120 ADHD Medications with Dr. Russell Barkley

This episode is sponsored by Marley Spoon. By February, the whole new year, new routine thing can start to feel exhausting. If you're anything like me, you want to eat well, but not at the cost of your sanity. And that's where Marley Spoon has been such a relief. What I genuinely love about Marley Spoon is how ridiculously easy they make everything. Like really, really ridiculously easy. You choose from over 100 recipes each week. All chef designed, made with quality ingredients, and flexible enough to match your actual energy level. They've also got a marketplace where you can add meal shortcuts, drinks, and groceries. A one-stop shop that makes everything feel just a little more doable. And let's talk about those nights when cooking feels like just too much. I can't do it. Marley Spoon's prepared meals are perfect for that. Heat, eat, done, no guilt, no takeout spiral. Just dinner that works for your family. And when I do want to cook, their tray-baked meals are my go-to. One tray, minimal cleanup, and a meal that tastes like I put in way more effort than I actually did. There's something really grounding about having meals handled. Knowing dinner is going to taste good without spending mental energy planning, shopping, or deciding. This new year, fast-track your way to eating well with Marley Spoon. Head to MarleySpoon.com/offerslash. I have 8 HD. For 45% off your first order and free delivery. That's MarleySpoon.com/offerslash. I have 8 HD for 45% off your first order and free delivery. MarleySpoon. Meals reimagined for real life. Welcome to the I Have 8 HD podcast where it's all about education, encouragement, and coaching for adults with 8 HD. I'm your host, Kristen Carter, and I have 8 HD. Let's chat about the frustrations, humor, and challenges of adulting relationships, working, and achieving with this neurodevelopmental disorder. I'll help you understand your unique brain, unlock your potential, and move from point A to point B. Hey, what's up? This is Kristen Carter and you're listening to the I Have 8 HD podcast episode number 120. I am medicated. I am caffeinated and I am ready to roll. Gather rounds, come close, let us hold hands, and celebrate together because you are all going to freak out. You've been begging for this episode. It's finally here. Today, I'm going to chat with the legend Dr. Russell Barkley about 8 HD medication. If you haven't yet listened to last week's episode, episode 119, go listen to that. I do a long intro on Dr. Russell Barkley who he is, why you should be reading his books and paying attention to everything he says, but I'm going to assume that if you're listening to this episode, you know exactly how incredible this thinker is. How incredible his brain is, and I can't wait for you to hear his take on 8 HD medication. I love this conversation that we have, especially Dr. Barkley's no nonsense, straightforward approach to 8 HD treatment, medication, and all the things. And even if you're happy with your 8 HD treatment protocol, I encourage you to still listen. I promise you'll get a ton out of this episode because Dr. Barkley has a really holistic approach to 8 HD treatment, and we talk about so much more than just like the basic 8 HD meds. If you're listening to this episode and you have yet to be diagnosed with 8 HD, maybe you're just exploring the idea of the possibility of maybe having 8 HD. I want to say I got you, no problem at all. Okay, so on my website, I have a psychologist approved list of 8 HD symptoms that you can print out. You can circle the ones that you relate to and that you identify with, and you can even take that list to your diagnostic appointment with you if you want to so that you can remember what symptoms you're relating to and remember why you made the appointment in the first place because if you have 8 HD, chances are your memory, it's probably not so great. So having something in front of you to take with you to that appointment, or even to talk to your family and friends about like, hey, I know we haven't discussed 8 HD in detail. Here's a list of symptoms. Here are the ones that I relate to. You know, what else do you see in me? And it can be a really good conversation starter. So anyway, you can go to my website, I have 8 HD.com/symptoms for that free printout. I know you'll find it to be helpful. And here's the moment we've all been waiting for. My conversation with Dr. Russell Barkley about 8 HD medications. Let's get these kids and especially these young adults, the services that they need, you know, 100%. That's a perfect segue into what are the best ways to treat 8 HD medically. So I get so many questions about this and I am not qualified to answer and I always point them toward your book and, you know, their own doctor because I am a life coach and I'm a woman with 8 HD. But I am not a doctor, psychologist or psychiatrist and I want to make sure that I stay in my lane, which is a huge reason why I wanted to have you share your wisdom with us. Tell me what is like the best or most commonly prescribed medications for 8 HD. Okay, well, if I can just take 30 seconds and put that in some context here. Treatment programs for people with 8 HD, kids and adults, but especially adults need to have five components and I teach this to physicians, residents, psychiatrists, whatever. You got to do all five. So stop thinking that this is just a prescription away from a solution. Now for some people it is and I don't want to belittle that. But here are the five things. Number one, get yourself an appropriate expert evaluation. We need to know what's going on here because 80% of people with 8 HD have a second disorder and 50% have a third disorder. We've talked about anxiety, depression, emotion regulation, you know, maybe, you know, perimenstrual or perimenopausal symptoms and other things. You know, so what is happening out there? That requires a very thorough evaluation, which is going to take three to five hours, not 30 minutes, and maybe done on three visits for an hour each. But if it's being done in less than three hours, you're missing stuff. So evaluation, second, education, people need to do what you're doing. They need to listen to these podcasts. Go to Chad.org website. Go to ADD.org. If you're in Canada, go to cadra.ca. If you're over in Europe, go to the European Network for Adult ADHD. There are websites out there by foundations that have no bias. You don't just go on Google. You're going to get 5 million hits and a lot