ADHD drugs are not a quick fix for brain enhancement
Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
Can drugs that improve concentration in people with attention-deficit/hyperactivity disorder also help people who do not have ADHD?
We're exploring that with Dr. Stephen Faraone. He's a Distinguished Professor and vice chair of research of psychiatry and behavioral sciences at Upstate.
Welcome back to "The Informed Patient," Dr. Faraone.
Stephen Faraone, PhD: Thank you, Amber. Great to be here again.
Host Amber Smith: College campuses and various workplaces are full of people who may turn to stimulants to help them stay awake and perform well on exams or during important deadline projects. Some of the stimulants they use are prescribed for helping people with ADHD to improve their concentration.
Do these medications work in people who don't have ADHD?
Stephen Faraone, PhD: Well, what I would tell you is that the medications will have an effect on these people, but they won't help them in the same domains as they help people with ADHD.
So, for people with ADHD, they improve concentration, they reduce hyperactivity and impulsivity, but for a person without those problems, it's not helpful.
It's almost like saying, I'm nearsighted, so I need glasses, but if I give my glasses to somebody who has perfect vision, it's not going to help them. In fact, it could make their life worse; it would make their life worse, from wearing glasses.
The college kids that use the stimulants think that because it helps people with ADHD, that somehow it's going to make them into super students and do better. And it doesn't. I mean, we know from studies that clearly show that actually the kids that use stimulants to help them through college end up doing worse overall in terms of grade point averages than other kids.
And we know from a recent study by some colleagues of mine in Australia that when you look at adults performing neuropsychological tasks, adults who don't have ADHD, having stimulants on board does not help them at all. It's not useful.
Host Amber Smith: Well, how do these things work?
Like Ritalin and dextroamphetamine, how do they work? What do they do in the body?
Stephen Faraone, PhD: Well, we know about those two medications, the class is called stimulants. People know them as Ritalin or Concerta for methylphenidate, or Adderall or Vyvanse for amphetamine, and there are many different variants of that.
What they do is that they target proteins in the brain, actually one specific protein called the dopamine transporter, which is -- I'll have to explain this, because it does get a little technical, but in the, brain is a collection of cells called neurons. These neurons talk to each other. They're not physically connected. They're separated by small gaps. We call those gaps a synapse. And for one neuron to talk to another, it has to send chemicals across the synapse to propagate the message. To give a clear message, you have to have each of these neurons sending a chemical message to the subsequent neuron.
If there's not enough chemical in the synapse, the message gets garbled, gets confused, and is not as effective as it is in controlling the type of behavior or mental activity that these neurons regulate.
In the case of ADHD, the medicines literally block the activity of a protein called the dopamine transporter. And it prevents the dopamine transporter from removing a chemical called dopamine from the synapse. Because we think what happens is that, with people with ADHD, there's too many dopamine transporters that are removing the dopamine from the synapse too quickly, so the message isn't getting through.
So by blocking the transporter, you enable more message to get through and a less garbled and a clearer message to get through.
Host Amber Smith: So, the role of dopamine: We do need it, but not too much of it?
Stephen Faraone, PhD: Everybody needs dopamine. Dopamine is a very important neurochemical in the brain, among many others, and we need dopamine, for sure.
I should point out other medications for ADHD, which are not stimulants, medications like atomoxetine, viloxazine, clonidine and guanfacine. And these all work in another system called the norepinephrine system.
Essentially, the effect is similar. They try to improve the communication between neurons that use norepinephrine as the communicating neurochemical, as opposed to dopamine.
Host Amber Smith: And these are medications that we know work in people with ADHD. They've been studied.
Stephen Faraone, PhD: These have all been studied. All FDA approved and indicated for treating ADHD.
Host Amber Smith: Can you tell us about research from the University of Cambridge that looked into this?
Stephen Faraone, PhD: Well, this was a study where they literally had adults do some psychological tests, mental calculations, things of that sort. The goal of the study was to see if you were to give them a dose of stimulants, the kind that you would give to a person with ADHD, does it improve their performance on these tests?
