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Old 06-06-11, 01:54 PM
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My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowledge!

Hey all,

So, as most adults with ADHD find, and especially those newly diagnosed like me, the process of "trial and error" when personalizing/matching ADHD medication(s) to oneself in addition to titrating them seems grossly unscientific and frustrating. As with other psychiatric conditions, there is no blood, genetic test, or brain scan that can diagnose ADHD. A big source of my frustration has to do with how little knowledge we have about the neuropathological basis of ADHD in addition to any genetic regulatory/epistatic and proteomic level biomarkers to test for, which could help a) diagnose a very "real", indisputable disorder in the brains of ADHD patients, and b) guide psychiatrists down a protocol for better targeted medication therapies (AMP vs. MPH vs. non-stims according to what ADHD subgroup people are: Inattentive, Hyper, or Combined).

The past 5 weeks I've had to throw myself to the cognitive/behavioral mercy of 3 different stimulant medications in all their side-effect glories: from Adderall to Focalin to curretnly Ritalin, and I've had to indepthly research them all upon every switch in order to assess expectations (just "taking them and seeing what happens" and constantly evaluating them day-to-day for 2-3 weeks each is an agonizing process). Adderall seemed perfect in the behavioral department, but I couldn't do cognitive tasks/follow lectures or lab presentations, text, email, etc. fast at all. I was cognatively slow on Adderall to a pronounced degree (moreso than others I've come to find out). The MPH side of meds let me think clearly, but they don't give me the concentration/motivation Adderall gave me. Instead I'm just quiet, still, and stuck on whatever task it is at hand (whether it be productive or procrastinatory). And while I'm grateful that I'm moving in the right direction, I can't help but think that it is a monumental loss of energy and time considering how biomedically advanced we're supposed to be.

We are in freaking 2011, ADHD medications are a $4+ Billion dollar industry, and they're just NOW getting around to doing global-genomic studies, fMRI clinical trials with ADHD medication efficacies, cross-medication and dosage effecacies on cognitive vs. behavioral performance? They didn't really even know that ADHD persists in adults until relatively recently, when they've had Ritalin since the freakin '50s?!?

Here is a compilation of new studies I've researched that show that there is indeed breakthroughs about to happen in the basic biomedical research area of ADHD. I hope this helps you, because I've been obsessed with it all for the past month. Various levels of results I've found:

1) Newest Neuro/Genetic Research: (Poelmans et al paper):
They've started making breakthroughs in neurodevelopmental protein maps/networks specific to ADHD helping with understanding the disorder (using the new "Ingenuity" and "BINGO" pathway bioinformatic analysis software that my lab has also started using with immunological studies -- essentially does a battery of tests on many genes (microarray analysis) and computes very complex down & upregulatory effects of genes on one another -- very cool! but still in its infancy with kinks to work out, but still offers an unprecedented complex computational analysis that would take us an eternity to do by hand), specifically 45 out of 85 ADHD gene candidates that are directly related to neurite outgrowth and pathway formation that they can now rigorously investigate. They also have brand new ADHD candidate genes that will hopefully guide research into psychopharmacological ADHD treatments in the near future.

They're beginning to also find genetic microdeletions, gene copy number variants, and significant (though subtle) epistatic interactions among neurochemical pathway genes all over the place, and also specific gene deletions in genes related to melatonin signaling pathways which lead to melatonin deficiencies (hence another reason many ADHDers find it harder to fall asleep, amongst a ton of other multifactorial reasons).

2) Newest Opinions on General Treatments for ADHD (Medications in combination with behavioral therapy):
Stimulant medication still provides the most dramatic/effective treatment for adult ADHD symptoms even over cognitive behavioral therapy alone, and a recent finding that meta-cognitive therapy (MCT) is found to have the best success as a supplementary treatment for ADHD over simple cognitive-behavioral therapy (support group sessions with a psychologist moderator). Dr. Mary Solanto, a world-wide leading ADHD PhD psychologist of the Mt. Sinai School of Medicine and AD/ HD Disorder Center who published this 2010 paper developed a 12-week program at Mt. Sinai School of Medicine AD/HD Disorder Center to help people with ADHD learn to manage time, break down daunting tasks into manageable steps and keep themselves organized.

