely.

Dr Greg Mattingly: Yeah.

Dr Birgit Amann: it's really important to explain that to patients because they're really perplexed. Why didn't anybody ever consider this for me? And then you have to talk about exactly that. A lot of times after you treat them, it's kind of bittersweet, like they did succeed because they had the IQ to do it, but it doesn't mean it wasn't without more challenge than it would've been otherwise.

Dr Greg Mattingly: Yeah, 100 percent. You have to remember too, for the diagnosis of ADHD, we have a certain set of symptoms. We look at those 18 symptoms, 9 inattentive, 9 hyperactive/impulsive, but it's not just symptoms. What's the second part of the diagnosis?

Dr Richard Price: Functionality.

Dr Greg Mattingly: Yeah. It has to be causing impairment. So if you were getting by, even though you had symptoms, you don't meet criteria for having clinical ADHD. It's when you start decompensating and having impairment when it's affecting your marriage, your job, your driving ability, your ability to pay your bills, that's when you now meet criteria for the diagnosis. So a lot of our women that come in, they may not have had ADHD as a diagnosis, but they've had symptoms that are now, when they’re age 25 or 30, causing impairment, right? So how do you explain that to them that maybe they've been treated with an SSRI, maybe they've been treated with other things for stress. How do you help to demystify that for them and get them on the right journey? What do you do?

Dr Richard Price: Well, when you consider agents that address ADHD as well as many of the other comorbidities, then you get the silver bullet. You get something that could perhaps treat the whole spectrum of why they're coming in. The core symptoms of ADHD and many of the associated symptoms that often require separate treatments may only require a monotherapy.

Dr Greg Mattingly: Yeah. I wrote an article a couple of years ago with 3 other colleagues, and we chose the 4 of us to all have unique perspectives, different backgrounds. So one's a child psychiatrist that works in addictions. One was an internationally trained psychiatrist talking about an international culture. One was a younger psychiatrist talking about younger patients and what's the modern digital world like? And a lot of our discussion was that ADHD plus. Now when it's ADHD plus depression, ADHD plus anxiety, ADHD plus substance use, does it make sense to tackle the ADHD first or should we tackle the other things first? So what are your thoughts there? How do you unpack that ADHD plus group that we see quite often?

Dr Richard Price: Well, prior to some of the most recent advances in our field, we had to think of it in this categorical way. And often ADHD got short shrift. It was the last thing.

Dr Greg Mattingly: Correct.

Dr Richard Price: We're going to treat this first and this second, and we'll top it off with some ADHD medication, which could exacerbate the other conditions if those weren't treated first. Now we have more modern agents, perhaps we'll discuss today, that could address the full spectrum of ADHD plus many comorbidities.

Dr Greg Mattingly: Yeah.

Dr Birgit Amann: I wish I had more opportunity to look at it and decide one or the other, because they come to me having already been on, currently or prior, the SSRIs, the benzos. So I don't even have the luxury of making that decision a lot of times, unfortunately.

Dr Greg Mattingly: A really important study that came out, I think it came out about 2 years ago, and it was written by Steve Faraone and some of our colleagues, some of the really preeminent researchers in ADHD, and they looked at the impact of comorbidity over time. Untreated ADHD tends to become complicated ADHD. You pick up anxiety, you pick up depression, you pick up sleep issues, you pick up substance use issues, you pick up anger control issues, right? So it becomes more complicated the longer it goes without treatment, and those complications dramatically increase mortality rates. So ADHD by itself was a pretty bad condition. It predicted negative outcomes when it came to jobs, lifestyle, living, but even higher mortality, about a 50% higher mortality; ADHD plus one or two comorbidities, all of a sudden you're getting a 400%, an 800% higher mortality rate. And if you look at the mortalities, Birgit, what do people with ADHD who have those comorbidities, what do they tend to die of?

Dr Birgit Amann: Suicide, accidents,

Dr Greg Mattingly: Yeah.

Dr Birgit Amann: injuries.