of it's going to be nonsense and some of it's going to be, you know, sort of Scientology type misrepresentation, not to just pick on them because there are other groups doing it too. But they have an acroagrine. So be careful where you get your information because there's a lot of nonsense out there. And so start with the reputable websites whose job it is to educate us because those are our national foundations. And as I said, would be Chad.org, ADD.org. And there are some others out there as well. And then, okay, so we got diagnosis, which is evaluation. We have education. Okay. And that means learn about your disorder. Read widely. David Lindsay the novelist decades ago had a great phrase and a novel. And I've used it ever since. Kudos to David. Truth is an assembled thing. You don't get it from one source, one site, one person. You read widely, listen widely, and out of that will come distilled, this information that keeps repeating itself. And that's going to have that's reliable information. And but you don't want to put all your eggs in a single, you know, book or website. Get out there and read and listen. But be skeptical. Be critical. Put on that scientific hat because you're always going to say, where's the evidence for that? Particularly if it sounds rather far fetched. Like, you know, oh, you could get over this if you just played an app or went to lumosity and did some brain games for 45 minutes a night. Well, no, you're not. And you would have learned that had you read more widely than just believe the advertising that these, you know, apps and websites are using. So that leads to something under education that's very important and you brought it up early and I loved it. Own it. You got to own this condition. There's nothing wrong with that. It's part of you. Look, I'm bald. I'm colorblind. I'm old. I have a left facial weakness, which is causing me to list, you know, list a little bit. I'm a mediocre golfer and I don't particularly dress all that well either. And tell me when I was in the Air Force, they wouldn't let me anywhere near anything that involved mechanics. There's a reason I'm in a verbal profession. You know, I own all of that. Let me tell you that's me, you know, I'm not ashamed of that. I'm that's my individuality right there. And, you know, I'm good with that. So as Adam Levine said on that YouTube video, own it because Adam is major ADHD, like Michael Phelps and many other success stories, some own bios most recently being in the news because of her mental health issues, which she's She's also a ADHD. - Not a nice among us. - And she owns it, you know? And at times, sometimes you gotta step back and say, "Overwhelmed here, can't handle this." And I was so proud of her. I know people were so embarrassed, "Oh, how could you do that to our country?" And blah, blah, blah. And I thought, "Oh, this girl, just like the tennis players, just like some of the golfers, have said there are times in places I'm not ready for this. Just give me a moment to recover. Give me a chance here." So bless our heart for doing that. So own it. You know, when you own it, my God, the freedom that comes from acceptance and acknowledgement. Then we get to medication, which I'll come back to, okay? And because those are some of the best things we have, then we get to modification, working with you to try and change your behavior where we can, recognizing that we're up against a neurobiological set of limitations here. So, you know, we're not gonna train it out of you, but there are things we could do to try to help you be better with your symptoms and your time management. So we call that modification, and then there's accommodation. How can I change my workspace, my environment, my life? So that I'm less impaired. It won't get rid of your disorder, a ramp put it into a building, doesn't get rid of somebody's motor disability in a wheelchair, but it lets them in the house or the building they can participate. So there are so many accommodations that we talk about on my book and elsewhere that I'm sure you use them too, that are ways of changing my space and reorganizing it. So I'm better at what I do. I'm still ADHD, I'm still symptomatic, but it doesn't affect me so much as it used to do when I do these kinds of things. So whether it's getting an adult ADHD coach or whether it's using a day planner, not your computer, because we think low tech for adult ADHD is much better than high tech. And the reason is you'll lose the high tech, you won't find the power cord, you can't find your smartphone. You didn't put the stuff in Sunday night into your calendar for Google. And even if you do, it's off, it's in your office, you're in your car, what good is that gonna do? So high tech has not worked out with the promise we thought it might. So all of that is to say to reiterate, evaluation, education, medication, modification, accommodation, you gotta be doing all five. Now yes, let's get to the medications. There's three kinds of medicines out there and a whole slew of delivery systems. But let's talk about three types. We have the stimulants been around since the 1930s to 1950s. There's two of them. There's methylphenidate, which everybody knows is riddling, but that's the drug name and there's emphetamines. And most people know the, you know, like the prescription brand name of, you know, Adderall by Vance, but that's emphetamine. Okay, so those are our stimulants. We had a third, but it caused some rare liver problems in the back in the 70s and 80s. We took it off the market, not we, but the drug company took it off the market. So we have stimulant medications. Why are they called stimulants? They activate the executive brain. They activate the inhibitory circuits. It's like you adding break fluid to your car. Oh my God, it stops, right? Whereas with, you know, you were low on break fluid. Well, people with ADHD are kind of, you know, if you will, literally or figuratively rather, kind of low on break fluid. So let's enhance that activation. Now, it's not just inhibition, we're activating. It's all the other six executive functions get activated because they're all interconnected in functional networks. So that's why we call them stimulants and that's why they work so well for people with ADHD, but they're not sedatives, they're not paradoxical. They, you know, they really are activating the brain. Good for them. Unfortunately, there's a center of the brain called the reward circuit that they also activate. And that's where the potential for