Unmet Needs in Management of ADHD

Theresa R. Cerulli, MD: Dr Mao, what are the most pressing unmet needs in the treatment and management of pediatric and adult ADHD [attention-deficit/hyperactivity disorder]? We’d love to hear your thoughts on this.

Alice Mao, MD: One unmet need is that despite the efficacy and benefits of all the methylphenidate and amphetamine medications available, there are still a few folks who can’t take stimulants. Perhaps they get ticks or become highly irritable on the stimulants. I treat a specialized population of children with autism and comorbid conditions, such as ADHD. For me, one of the unmet needs has been to have a nonstimulant preparation that doesn’t require being swallowed, because I have a lot of patients who still have difficulty swallowing. I’d like to have a nonstimulant that’s well tolerated and can be administered in a way other than being swallowed.

Viloxazine, which was recently developed, has been helpful in that population because it can be sprinkled. For folks who can’t tolerate stimulants or who have had adverse effects from taking stimulants previously, I’ve been pleased that we have another new option available, such as viloxazine, because it’s a nonstimulant that doesn’t have to be crushed to be taken, as we’ve had to do with immediate-release guanfacine or other compounds. For me, that’s been an unmet need that’s important for clinicians who are treating populations of folks with ADHD who have comorbidities that can be exacerbated, such as anxiety or mood disorders, when taking the stimulant medications.

Theresa R. Cerulli, MD: Dr Feld, what are the most unmet needs still remaining for all ages?

Michael Feld, MD: I’ll start at the professional level. There’s an unmet need of having enough providers.

Andrew Cutler, MD: Yes.

Michael Feld, MD: A lot of nurse practitioners love treating ADHD. It’s on us, the KOLs [key opinion leaders] and leaders, to get people to be passionate about diagnosing ADHD, comfortable treating the comorbidities, and exposed to the new biotechnology. As Andy said earlier, I see some child psychiatry fellows come out of top-level programs in the Midwest, and because of what their exposure is, they don’t even know some of the newer medications. They go into private practice scenarios in which patients come to their office, and they haven’t even used some of these newer medications.

Andrew Cutler, MD: Yes.

Michael Feld, MD: It’s not only at that level. It’s mostly going to be nonpediatric psychiatrists and neurologists, so how do we get the word out? We need to show that we have enough passion and intelligence to teach primary care doctors who aren’t just teaching about pharmaceuticals to make a company a new medication. We’re here because these medications are changing the treatment, efficacy, and effectiveness of ADHD.

A lot of people are comfortable with 2 or 3 medications and not treating comorbidities. We start by teaching the providers that you have to get comfortable diagnosing correctly, looking for comorbidities, and being open to new treatment options and experiencing them. Because once they experience them, they’re going to understand the differences. A lot of vouchers and co-pay cards don’t require prior authorization, and there’s a maximum amount of money, so you could still use these medications for a vast majority of patients, even if they don’t have a commercial insurance that’s going to potentially cover it too quickly. I’m pretty aggressive that way.

The stigma of psychiatry still exists. It’s up to us to show that we’re valid clinicians who change people’s lives and that we help children, adolescents, and even more so adults by treating ADHD, particularly with comorbidities, and make people’s lives more functional, more effective, more productive, more worthy. For me, treating ADHD is probably the most rewarding disorder to treat in almost any field of medicine. But we have to continue to be reliable, valid, intellectual providers who make the treatment of ADHD truly scientific, because there’s so much stigma, misuse, abuse, and poor prescribing. We should hold our own and stay strong and push the proper treatment and diagnosis of ADHD.

Theresa R. Cerulli, MD: Well said, Dr Feld. Thanks for sharing all of your professional and personal experience and participating with us. It helps educate the listeners. Hopefully your passion shines through so that people understand that we’re trying to educate because we care. We care about your understanding, the patients, and the clinical outcomes most of all.

Birgit H. Amann, MD, PLLC: I’d like to share 2 unmet needs. One is that we’re trying to educate primary care prescribers and clinicians about the diagnosis and treatment. But too often, a patient will wait 3 or 4 months to see me. They’re diagnosed, but they’re on the first of the dose in the dose range.