"One mantra of the program is: "If it's not in the planner, it doesn't exist," says Dr. Solanto. In a study of 88 patients published last month in the American Journal of Psychiatry, they found that those who participated in the program improved significantly more than those who received more standard supportive therapy."

'Generally, ADHD can make life very difficult. It's thought to be an imbalance in neurotransmitters, the chemical messengers that relay signals in the brain, particularly in the frontal cortex that governs planning and impulse control. Adults typically have trouble with paying attention, focusing and prioritizing. Managing time and money are particularly difficult.
"What it really is is a disturbance of the executive functions of the brain -- it's the inability to plan things, to initiate them at the appropriate time, not to skip any of the steps and to terminate them at the appropriate time." -
http://online.wsj.com/article_email/SB10001424052702304620304575165902933059076-lMyQjAxMTAwMDAwNjEwNDYyWj.html

This paper is now currently changing the landscape of how psychiatrists/psychologists/APA may advise future protocols for ADHD behavioral therapy. (Quick summary article on this paper from Medscape.com: http://www.medscape.com/viewarticle/718932).

Yet Dr. Solanto admits that meta-cognitive therapy is still relatively new, and isn't offered in most local communities. Also, there's debate over whether her method in the study was really metacognitive therapy (MCT), but instead just rather a combination of cognitive-behavioral therapy (CBT) with time management and organizational skills training (challenge OP/ED article here: http://ajp.psychiatryonline.org/cgi/content/full/168/3/327-a). I just bought her book Dr. Solanto just recently published (March 2011) for physicians to use, interestingly titled "Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction" (ISBN-10# 160918131X). It nonetheless goes into graphic detail about new CBT methods for ADHDers that she used in the 12-week sessions that include even all the new smartphone syncing note/organizational apps like Evernote, iCalendar, ToodleDo, Outlook, etc.

In addition to medication and self-help books (I don't have much time before med school starts in the Fall! lol) I'm also thinking of hiring an ADD behavioral therapist or counselor, and have found http://www.coachfederation.org/ to be helpful in finding an ADD coach, though I may just choose a local one. Having someone there who can whip your *** into shape and hold you accountable once or more times a week to get a good organizational system down seems like a pretty good idea, as I don't want to take any chances on another undergrad-style ADHD coping disaster.


3) Newest Evidence for Stimulant Medicinal Effects on Cognitive and Behavioral Outcomes:
Basically, I wasn't crazy when I thought the Adderall was making me think excrutiatingly sluggishly (Ha!). There have only been spotty studies in the past on stimulants and how they affect academic performance. Basically there has been no recent substantive adult ADHD research, and the focus was always on kids. In the 90's researchers only focused on improvement of behavioral symptoms of ADHD in children and an "overall improvement" in school. They did not delve into the variables of different stimulants used (MPH vs AMP), high or low dosage and each of their affects individually on behavioral remission vs. cognitive increase/decrease. They've finally had brand new (2011) studies come out which focus only on MPH that show that MPH does improve academic performance, but that lower doses actually assist academic cognitive processing more than higher doses. Even though higher doses of MPH produce more desired behavioral symptom relief for parents, the kids can't think as straight on the higher doses and do better on lower doses on tests/math problems, verbal reasoning, etc. Kind of makes sense, but they LITERALLY have not done any of these studies before (ludacris, right?). They've also found in another 2011 study that long-acting MPH (Concerta, LA, Methadote, etc) improve overall academic and memory function and decrease impulsivity in kids overall. This is because they comply with medication more if it's once a day (DUH) and don't have to go to the school nurse every lunch and get teased by kids. The goal for most people once they're set/titrated on a med or combo of meds is to have a long-lasting dose exposure. They've also found (2011) that MPH improves cognitive performance a little, but not by being a cognitive processing or organizational/executive function enhancer, but by simply helping the brain be aroused at a higher/normal state to allow for better focus/attention and less impulsivity and anxiety. They also found out (Chinese study) that IQ isn't significantly affected, but that overall cognitive performance is helped, again through better focus/concentration/less impulsivity.