addiction can come in with the stimulants, which is why they're scheduled, you know, controlled substances. Not that you get addicted taking them orally the way you do for ADHD, but there's the potential to alter the drug, to crush it, to inhale it and snort it like cocaine or inject it. And then it really is just like cocaine. So, but use the way we use it clinically. It is not addictive. Now, it doesn't mean some people can't get a dependence on it, but that's more psychological than physiological. Okay, the second category of drugs, and we can come back and talk about the stimulants because my god, there's like nine delivery systems out there that are just ingenious for keeping these medicines in the body throughout most of the day. Because the big problem we had when I came to work in the 70s is we only had the regular tablets. They last about three hours, maybe five. So kids and adults were taking these things three to five times a day. And we've solved that problem with these extended release delivery system. Second category of drugs came around in 2003. And those are the non stimulants. You know it is strutira. It's adomoxetine. And then just last month, yeah, last month, maybe two months ago, FDA approved another drug like adomoxetine called Veloxazine. It's brand name is Calbury. It's very similar. They're both non stimulant drugs that work on nor epinephrine much more than dopamine. The stimulants work more on dopamine and somewhat on nor epinephrine. These drugs go the opposite route, more on nor epinephrine, little bit of downstream effects on dopamine. But they don't activate that addiction reward center in the brain. So they're not scheduled. They're easier to prescribe. They have no abuse potential. And they're pretty good medications. They're nearly as equivalent as methylphenidate riddling is in terms of how they change behavior and improve people's lives. The amphetamines are the most important thing we have. So they're not as good as the amphetamines at that. But the amphetamines come with their own problems because they are so potent. They also can have side effects and we can talk about those. So we have the two non stimulants now that are on the market. Calbury is only for kids, but it probably will be approved for adults. They just got to go back and get their indication. There's no reason it wouldn't be because Adamoxidine is already out there for kids, teens and adults. All right, now we have the third category, which came about right in the late 2000, when I was around 2008, 2009. Those are the alpha two agonists. You know them as hypertension drugs. They are anti-hypertensives. They've been used for decades to lower blood pressure in people with blood pressure problems. But as a spin-off from that, it was discovered that they're useful for managing ADHD as well. Using the same mechanism, but the mechanism in this case is working in the frontal lobe, not in the blood pressure centers of the brain and body. So, but they still work. And these alpha two drugs because that's what they work on. There's a little port on the nerve cells in the frontal lobe. It's like little windows or little, I hate to use the word, swinkters, but these little things that open and close on the nerve cells. And if they open, this is the alpha two port, right? Noise gets in, right? And if they close and shrink down, the signals are stronger, right? And the brain can communicate. And these holes are opening and closing to vary the activity of a nerve cell. That's all natural, okay? But what happens when you take a anti-hypertensive drug as it closes the ports? Now these signals that are supposed to be getting through the brain, activating the executive brain, are activated. So the alpha two drugs kind of are like fine-tuning the frontal lobe rather than hitting it with a hammer, which is what the stimulants are doing, you know, wamp. What you're seeing here is, let's just work on that little port and get these signals a little stronger, a little less noisy and by God it worked. So now we have two anti-hypertensive drugs. We have Guantfacine and Clonidine, both in extended release. I'm using the chemical names because there are different commercial names depending upon the company that manufactures them. So now we got six medications, two stimulants, two non-stimulants, two alpha two drugs, woohoo. And we've got a bundle of delivery systems out there. So what's neat is we can now kind of match the medicine to the case, to the uniqueness of people that we couldn't always do before. We can even try to find the right delivery system for you. So are you somebody who's better on a pellet extended release like an AdleroXR, which tends to activate a little earlier in the day, or are you better on a concerto-osmotic pump? People don't realize that little concerto-capsule is a water pump. And you swallow it and it absorbs water and that pushes on the liquid methylphenidate that's in there, the sludge. And over 10 hours, it, like a tube of toothpaste, being squeezed is squeezing out liquid methylphenidate. Isn't that crazy? I mean, that's ingenious. The company that, yeah, the company that manufactured that Alza was bought by Johnson and Johnson for a billion dollars back in the '90s to get that capsule, because you can use it for other drugs, not just this. But I mean, talk about genius. And of course, you know, we have the patches. We have the Vivance ProDrogue, which is very different. Even though it's the same medicine as Adderall, it's put in a different delivery system. And so it works a little differently for people. And some people are better on Vivance than on Adderall. There are others who would be better on methylphenidate. It's not quite as potent. Others would do better on Adamoxetine. So, you know, we can kind of look around at the drugs and the delivery systems and talk to you about it and maybe play a little bit with those medicines to try to get it right. But boy, do we have a huge kind of-- medicine chest, if you will, of options for people now that back when I came into the field, it was riddle in and dexatry. That's it. And you know, you just had to tough it out and take them five times a day and you were on this roller coaster all day long. On off, on off, on off, right. And we had, you know, schools objecting to giving these drugs at school because they're controlled substances. And we had teachers using the bully their students. Well, I guess you didn't take your medicine. You better get down to the nurses stage. I mean, the crap