Rethinking ADHD Treatment: The Power of Non-Stimulant Medication for Executive Dysfunction

Dr. Tracey Marks, a psychiatrist, addresses the common misconception that stimulant medications like Adderall and Ritalin fully resolve all ADHD symptoms. She highlights that while stimulants are highly effective for attention, concentration, distractibility, and hyperactivity, they often fall short in directly improving core executive functions such as planning, time management, organization, and emotion dysregulation. A significant focus is placed on \"set shifting,\" the ability to fluidly switch between tasks and return, explaining how impairments in this area can severely disrupt productivity, even for individuals on stimulant medication, potentially leading to a perceived premature wearing off of the drug.\n\nThe podcast then introduces non-stimulant medications as a vital alternative or complementary treatment, particularly for executive dysfunction. Dr. Marks details the four currently available non-stimulants: clonidine (Kapvay), guanfacine (Intuniv), atomoxetine (Strattera), and the newer viloxazine (Qelbree). She notes that clonidine and guanfacine are primarily approved for children and adolescents, often used as second-line treatments or add-ons. Atomoxetine, approved in 2002, is a norepinephrine reuptake inhibitor (NRI) that can take a month or more to show effect, with the host noting "so-so" results in her adult patients.\n\nThe episode emphasizes viloxazine (Qelbree), approved in 2021, as a promising advancement. Qelbree, also an NRI, works by increasing norepinephrine in the prefrontal cortex, which secondarily boosts dopamine and serotonin. A 2023 study is cited, indicating Qelbree's superior efficacy and faster onset compared to Strattera (within one week for children, two for adults). Crucially, another study showed Qelbree significantly reduced executive function deficits in children, offering strong potential for adults, and 85% of patients who added Qelbree to their stimulant regimen were able to taper off the stimulant entirely.\n\nDr. Marks concludes by advocating for a more nuanced approach to ADHD treatment, recognizing that executive dysfunction requires targeted interventions beyond what stimulants typically provide. Qelbree represents a significant step forward for individuals whose ADHD symptoms, particularly those related to executive functions, are not adequately managed by traditional stimulants. She also touches on practical considerations such as daily dosing for NRIs and the need for insurance authorization for newer brand-name drugs like Qelbree, which may require patients to first try and fail older alternatives like Strattera.

"the stimulants like Adderall and Ritalin don't do a lot to address these issues."

"These medications work very well for attention, concentration, and distractibility, and hyperactivity, but they're not so great for directly improving the executive functions."

"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."

"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."

"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."

"Qelbree was more effective and worked faster, within about a week for children and two weeks for adults."

"This increased norepinephrine has a secondary effect of increasing dopamine and serotonin in this region of the brain."

"of the people who had Qelbree added to their stimulant, 85% of them tapered off the stimulant after they were stabilized on Qelbree."

"Another study... 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."