Dr Greg Mattingly: I call them deaths of despair. Right? Deaths of despair. So if I'm a woman with ADHD and I'm struggling, I may choose a mate who also doesn't have a healthy lifestyle. So women with ADHD are three times more likely to die as a victim of domestic partner violence. People with ADHD and depression are more likely to take an impulsive suicide: I get overwhelmed. I didn't wake up this morning planning to commit suicide, but all of a sudden something snaps. I'm overwhelmed, and I start feeling this despair that I can't modulate.”

Dr Birgit Amann: But Greg, then if you think about what we're dealing with as we talked about this shortage, so all these patients who even treated have that risk are untreated for their ADHD.

Dr Greg Mattingly: Because they're cycling through, they can't get their medicine through their pharmacy.

Dr Birgit Amann: They can’t get their medication. They're at even greater risk.

Dr Greg Mattingly: Yeah, I know you told me about a pharmacy scolded you.

Dr Birgit Amann: That’s right.

Dr Greg Mattignly: Because patients were crossing across from one area of the city to another trying to find their medicines.

Dr Birgit Amann: That’s right, I had read,

Dr Greg Mattingly: “How dare you send patients to our pharmacy? This is for our patients. We're out of medicine too.”

Dr Birgit Amann: Mm-hmm.

Dr Greg Mattingly: Yeah. The good news is for clinicians out there, this is finally coming to the attention of some of the people that make differences when it comes to policy. We had a senator from Oregon who called up the FDA and the DEA and the CDC and made them come in and testify to Congress and said, listen, I've got a kid with ADHD. I have constituents with ADHD. I have pharmacies all across my state in Oregon that are calling me because they can't get their medicines. So be honest about what's going on and let's work on solutions together. There's an upcoming meeting coming up in December, the National Academies of Sciences, Engineering, and Medicine, where everybody's going to be brought together to talk about this. So I'm looking forward to participating in that as we all work together as a team saying, okay, what are some of the newer agents? What are some of the shortages? What's the importance of treating ADHD but treating it holistically in the landscape of what we deal with. What else? Any other thoughts from you guys about current things that you've seen in your practice?

Dr Richard Price: So on the flip side, I've seen over self-diagnosis and misdiagnosis of ADHD. People coming in saying, “I took some kind of online screener. I think I have ADHD.” Someone gave me some amphetamine, some Adderall, and that's what I would like please.” And they're coming in requesting a certain medication by name based on a self-diagnosis. Could be a misdiagnosis or it could be a comorbid diagnosis with something else, or first-line stimulant option may not be the first-line option for them.

Dr Greg Mattingly: One of the studies I've used a lot for education, and Birgit, I know we've discussed this study, was a study done by some of our colleagues up in Montreal. And they looked at the top 100 ADHD TikTok videos.

Dr Birgit Amann: Mm-hmm.

Dr Greg Mattingly: And they said, okay, how often are people seeing those videos on TikTok that talk about ADHD? The average video was viewed not by 10,000 people or 100,000 people. The average video was seen by 2.6 million people. The average ADHD TikTok video was shared with another 600,000 people by everybody that watched it. When they went and looked at those videos, what they realized is 2 out of 3 were misinformation about ADHD. Pop some of this and it'll make you smarter. Pop some of this and you'll ace your quiz. Do this and whatever. Don't take your medicine on this day. Take it on this day. So it was misinformation. Only about 20% to 30% was actually considered reasonable information. So I think social media can be our friend because it increased awareness, but it can also sometimes be our enemy because it teaches the wrong habits and the wrong traits, right?

Dr Birgit Amann: Those are the patients that get really frustrated because I'll make them start all over. I'll say, we're going to go right back to, as you said, what were you like as a kid? I need to be comfortable with this diagnosis before I'm writing you this medication, which they don't love if they've been able to access it prior to now.

Dr Greg Mattingly: Let me, I’ll throw it out there. Something we all deal with. I bet every clinician at home has dealt with this, and it's the short-acting stimulant trap, right? They come in and say, “I tried this and it really helped.” How do you handle that? Well, because a couple of alarm bells go off in my head right away when a patient says, “I tried a controlled substance.”