And the answer is it didn't help them at all, which is something that makes perfect sense to me because they don't have the problem that the medication is supposed to improve. So, giving them the medication is not going to help them.
Host Amber Smith: Well, if stimulants don't improve concentration, is there a benefit to someone taking them if they just are trying to stay awake, either to drive or to study?
Stephen Faraone, PhD: There's no question that if you take a stimulant, it will keep you awake. I mean, the U.S. Air Force will give stimulants to pilots; they have to fly long, long missions, for sure. We know that stimulants keep people awake. College students will sometimes, therefore, use them to stay awake and study, so they can cram for a test, but we know that's a very bad way to study for tests, and it actually hurts them because if they think, "Oh, I don't have to study until the night before because I'm going to stay up all night studying, because I'm going to take Adderall or Concerta, and then I'll be wide awake in the morning, and I will be able to take the test," they're totally wrong, because the method of cramming for tests does not work, in general.
And taking the medication to help you do that probably worsens your performance on the test, because you may get side effects from the medication, such as feeling jittery because you took too much or having headaches, having other side effects from the medication that would put you in a situation where you're not going to test as well as you might otherwise.
I should also point out that many of the people who misuse these medications, they think, "Well, I'm not abusing a drug, because this isn't a street drug. This is a drug that was, approved by the FDA, it was, given by a doctor to my friend for his ADHD, so therefore it's safe."
And the answer is, well, yes, the drug is safe, but there's a qualifier there. It's safe when it's prescribed by a physician for appropriate use, and the person has been cleared for that appropriate use. So, for example, there are some cases where you wouldn't prescribe the medication if somebody had a pre-existing cardiac condition, because it could kill them. People who misuse it, they haven't been screened for conditions that might hurt them if they take the medication, and that can lead to problems.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.
My guest is Professor Stephen Faraone. Much of his research focuses on attention-deficit/hyperactivity disorder, and today we're talking about whether medications that improve concentration in people with ADHD can also provide a mental boost to people who don't have ADHD.
So if ADHD medications don't boost concentration for people who don't have ADHD, let me ask you about the supplements -- Prevagen, Neuriva -- these are advertised as brain boosters to improve memory or give you a sharper mind and clearer thinking. How do they work?
Stephen Faraone, PhD: Well, the answer is they don't work. So, I think we can start and stop there.
I always urge people, when they hear something like "this supplement will help you with a certain mental activity, mental trait or physical trait," just go to PubMed.gov (a government cite for scientific research) and do a search, and can you find publications that actually show that? And usually the answer is no.
Occasionally you can find something might help you for a certain indication. But none of these so-called brain boosters have ever been shown to be dramatically effective or effective at all for helping people. Mostly, it's just a waste of money. Frequently, we don't even know the mechanisms of action, because they haven't really been studied, because most of these supplements are not useful. People haven't bothered to study the mechanism.
And one exception is the omega-3 fatty acids. These have been shown to have a small effect in improving the symptoms of ADHD, but they haven't been shown to help people who don't have ADHD.
And the effect on ADHD is small. For some people it may do very well, but it's a very small subgroup of people. I do mention that a little because continually the field is trying to explore for new ways to treat ADHD that don't involve drugs. And, honestly, my colleagues have searched far and wide. They haven't found a diet, and they haven't found much in terms of supplements besides omega-3. And even omega-3, if you try it, don't try it for too long. And if it's not working, because if it's not working after a month or two, it's probably not, going to work, and you should switch to something more effective.
Host Amber Smith: Prevagen, the advertising says that it contains an ingredient from jellyfish. Why jellyfish? Are they known to be sharp?
Stephen Faraone, PhD: No, (laughs) certainly not sharp thinkers. It's conceivable that there's some compound in the jellyfish that has some psychoactive effect. But frequently, these supplements will link on to something; there's some very tenuous association, like they might say in jellyfish we found this compound, and this compound has been found to help rats do better in a certain task, or something like that, and then all of a sudden say, "therefore it's going to help you," and it's usually the most tenuous of links.