Andrew Cutler, MD: Yes.

Birgit H. Amann, MD, PLLC: Now they’ve waited 3 or 4 months for me to simply take the dose to the next step. They’re tolerating it fine, but they aren’t getting any efficacy. An unmet need is to help primary care colleagues feel comfortable going into more of the dose range so that I can tackle the more complex comorbid ADHD. The second thing is that I’m seeing children at younger ages. We could benefit from more available for 3-, 4-, and 5-year-olds. That has come up often in my practice.

Theresa R. Cerulli, MD: Yes, the preschoolers. Of course, the teaching is that nonpharmacological approaches are first-line therapy for the preschoolers vs school age, where it’s a combination of the pharmacological and nonpharmacological interventions. The little guys are at more risk with the growth delays and…challenges, unfortunately. We don’t have great options for the 3- to 5-year-olds.

Birgit H. Amann, MD, PLLC: A lot of it is parental guidance in that age range, for sure.

Andrew Cutler, MD: I’d like to add 1 or 2 more things. First, I appreciate Mike Feld sharing his personal story. You’ve been an inspiration to me, and we’ve all benefited from that and from your bravery. You’re breaking the stigma by normalizing this. It’s a great example for us, for other fields of medicine, and for our patients.

Mike, you also got me thinking in totally different way. When I’m asked, “What are the unmet needs?” I’m thinking, “What new medicine do I need? What does it need to address?” You’re right that we haven’t done a great job educating our peers on how to use the tools that we already have, how to recognize and diagnose this disorder, and the fact that it can be in adults. As we said, 80% of adults are unrecognized and underdiagnosed. As we’ve been talking about, we have all these newer options that allow us to individualize our treatment. Mike, you got me thinking again. We need to help our colleagues and educate. One of the biggest unmet needs is [teaching] how to use the tools we have available and educating around all the complementary therapies in addition to our medications.

Michael Feld, MD: What Birgit said was maximally on target, because when I make a dose change, I look like a genius.

Andrew Cutler, MD: I’ve experienced that too.

Michael Feld, MD: I make a quick medication change, and people say, “How did you do that?” I’m not going to pat myself on the back. It wasn’t even intellectually challenging. They realize it was a step that wasn’t taken.

Andrew Cutler, MD: Exactly.

Michael Feld, MD: Exactly what you said, Birgit. These people wait so long, they remain untreated or they drop out of treatment because they didn’t think it was efficacious. There’s a disservice being done, and we end up looking as though we’re that good—and hopefully we are—but half those patients don’t need to come to us.

Andrew Cutler, MD: It’s how to use the tools we already have. If you’re going to use the drug, commit to it. The 2 times I look like a genius are exactly that: I raise the dose, or I switch from one MOA [mechanism of action] to the other, like methylphenidate to amphetamine or vice versa. It keeps us employed, but I wish more of our colleagues knew this stuff and could do a better job treating.

Michael Feld, MD: If a medication is on label to 100 mg, why wouldn’t you feel safe prescribing it up to 100 mg?

Andrew Cutler, MD: Exactly.

Michael Feld, MD: That isn’t what happens.

Theresa R. Cerulli, MD: I still teach with the residents at Harvard University, and the old saying “Start low and go slow” is still prevalent. There’s still fear around how to dose.

Andrew Cutler, MD: Yes, especially with stimulants.

Theresa R. Cerulli, MD: Especially with stimulants.

Michael Feld, MD: But if you have an adverse effect with a stimulant, you could stop it that day, so going slow doesn’t make sense to me.

Theresa R. Cerulli, MD: Well said, Dr Feld.

Andrew Cutler, MD: Yes.

Theresa R. Cerulli, MD: I don’t agree with starting low and going slow. That’s just what they’re used to hearing.

Michael Feld, MD: Yes, I get it.

Theresa R. Cerulli, MD: We’re the paradigm changers.

Transcript edited for clarity