What this new info does for me is establish a set of expectations (not just placebo effect or empty expectations that I'll get magically better at organization through a pill, but rather have to keep working on organization myself with better applications and methods). Knowledge is half the battle

So, I hope this is helpful to you all! (Sorry this is so long, I've stayed up all night b/c I was "hyperfocused" like no one's business this weekend literally glued to my computer trying to get to the effing bottom of what's going on with me). But at least I'm self-aware about "hyperfocusing" -- 5 weeks ago, I thought I was always just weird like that.

Happy Monday

Selected References (not full format, but enough):

1) Poelmans et al, Integrated Genome-Wide Association Study Finding: Identification of a Neurodevelopmental Network for Attention Deficit Hyperactivity Disorder (Am J Psychiatry 2011)

2)Segurado et al, Epistasis between neurochemical gene polymorphisms and risk for ADHD (European Journal of Human Genetics 2011)

3)Lesch et al, Genome-wide copy number variation analysis in attention-deficit/hyperactivity disorder: association with neuropeptide Y gene dosage in an extended pedigree (Molecular Psychiatry 2011)

4) Chaste P et al, Genetic variations of the melatonin pathway in patients with attention-deficit and hyperactivity disorders (J Pineal Res. 2011 Apr 27. doi: 10.1111/j.1600-079X.2011.00902.x. [Epub ahead of
print])

5) Solanto, et al, Efficacy of Meta-Cognitive Therapy for Adult ADHD (Am J Psychiatry 2010)

6) Knouse et al, Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder (Psychiatr Clin N Am 33 (2010))

7) Hale James et al, Executive Impairment Determines ADHD Medication Response: Implication for Academic Achievement (J Learn Disabil 2011)

8) Wigal et al, Academic Behavioral, and Cognitive Effects of OROS Methylphenidate on Older Children with Attention-Deficit/Hyperactivity Disorder (Journal of child and adolescent psychopharmacology 2011)

9) Zhang et al, Effect of Methylphenidate on Intelligence Quotient Scores in Chinese Children With Attention-Deficit/Hyperactivity Disorder 2011)

10)Claire Advokat, What are the cognitive effects of stimulant medications? Emphasis on adults with attention-deficit/hyperactivity disorder (ADHD) (Neuroscience and Biobehavioral Reviews 2010)
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  #2  
Old 06-06-11, 02:05 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

I didn't think add was a psychiatric disorder.
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Old 06-06-11, 02:15 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

Very interesting stuff.......and thanks for breaking your work down into easier to read blocks than it seems most of the first time members tend to write with ....it is a big problem here, if most of us see a long post with more than 3 or 4 lines in a row, we call it "wall of text" and our brains say ....uhm ...no.........


I found your post fairly easy to read and getting it read is the first step ......


and while I have nothing to add to what you've written about, I do have one suggestion ......you might want to try dextroamphetimene .....the Dex IR, tablet, not the XR ..capsules, as the tablets are easier to control your dosage.....they are shorter lasting.....so you have to take them anywhere from 2 times to 4 times a day ......



but they are pure dextro ...yada yada yada ....without the othe ingredient that Adderall has ......I know for me, dex is the only thing that works.....I tried adderall, but didn't much care for it .....and I think you take less dex for much the same result .....


just a suggestion .....good luck with your research and medical school .....my dad was a doctor ( OB-GYN) and he loved his work.,...and old- fashioned type of doctor , Marcus Welby in real life .....don't let the suckers ge3t you down .....they will try .....