we put up with back in the 70s and 80s. I mean, the kids and their families, you talk about stigma, you know, and the teachers were not very helpful back then. They didn't want to be doing this and, you know, they could use it as a club against these kids to kind of discriminate against them. So, you know, that's all changed. Wonderful. What technology has done in the last 30, 40 years to help us solve these problems. And then just two years ago, this month, a company came out with a medicine for families where you take the, the methylphenidate at night at nine o'clock and it doesn't activate for nine hours. But it's activating when your kids waking up. So he's on medicine for those critical early morning weekday hours where everybody's going nuts. Everybody's got to get out the door. You, your brother, your sister, mom, dad, and there's this drop dead hard deadline, you know, that you got to be out the door and you've got an unmedicated child who's probably got some sleep problems from insomnia. And he's making the whole house crazy, right? And this medicine called joint APM. It's just methylphenidate. But in such an ingenious delivery system called delayed activation extended release that, you know, when they came out with this, it was just unbelievable. You know, I was privileged to consult to the company around doing some research on families because I'd studied families for 20 years earlier in my career. And they were saying, okay, this is what we want to do. How do we do this? How do we measure this? How do we make sure that it's doing what we wanted to do for families? Because even families whose kids are on medicine will tell you that that first hour to hour and a half is gone so. I mean, they're just crazy because it takes that long for these other medicines to start to activate. Now, I think they're going to go back and get an adult approval for this because there were reasons why adults might benefit from delayed activation. Like, hello, I got to get up and go to work. But we know that adults with ADHD have a delayed diurnal rhythm, which means that the hour of the day, their most alert is delayed. It's different. It's about three to five hours later than a neurotypical. And as a result, they prefer afternoon and nighttime hours. But your employer says, oh, no, you know, you're here at eight or nine. And, you know, they may or may not be ready for that. And boy, on Reddit the other day, I was talking with somebody about how often he has to reset his alarm clock because it's like slam, slam, ten minute, ten minute delay. He just can't get his butt, you know, out of bed. Well, that would be something that a delayed activation medicine might be beautiful at helping the adults with this delayed diurnal rhythm and getting ready for work in the morning. So stay tuned. I know the company has plans to, you know, go back and get adult indication. And then they're going to use emphetamine and remanufacture that in the same device. I don't think of that. You know, 10, 15 years ago of myself as a new mom. Yeah, with kids who are waking up at five or six in the morning, God help you. And I, you know, I'm not on ADHD medication because I'm nursing and it was, it was a disaster. Yeah. And if I would, it would have been able, um, okay, so let's fast forward. Maybe I'm not nursing anymore, but I'm able to take a medicine at night that just already is in my system at five or six in the morning when I am required to get up and take care of tiny humans who are literally yelling in my face as I am trying to like become a fully formed human being in the morning, which is just, I mean, it is not easy work. Well, I take it in the morning, women in particular, I have told us they go off to work feeling like terrible moms, you know, like I'm a failure. And I'm not talking about just ADHD moms, although they have it even worse. I'm talking about moms of typical children who have had, with ADHD, that is, who have had such a tough time in the morning and have found themselves behaving in ways they don't like to their children in order to get these deadlines and get people where they need to go. And the first hour as they get to work, it's like, God, I feel so bad. Yeah. You know, I need to write him a note or a power. Yeah, damage control. Yeah, that's not me. That's not who I think I am. And, you know, so hopefully these, these delivery systems will help us out of these, these other quandaries because, you know, there's, there's always a new problem that we have to solve it in this field. So, so that's your medicine, you know, stimulants, non stimulants and anti-hypertensives, lots of different drugs, lots of different delivery systems. And each type of drug is different. And so, you, we can start to think through, okay, who's that going to be better for compared to others? Like, you come in with ADHD, but you've got this raging social anxiety that's going along with it. And so, while we could do a stimulant for you, amphetamines are known in some people, not most people, but some to exacerbate anxiety. Methylphenidate can do it too, but amphetamine being more potent can do it even worse. And that's not a blanket statement. It doesn't increase anxiety in everybody, but it doesn't some people. And so, for them or for people with nervous ticks or Tourette syndrome, or, you know, little nervous rituals like, you know, here twisting or, you know, nail biting or something which the amphetamines can make worse, again, more so than methylphenidate, we might go to a non stimulant with them. And because, Adamoxetine treats anxiety, people don't realize that. It doesn't just treat ADHD. And also, it can help a little bit with demoralization. It's not a good anti-depressant, but often adults with ADHD don't have clinical depression. What they are demoralized, the word clinically is dysthymia. It's a milder variant of sadness and depression, but it can occur as a result of chronic failure. And that's where the anxiety, I think, is coming from. You fail often enough. You're going to get anxious, especially about those situations that you typically fail in. And so, that helps, I think, to understand why anxiety increases with age, with people with ADHD. So, those people we might be opting for a non stimulant. There are other reasons we might do that too. And people with high blood pressure, people who have had heart surgery or something like that, you wouldn't want a drug that's pushing up their blood pressure in a heart rate under those risk scenarios. And so, you could