How Can Clinicians Collaborate to Improve ADHD Medication Adherence?

How can prescribers and other clinicians collaborate in order to help improve adherence to treatment to manage attention-deficit/hyperactivity disorder (ADHD)? And what keeps patients and their families from adhering to medication? Thomas E. Brown, PhD, presented about this topic at the 2018 Annual Meeting of The American Professional Society of ADHD and Related Disorders (APSARD) in Washington, DC, in January.

Studies show that among both children and adults, there is low adherence to medication treatment for ADHD. Many patients do not take the medications consistently, Brown said, or they don’t get prescriptions refilled. There are several reasons for this, he said in his presentation called "Collaboration Between Prescribers and Other Clinicians In Managing ADHD."

Patients or families may have insufficient or an unrealistic understanding of how stimulant and non-stimulant medications work, and how they may help.

• The medicines may not be effective, or the dose might not work.
• There may be unacceptable side effects or rebound effects.
• The medicine may not last long enough through the day.

For prescribers who prescribe ADHD medicine (psychiatrists, pediatricians, general practitioners), there are other challenges, Brown said, mostly involving time.

• Office visits, especially for primary care providers, are too short to allow time to provide patient education about how medicines for ADHD work.
• Time is limited for follow-up to see how a patient is responding.
• In addition, providers may have insufficient training about how to adjust medications to fit individual differences.

In addition, because stimulant medicines are Schedule II medicines, some providers may have liability concerns.

Non-prescribing clinicians, like psychologists or social workers, may have insufficient training about ADHD medicines and the variety of factors that impact one’s individual responses to the medications. They may have an insufficient understanding of prescriber concerns about liability, and they may have difficulty in communicating with prescribers.

However, non-prescribing clinicians who are what Brown called “adequately prepared” in this area can act as a go-between with patients and prescribers, by:

• Helping to educate patients about medications, including possible side effects and the process of dose adjustments.
• Helping patients identify benefits and any limitations of their current medication plan.
• Assist patients with sharing information and going back to their prescriber with questions.

One common misunderstanding has to do with how many people understand ADHD to be a chemical problem in the brain. That oversimplifies it, Brown said, ADHD is far more complex than that.

He told his audience some still believe ADHD is "a chemical imbalance in the brain—too much or too little,” or “You take some medicine to fix the imbalance and then you’re OK.” It leads to a myth that “you can fix a chemical imbalance in the brain like there’s too much salt in the soup,” said Brown. “It’s much more complicated than that.”

Rather than single neurons talking to each other, he likened communication within the brain to be more of a symphony across regional communications networks, with some signals in the brain stronger than others. The signals differ in strength based on how important the brain thinks the signal is, he said.

Moreover, the way medicine works has nothing to do with age, weight or symptom severity. Medicine works according to the sensitivity of the body’s chemicals to that medicine, absorption and metabolizing speed, what other medicines are in the body (both legal and illegal), and patient expectations (ie, the placebo effect).

All of this has to be conveyed to the patient, he said, and medications, dose and timing need to be adjusted to individual needs, body chemistry and schedule.

Brown was previously on the clinical faculty at Yale Medical School and recently relocated to California, where he is adjunct clinical associate professor of psychiatry and behavioral sciences at the Keck School of Medicine of the University of Southern California.