but in terms of like whether you're going to become quote unquote dependent on a particular psychiatric medication the first question is is it doing what it's supposed to do and do you want it to continue doing what it's supposed to do my doctor just told me I've become dependent on ADHD medication what does that even mean I got off the phone with my doctor just now to get my Adderall prescription refilled during the call he asked me do you take it every day or as needed so I told him honestly I take it every day
because I feel I need it every day my ADHD doesn't just vanish but on the odd day that I forget to take it I do just fine it's when I forget for multiple days that it becomes an issue and he said it sounds to me like you've become dependent on stimulates okay so I told him that I actually was planning on visiting a proper psychiatrist my prescription was given by a GP and seeing about altering my prescription maybe a non-stimulant would work or a lower dosage and he replied no stimulants work best for ADHD symptoms
so now I'm very confused as to what he's going on about to be honest I shouldn't take my medication if I don't need it because I'll become dependent on stimulants but I also need to take stimulants because it helps me the most therefore making me dependent it's really confusing logic and I don't know how I feel about about it he didn't really elaborate either no concerns about my blood pressure or anything he just said hey you're dependent just letting you know your prescription is ready for you to pick up it's just really confusing and I'm
paranoid about my health as it stands so this is really tough because especially if you've got ADHD like anyone who's taking psychiatric medication usually has a concern that they're going to become dependent on it I've seen this whether people have OCD whether I have major depressive disorder whether they have bipolar disorder whether I have ADHD people are afraid of becoming dependent on medication and then sometimes you'll have clinicians who will be like oh yeah you're dependent on this medication now like a doctor is telling you this and that's kind of terrifying like isn't dependency on
medication like a bad thing and then you're like not really sure and sometimes you'll even ask your doctor like okay like is there some way to get off the medication and they'll say like no this is the most effective treatment so I disagree with a lot of what this GP says I'm pretty sure the evidence backs me up better than it backs the GP up we'll talk about that for a second but what I'd love to do is talk to you all today about what medication dependence means is it okay is it not okay and
how people wind up being dependent on medication and is that scary so the first thing to understand is that the reason we prescribe medication is to sustainably help people right so I'm going to ask you all a question let's say I have a heart transplant and as part of my heart transplant I have to take immunosuppressive medication every single day why do I have to take immunosuppressive medication so let's do a quick jaunt into physiology and transplant rejection not what y'all were expecting today but let's explain this principle so I have a body my body
has an immune system my immune system learns what is me and what is not me and then what the immune system does is starts to attack things that are not me right pretty easy turns out out that I got a bum ticker and I need a heart transplant so what I'm going to do is I'm going to get a heart transplant and in order for my immune system to not destroy the transplanted heart because it comes from another person I have to take immunosuppressive medication now this begs the question am I now dependent on immunosuppressive
medication like sort of right I'm not I mean like I guess I could stop taking it so this is a key thing to understand medication is there to accomplish a particular goal that's really the the beginning and the end of it right we'll add a little bit of nuance in a second but in terms of like whether you're going to become quote unquote dependent on a particular psychiatric medication the first question is is it doing what it's supposed to do and do you want it to continue doing what it's supposed to do so when people
take an antidepressant medication or anti-anxiety medication for example they're like do I have to be on this the rest of my life that's usually like one of the earliest questions they ask the short answer is you don't have to be and we'll get to that in a second but this is where I'd say the purpose of medication whether it's cholesterol medication immunosuppressive medication weight loss loss medication or ADHD medication or depression medication the goal is the same it's to try to keep you healthy now just like with many of those medications if you do particular
things as a patient you will no longer need the medication to do that to do that job for it so let's say I have type 2 diabetes which means that due to the number of adipocytes or fat cells that I have in my body this is an oversimplification my body has become resistant to insulin and so since it's resistant to insulin I can take certain medications that will increase my insulin sensitivity and what I can also do is adjust my diet reduce my the level of my adipocytes right start to exercise and do other kinds
of physiologic things that make it so that I no longer need the medication so am I going to be dependent on this medication for the rest of my life well that depends on my other behaviors and what else I do so let's talk a little bit about ADHD medication so some people with ADHD require medication on a daily basis generally speaking stimulant medication from most people that are prescribed for ADHD I will actually recommend it on a daily basis so the goal with people with ADHD is generally speaking the ADHD kind of screws up their
life right if I go to work every day and I need to pay attention every day I don't want to be like missing some days and be like okay other days like if I show up three hours late to work once a month because I didn't take my ADHD medication every single day like I'm gonna lose my job so what I found is a as a psychiatrist working with people with ADHD is you can't afford to have ADHD 20 of the time like you can't treat 80 of it you're still going to get screwed if