Dr Richard Price: So here's the question that they always get wrong. And hopefully they're not watching this, but clinicians are watching this. When you took that stimulant, it helped you focus, yeah? “Oh yeah. Helped me focus.” Did you feel more alive, more energized, more pumped up? “Yes, I loved it.” Now with ADHD, I would expect they would say, “Yeah, helped me focus. I was more calm, I was more settled.” And hopefully this gets to the right audience. The clinician should hear this, so that people are not beating the system, as they're trying to do. But this question they universally get wrong, and that leads me to believe that they're using it perhaps for the wrong reasons.

Dr Greg Mattingly: It's a great question. Because we know stimulants can be misused for other uses, right? And some of the common ones is, I'm not sleeping enough, so I want to a stimulant. Maybe I'm trying to control my appetite, so I want a stimulant. Maybe I want to pull an all-nighter because, I want a stimulant. So those misuses, one of the things I've seen is if you go down that trap with that patient, that patient says, “Oh yeah, it felt great. I had lots of energy. Man, I didn't need to sleep much. I got a lot accomplished.” People build a tolerance to that effect, right?

Dr Birgit Amann: Mm-hmm.

Dr Greg Mattingly: And the trap is they come back the next month, they say, “Hey, could I have a little more?” And 6 months later, they're wanting a little more because you build a tolerance to energy and appetite suppression. One of the beauties of ADHD is when you get it right, people don't tend to build a tolerance. The dose that works, whether it's a stimulant or a nonstimulant, once you get somebody optimized, what happens?

Dr Richard Price: They're functioning better. If they've got the right agent, they're doing well. They're not dependent, they're not withdrawing, they're happy, they're functioning, and people around them are very happy when you get it right.

Dr Birgit Amann: And the other thing is optimized. I talk to my patients about that all the time. You're going to get a certain amount of help from your medication, but optimized also includes coaching and organization skills and counseling and things like that. So that's another important piece because they want it all to come from the short-acting medication that they're taking.

Dr Greg Mattingly: There's a really important concept that we don't talk enough about these days, and that's the dyadic response to treatment. And Russ Barkley, way back when in the 1960s, did a study. He treated children with ADHD, and he didn't look at the impact on the children. He looked at the impact on the rest of the family. So your dyads are your most important relationships. A husband/wife, a boyfriend/girlfriend, two partners in a relationship, a parent and a child.

Dr Richard Price: And the siblings.

Dr Greg Mattingly: And the siblings! And the siblings, they're all part of those dyads, right? I think the beauty of ADHD, when you get the right treatment, you're not just helping that patient, you're helping everybody else in that dyad, right? So a dad with ADHD who gets treatment, our good friends up in Washington did this study, if a dad with ADHD has a son with ADHD, when I treat the dad and help him to do better, how are his kids doing?

Dr Richard Price: Everybody's so pleasant.

Dr Greg Mattingly: Everybody's better.

Dr Richard Price: Everybody's happy. It's a happy home.

Dr Greg Mattingly: And I'll tell my dads with ADHD, he said, listen, if you run around with your hair on fire, everybody else is going to run around with their hair on fire. If you come in and yell and scream after work, probably everybody else is going to blow up after school. So when you treat one person to get them doing better, you influence the whole family system unit. But that goes back to, I know one of your concepts that you're a big fan of, ADHD doesn't just disappear when you leave work or leave school.

Dr Birgit Amann:  Mm-hmm.

Dr Greg Mattingly: It's all those other important parts of your life where ADHD really affects it.

Dr Richard Price: When have a dyad come in, one or the other will say, “Someone's going to leave here with medication. Either this one's going to take it, we’ve got a problem to solve, or I'm going to have to take something to deal with them.” So everybody's impacting everyone else.

Dr Greg Mattingly: I'll have parents come in all the time, and I know we all do this, but I'll talk to the kid.

Dr Birgit Amann: Me too.

Dr Greg Mattingly: So instead of talking to the parent, I'll say, “Jimmy/Susie, tell me about you. What do you like to do?” I start with strengths, not weaknesses, none. Then I start walking through their life. If a parent starts interrupting me, that tells me a lot about the relationship. After I get to talking through the kid and where I think they are and where they're with symptoms and where they're starting to have struggles and all of those things, I'll turn to the parent. I'll say, “So what did we miss” with Jimmy or Susie? Some of these parents are so twisted up, what comes out of their mouth. It's a slew of all the things they don't like about their child.

