Understanding ADHD With Non-Stimulant Meds

Last week Dr. Jeffrey Newcorn, a child and adolescent psychiatrist and professor at Mount Sinai Medical Center, stopped by the Child Mind Institute to give a presentation on advances in ADHD medication—specifically his research on atomoxetine (brand name Strattera), a non-stimulant compound that is seeing increasing use.

For me his most interesting point was that because stimulants are so effective at treating most cases of ADHD, the field has come to define the disorder—in the criteria listed for a diagnosis—partly by the targets of that treatment.

“Our criteria are really strongly built to things that stimulants make better,” Newcorn said. “So there is a real premium on efficiency of processing, getting tasks completed, finding boring things interesting—the things that stimulants do better.” But as a clinician and researcher, Newcorn sees two problems here. For one, there are many more dimensions to the disorder—as he puts it, “all the things about ADHD that we’d like to track better that aren’t part of our criteria.” And—relatedly, as he demonstrated—though most people with ADHD respond to stimulants, many don’t. How to help them, he said, begins with understanding how they are different.

Newcorn’s rationale for pursuing atomoxetine emerged from a widely known clinical fact: there are two classes of stimulants, and if one doesn’t work well for a young person with ADHD, chances are the other class will. About 80% of patients will respond to either methylphenidate or amphetamine. Are those other 20% just out of luck? Not if you broaden your idea of what “response” is, and understand that the two classes of stimulants, though similar, work differently in the brain. Why can’t something else work?

“It makes sense to look at atomoxetine,” he said, which targets some of the same neurotransmitters as stimulants—but in a very different way and in different parts of the brain, as Newcorn illustrated with imaging studies. Its effects are also different, he postulated, serving more to “drive mental effort” and “increase” the signal as opposed to stimulants, which “decrease noise.” And it can help people who have been labeled non-responders to treatment.

The upshot here is that all cases of ADHD aren’t the same—and that Newcorn is blazing a trail into a future of personalized medicine. There is no place and no need anymore for a “one size fits all approach” to ADHD treatment, he said. Instead of settling on averages—on the sunny but still wanting 80% response rate for stimulants—we can and should figure out “which drug is best for which patients.” Or, as he put it, “our goal is not to treat partial responders with something that doesn’t work too well.” And by thinking about ADHD in a more catholic way, we find that the tools to achieve a better goal may be in front of us.