you like your 20 like if your ADHD is like active 20 of the time there are some cases where for example like people don't need it for work what they'll do is they'll like not take their ADHD medication on the weekends or things like that there are individual plans that you can kind of come up with but it's okay to take ADHD medication every single day does that build dependence oh before we go on so people are asking about weekends so like here's the thing sometimes you need your ADHD Medical education on the weekend as
well why because you have to do all the crap that you don't get to do during the week on the weekend like you got to do laundry you got to pick up groceries you got to drop off packages to return to Amazon you gotta you know pick up birthday cards you got to be on time to social events so it's fine to use my ADHD medication every single day so does that mean you become dependent well there's two issues to consider with ADHD medication the first is that there may be a physiologic dependence so this
is neither good nor bad it's not a value judgment it just means that if your body develops a physiologic tolerance and dependence on a particular chemical substance that means if you don't take it you're going to have withdrawal symptoms and that could be bad so we develop different kinds of you know symptoms with ADH I mean different kinds of Tolerance with ADHD medications that's not necessarily a bad thing it's just something that you need to be aware of almost from a safety standpoint so that's where like we can become dependent on caffeine is that does
that mean that morally we're bad people and we're addicts not necessarily it just means that if you don't have caffeine you may have a headache that's it it's just to understand the physiology now the second thing about pendant says do I have to take this medication for the rest of my life that's what basically people are asking when they they're saying am I dependent on this medication and that's where that depends it depends and then you may say well Dr K that's weird like how can you say that depends what does it depend on just
like any other medical illness or not any but many other medical illnesses how long you need to be on medication the dose of the medication that all depends on what else you are willing to do as a patient so let's go back to our diabetes example if I start exercising every day if I eat low glycemic index Foods if I start you know doing other particular things like doing yoga or other practices that support type 2 diabetes and stuff like that then I may not need to be on the medication for the rest of my
life right so if I can like get to where I need to go without the medication then I won't be dependent on the medication I won't need it so the question is okay what does that mean for ADHD what's the equivalent of eating healthy and exercising for ADHD first of all eating healthy and exercising both do help ADHD D we go into some of that stuff in the guide that we've got hopefully coming out in about a month on ADHD so we'll go over a lot of different treatment options and stuff like that in more
detail the key thing to remember about ADHD let's talk about science okay what is the evidence-based data suggest so first thing that evidence-based data suggests is that medication and Psychotherapy are equally effective roughly in terms of effect size what does that mean that means that if I have a hundred people with ADHD and I put 50 of them into Psychotherapy and 50 of them into medication or give them medication the symptom reduction that they get in terms of of ADHD is the same okay you actually don't need a pill you can just go to therapy
and you will get roughly the same effect size now people may ask like how do you get therapy for ADHD it gets complicated there's also a bunch of info on this in the guide but basically a lot of the Psychotherapy for ADHD is developing structures and systems to account for your ADHD essentially putting up guard rails so that your ADHD does not negatively imp impact your life it is literally teaching people things like how to organize how to prioritize how to set alarms how to set reminders we go into a lot of detail about how
to develop a good organizational system in the guide but it teaches people these kinds of skills and so just like any other psychiatric illness there are certain skills you can learn that will mitigate or prevent the illness from harming you so a simple example of that is anxiety and meditation so if I have an anxiety disorder and I'm feeling very anxious and I learn to meditate that can reduce the symptoms of anxiety and reduce my quote unquote dependence on anxiety medication ADHD is no different we can learn particular skills that's what Psychotherapy teaches us now
here's where the data gets interesting so when you take people who have been given Psychotherapy and people who have been given ADHD medication effect size is roughly the same difference is duration of benefit after ending treatment here's where the dependence comes in so when I take ADHD medication if I stop the ADHD medication I'm more more likely to go back to square one whereas the cool thing about Psychotherapy is if I do Psychotherapy for let's say 20 weeks and I'm done seeing my psychotherapist I will still get the benefit of that therapy for a year
two years maybe even three years or even somewhat quote unquote permanently depends on the person but what we know is that the benefits of ADHD medication even last after you've done taking the medication so people will still get positive benefits for six months nine months after stopping medication so their symptoms don't return back to normal right away necessarily over long you know large populations and longitudinal studies so the duration of psychotherapy far outweighs the duration of medication which is an important consideration so when people ask me am I going to be on medication for the