Dr Richard Price: Or themselves, and it’s the “we”

Dr Greg Mattingly: Protect themselves.

Dr Richard Price: “We are having trouble in school.” We? You're in school?

Dr Birgit Amann: But parents do a better job giving their kids that negative attention than they ever do giving them positive, and especially ADHD kids. So that little boy or girl's self-esteem is shot not only from the friend impact, they're rejecting, but mom and dad?

Dr Greg Mattingly: Constantly having to pull things away, reprimand, whatever.

Dr Birgit Amann: Right, right.

Dr Greg Mattingly: So Birgit, when I get to that point, and I'll listen to them, it's usually the mom, sometimes the dad, and I'll listen for a minute or two to this string of negative things. “Jimmy's having troubles in school. I keep getting called. He's, he won't behave himself. He's picking on his sibling.” He's all these things. I'll listen to that for about a minute or two, and I'll interrupt the parent and I'll say listen, I know we're struggling, but tell me the 2 or 3 things you love the most about Jimmy.”

Dr Birgit Amann: Mm-hmm, right.

Dr Greg Mattingly: And some of them can't do it. And that tells you a lot about the work we got to do both with medicine and outside of medicine to help restore the family dynamic, the self-esteem. There's another important concept. I got asked to write an article, a review article a few years ago, and so I could talk about ADHD management, choosing the right medicines, stimulants, nonstimulants, blending them, all the things we do. But I get to talk about behavioral intervention, and I talked about a concept in this article about positive parenting. How many of our parents have shifted to negative parenting – scolding, taking things away? But if you're already twisted up and somebody scolds you, does that help to improve your behavior?

Dr Richard Price: You're just reinforcing the negative behavior like you would train anybody with behavioral therapy or even a primate.

Dr Greg Mattingly: Yeah.

Dr Richard Price: So when you help them find their strengths, they're creative, they're spontaneous, they're funny, they're musical, they're artistic. These are wonderful traits for a society to move forward and to evolve. And we want to also help identify something that they enjoy doing and they can do well, so they can take great pride in that, and then a lot of these other negative symptoms fall away.

Dr Greg Mattingly: Love it, love it, love it, love it. So in my article, I talked about the concept of positive parenting,

Dr Birgit Amann:  Mm-hmm.

Dr Greg Mattingly: and helping parents to shift more to a positive parenting model to help modulate that. I think it's right. You look at it, I'll look at my kids and I'll say, “Listen, you're a good kid with a good heart, and when you pause and take time to listen to it, you'll make the right decisions.”

Dr Richard Price: Or you want to be good, but I just can't help myself.

Dr Greg Mattingly: That's right.

Dr Richard Price: My essence is good.

Dr Birgit Amann: Yeah.

Dr Greg Mattingly: But when this <pointing to head> isn't allowing you to slow down and pause because you have symptoms of ADHD that are causing impulsivity and those things, it's hard to pause to listen to this <pointing to heart>.

Dr Birgit Amann: Well, it reminds me of a little boy, because I talk to my kids too in the office, and he said, “I have a good brain and a bad brain, and my bad brain makes me a bad boy.” And his “bad brain” was referencing when he has his ADHD symptoms, he's impulsive, he gets in trouble at school, he's kicked out. It was very powerful.

Dr Greg Mattingly: I was recently working with a producer, a video producer who does a lot of documentaries and series and educational things, very successful on the outside, owns his own studios, very successful. And he had watched a video that I and some other colleagues had done on adult ADHD, and he said, “Dr Mattingly, oh my god, it's me. I'm very successful on the outside, but I can't tell you how many times I've had a utility bill shut off...

Dr Birgit Amann:  Mm-hmm.

Dr Greg Mattingly: ...because I forgot to pay something. I get hyper-focused on the things I enjoy, and I let everything else around me fall apart, my personal life, my financial life.” Adults with ADHD tend to spend impulsively, so they have less financial savings. So if they get to that rocky time in between jobs or what happened during COVID, our adults with ADHD and our families with ADHD had less financial reservoirs to be able to manage those kind of periods where things went south in their life.