turn to the anti-hypertensive drugs, which don't raise blood pressure. They actually lower it. One of the side effects is lightheadedness. And we have to watch that because we don't want to drop your blood pressure too low, where you're fainting while riding your bike. That's very rare, but it's possible. That can happen. So, I'm just walking through some of the scenarios where we might be opting for different medicines for different people. Do you think that most clinicians have a good understanding of the variety of medications available to treat ADHD and the variety of human being in the way that ADHD presents itself in different people? Or. No. Sure to answer. But here's the longer answer. Child psychiatry, yes. I mean, they were the original game in town. They tracked this stuff. Child Psychic Pharmacologist know everything I'm telling you. The second group are the adult psychiatrists who are younger and got the training when they were in residency. And they're pretty good at doing this too. The third group of people are primary care people who have gone back to specialize in adult ADHD. And I know a number of primary care people who said, "I like this because this is the most treatable disorder. I can't tell you how effective and successful we are at helping people, most people, not everybody." But it's a great practice to be in. And so, I know some primary care people who have moved over into this field. That's super rewarding. Yeah, yeah. Very much so. Yeah. I mean, people call you crying because you save their marriage, their life. They got their college degree. They got a promotion. It's just mind-boggling. We don't hear that with bipolar or depression or stuff like that. They improve, but not like this. So, you know, my point then is we've got the adult psychiatrists are learning, depending upon how old they are and whether they're willing to learn. Primary care people are the new game in town. And boy, are we just the past year or two, Chad and I and others have been on a campaign to promote adult ADHD as a public health disorder because of all the medical and health-related problems that go with this. That primary care docs are being asked to treat, but never screen for ADHD to see if that's the gorilla in the room, so to speak. You know, the wizard behind the curtain that's pulling all of these lifestyle levers and making you eat too much sugar and gain weight and watch too much TV and, you know, have a propensity for bulimia or binge eating and maybe, you know, tobacco abuse or internet gaming or alcohol. Everything I've just mentioned is linked to adult ADHD and then some, okay. But they don't know that. So, an obese person comes in and says, I really need to lose weight, so they try something. It fails. That's the moment you get out the adult ADHD rating scale and you screen that person because what you're seeing is if they can't self-regulate enough to help with self-improvement, that's probably adult ADHD. So get out out, screen for it, and then treat the ADHD first. Every form of self-improvement, we all try to do in our lives, requires self-regulation. If your disorder has robbed you of that, how can you self-improve? You can't quit smoking, you can't get off the internet, you can't stop binge eating, you know, you're going to be doing all of these things that have long-term health consequences as a result of your impulsivity and impaired self-regulation. So let's treat that first. Then we'll come back and do detox and, you know, get you off a nicotine or cut down alcohol or help you lose weight or get you into an exercise program. But honey, you're not going to the gym if your ADHD isn't controlled. And so you see what I'm talking about, that's why we are championing this view with primary care people now, trying to reach out to them because they get no training in ADHD. They get in an anxiety and depression. They're all very comfortable. I mean, you know, even gynecologists are screening their women for depression and anxiety and treating it, you know, you can get a prescription from your gynecologist. But, you know, they're not doing that for ADHD, but they need to be 40% of people that go into weight loss clinics are adults with ADHD. 25% of people in cocaine treatment programs are adult ADHD. 25% of prisoners have adult ADHD. Don't even get me started on people who have other addictions, you know, like tobacco and so on. The rate of ADHD in these other areas of health is so high that if a person doesn't succeed in self-change, that should be the moment you screen for ADHD. And let's see if that's what's causing you to have these failures in self-control. And then let's see if we can treat that. So, I mean, this is all new. We just started this about a year, a year and a half ago. And of course, then the pandemic hits, and it ruins our message. But we're back to remessaging this as a primary public health disorder. Because by the way, it shortens your lifespan by 11 to 13 years if you don't treat this. Now, that's worse than any other health issue we are trying to address in this country. We want people to lose weight, cut down smoking, cut down alcohol, increase exercise. ADHD is five times worse than any of those. It's worse than all of them combined. Why? Because ADHD predisposes you to all of them, not just to one. So, you know, we published this study two years ago. First study ever done showing the reduction in expected life. If you don't manage this disorder, we already knew the kids were quite slightly. Yeah, it's disheartening. Well, it's it's, but it should be motivating, which says, I can change this. Every factor I just mentioned is changeable. This is not cast in stone, you know, but it's not going to change if you don't recognize that the that the elephant in the room is ADHD. If you just try to treat weight loss, smoking, and all these other things I talked about, and you're not looking for ADHD, you'll fail. But if you'll screen for ADHD, you can succeed. You can make those other changes. You can let people have a natural life expectancy again, where they didn't have it. People don't realize how life-threatening ADHD, as I know, because I lost my twin brother and my nephew to it. But, you know, kids are twice as likely to die by age 10 from accidental injury. There's no disorder that predisposes to accidents the way this does. Adults with ADHD are five times more likely to die by age 45 than anybody else, right? All for the same reason, right? Accidental injuries, suicides, homicides, lifestyle choices