ADHD Diagnosis

ADHD is a subjective diagnosis primarily based on patient-reported symptoms. A number of questionnaires have been developed to help aid in the diagnosis of ADHD. Some are administered by mental health professionals, and others are available online. The utility of these diagnostic tools is questionable since most patients will be able to discern which responses support a diagnosis. Since I do not prescribe stimulants, I am comfortable treating patients who have reviewed the diagnostic criteria and feel they meet them. A link to ADHD diagnostic criteria is provided below.

DSM-5 ADHD diagnostic criteria

ADHD Medications

Stimulant medications, which include amphetamines and methylphenidate, are often used to treat ADHD. These medications are schedule II controlled substances that are highly addictive, habit-forming, and widely abused; therefore, I do not prescribe them. Fortunately, there are other treatments available. A review of those therapies is provided below, along with results from a study that compared the efficacy of different ADHD meds.

Atomoxetine (Strattera®) - atomoxetine is a norepinephrine reuptake inhibitor approved to treat ADHD in children and adults. It has been around for a long time and has proven effective in trials. The main side effects are nausea (26%), dry mouth (20%), and decreased appetite (16%). It can raise heart rate and blood pressure in some patients, so people with hypertension should monitor their blood pressure during therapy. It has a cheap generic.
Clonidine - clonidine is a blood pressure medication that has been around for a long time. It works by decreasing sympathetic outflow from the central nervous system. It is FDA-approved for ADHD in children (6 - 17 years) but not in adults. Given that it has proven effective in children and used safely in adults for many years, a trial of clonidine is appropriate for adult ADHD. The main side effects are somnolence and dry mouth. It can lower blood pressure, so patients should monitor their blood pressure when starting it. It has a cheap generic.
Bupropion (Wellbutrin®) - buproprion is an antidepressant that is widely prescribed. It works by blocking the reuptake of norepinephrine and dopamine in the central nervous system. Bupropion is not FDA-approved for ADHD, but a handful of small studies have found it to be effective in children and adults. Given its efficacy in small trials and long safety record, a trial of bupropion is appropriate in adults and adolescents with ADHD. The drug also has a cheap generic.

ADHD Medication Effectiveness

A number of randomized, placebo-controlled trials have evaluated the efficacy of ADHD medications. Treatment effects are mostly subjective and must be measured with questionnaires. Many different surveys with differing scales have been used in ADHD trials to measure the effects of medications, making it difficult to make comparisons across trials.
A systematic review and network meta-analysis published in 2018 took outcome data from 133 double-blind ADHD trials (81 in children and adolescents, 51 in adults, and one in both) and standardized it so that the effects of different medications could be compared across trials. Outcomes were normalized using the standardized mean difference (SMD), which is the average difference between treatment and control groups divided by the pooled standard deviation of the two groups. This method expresses the effect size relative to the study's variability, allowing for comparisons between studies that use different outcome measures. Results from the analysis are presented in the table below.

Effect sizes are expressed as the SMD (95%CI)

SMD - standardized mean difference which represents the standarized treatment effect

Reference [7]
Effects of ADHD Medications in Controlled Trials
Drug	Children	Adults
Amphetamines	1.02 (1.19 to 0.85)	0.79 (0·99 to 0·58)
Bupropion	0.96 (1.69 to 0.22)	0.46 (0·85 to 0·07)
Methylphenidate	0.78 (0.93 to 0.62)	0.49 (0·64 to 0·35)
Clonidine	0.71 (1.17 to 0.24)	N/A
Guanfacine	0.67 (0.85 to 0.50)	N/A
Atomoxetine	0.56 (0.66 to 0.45)	0.45 (0.58 to 0.32)

ADHD Treatment

ADHD Diagnosis

ADHD Medications

ADHD Medication Effectiveness

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