Dr Birgit Amann: Well, and people thought, “oh, I don't need my medication because I'm not at work,” or my kid's not at school. And that lasted for 3 weeks and then it just all went crazy.

Dr Greg Mattingly: A hundred percent. A hundred percent. So how do you coach beyond the medication? What do we do behaviorally to help our families with ADHD? What are some of your practical tips as far as helping with impulsivity, helping with organization, helping with strategizing to have a successful day tomorrow? What are some of your tips?

Dr Richard Price: Structure.

Dr Greg Mattingly: Yeah.

Dr Richard Price: Structure, structure. And we lost that in the pandemic. Structure broke down. Kids are home, parents are home, everyone's getting on each other's nerves. We lost the structure. So now that that's passed, rebuilding that structure, having set times planned in advance where you can have some flexibility, but you can see predictably what's going to happen this day, mapping it out day by day, week by week, the night before, you can head off a lot of things when you institute that structure. And that's just like executive coaching that you can teach them, very teachable, and they implement that. And that's a big part of the treatment approach is not just relying on medications, but building in that structure.

Dr Greg Mattingly: You mentioned a group we don't talk much about with ADHD, but it's actually as a percent the fastest growing group with ADHD. It's seniors.

Dr Richard Price: Mm-hmm.

Dr Greg Mattingly: So if you look at the most recent CDC data, women are the fastest growing group as far as coming in for ADHD care, but as a percent of people, seniors are the ones growing the fastest.

Dr Richard Price: Yeah.

Dr Greg Mattingly: Because we live into our senior ages. I just turned 60, so I qualify as a senior I guess, at this point.

Dr Richard Price: Well, you're looking great.

Dr Greg Mattingly: Yeah?

Dr Richard Price: Keep up whatever you're doing.

<laughing>

Dr Greg Mattingly: But more and more of our patients are wanting to be productive into their fifties, sixties, and so those management strategies… But what made me think of that was that's a period of life where a lot of times the structure that has kept people doing well – I get up, I go to work. I get up, I have this job. I get up and I take my kids to school. And all of a sudden you look around the house and you go, what happened? Right? So helping people to regain that structure as they go through those transitions in life, structures with college, and we've talked about this Birgit. I'll coach my college kids. I always have my pre-college visit about 2 weeks before they go off to school. We'll talk about what are the winning strategies to have a winning semester. And I'll ask my kids with ADHD, I'll kind of set them up. I'll go, “What's the most important semester of college?” And all they're thinking about is I want to go there and drink and party and have fun. Right? I say the most important semester is your first semester.

Dr Birgit Amann:  Mm-hmm.

Dr Richard Price: That transition.

Dr Greg Mattingly: Yeah. If you have a winning first semester, it sets the tone for the rest of college. If you go there, though, and you haven't thought through it and created the structure for your day at school, knowing where I'm going to go and study, knowing where I'm going to go and have fun, knowing where the gym is, all of those things that give you structure with ADHD, and that first semester gets off to a rocky start. It's hard to dig out of that.

Dr Birgit Amann: Well, and the other thing is they need to remember that they have resources in college. In elementary, middle school, even high school, Those resources came to them. They have to seek them out to have that successful semester, so they have to be aware of that too.

Dr Greg Mattingly: Yeah. Let's dive into, we've talked a lot about psychosocial and unmet needs. Let's dive into the world of medicines a little bit. Okay? So medicines for ADHD are considered pretty foundational parts of treatment when we talk about treatment. So we do psychosocial stuff, we do all the other things, but we know that for most of our patients with ADHD, some type of medication will be foundational. How do you pick and choose? And the way I kind of break them down in my mind is we have stimulants and nonstimulants. Among the stimulants, we have the amphetamines, we have the methylphenidates, and then we have various durations and preparations of methylphenidates/amphetamines. In the nonstimulants, I break them down to a couple of categories there as well. I think of the alpha-2 agents, guanfacine, clonidine. I tend to think about atomoxetine, and I tend to think about viloxazine. And so I break them down into 3 categories, the alphas, atomoxetine, and viloxazine, when I'm thinking of the nonstimulants. Does that resonate as a way you'd kind of think about it? Stimulants, 2 categories, nonstimulants, a couple of different options with distinct molecular…

Dr Richard Price: So that's exactly the way I think about it, except you mentioned viloxazine last. Given my personal experience, my patient experience, which I know a lot of clinicians haven't had yet, that's my first mention.