that they're making. I mean, eventually, these lifestyle choices rack up. Yeah, they do. By the time you're in middle age, you're paying for the consequences of a life of impulsivity. And, you know, that can be changed. You know, to me, that's the message. You know, I get a lot of pushback, and I'm sure you do too, because there's misinformation about the risks of ADHD medication. And I've done several episodes on the risks of not meditating. And so could you, though, walk us through just briefly? Of course, there are risks to taking any medication. What should people be on the lookout as far as risks for medication? And then give it to us, give it to us straight with like the actual risk of not treating it. Absolutely. Okay, very quickly. Here's the rundown. First overarching method. These are the safest drugs in psychiatry. Bar none. There is no category of medication that we use for mental disorders as safe as these. So get over it. You know, this is not a straight jacket of the mind. This is not a chemical billy club. It's not the Soviet Union in the 1960s, where we're using anti-psychotics with political dissidents. You know, nobody's papering over anything. Second, you need to think of these medicines, not so much as medication, but as genetic therapies. They're neurogenetic treatments. They go right into the brain. They alter the activity of genes and nerve cells in the brain at the very heart of where ADHD is coming from. They are equivalent to insulin for diabetes. So there's no papering over. We're not covering up the real problem, which is your mother. We're going to instead address the underlying neurobiology. The sad part is that it only does that when the drug is in your bloodstream. And when the drug washes out, you're back to your ADHD self again. Now, as an aside, we can come back sometime and talk about that. There are 35 studies showing that the longer you stay on an ADHD stimulant, the more normal those brain areas become permanent. Wow. Not amazing, right? Permanently. Permanently. Yeah. So what we're seeing is people are saying, oh, these drugs are ruining your brain. No, they're not. And if you keep activating those underdeveloped brain areas, they get better connectivity. They get better functional coordination. And in some people, perhaps 25% to 40%, those parts of the brain grow. We have neuro imaging studies. Just go to Google Scholar, type in ADHD plus neuro protection. And you will see all these studies per collate up. Now, it's still debatable why this is happening, what the mechanism is, you know, whether it's some kind of confounding, but it's probably not conf-- when you get 35 studies that are finding the same thing, it's not error, you know, you pay attention to that. So that's just in a side. So back to it. All right. So number one, they're safe medications. They have annoying side effects. No doubt about that. And we have to work on that, all right? And work with you on that. Number two, their direct therapies for the mechanisms that ADHD arises from. You're not papering over anything. Okay. So let's do the rundown. The stimulants, the most common, and there are the big four or five are these insomnia. They're going to keep you up a little later at night, even as they're, you know, even though they're worn off, all right? So we have to try to deal with that. And there are ways to deal with that. I don't want to go on all of that. But physicians know how to play around with timing dose, maybe different drug, different delivery system. We can work on that. If not, we'll just work on some other sleep mechanisms, melatonin, you know, something else for you. The second is appetite suppression, which is a concern in children because they may not grow as quickly. So they're going to be about two to four pounds less in that year or two. But that's temporary. And they may be about a centimeter smaller than they would have been in their height. They don't shrink. They don't just don't grow at the same rate they would have. But in adults, that's not an issue. I mean, many of the adults tell us the appetite suppression is a bonus, not a side effect. So, you know, because it helps me with my binge eating, which I'm prone to do, not me personally, but you get it. All right. So the next ones are headaches and stomach aches, which occur in about 20% of people. The big one isn't some of you, 50% appetite suppression, about 40 to 50%. Then there are those two. Then we get down to these little tiny probability side effects. One is irritability, particularly as the drug is washing out late in the afternoon. Okay, we'll switch it to a different drug, or maybe we'll do a combo of medicines, cutting down the dose of both. So maybe we can we can manage that. The other is a propensity for sort of a tearfulness, very emotionally sensitive, not irritable. It's almost like a sentimentality, if you will. But and again, about one in 10, one in 20 people, but we got to deal with that. All right. And then we get down into nervous mannerisms, particularly with amphetamines. If you're already prone to nervous mannerisms like hair pulling and lip biting and nail, you know, it could increase with these, because they're going to make you feel tense as they're activating. Adderol in particular is known to do that a little bit less for vivants, but or people get TMJ, you know, they get, you know, they're grinding their teeth or all of a sudden, you know, my jaw is aching. And so there's that that we have to deal with. But again, you're talking about 10% or less, right? Then there's about three to 4% who if you had nervous ticks, they could get worse. So if you had a little bit of tick disorder or Tourette syndrome, sometimes it gets worse, about 30% of the time it worsens it. But mainly the amphetamines, not methylphenidase so much. On the other hand, the other 60% of people with tick disorders don't see any adversity to that. In fact, some of them even report a little bit of improvement. So, again, it's not a one rule one size fits all. We got to try you on it and see whether you're going to be the one that it exacerbates or you're going to be the one that helps. We just don't know, you know, and we have to wait and see. But there's no harm done because the medicine only stays in the body less than 24 hours. And if you're having an adverse reaction, it washes out within the day. And so now we know, you know, unlike other drugs where we got to keep you on them for weeks. And you have to take for them down for weeks. You don't do that with