Subscribe
Share
Share
Embed
Adult ADHD from the board-certified PMHNP behind the YouTube channel Focus Path and the book The Process. Clinical perspective on medication, frameworks, and the conversations the internet hasn't been having.
This is Actually ADHD, sponsored by
the Focus Path YouTube channel, your
choice of mental health infotainment.
And I am your host, Jonathan Murphy,
and I'm a psychiatric nurse practitioner
that's been working with adults with
ADHD for a decade And today I'm going
to talk about my new book, "The Process:
An Adult's Guide to ADHD Medication."
It's available on Amazon.
it comes from a lot of hard work, and it's
great to have all of the things that I've
learned about ADHD medication and ADHD
treatment for adults all in one place.
But since this is the first episode,
why should you listen to me?
Well, let's get into that.
Why me?
Let me tell you about when I first started
as a psychiatric nurse practitioner.
Looking for jobs, I saw an ADHD treatment
center and I felt a wave of relief.
I said, "I know this."
The first six months
were a quiet realization.
I knew ADHD as a patient.
I didn't yet know it as a clinician.
So I got serious about my own
medication, and I leaned in and
accepted my fate as the ADHD guy.
I'd soon come to find the world of ADHD
treatment is dry, boring, and clinical.
Nevertheless, optimization
process is extremely predictable.
Patients come in, the medication
works, and their lives improve.
Done well, well, it's one of
the most reliably effective
treatments in modern psychiatry.
So the reason I'm talking to you now,
the reason I wrote the book, is because
the field has been getting a lot of
things wrong for a long time now.
The information online, it's reaching a
place where the patients that are trying
to navigate the system are being failed.
Prescribers in primary care
and general psychiatry often
do not have the experience to
optimize adult ADHD medication.
As a consequence, patients are left to
figure it out for themselves, and the
systems that would normally help them
have lost control of the narrative.
The professional associations,
and the academic institutions have
lost control of the narrative.
The optimization process
is not complicated.
It is predictable.
It works.
But something that I wanted to do was jump
into the history of ADHD because Russell
Barkley is known and credited for showing
that observations that constitute ADHD
have existed back to the 18th century
. So that's observing the behavior, but
then there's the medication history.
Stimulant medications were synthesized in
the late 19th and early 20th centuries.
Amphetamine was first synthesized in 1887.
Those therapeutic uses were not
recognized till decades later because
the making of drugs and chemicals,
especially when you go back to the 19th
century, you know, it's like people
are trying to figure out how to make
chemicals, make drugs, chemistry,
pharmacy, you know, the apothecary
But it's so, so when amphetamine
was created, they didn't
know that it was a stimulant.
But Benzedrine was the first
time it came to market.
It was a amphetamine inhaler for nasal
congestion in the 1930s, and it was
used for a variety of conditions.
By the '40s and '50s, amphetamine
tablets were available on drugstore
shelves and prescribed liberally
for fatigue, mood, and weight loss.
Think about that one So yeah, you
don't hear about that, you know?
Right.
The specific application to
children with what would later
be called ADHD began in 1937.
Charles Bradley, working at a children's
home in Rhode Island, was treating
children for headaches with Benzedrine
and noticed their behavior and school
performance improved dramatically.
The kids get a stuffy nose, next
thing they're just doing much better.
So that, that was the first documented
observation of stimulant medication
treating what is now recognized as ADHD.
So now we're gonna go into the DSM.
1968, hyperkinetic reaction of childhood.
1980, attention deficit disorder.
1987, attention deficit
hyperactivity disorder.
In 2013, okay, explicitly recognized
that ADHD extends into adulthood,
because those kids grew up.
Okay.
The pharmacology has also
evolved significantly.
Immediate-release tablets, all right?
Those tablets, they were the standard
in the '40s through the '90s.
1990s, the introduction of
extended-release formulations
in the early 2000s.
Concerta in 2000, Adderall XR in 2001.
Vyvanse in 2007 changed the
clinical picture entirely.
Patients could now take a single
morning dose and have stable
medication coverage through the
whole day without the spike and crash
cycle of immediate-release tablets.