Dr Greg Mattingly: Okay.

Dr Richard Price: That's my first thing I think about, whether they're a viloxazine candidate or not, and then I move to the other ones because of side effects and liability.

Dr Greg Mattingly: So you've taken our typical thinking, you've flipped it upside down. 

Dr Richard Price: Flipped it upside down, a paradigm shift.

Dr Greg Mattingly: So tell me about that. I know you've been involved with a lot of research. You've written a lot of articles, you teach, you mentor other people. What made you think about flipping that paradigm upside down?

Dr Richard Price: Well, seeing is believing. One of the speakers here mentioned about different levels of evidence, the research evidence, and you have taking things on faith and then taking things on eminence, the eminence of the experts who tell us what to do. But then I think you have another level of evidence, and that is your patients’ experience, what they're telling you, and you're listening very carefully, how is this working for you? How quickly is it working? Side effects, tolerability, overall picture improving? Beyond the rating scales. First, you want to see the rating scales, you want to compare and contrast, but how are you doing? When you hear the feedback from your patients who are appropriately dosed? We can get into that. That's what convinced me that the paradigm needs to shift, and I can't expect people who haven't used it, who are just looking at a study or reading the literature or seeing things on TV to understand that. So I don't fault them for it, and I'm not frustrated by it. I know change will take time, but as more and more patients, older and younger, and clinicians get experience with other options, they may start to change their thinking.

Dr Greg Mattingly: Yeah, I love it. Having been a part of a lot of ADHD research trials over the last 25, 30 years, taking short-acting stimulants and making them long-acting stimulants, thinking about developing nonstimulants, but nonstimulants with different mechanisms of action that bring different things for different patients, and then thinking about those unmet needs and where do we flip the gaps sometimes in the way we're treating. Birgit? How do you think through the different treatment options, so between stimulants, nonstimulants, the various classes of medicines, how do you describe them to a patient?

Dr Birgit Amann: I mean, very similarly to both of you but, and I do talk with my patient about all of them and categorize them like that. I also think about, for example, viloxazine and atomoxetine are the only 2 with adult indication in the nonstimulant realm. And then there's a lot more that goes into it, as we'll talk about, related to other aspects. But I think about what have they been on before? What was their response to that? What were the side effects that they had? Is there a family history of response to a certain medication? What's the time constraint? If you have somebody who has severe impulsivity and there's a safety issue, then I can't have a medication that takes 4 weeks to build. I've got to really act on that quickly. There's a lot of different aspects that you take into consideration as you're looking at treatment for them.

Dr Greg Mattingly: Yeah. So symptoms, areas of impairment, duration of coverage, and I think the 3 of us in this room, and probably most of the audience, we've gone from saying, “Hey, listen, when do you need it?” to pretty much thinking, let's keep it as long as we can in the system. I want those symptoms to be under control so they're not causing impairment, not just in the morning when you're getting up or going to school or going to work, but in the evening when you're home with your family, when you're dating, paying bills, making decisions there. I want those symptoms under the best control I can have throughout as much of the day as possible.

Dr Birgit Amann: But when we use stimulants, that means very commonly that we're going to have to have that main agent and then another medication that's short-acting. Again, we're trying to minimize the short-acting. so we have somebody who can be forgetful and distracted and they're not always going to remember that extender, and then they're not treated in the evening, and that can be very powerful in a negative way.

Dr Greg Mattingly: If there's a take-home for our audience, and I hope they listen to this point, and I'll probably repeat it a few more times as we go through: One of the biggest mistakes is no short-acting stimulant has an FDA indication for adults.

Dr Birgit Amann: Mm-hmm.

