Stimulant medications

Date: 1960s forward

Type of psychology: Biological bases of behavior; cognition; developmental psychology; emotion; learning; psychopathology

Stimulant medications are one of two classes of medications used in the treatment of attentional disorders (the other is antidepressants). They work by stimulating the parts of the brain that inhibit perceived incoming stimuli and process outgoing stimuli, in effect, slowing the brain so that focus, attention, and mood reactivity are improved.

Introduction

In 1937, Rhode Island psychiatrist Charles Bradley first used stimulant medication in controlling behavioral disturbances in children with brain injuries. Stimulants, which are controlled substances (drugs listed on the US government’s Schedule of Controlled Substances and that have abuse potential), are now used to treat a range of conditions including cancer-related fatigue, cocaine abuse, geriatric anorexia, geriatric failure to thrive, narcolepsy, prescription drug abuse, sleep-disordered chronic obstructive pulmonary disease (COPD), and Tourette syndrome. Their primary use is for treating attention-deficit hyperactivity disorder (ADHD, sometimes known by the older term ADD). In the 1960s, multiple placebo-controlled trials showed that two stimulants, methylphenidate (later marketed in varying formulations as Concerta, Daytrana, Metadate, Methylin, and Ritalin), and dextroamphetamine (later marketed in varying formulations as Adderall and Dexedrine) were able to control impulsivity, inattention, and hyperactivity in children suspected of having a condition then called “minimal brain dysfunction.” By 2011, according to data from the US Centers for Disease Control and Prevention, 11 percent of US children between the ages of four and seventeen had been diagnosed with ADHD, and approximately 6.1 percent of American children were taking ADHD medication. Though it is well established that ADHD is chronic, with symptoms becoming problematic by age nine and continuing throughout adulthood, actual use of the medication often does not go beyond the first year it is prescribed, and a majority stop taking it all together by midadolescence—even though symptoms persist. Often, at the same time that the prescribed use of stimulants tapers off, illicit use of stimulants for academic or recreational purposes grows among secondary and college-age students.

Clinical Use

The term stimulant is counterintuitive, especially as people with ADHD are generally seen as being overstimulated. The action of this class of medication, however, is in its stimulating the parts of the brain that are involved with inhibition, control, and delay. These inhibitory circuits are underactive in people with ADHD. They have difficulty controlling how much and how fast external stimuli enters the brain, and therefore their attention shifts quickly to the next perceived stimulus, making it hard to stay on track. In ADHD, the brain is constantly, almost randomly, shifting tracks so that the person finds it hard to sustain focus and see tasks, thoughts, and even conversations through to the end. Massachusetts psychiatrist Edward Hallowell compares the action of stimulant medications in the brains of persons with ADHD to applying (stimulating) the brakes on a car, allowing the driver to be in control of the vehicle. Mental focus and mental executive functions (the cognitive brain functions responsible for sequential reasoning, ordering and prioritization of information, planning, and tracking intellectual stimuli) improve without added effort. Planning, organizing, sequencing, and tracking are made much easier.

In addition to improved mental focus, people with ADHD who receive stimulant medications generally experience improved occupational, educational, and social performance. People experience greater self-satisfaction with their work and interactions and receive less negative feedback and reactions from others. Stimulants make these people easier to talk to and work with; interactions require less effort on everyone’s part. People with ADHD are less irritating to others and become less irritable themselves. Stimulants produce patience and greater interactive calm with greater productivity—again, all with less effort than previously. Most patients taking prescription stimulants report that they are more centered and more productive while feeling more relaxed and less intense. Despite these benefits, people should not take stimulant medications until they feel comfortable doing so.

For reasons that remain elusive, some people who do not respond well to a stimulant such as Ritalin can respond well to a different one such as Adderall. It is common for patients to have to try two or more medications (or different formulations of the same one) before they find the one that works best for them.

Because compliance (taking medication as prescribed) drops off as the number of doses per day increases, most patients are put on a long-acting version of a stimulant. The medications that carry the designation LA (long-acting) or XR (extended release) are consumed whole, with the effect sometimes occurring within the first twenty minutes. The outer shell dissolves, releasing stimulant into the bloodstream. The inner portion of the capsule slowly releases more stimulant as it continues to dissolve. These longer-lasting stimulants remain neuron-active from eight to twelve hours, with different individuals metabolizing the medication at different rates.

Side Effects

Most patients using stimulants experience a decrease in hunger, although these medications should not be used for weight control. For this reason, they should be taken while eating or right after a meal. Concerns about this class of medication stunting growth have grown out of anecdotal accounts of children, usually taking Ritalin, who stopped eating and consequently lost weight and stopped growing. Some studies have shown actual differences in children’s weight and body mass. Following an at-breakfast or right-after-breakfast regimen avoids this potential.

Uncommonly, stimulants can produce tension, anxiety, and temper outbursts. These side effects often spontaneously remit but should be addressed by the prescribing health care provider, who will usually be a pediatrician, family physician, or psychiatrist.

The beneficial effects of improved attention and focus are harmful for getting to sleep. For this reason, those patients with a typical day-night schedule should not take a longer-lasting stimulant after noon.

Another side effect can occur when the medicines reach the end of their effective half-life: rebound. As the benefits wear off, some people experience a reemergence of symptoms. They can even experience greater inattention, irritability, or restlessness than usual. Nearly all these patients can avoid, or at least lessen, rebound through the use of longer-acting stimulants. When these medicines are used and rebound does occur, it occurs less intensely and lasts for a shorter time.

Conclusion

Stimulant medications are the first line, though not the only, therapy for treating ADHD. They have been shown to increase intelligence quotient (IQ); improve academic, social, and job performance; reduce absenteeism; and, for the vast majority of patients, improve their sense of self-mastery, interpersonal connectedness, and quality of life.

Bibliography

"Attention-Deficit/Hyperactivity Disorder (ADHD): Data and Statistics." CDC. Centers for Disease Control and Prevention, 13 Nov. 2013. Web. 17 July 2014.

Hallowell, Edward M., and John J. Ratey. Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder. New York: Ballantine, 2005. Print.

Gillberg, Christopher. ADHD and Its Many Associated Problems. New York: Oxford UP, 2014. Print.

Klykylo, William M., et al. Green's Child and Adolescent Clinical Psychopharmacology. 5th ed. Philadelphia: Lippincott, 2014. Print.

Ratey, John J. A User’s Guide to the Brain: Perception, Attention, and the Four Theaters of the Brain. New York: Random, 2002. Print.

Richardson, Wendy. AD/HD and Stimulant Medication Abuse. Pottstown: Attention Deficit Disorder Association, 2005. Print.

Watkins, Carol. Stimulant Medication and ADHD. Baltimore: Northern County Psychiatric Associates, 2004. Print.