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The Nuance

Can Better Habits and Therapy Replace ADHD Drugs?

Going off medications can be enticing for people who have been on them for years. But is it safe?

Credit: Andrii Zastrozhnov/Getty Images

AAccording to the National Institute of Mental Health, one of the hallmarks of attention-deficit/hyperactivity disorder is impulsivity — or making hasty decisions without taking time to think through the consequences. That’s probably a good thing for someone with ADHD to keep in mind before abandoning prescription medication.

“Just as taking a new drug can seem like the best way to solve a health problem, going off a drug can also be an enticing option — especially if someone has been on a medication for years and feels they no longer need it,” says Dr. Michelle Riba, a clinical professor of psychiatry at the University of Michigan.

“We all want a quick fix,” she says. “But it’s very important for someone to work with a doctor before making these sorts of changes.”

At the same time, she and other experts say there are some — and maybe a lot — of people in the United States on ADHD drugs who may be able to find relief from non-drug treatment options. “It’s also possible that some people diagnosed with ADHD as kids — and who have been taking drugs for it ever since — have been prescribed ever more complex drug combinations that have little or no evidence of benefit,” says Julie Zito, a professor of pharmacy and psychiatry at the University of Maryland School of Medicine.

“In the beginning, the big hallmark for children with ADHD was hyperactivity, but then in the 1980s we decided that inattention was also important,” Zito says. “Expanding the disorder’s diagnostic criteria brought in a lot more young people, and rates of ADHD spiraled,” she says. More than 9% of U.S. kids have been diagnosed with ADHD, according to recent figures from the CDC. And these rates are actually down a bit compared to the highs reached back in 2011 and 2012. “Medication — mainly stimulants — is the usual treatment for these kids,” she says. And so many adults — either those diagnosed with ADHD as children or later in life — are on these drugs.

“Adult ADHD is a more recent phenomenon and has its critics,” Zito says. In adults, symptoms of ADHD overlap with many co-occurring conditions — including depression, anxiety, and personality disorders. This overlap makes an ADHD diagnosis “difficult to justify with certainty,” she explains. “There are diagnostic criteria for adult ADHD, but these involve interpretation and there is no objective measure to verify the diagnosis,” she says.

“There is little doubt that adults identifying themselves as candidates for an ADHD diagnosis have significant problems warranting care,” she continues. But solutions may lie in psychotherapeutic treatment and not with medications alone. “I think we have problems in the way we’re living, and not every problem in living should turn into a medical diagnosis treated by a drug,” Zito says.

“There’s no protocol in place for discontinuation or de-prescribing.”

For example, along with impulsivity and hyperactivity, problems related to concentration and organization are considered primary symptoms of ADHD, per the NIMH. And there’s some preliminary evidence that media multitasking — surfing the internet while watching TV, or trying to text or absorb digital information while engaging in other non-media activities — is associated with poor attention, reduced task “vigilance,” and impulsivity, especially among kids.

“Of course it’s hard to focus and stay on task when you’re doing three things at the same time on your phone,” Riba says. “It’s possible that some people diagnosed with ADHD are making their symptoms worse with these and other unhelpful activities,” she says. There’s evidence that making lifestyle changes can help those with ADHD.

Research from Massachusetts General Hospital has found that cognitive behavioral therapy (CBT) can help people with ADHD manage their symptoms. CBT is, in simplified terms, a form of psychotherapy that teaches people to reframe how they think about their symptoms or issues and take real-world steps to address them. “Our focus with the CBT program has been on giving people a scaffolding to help them function better and get more organized,” says Susan Sprich, director of the Cognitive Behavioral Therapy Program at Mass General. “A lot of the things we work on seem really basic — things like making task lists and having a calendar — but a lot of people with ADHD don’t have good strategies in place for this.”

Sprich says her research found that in both kids and adults those with ADHD who underwent both CBT and drug therapy had better outcomes than those who used drugs alone. An unpublished pilot study she and her colleagues conducted found that even absent medication, CBT had similar effects. She says drugs clearly help some people with ADHD address “core” symptoms like an inability to stay focused. But her research suggests that psychosocial treatment like CBT can also be effective. There’s also evidence — again preliminary — that mindfulness-based meditation programs can help some people with ADHD manage their symptoms.

Riba says that anyone considering going off ADHD drugs should first try to mitigate their symptoms with a mix of lifestyle changes and psychotherapy. “If your sleep or diet or exercise or organizational habits are poor and you can’t improve them while you’re on a drug,” she says, “you’re even less likely to succeed if you go off a drug.”

On the other hand, if a person with ADHD feels like they have their symptoms under control and good habits in place, she says they could consider tapering off their drug use with a doctor’s oversight. “This has to be done slowly and carefully and with support,” she says.

Unfortunately, there’s no roadmap for people with ADHD to follow when going off their meds. When it comes to ADHD drugs — and many other prescription medications, for that matter — “there’s no protocol in place for discontinuation or de-prescribing,” Zito says. She also points out that most ADHD drugs are stimulants. “Of course if you go off them you’re not going to feel as upbeat,” she says.

In other words, the road off of an ADHD medication is likely to be a bumpy one. But staying on these drugs isn’t the only option.

I write about health and science. I live in Detroit with my wife and kids. I’m trying to learn German, but my progress so far is nicht gut.

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