Dr Greg Mattingly: Short-acting stimulants were only tested in kids. We don't have duration data, we don't have safety data. We don't have efficacy data. So all the short-acting stimulants, their indication is pediatric and adolescent. They don't have adult indications. So when you start using them in adults, you're already going off-label, and you put your patients and yourself in harm's way because they can be misused for the wrong things, or you can have breakthrough symptoms where they're not giving you adequate coverage. I think it's something we don't talk enough about because it's very easy. The patient comes in and says, listen, I tried my roommate’s or my college friend’s or my kid’s, whatever this, can you give me some? It's very easy, clinician, you want your patients to be happy.

Dr Birgit Amann: Well, the other thing is we're giving them a lot of ups and downs in their day. We're giving them these peaks and troughs, peaks and troughs, and that can cause great difficulty, both with their ADHD symptoms but also emotionally. So that's not ideal. We want to have a smoother course of treatment.

Dr Greg Mattingly: So when you flip that paradigm upside down, okay, patients aren't used to thinking about that. How do you start that discussion?

Dr Richard Price: Well, I think about it in the way we think about anxiety, right?

Dr Greg Mattingly: Yeah. Words matter. So I know,

Dr Richard Price: So alprazolam (Xanax) highly effective for anxiety. So we could give Xanax 3 times a day, and as long as you take it on the clock, you take your Adderall on the clock, you're going to be covered until you're not covered, whatever. But we would never do that. We would always talk about an SSRI first, and maybe if we need to top it off with a PRN benzo, but that would be your foundational treatment. I'm looking at ADHD the same way. ADHD is not just focus for anybody. It really is a comprehensive, full spectrum, affects every aspect of your life, and I'm looking at other agents as foundational treatments that are still pretty rapidly acting, not addictive, don't have on-off effects, treat comorbidities very well, and if needed, topping off with a stimulant in those situations where it might be needed. That's a paradigm shift, but we've got our minds around it when it comes to anxiety and other potentially misused medications, I predict that as people get more experience with newer agents, they may start to see things differently than we have for the past 50 years.

Dr Greg Mattingly: It's interesting, with ADHD, if this was bipolar disorder, if this was schizophrenia, if this was, let's use other medical conditions, hypertension, we wouldn't say take it when you need it. We wouldn't say, hey, take something that lasts for 4 hours and you got to take it again to keep your symptoms under control. That would be like using short-acting clonidine to treat your blood pressure. Probably works, if you take it 4 times a day. What's the chance you're going to take it 4 times a day?

Dr Richard Price: And the pharmacy might be out. Uh-oh!

Dr Greg Mattingly: There you go. And there are rebounds, right? But I love that idea about thinking about, okay, instead of top down, let's flip it around and go the other way. What have been some of the limitations when we think of nonstimulants? So I think many of us got burned years ago when the nonstimulants first came out. We thought it was going to cure everything with ADHD. We started, back then, it was atomoxetine. That was the first one. You and I were researchers in those trials.

Dr Birgit Amann: Yep.

Dr Greg Mattingly: I remember us sitting in meetings and talking about using rating scales and all this kind of stuff, and one of the things we learned quickly was atomoxetine takes a pretty long time to start working.

Dr Birgit Amann: Right. That's a huge limitation because, again, we have patients that if they are having a lot of difficulty with impulsivity or whatnot, they can't wait that long. Wait. In fact, timing, you can't necessarily consider atomoxetine during the school year. You have to wait until summer. Whereas we could get going with other nonstimulants, for example, that we have, and get a response much quicker. We can use a holiday break and see an effect within 2 weeks. So that's a big limitation. Side effects. Atomoxetine has a lot of gastrointestinal side effects that could not only cause them to not take the medication and then it doesn't build. It also can cause us to have to delay the titration process, so it takes even longer.

Dr Greg Mattingly: Yeah. Atomoxetine is itself a direct GI irritant. You have to keep it in the capsule. And I made this mistake in my clinic years ago. I had a young boy who was kind of a pre-adolescent, a little oppositional, wasn't wild about taking medicine, and he told his mom, he goes, I can't swallow that capsule. And being a kind of naive clinician, I told his mom, I said, ah, just open the capsule and put it in some pudding or some applesauce or some yogurt or something like that. The kid came in to see me the next visit and he goes, “Dr Mattingly, you can't do that with that stuff. It's terrible.” I'm like, “Oh, you don't want to take your medicine?” He goes, “Well, I don’t want to take it, but it's terrible.” And I'm like, “Oh, come on.” And he goes, “Mom, open one of those capsules.” And I put a little bit on my finger and then a little bit on my tongue. My tongue burned the rest of the day. It's a direct GI irritant, so you're right. GI side effects with that were something you couldn't get around. You had to titrate slowly to avoid the GI side effects, which meant that onset for efficacy was 4, 6, 8 weeks quite often.