And this is what makes the
optimization process possible.
This is the whole principle
behind my medication philosophy.
And the adult ADHD treatment field is in
many ways newer than the patients in it.
The framework for treating adults
specifically has matured over the
last twenty to twenty-five years.
Many were diagnosed late after years
of struggling without a clinical
lens to manage their symptoms.
What hasn't changed is the
underlying clinical reality.
Patients with ADHD respond to
dopaminergic stimulation and
medication that can change their lives
with ADHD, the conversation
of is ADHD real?
Well, okay, so we just went over that.
It's real because it's a
diagnosis, a diagnostic label.
So it's real on that basis.
It's in the DSM.
is it legitimate?
So this is what Russell Barkley showed.
This pattern of behavior is
observed back to the 18th century.
And then the stimulant medication
Pops up and it was prescribed
for all these reasons, you know,
like we just heard the history.
And this is another thing
Russell Barkley is credited for.
We can see the benefits of the stimulant
medication for a certain group of people.
It's not the majority, though.
And as someone that actually has ADHD,
when I went to start working prescribing
this medication, I had taken the
immediate-release tablets I started being
prescribed when I was in high school,
and it was an on and off sort of thing.
But I alwaysâ¦
Obviously, it's helping if I'm
continuing to take them, but I
wasn't given good advice, and I
didn't understand how the medication
should be applied, taking too much.
Taking medication as needed.
You know, take some when you need to
focus, you know, that kind of logic.
And it made me feel like
the meds are the problem.
So when I went to the West Coast
to start my first job, the ADHD
clinic, I was going in with like
a anti-medication sort of mindset.
Medication was like not good for me.
I need to go and help
people get off this med.
I don't know.
I at least knew I felt comfortable
prescribing medication that I,
like, knew more about, I suppose.
But then it was like Seeing the different
reactions and realizing, wow, like I--
several life stories explained in front
of me, It's less about the medicine and
more about like ADHD as a diagnosis and
hearing your life story in a diagnosis,
and then you reflect and, you
know, I was like the kid that was
d- you know, sleeping in class.
You wake up, everyone's
laughing, that type of thing.
And, um, but the medication
thankfully got me, saved my life.
I don't know where I'd be today,
and I was able to graduate high
school and get it together.
But, um, life didn't really improve
until that moment because while this is
happening, I'm-- never lived cleaner,
more like a monk, working every single
day and, um, oh, exercise, you know,
all the things you're supposed to do,
and I was pinching my leg, you know.
So then I got a psychiatrist there,
and he worked with me, and take the
medication every day like it's a vitamin,
and you find the right dose, and then
all of a sudden everything got better.
And so I know that like the this
conversation about ADHD, it's as
if everybody is gonna be better in
life with a stimulant medication.
That's just not the case.
It's not.
There's no way.
Now, can people take stimulant
medication to improve their performance?
Sure.
That's risky when you don't really
need to because when you're bringing
in a stimulant when you don't need
to, then you'd be overstimulated,
and ultimately it's like any other
recreational substance, you know?
It's ultimately, it's like ADHD
medication, the benefit of it is
should- people can be like, "Oh, okay,"
they can actually fall through their
lives as opposed to disorientation
or just, um, the sense of time.
, I don't really remember much, but
I do remember this one moment of
taking the medication when I was
like 16, 17 and being like, "Oh my
God, what am I doing with my life?"
But up until that moment, everything
was just constantly in the moment.
Like, I was just watching
a movie that was playing.
So in the beginning too, I was,
um, nervous about, I knew people
were wanting to get on meds.
Cause they got evaluated before
they got to me, so I was like you
know, they were set up and excited.
You know, this clinic you know, they
had shady business practices, at first
I was like, "Oh, they're already vetted,
so I can just prescribe the med."
But then quickly I was like, "Oh,
well, what if I don't agree?"
'Cause I was developing a
better sense of the diagnosis.
I was like, "I don't know," but like not
sure, maybe they have ADHD, maybe they
don't, but I like didn't trust my gut.
And they came back and they were
like, you know, tweaking it.
They couldn't even take the med, you know.