The ones I would trust the most, if I were to say to someone, if you have to, if you're somebody who just has to use supplements, and you refuse to use standard treatments, I would go with those that have been used for centuries.
So, for example, my colleagues in China still use traditional Chinese medicines to treat ADHD. They have a whole variety of herbs and things of that sort, acupuncture, and they have some interesting data that I would say it's intriguing, but not compelling. And it's not compelling because they haven't done the right kinds of controlled trials to convince me. But the actual data themselves are intriguing enough to say this is worth consideration, and the fact that they've been used for a few thousand years suggests that there is something to it.
But for the most part, I will tell people, "Don't spend a lot of time chasing down these treatments." I can tell you a personal story of a friend of mine who said, "Hey, Steve, I know you're an ADHD expert. Could you talk to my daughter? I'm sure that my grandson has ADHD. She keeps taking him to all these alternative-medicine doctors and practitioners, and it's been two years, and nothing's happened. Could you just tell her what you think is the facts?"
And I did. And, I'll tell her what I'll tell the rest of the people out there looking for alternative medicine, and that's very simple: "Look, if you're afraid of drugs, just do this. Ask your pediatrician for a prescription of what he or she thinks is an appropriate medication. It'll most often be a stimulant drug. And then just try it for a day. If you don't like it after a day, if you think it's horrible, then you can stop. One day it's not going to harm anybody, but I'd suggest you try it for at least a week or two. And then, if you don't see anything you like, you can just stop right away."
Well, this daughter of the friend of mine, she called me back in a week after she got the prescription, and she said, "Oh, my God, I wish I had talked to you two years ago, because he is so much better, and I've just wasted so much of my time with these other, so-called doctors."
In some ways, they're really quacks, because anybody who does not treat people based upon the evidence base is really not doing appropriate medicine or appropriate clinical work, including my psychology colleagues. I'm a clinical psychologist, and psychologists who like to treat ADHD psychologically are doing their patients harm, because they're denying them medical treatment that we know is much better than any psychological treatment that we have.
Host Amber Smith: Now, a lot of these supplements, though, that are on the market saying that they promote cognitive improvement or alertness or clarity, memory recall, those sorts of things, these are supplements that don't have the oversight of the FDA (Food and Drug Administration) for approval, right?
Stephen Faraone, PhD: Oh, that's right. None of them have been approved by the FDA at all. Their rules for advertising are, I guess, fairly lax, because they're allowed to make these claims. And if you read the fine print, the fine print on many of these supplements will tell you that basically they haven't been approved for what they're claiming that they're useful for.
Host Amber Smith: So has science found anything that can actually help people focus? Anything to eat or avoid eating or any sort of lifestyle modification?
Stephen Faraone, PhD: Well, in general, I always encourage people to say, to start with the obvious things, get a good night's sleep, have a well-rounded diet, exercise regularly, don't become overweight, take care of yourself medically. If you do those basics, that's going to help everybody concentrate better and do better. Those things are far more important.
You know, the problem with us Americans is we're looking for a quick fix. Is there a quick fix, so I can eat as much as I want, I don't have to exercise, and I can still be super sharp and effective?
And the answer is you can't, basically. Most of us can't. We have to take care of ourselves. A lot of people take care of their cars better than they take care of themselves. It's bizarre.
Host Amber Smith: Well, Dr. Faraone, I appreciate you making time for this interview. Thank you.
Stephen Faraone, PhD: Happy to do it. Thank you.
Host Amber Smith: My guest has been Dr. Stephen Faraone. He's a Distinguished Professor and vice chair of research of psychiatry and behavioral sciences at Upstate.
"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.
Find our archive of previous episodes at upstate.edu/informed.
This is your host, Amber Smith, thanking you for listening.