and it is a sin in how little we know about ADHD in adults ......maybe you can become part of the solution ! .....be sure and checkl out Dr. Russell Barkley ( spelling?) and the videos he has put out, youtube has lots ., and there are some here, but I cna't tell you how to find them .....
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Old 06-06-11, 02:17 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

Sarah, what did you think it was ? .....it is a neurological disorder, true, but it falls under the purvue of Pyschiatry .....
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Old 06-06-11, 02:20 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

wow thank you so much, I'll have to come back and take a look at this again and again. I'll try and comment later .. my mind is scattered right now.
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Old 06-06-11, 03:17 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

That was amazing. Great research! I can tell you are benefiting with Ritalin a lot.

I always think the lower the dose the better, but some people vary.
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Old 06-06-11, 07:05 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

Pharmaceutical companies don't do enough studies! It's so wrong!

"We are in freaking 2011, ADHD medications are a $4+ Billion dollar industry, and they're just NOW getting around to doing global-genomic studies, fMRI clinical trials with ADHD medication efficacies, cross-medication and dosage effecacies on cognitive vs. behavioral performance? They didn't really even know that ADHD persists in adults until relatively recently, when they've had Ritalin since the freakin '50s?!?"
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Old 06-06-11, 08:20 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

I found this to be a very interesting read.
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Old 06-10-11, 10:42 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

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Originally Posted by MedStudent82 View Post
The MPH side of meds let me think clearly, but they don't give me the concentration/motivation Adderall gave me. Instead I'm just quiet, still, and stuck on whatever task it is at hand (whether it be productive or procrastinatory).
Interesting. This is similar to my experience with Ritalin too. Don't get me wrong - it's been a very good experience being on it, but it doesn't do too much to improve organizational thinking and it doesn't provide that kick to get onto a productive task. Reducing the impulsivity and restlessness and boosting focus is very useful tho.

Which makes me wonder - is there a stimulant that retains the focus from Ritalin but also boosts organizational thinking? Would Adderall/Dex/Focalin be better?

Oh, and BTW: great post. Very interesting!
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Old 06-19-11, 05:43 AM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

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Originally Posted by quark View Post
it doesn't do too much to improve organizational thinking and it doesn't provide that kick to get onto a productive task. Reducing the impulsivity and restlessness and boosting focus is very useful tho.

Which makes me wonder - is there a stimulant that retains the focus from Ritalin but also boosts organizational thinking? Would Adderall/Dex/Focalin be better?

Oh, and BTW: great post. Very interesting!
Thanks quark. I've had the strangest two weeks of my life the past two weeks on Ritalin though, and won't touch it with a 10-foot pole now (won't go into it, but it was a "stealth" primer for severe hyperfocus. Like, 22/7. (yes, 22, not 24). Saw the doc last Thursday, and we're going back to Focalin. The MPH side of meds make me focused and less impulsive, but I'm completely inactive on them. I feel so very "meh" on them.

Couple days before my appt with the doc, at his suggestion I took Focalin, then Adderall to remember what they felt like again. Focalin was a tiny bit better than Ritalin, but I was just stuck/lingering to stupid/procrastination stuff all the time. As soon as the Adderall kicked in the afternoon after I took Focalin that morning, (only 5 mg Adderall mind you), I immediately --and I mean immediately -- stopped dragging my feet, got up, and got s$#t done. I was myself - I was motivated to do stuff. I could release whatever minor task I was dragging out while on MPH, pick-up, and do what was important. I had bounce in my step and just... felt right. It was also harder to think. Just like the first 3 weeks I was on Adderall. Which is what made me sad when I discussed this with him last Thursday. There is a tradeoff between Ritalin/Focalin and Adderall for me. I cannot do Adderall in med school. I simply cannot follow through presentations/lectures slower to thought. Behaviorally, I'm great on Adderall. Mentally/cognitively, I suck more. Even at such a low dose. This ties into the research I did though. Behaviorally, it can be one way, and cognitively, another. Everyone is different though, of course. I'm just sad, b/c I don't want to be "meh" on Focalin all the time from now on. We discusses Dexedrine, but he seemed to think it would be very similar to Adderall. Since I steered myself wrongly in the direction of Ritalin with him, I thought it best to let him take the reigns and decide. Though I am very curious still about that last "quadrant" of stims (Dex) I haven't tried yet.

