Multimodal Treatment of ADHD

Transcript:Theresa Cerulli, MD: Andy, help us out. Discuss the efficacy of multimodal treatment options for ADHD [attention-deficit/hyperactivity disorder] in adults.

Andrew J. Cutler, MD: I think in any field of medicine we know that we give a multimodal treatment plan. For instance, if you're treating diabetes, you don't just give insulin. You talk about dietary and lifestyle interventions. I think the same would be true here. The problem is that our nonpharmacologic treatments haven't demonstrated as much efficacy on their own as they have in combination with the medications, or compared to the medications alone.

That being said, there are some things that are reasonable. I think part of the issue is that it is very hard for a person with ADHD, for instance, to participate in therapy or other kinds of nonpharmacologic strategies because of the problems with attention and organization and stick-to-itiveness.

However, that being said, again, the combination of medication with various modalities is very reasonable. That would include things like ADHD coaching and organizational techniques. I find, for instance, that people do very well with various digital devices. The advent of smartphones has been tremendously helpful for a lot of people.

There is also very good evidence on sleep hygiene and ADHD. We know that there is a higher incidence of sleep abnormalities in patients with ADHD, and medication could contribute to that. So sleep hygiene is critical. We know if you're sleep deprived, you will have problems with attention and executive function and cognition, and mood and energy.

We also know that diet can be very important. The brain needs energy and fuel. It needs healthy energy and fuel. Certainly, feeding it refined sugar and chemicals is intuitively not helpful.

There is evidence of exercise and ADHD, as Dr Wilens mentioned earlier. This is something I recommend all the time. You don't have to be like Arnold Schwarzenegger and go to the gym and pound heavy weights. You can simply do things like go out for walks, walk your dog, or get on an exercise machine while you're watching TV so you're not even aware you're exercising. All of these things are reasonable.

Another area that's really exciting is the idea of digital therapies, or digital interventions. Some of these can be digital forms of cognitive behavioral therapy, but some of these can be things like a therapeutic video game, or what's called BCI [brain-computer interface]. One was recently released into the market. There's another one in development that could be on the market very soon. These are some of the multimodal treatments that can go into augmenting the medication treatment that we’re going to use. I find patients like having these kinds of options. They feel more of a sense of engagement and control over their treatment. I’m sure Dr Wilens has a little more information about some of the data on these interventions.

Timothy E. Wilens, MD: I don't think there's an adult that I see who doesn’t need some additional assistance. If we've treated them medication-wise, they need something else. And really, the data show us that if you look at medicines versus therapies, over the long haul, and our European colleagues have helped us realize this, medicines are really fundamental. The medicines are the foundation to which you add the cognitive behavioral therapy, and probably not the opposite.

It's probably not sufficient to do cognitive behavioral therapy without any other treatment and expect to get as good of an effect, particularly if you're following these patients over the long term. I think the data do help drive us in that direction. I also think that you raise the whole issue of, we don't have the solution at this point. So we're trying this, we're trying that, and we're trying that in addition. I think you have to be creative, as a treater, pick 4 or 5 things, many of the things that Andy just laid out for you, that will be helpful for these adults.

David W. Goodman, MD: I highly agree with you. I completely agree with you.

Theresa Cerulli, MD: In terms of multimodal treatments, are there any medications that have been studied and FDA approved? Are there any medication combinations that have been studied and FDA approved, to be used safely and shown to have efficacy, in combination?

Andrew J. Cutler, MD: This is a good point. We do this all the time. The fact is that the alpha-2 agonist extended-release guanfacine and extended-release clonidine now have now a very good database and are actually FDA approved for use in combination with stimulants. What's nice about them is they smooth out some of the effects. With stimulants, you have a certain duration of time before they start working after you take them. And then, of course, they have a certain duration of effect and then wear off. They have to, or you wouldn't go to sleep at night. And so, there are times in the morning or in the evening when the stimulus is not necessarily effective. And theoretically, adding these medications can cover those times.

Also, they have synergistic and complementary mechanisms of action. And also, one of the most unusual things I've seen in my almost 30 years of clinical research, in psychopharmacology, is that adding these 2 medications together actually decreases the adverse effect profile. It's as if there is a little bit of complementarity not only in efficacy but also in tolerability.

Transcript Edited for Clarity