rest of my life it's like well that depends on whether you develop an organizational system that will protect you from your ADHD and if you can learn how to organize if you can learn how to prioritize if you learn all these things chances are you don't need medication so the GP said stimulant medication works the best oh so there's something really tricky about stimulant medication which is not necessarily that we're works the best so there are head-to-head studies that show that non-stimulant medications and stimulant medications basically work the same in terms of the effect size
the big difference between stimulant non-stimulant medication is first of all stimulants work faster than non-stimulants so there's a medication called bupropion for example that is just about as effective as stimulants the difference is that bupropion takes like a month to really kick in whereas stimulants you'll feel the benefit within 24 48 or 72 hours so stimulants are better in terms of acting fast but they don't necessarily work they don't reduce your ADHD symptoms more than non-stimulant medications on the whole the second thing about stimulants that makes them feel like they work the best and I'm
not surprised to hear that from a GP is that patients think they work the best so there's a very simple principle in our brain that the more rapid the reinforcement the more behavioral reinforcement we see sorry the more rapid the benefit the more behavioral reinforcement we see so for example like stimulants work instantly so what happens from a patient perspective is patients will tell you stimulants work the best for me nothing else works and why do they say that it's because they notice the benefit immediately whereas non-stimulant medication takes days or weeks to really kick
in so people don't notice it but if you actually do studies where I take 100 people on stimulant medication 100 people on non-stimulant medication and I measure objectively how bad their ADHD is let's say three months after they started medication what I'm going to find is they're both equally effective but the subjective experience of the two patients is going to be very very different the subjective experience is going to be any day I miss my medication with ADH with a stimulant people notice it right away so there isn't a difference in efficacy what there is
is a difference in sort of noticing or kind of like an awareness bias where you can really feel the difference of the medication whereas when you're on a slower acting medication you don't quite feel it as much so that's part of the reason why people say stimulants quote unquote work the best I don't think they actually the data suggests that they don't work substantially better than non-stimulants it's just the difference is a lot more noticeable and therefore is much more likely to reinforce the behavior so a lot of people are genuinely concerned about am I
going to be dependent on my ADHD medication the answer is maybe right so what we what I tend to see as a clinician is that a lot of people will find it very convenient to just take a medication every day because they don't have the time or the energy or wherewithal to learn organization prioritization whatever especially if we're talking about like people who are students right so sometimes like I'll get someone who's like a sophomore who's coming in during midterms you know you can teach me organization and planning but in the two months it takes
me to like figure out how to use a calendar effectively like my midterms are going to be gone and I'll have failed them so sometimes people will need medication because it's the easiest thing to do now how dependent on it you become not just from a physiologic perspective but we're talking like long term do you need to take a medication for the rest of your life the answer is that depends it depends on the severity of your Ada HD it depends on what other kinds of things you're willing to try so we also know for
example that meditation strengthens frontal lobe function and the goal is going to be over time to like literally like reduce your mind's distractibility through practices like meditation the more of that kind of stuff you do the less dependent you're going to become on your medication and the last thing about people sort of saying stimulants work best well I think they work fastest and they work most noticeably but fastest and most noticeable does not technically mean best but it oftentimes looks like best because think about it from the GPS perspective when I give someone a non-stimulant
medication they come back in two weeks and they say the medication isn't working I'm still having problems then as a general practitioner I switch them from a non-stimulant to a stimulant they call me the next day and they're like this medication has changed my life and so then as a GP I don't blame the GP for you know they can't stay experts in everything you know I don't blame them but they'll sort of say like oh okay like so it seems like stimulants work better and then then what what happens is the GPS the next
time someone comes in in with ADHD I just start them on the stimulant and then I don't ever hear from them again except when it's time for refill ask them how's the medication working they say it's working great so these kinds of biases not really the gp's fault in a sense right because they can there's very natural ways why GPS will get to that conclusion last thing that I I kind of want to say is that if your doctor uses terms with you that you don't understand or terrify you like to say like oh yeah
you're dependent on this by the way that may mean something different from to them than it does to you and if your doctor says things that scare you ask them to explain themselves be like what do you mean by that what does that mean what are the implications of being dependent on ADHD medication is this a bad thing like what do I do about it second thing is by all means get a second opinion if a doctor is not talking to you enough if they're not explaining things enough then by all means get a second
opinion explain to them that you need more explanation and also like by all means go see a specialist so someone's asking how does one's life of lie 2915 is asking how does one's life change if they get diagnosed with the ADHD chances are their life gets substantially better so that's kind of a weird thing to say because remember getting diagnosed with ADHD or not getting diagnosed like you have the ADHD whether it's diagnosed or not it's affecting you whether you have the ADHD or I mean whether you get have the diagnosis or not you've got