Dr Birgit Amann: Well, and then in my experience, I didn't find it terribly effective anyway for hyperactive impulsivity. It was more, if anything, for inattentive. And I would say the opposite in my experience for guanfacine and clonidine is that that's more if they have hyperactivity and impulsivity, but I'm not seeing enough for inattention. So I'm more commonly utilizing those as a combined approach with a stimulant, or maybe because the stimulant, we need to target the bookends of the day. So I'm blending it, but in and of themselves, I don't find them a monotherapy for most of my patients because most of my patients have combined-type ADHD.

Dr Greg Mattingly: Yeah. So with atomoxetine, which was our first one out, it probably didn't quite deliver what we were hoping for, right?

Dr Birgit Amann: Mm-hmm.

Dr Greg Mattingly: So I think it left many clinicians with a negative perception about what a nonstimulant is.

Dr Richard Price: Correct.

Dr Greg Mattingly: And I bet if we ask the audience out there, what's your perception of a nonstimulant?

Dr Richard Price: It's weak, slow.

Dr Greg Mattingly: Takes forever, people give up. And the data showed that if you had tried a stimulant in the past, people didn't give a nonstimulant atomoxetine a chance. It just took too long. So if you had been a prior stimulant responder or exposure, you were even less likely to give atomoxetine a chance versus if you'd never tried it. Then the next ones we developed, I developed guanine and clonidine extended-release hitting the alpha-2 agent. I think that they're effective for the right kind of patient.

Dr Birgit Amann: Patients with ticks. That's a…

Dr Greg Mattingly: Certain symptom, clusters, right? Impulsivity, hyper arousal, ticks and twitches, but probably didn't quite give us the cognitive bang for our buck we were looking for, right?

Dr Richard Price: Mm-hmm.

Dr Greg Mattingly: I think what we learned with each of those, though, is we can learn to blend them sometimes. And I know some of your research looked at exactly that.

Dr Richard Price: Mm-hmm.

Dr Greg Mattingly: Maybe a stimulant didn't give us all we wanted, but sometimes we could use a little nonstimulant with a stimulant to get the best of both worlds, right?

Dr Richard Price: But you also get the polypharmacy. So again, as we evolve to something that maybe could be a monotherapy, even better. But yes, that would be the thinking. Maybe a year or two ago, perhaps things could evolve.

Dr Greg Mattingly: Okay. When we start thinking about some of those traditional agents, one thing we don't talk enough about is the role of sleep.

Dr Richard Price: Mm-hmm.

Dr Greg Mattingly: Right? ADHD patients tend to be bad sleepers. I've written a couple of articles during my career looking at different compounds, measuring sleep effects, and we know that most of our ADHD patients at baseline, it's about 80%, meet criteria for some type of sleep disorder. So it's another one of those symptoms you want to keep in the back of your mind. You want to measure long-term with treatment, what's happening to your symptoms, but how are you doing as far as being able to slow your brain at night? This isn't meant to keep you awake and keep you aroused. It's meant that I can shift in and out of… We had a good friend years ago, Dr Dobson, who's up in Colorado, right here where we are now, and he talked about, I know I have a medicine just right, and somebody can really focus, but they can also relax, take a nap, read a book, listen to music. So I don't want you to be so revved up that, hey, I can kick in and I can focus. I want your brain to be locked into where you can do what you want to do with it. Right?

Dr Richard Price: Well, this is the balance is that you want to have the focus, but you don't want to have that hyperfocus.

Dr Birgit Amann: Right.

Dr Richard Price: And when I find that patients have any element of inherent hyperfocus to their ADHD, sometimes the stimulants are not going to be your first choice. They're not going to work out as well.