Time will tell. Not seeing him for a month now (lord), so we'll see how it goes. Meantime, organizational skills are definitely needed to be improved on our own in addition to these meds. I definitely am seeing that now. And that's supported 100% by the research above. Keep me posted on what you try/find out man.
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Old 06-19-11, 07:19 PM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

Quote:
We are in freaking 2011, ADHD medications are a $4+ Billion dollar industry, and they're just NOW getting around to doing global-genomic studies, fMRI clinical trials with ADHD medication efficacies, cross-medication and dosage effecacies on cognitive vs. behavioral performance? They didn't really even know that ADHD persists in adults until relatively recently, when they've had Ritalin since the freakin '50s?!?
I agree with this too. ADHD is a spectrum disorder but there seems to be very little in the way of understanding the spectrum. Inattentive, combined, and hyperactive is not much of a spectrum. Have you come across Dr. Charles Parker and his corepsychblog? I personally can't be bothered to go through the blog (wonder why?), but I found his videos very interesting. I don't have a medical background to really evaluate the veracity of his theories/claims (he seems more than a little aggressive at times!), so judge for yourself. I found myself agreeing with the way in which he tries to describe the spectrum. I could be wrong. Anyway, here is his youtube channel. The videos I watched are under the ADHD medication tutorial: http://www.youtube.com/user/DrCharlesParker

I'd really like to know what other people on this forum think of this guy (but perhaps the Ritalin subsection isn't the right place to ask).
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Old 05-26-12, 02:34 AM
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Re: My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowle

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Originally Posted by MedStudent82 View Post
The past 5 weeks I've had to throw myself to the cognitive/behavioral mercy of 3 different stimulant medications in all their side-effect glories: from Adderall to Focalin to curretnly Ritalin, and I've had to indepthly research them all upon every switch in order to assess expectations (just "taking them and seeing what happens" and constantly evaluating them day-to-day for 2-3 weeks each is an agonizing process). Adderall seemed perfect in the behavioral department, but I couldn't do cognitive tasks/follow lectures or lab presentations, text, email, etc. fast at all. I was cognatively slow on Adderall to a pronounced degree (moreso than others I've come to find out). The MPH side of meds let me think clearly, but they don't give me the concentration/motivation Adderall gave me. Instead I'm just quiet, still, and stuck on whatever task it is at hand (whether it be productive or procrastinatory). And while I'm grateful that I'm moving in the right direction, I can't help but think that it is a monumental loss of energy and time considering how biomedically advanced we're supposed to be.
The brain is incredibly complex. We can hardly comprehend how complex it is.

Add all the other factors that influence personality and physical function (sleep, diet, sunshine, etc.), and there are lots of moving targets.

re: above stimulant experimentations. Some people find a combination of AMP and MPH work best. We've known that for a few decades.

But frankly, I don't know many people who do well on any of the old-generation Rx (Ritalin, Adderall, Dexedrine). Too many problems with quick starts and bad rebounds. Not to mention that 75 percent of late-diagnosis adults will have co-existing conditions, most of which can be exacerbated by stimulant monotherapy.

There are protocols out there. You don't have to reinvent the wheel. Nor do you have to wait for genomics, etc. to pinpoint targets. In fact, with all the widespread disparagement of Big Pharma, as well as attacks by crusading politicians such as Chuck Grassley, and the fact that most "easy" medication targets have already been discovered, we should all be thankful we have the medications for ADHD that we do.

I was watching an old video, a panel of teens with ADHD created by Chris Dendy, and I felt awful for these teens talking about their only Rx choices at that time: IR Ritalin, Dexedrine and Adderall.

Good luck sorting it out.
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