ADHD either way it's impairing your function whether you have a diagnosis or don't have a diagnosis the only thing that the diagnosis hopefully the main thing that the diagnosis does is gives you the opportunity to do something about it engage in treatment now what we do know is that living a life of untreated ADHD leads to all kinds of problems we've probably got a lecture that we're going to share with you all in about a week or two about this about the ADHD Iceberg but for example we know that something like 50 to 70 percent
of people with ADHD let me think about this the statistic that sounds High even to me I think I may be misquoting this but if you look at the comorbidity of ADHD and depression three three to five percent of people with depression will grow up to later be diagnosed with ADHD but of the people who have both 50 to 70 percent of people with ADHD will be will also have depression later in life for that comorbid population so what does that mean does that mean that if you've got ADHD you have a 50 chance of
getting depression no there's four people who have both if you take that subset of people who already have both what you see is that there is a causal relationship ADHD leading to depression and it doesn't go the other way it's not just correlated one causes the other and why is that it's because growing up with ADHD especially untreated ADHD shapes your life to be depressed later so I'll give you a simple example of this very fascinating study that found that kids with ADHD are less likely to be invited to birthday parties than neurotypical kids think
about that for a second so if I'm an ADHD kid why does it mean I'm going to be less less likely to be invited it's because I don't pay attention so all the other kids are talking about Pokemon cards and I start randomly talking about something that's completely unrelated and the kids all look at me like I'm weird because I'm highly distractible I can't keep Pace with the conversation I also don't pay attention when they're talking to me right so over time like those kids aren't going to want to invite me to their their birthday
party and then over time if I stop getting invited to birthday parties what does that mean for the development of my social skills I don't get opportunities to like develop my social skills because I get invited less can't level up if you don't Zone in to where the fighting is right like you can't get any XP if you're not invited to the game and so over time kids with ADHD experience more social isolation and loneliness Rusty social skills which in turn makes it harder for them to get promoted at work because a lot of getting
promoted at work has to do with social skills and so what we tend to see with kids with ADHD especially when it's undiagnosed and untreated is that living a life of undiagnosed ADHD predisposes you to depression through features like under performance of academic underperforming in an academic sense so it's under achievement academically for kids with ADHD there's lack of social opportunities which leads to isolation and loneliness this there are all these different factors where you can almost this is what we do in the lecture that there's a whole lecture about this and Dr K's guide
to ADHD and doing stuff where you can map it out how growing up with ADHD leads to particular factors which later in life lead to depression because what ADHD does is all of these factors over here are risk factors for depression later in life so hopefully getting diagnosed changes your life for the better scalicious is saying I often hear people say that ADHD and other diagnosis disorders are being over diagnosed do you think that this is true so I've said this before I'll say it again I think ADHD is both the most over diagnosed and
at the same time the most under diagnosed psychiatric illness so you may ask a question wait how can something be over diagnosed and under-diagnosed what I mean by that is I think that ADHD is oftentimes missed in people who have it so this is why we're seeing a lot more adult ADHD diagnosis why is that it's because the diagnosis was missed when they were kids why was it missed when they were kids because the kids were super smart and built up compensatory mechanisms that did not that allowed them to hide the ADHD so when you
see a smart kid with ADHD oftentimes that kid won't get diagnosed because even though they can't pay attention they can use brute force reasoning to figure out what is going on so I'll give you all just a classic example so kid isn't paying attention in math class I'm my mind is wandering I can't pay attention teacher says my name twice and then suddenly I snap back to it I can see the whole classroom is looking at me teacher is looking at me and I can see that people are upset using my ADHD brain which can
quickly interpret information I glance around the classroom I see teachers holding chalk I see there are four problems on the chalkboard three of them have answers I look at the fourth problem that doesn't have an answer I calculate very quickly because I have a high IQ I say the answer teacher looks at me with suspicion because they were sure I wasn't paying attention but I came up with the answer they write the answer and then they move on kids with ADHD develop compensatory mechanisms leads to under diagnosis of ADHD at the same time people over
diagnose ADHD parent parents are frustrated with their kids kids don't listen all they ever want to do is watch the iPad parents never train attention in their kids anytime the kid is upset anytime the kid is distracted anytime my nanny doesn't show up I'm guilty of this as well take the iPad turn on the screen shatters the kids attentional span incl increases emotional dysregulation kid has problems at school because I never sit down and read with them at home parents are like kid doesn't listen because I don't have healthy boundaries at home kid gets diagnosed
with ADHD so it's both over diagnosed and under diagnosed sounds like me oh yeah you betcha foreign