the stimulant medications. So that's a good thing because we can play with their drugs. And if we make a mistake or something happens, it's not going to last for very long. And then we get down to the extremely rare side effect, less than 1% who may develop a psychotic reaction to the stimulants, not to the other drugs, but to the stimulant. We know that stimulants taken at high doses can cause paranoia, tactile and auditory hallucinations, more tactile in kids. You feel like bugs are calling on this kid. It's about 1 in 100, according to the big databases that have been looking at this. So is it there? Yes. Is it common? No. And it usually suggests that somewhere in the family line, there's a genetic propensity for psychosis or thought disorder. And the stimulants are kind of activating a little bit of that. But we don't worry about that. Is that only-- if somebody were to have be that rare person when the drug wears off in 24 hours-- It's gone. Goes away. And if it's really bad because you're on an extended release, which is going to last 10 hours, you go to the ER, and they will give you an anti-dopamine drug to shut that down, like Haldel, Halopyridol. So if it's really bad, if you're flagrantly psychotic, we're going to give you an anti-psychotic to shut that down. But it's only going to last for the time that the drug is in the body. And now we know. So those are the big side effects. Now, there's a slight increase in blood pressure and heart rate. It's the equivalent of walking up a half a flight of stairs. Big deal. But it is there. You can handle it. And if you're in that zone of high blood pressure already, or you already have arrhythmia or other heart conditions, we probably wouldn't want you on this. We might move you to one of the non-stimulants, or even that anti-hypertensive drug. But that's the physician's job is to screen out these contraindications against that. So that would be one of the other ones. And then I said, as in kids, we kind of watch their growth a little bit because of small percentage of them aren't growing as quickly as we would like. They're already small in some cases anyway. That lasts a couple of years. And by the time you're a teen or a young adult, that's not happening anymore. So we don't worry so much about that. Now, as you said, there is a downside to not treating. So that's the downside to treating. You could have some annoying side effects. And you might not like them very much. And we'll try to deal with those. But that's true of all medicine. You know that, Christian. So this isn't the only medicine that does that. The downside is this. I've already talked about twice the mortality in children, high rate of accidental injury, four to five times mortality in adult from injury, suicide, homicide. Then we've got the driving. You've got four times the speeding tickets, three times the crashes. The crashes are two to three times worse. You could even die. You could kill people. My brother died in a car accident from his ADHD wrist taking. So there's that downside. Then there's the risk of suicide in high school and young adulthood, which is when it reaches its peak, even in the typical population, it's at a even worse peak in the ADHD population. Depression makes you think of suicide. ADHD makes you do it because you're so damned, disinhibited that when you get this idea, you try it. And you're so impulsive, it's worse, and it likely succeeds more than it would in somebody who didn't have ADHD, hence my nephew. At 15 minutes going from being, you know, everything is just fine to hanging in his closet on an electric court after an argument with a girlfriend. I'm sorry. It's the disinhibition that we're talking about here. So, you know, when people say, oh, there's a downside to medication, honey, there's a downside to this disorder that is markedly worse than what this medication will ever do to you. What about your marriage? What about the fact that you didn't finish college and can't seem to finish your degrees? What about the fact that you've been fired from seven jobs in 10 years? Not atypical of the-- how can you progress up the income ladder and the employment prestige ladder? So to speak. When you're constantly skipping around, oh, I don't like my boss. I guess I won't go in today. I had one young adult call me. It canceled his appointment because what he said was, you know, I got up this morning and my buddy's going to Denver to look for a job. You know, and this kid's in Milwaukee. And, you know, and he says, so I'm not coming in today. And I said, do you know anybody out there? No, do you have a home? No, do you have a apartment? No, does he have any money? No. But it sounds like fun. See ya. I mean, that's what we're talking about here. This disinhibited Jouat-A-V, you know, damn the torpedoes. Well, that sounds like fun on vacation. After about a week or two of that, we all get to get back to work. We got responsibilities and jobs and kids and work. But that just, you know, kind of typifies to me this impulsive occupational decision making that goes on around ADHD. And you've pointed out a number of the other problems. You know, the emotional difficulties that can come up at work or at home in relationships that we have to deal with. So, you know, these people, they're losing relationships like crazy. Yes. Their divorce rates are higher. Their friendships don't last as long. They're engaging in risky sexual behavior. There are 10 times more likely to have a baby as a teenager. They're not using contraceptive because all of this requires a little bit of planning and forth thought with regard to sex life. Yeah, executive function. Yeah, and they're not doing it, right? So duh, there are four times more likely to get sexually transmitted diseases, you know. And it's like, hello. Right. You know, those are your risks. And let's talk about mommy since we're on the subject because this is a new area. Can you take these medications if you're pregnant? Yes, please tell us the things. Okay, well, all we have right now are several big population studies like out of Denmark and Sweden using the entire population here in the US using some of our big databases. Here's what we find. We're not seeing an increase in lots of malformations in the physical, like physical deformities. Okay. Nobody's looked yet at whether they predisposed to developmental or psychiatric problems, but so far, malformation. On the other hand, there was a slight uptick to about 2% of the kids that had some minor malformations in