Medication works best when properly optimized for the individual
Samuele Cortese, MD, PhD discusses types of useful medication available and the importance of clinicians and patients working together to find the “sweet spot” that allows the right medication, at the right dose, to provide the maximum benefit as part of a treatment plan.
Transcription follows this 5:27 minute video
Lightly Edited Transcription
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Well, first of all, I think we need to bear in mind that there are mainly two types of medications that currently we use to tackle ADHD symptoms. These are the so-called stimulant and the non-stimulant medication. There is a difference not only in the mechanism of action but also in the clinical effects because, in general – when they say in general, it means at the group level, so on average – stimulants do better than non-stimulants in terms of what we call the efficacy, so the reduction of the severity of the symptoms that we can measure in studies, in particular, randomized control trials.
And, indeed, the stimulants are the most efficacious medications that we use in psychiatry, so they do, on average, better than other medications such as antidepressants, support antidepressants, antipsychotics, and so on.
Non-stimulants – they are also good, but their effect as slightly lower than the stimulants. Once again, what I’m saying is true at the group level because we do know that the response to this medication is individual, so there are some persons who do better, they respond better to non-stimulants, for instance. In general, if we look at all the data available from the literature, I think it’s fair to state that roughly 70 percent of those who try a stimulant respond good or quite well to the stimulant. So 30 percent do not respond very well, or do not respond at all. And, of these, roughly 50 percent respond to another second line option non-stimulant. So, on average, we are able to treat the majority of these patients.
I think, however, that an important point to highlight is that a medication will work well if it is properly optimized, as we say. And optimize means not only using the correct dose so, for instance, some individuals they do okay with low doses but for others we need to increase the dose. I have a lot of patients who tell me, “You know, I tried this medication. It didn’t work” but ultimately when you discuss with them the dose, it turns out that the dose is not correctly optimized. It also means to use correctly this medication to tailor the medication to the patient.
For instance, we do have a formulations which cover different hours and different lengths, so for some patients it’s okay to cover let’s say morning and part of the afternoon. For other patients, it is very important also to cover properly the second part of the afternoon and, ideally, the evening. So, you know, the question how many of this patients respond well to these medication depends also a lot on how these medications are used.
And the final point that I think is important to highlight in relation to this question is the issue of the short term versus the long term. So all the studies that we have are quite clearly suggesting that these medications do work well in the so-called short term – so, few weeks.
Some patients seem to say that these medications tend to be less effective over time. This can be due to this medication, per se, but once again also the way we use this medication. This is not entirely clear so far, but definitely it is something that I would like myself and my colleagues to study better in the future.
But I think that right now it is fair to state that at least in the short term, these are probably the best medications we have in psychiatry to treat some specific symptoms. They don’t treat everything, and as I said earlier, we do need also non-pharmacologic approaches to tackle more globally the impairment of individuals with ADHD.
About the Speaker
Samuele Cortese, MD, PhD, is currently professor of Child and Adolescent Psychiatry at the University of Southampton (UK) and Honorary Consultant Child and Adolescent Psychiatry for Solent NHS Trust. Professor Cortese contributes to the editorial management of the systematic reviews/meta-analyses submitted to CAMH. In 2020, he ranked No. 2 worldwide in terms of expertise on Attention-Deficit/Hyperactivity Disorder (ADHD) according to Expertscape.