If you have ADHD and executive dysfunction,
like disorganization, time management problems,
and emotion dysregulation,
then you probably already know
that the stimulants like Adderall
and Ritalin don't do a lot to address these issues.
That's where the non-stimulants come into play,
and there's a newer one that shows promise
at helping executive dysfunction.
I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
The primary first line treatment
for attention deficit hyperactivity disorder,
or ADHD for short, is stimulant medications.
They fall into two classes,
amphetamines like Adderall, Vyvanse and Dexedrine,
and the methylphenidate class,
which are medicines like Ritalin and Focalin.
These medications work very well
for attention, concentration,
and distractibility, and hyperactivity,
but they're not so great
for directly improving the executive functions.
They may indirectly help, like if you're better able
to stay focused without distractions,
you may be better organized for that day,
while the medication is working.
But once the medication wears off,
the disorganization returns.
So what exactly are we talking about
with executive dysfunction?
I have other videos talking in more detail about this,
and I'll have them linked to this video.
But briefly, you can think of executive dysfunction
as things like planning, time management,
organization, and even controlling your emotions.
But another big one is called set shifting.
Set shifting is the ability to switch attention
between tasks and then return to where you left off.
So let's say you're doing some work
and you're in a groove and someone says,
"Can we jump on a quick call
to discuss this thing?
It should only last about 15 minutes,
and then I'll let you get back to your work."
Well, that sounds really benign.
It's just 15 minutes, right?
What's the big deal with that?
For the person without a problem
with set shifting, it's not a big deal.
You just press pause, do the other thing,
then unpress pause, and then it's like you never stopped.
But for the person with problems with set shifting,
and executive dysfunction is not exclusive to ADHD,
and not everyone with ADHD struggles with this.
But if you do, that 15 minute quick call
can just ruin your productivity for the rest of the day.
And yes, that sounds really dramatic,
like the rest of your day, really?
Yes, really.
If you have this, you know what I'm talking about.
When you return to your work,
it takes so much work to shift your mind away
from what you were just doing,
or away from complete free flow mode
where you're just thinking
about a bunch of things that you need to do.
By the time you settle down
and refocus on the previous task,
it may be an hour or more later,
and now it's time for another interruption.
Here's why a stimulant medication
may not solve this problem.
If you're on a stimulant, you may be in hyper focus mode
where when you have to stop to have that quick call,
you may have trouble letting go mentally
from what you were doing and be unable to fully engage
with the person to talk about something else.
It's not like you can't talk at all,
but your mind may be wandering
while you're talking or listening,
and you're not getting the most out of it.
But even with the stimulant on board,
the interruption pulls you out of hyperfocus,
and that's enough to get you mentally jumbled.
It's like being on a fast moving train that derails.
The train can still move, but it's not good movement
and the friction brings it to a stop.
And similarly, when you're done,
you're not going to get back to where you were,
unless you take another pill,
which you shouldn't do if it's not time
for you to take another pill.
But some people will take a little more
just so they can finish their work,
and this is probably what is happening
when as me as the doctor, I'll hear people tell me
that the medicine seems to wear off
too quickly in the afternoon.
That wearing off may be because that the dose is too low,
or you're becoming tolerant, so it's wearing off.
Or it could be because interruptions
have caused you to lose your focus,
and you can't get it back
because of trouble with set shifting.
So all of this to say work productivity
is more complex when you factor in executive functions.
So here's where the non-stimulant medications
can come to the rescue.
Currently, there are four available
non-stimulant medications,
clonidine, brand name, Kapvay,
guanfacine, brand name Intuniv,
atomoxetine, brand name Strattera
and the latest one approved in 2021,
viloxazine, brand name Qelbree.
Clonidine and guanfacine
have been around for more than a decade.
Clonidine extended release was FDA approved in 2009,
and guanfacine in 2010.
They were only approved though for children
and adolescents with ADHD,
and still are seen as second choices to stimulants
for children who can't tolerate stimulants,
or the doctors may use them
to add to their stimulant regimen to enhance the effect.
They also may be a good choice if you're trying
to target impulsivity in a child or adolescent.
Atomoxetine, Strattera,
was actually the first non-stimulant
approved for ADHD in children and adults in 2002.
So it's over 20 years old.
It's also been used for people
who can't tolerate stimulants,
or as an add-on to the stimulant.
In my experience prescribing it,
the results for my adult patients
was just kind of so-so.
The stimulants always seemed
to work better and faster.
Now we have viloxazine, Qelbree,
and a recent 2023 study compared it
directly to Strattera.
The results were that Qelbree was more effective
and worked faster, within about a week for children
and two weeks for adults.
Unlike stimulants, Strattera and Qelbree
have to be taken daily.
Strattera can take a month
or more to see a good effect.
Both medications are norepinephrine reuptake inhibitors,
so they increase the amount
of norepinephrine in the prefrontal cortex.
This increased norepinephrine
has a secondary effect of increasing dopamine
and serotonin in this region of the brain.
Also, in this comparison study
of Strattera versus Qelbree,
of the people who had Qelbree added to their stimulant,
85% of them tapered off the stimulant
after they were stabilized on Qelbree.
That's a big deal to feel like Qelbree
was enough to use all by itself
and they no longer needed the stimulant.
Then here's the other important finding.
Another study that I'll have linked
in the description of this video showed
that Qelbree significantly reduced
executive function deficits.
The caveat here is that this study was of children,
and you can't always generalize
those kinds of results to adults.
But the fact that the profile of the drug
shows that it improves executive dysfunction
in children is promising and worth trying to use it
for this purpose in adults.
Qelbree is still a brand drug,
so your doctor may need to complete
an insurance authorization in order
for your insurance to pay for it.
Some insurances will require that
you try and fail Strattera
before they will pay for Qelbree.
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Thanks for watching today.
See you next time.