the heart. Now, that's, we're talking about out of hundreds of thousands, we go from like one to 12, you know, in terms of number. So, you know, it's a slight uptick in cardiac malformations, but it's been found twice. Okay, they're not major, they're minor, but they're there. All right, and they can be detected in the offspring. So, it may be, and we're talking to stimulants here. We haven't looked at the other drugs in these studies that there's that little bit of risk. And then as you said, if you're a nursing mom, methylphenidate does get into the breast milk, but we don't know that it does much to the baby. Amphetamine can also do that, but it might produce some irritability in that child, because you're not gonna see a shorter, long attention span in an infant, but you're gonna see some irritability. So, there's that possibility. I mean, there's nothing major or danger is going on, but that could be happening if you're breastfeeding and taking a stimulant. So, you gotta have a sensitive discussion with moms or soon to be pregnant women around, okay, it hears what we know, right? 'Cause the drug companies will just tell you, don't take our drug, but that's a liability issue, not a science issue. So, the physician on the other hand, has to weigh the cost of that, because if we stop your medication, look at all these other things, the car accidents, the depression, the relationship, your marriage may not survive, you coming off this medication, your work, your care of your other children. You know, I mean, your health, all of these are gonna go down the tubes if you stop that medicine. So, here we go, you know, risk benefit, and then it's what do you wanna do? It's your call, not mine yours, but give people options with clarity around risk benefit, rather than some blanket, no, no, no, no, you know, can't go there, no, for you, you know, kind of like a soup Nazi, you know, we're just not doing that. (laughing) - I really do wish that I had someone in my life who was willing to have that conversation with me regarding quality of life. - Yeah. - An ability to manage, you know, you go from being an adult human who's barely getting by, and then you add in-- - Another human. - Yeah, another human, extra hormones, not sleeping, forgetting to eat, all of those other factors. Your life is no longer your own when you are a new parent with a baby, and I have so much compassion for that version of me, who did it totally unmedicated, unsupported. - Why? - I don't know how I did it. - I don't know how you did it either. - Yeah, but I'm just saying, have the discussion, make the choice, make an informed choice, but to me, when you look at risk versus benefits on both sides of this calculation, you know, I think it's worse not medicating than medicating, but that's not my choice. I'm not the mom, you know, so you have to evaluate that. And you can always change your mind, you know, so if you decide you're not gonna go on it, and two to three months into it, you know, your life is a hot mess, and maybe we restart. Or we go to an unsupported one. - I love that. The option to change your mind. - Yeah, that's right, it's never cast and stone, so that can happen, but I'm glad you ask about that, because that's just, we just talked about that this year, first time ever, one of our scientific conferences for professionals. There's an organization in the US called Apsard, American Professional Society for ADHD and related disorders. You don't have to remember that. Just type appsad.org and you'll get to our website, which is four people specializing in clinical practice, providing them with continuing education, annual conferences, lots of resources, the Journal of Attention, there's a lot of benefits to being in that organization. So if you want to stay up to speed, that's a great organization to belong to, to do so. But yeah, I mean, there's plenty of information out there. And particularly now, this issue is being explored, ADHD and women, the female hormones and women, you know, pregnant women. Remember, by the way, whether you take your medicine or not, if you have ADHD and it's the genetic type, which it usually is, the risk to your children for ADHD 25 to 35% anyway. So there's nothing to do with the drugs. That's the genetic transmission of the disorder. So, you know, you got to know that too, because you could be a mom with ADHD, wondering about having another child. And you've already got one with ADHD. And now you want to come off your medicine. Whoa. You really want to do that. And maybe you do. You know, maybe you want to go full natural organic and you choose. And I respect that, you know, ultimately, it's their choice. Just like, ultimately, it's the parent's choice to medicaid or not medicaid a child. But just know what you're getting into. I think the name though. Yeah, go ahead. I'm sorry to interrupt. I think the point though is that there is a choice. Yes. And I don't know that like I certainly wasn't given a choice. That conversation of choice was really not presented to me. So it was like, you're nursing or you're pregnant. You're nursing obviously. You're not taking medication. It wasn't discussed as a choice. And I think that's the point of what you're saying is like, no, it actually is a choice. You get to decide. Well, there's an expert over at Harvard, Master General Hospital, who specializes in tera-togenic effects of psychiatric drugs, who came to us and talked to us about this on the heels of that. There were these giant population studies that got published in the last couple of months. Around these kinds of risks and benefits. And so I think we can have that conversation now that we couldn't have had a year or two ago. When everybody was just saying, I don't want to be involved in this, get off that drug. Right. Because of liability. And we didn't realize that the liability of coming off was even greater than the liability of staying on. But you know, work it through, talk to your doc. And the information is slowly coming out there about this stuff. But it is, it is a choice as you say. Yeah. It's so empowering. Yeah. Well, so great talking to you about all of this. Oh my God, we could go on forever. I really could go on forever. I want to make sure that I'm respectful of your time. So I just want to say, thank you. Thank you. Thank you. Thank you. Thank you. Thank you. What a pleasure. What a dream. And I, I hope that we can continue to have these conversations. Yeah. And I hope that we can continue to have these conversations.