So the, when you're prescribing the
medication clinically to adults,
like I have all this experience,
20,000 hours prescribing experience
prescribing these medications, it's
like that's where the patterns come in.
So it's almost diagnostic.
So I've gotten a really strong
sense for this ADHD pattern.
And it's neurodevelopmental,
meaning it's, you're gonna be
able to track it for adults.
You have to go back in time.
And what you don't need to do, which
is hilarious, I see this type of stuff,
patient testimonials of you gottaâ¦
Oh yeah, there would be these ridiculous
practices that are just like CYA.
If you understand ADHD, it just makes
the most sense, but my previous employer
did this where it's like, f- talk
to a friend many people are against
ADHD, so, like, why are you gonna have
a family member that would be bias?
And, um
You know, it's not necessary.
Like, I don't know, it actually
obscures diagnosis more the
more that I think about it.
But
What I, I look for is, You have, like,
the symptoms of ADHD, and people, I think,
focus too much on those because to go,
"Doesn't everybody have this issue?"
Yes, but there's a-- this is a
chronic issue, and it's across the
lifespan, and there's, like, a pattern,
and you can track this pattern.
And when internally there's not as
much stimulation, so there's more
reliance on external stimulation.
So then across the lifespan, you
have what you're born as, what
the life situations around you.
There's other things going on, but
the presence you're seeing with the
executive function, you're seeing
a trajectory of adaptation forming
in childhood into adolescence.
I don't think that it's 100%
necessary to have this be the defining
characteristic, but there are clues there.
There's always a clue there, and
then you're getting into their
early 20s, and then when you're an
adult, you know, there's more of a
consistent chronic, uh, back and forth.
But That's if there's ADHD is the
thing that you see first because ADHD
is also, you know, and oftentimes
the diagnosis cannot be treated
until other things are treated.
So in other words, you can't treat
someone with bipolar if they're manic
for ADHD, even someone that's really
anxious or really super depressed ' cause
the stimulant medication only works as
well as the stage that it's set upon.
So I think the real question people ask,
like philosophically, like how do you feel
philosophically about pharmacotherapy,
using a medication to help with your life?
And it's an option, it's a
treatment in the controlled setting.
That's why the medication
is not just illegal.
It's because it helps in this one area.
That's why the symptom criteria matters
because we wanna make sure that we
wanna, we're prescribing the right thing
to the person for the right reason.
But at the end of the day, that
choice, people act like it's
such a life or death situation.
"Oh my God."
Because there's a lot of concerning
behavior out there culturally,
the narrative about stimulants.
But that isn't this.
I used all those other things to not be
consistent with treatment, but my life,
cut out all the noise, this helps me.
And it's obvious and it's plain to see.
And the great moment for many people
with ADHD is they look at their
significant other and it's always
very telling, you know, when you give
the ones in your life an opportunity,
they'll be like, "You know what?
That could be good for you.
So Ultimately, we need to ask ourself
before we can evaluate other people's
choices, we need to look at ours
because sometimes people have a
bias that have ADHD, so that's makes
the conversation messy and noisy.
But ultimately, if you do have
ADHD, then I would imagine your
function, that's the thing.
Functional decline meaning, like, a major
problem is present that results in maybe
issues at work, maybe issues with family,
maybe emotional issues, social issues.
A variety of different problems can
result from the way we're carrying
out our daily activities, and I think
car accidents, leaving the oven on.
There's a lot of low-key things
that you know, a lot of divorces and
people, uh, when they get their brain
online are able to self-actualize
and move their life forward.
We're bringing in ADHD in
the way it actually is.
This is why I'm calling the podcast
"Actually ADHD," is because it
actually makes sense when you're
looking at a psychiatric evaluation.
Cause it's really an issue with the brain.
You need executive function.
You need that level of
awareness to engage.
And when you treat ADHD for someone
that meets criteria for ADHD, it
needs to be treated for the person to
experience, like, holistic improvement.
It can be the barrier,
But it's not everybody.
But, it's really important that
the symptom criteria is clear,
and I'm not gonna go over that.
But next time I'm gonna get into
the medicines and my process
for this, the medication.
So this is the part you know, you wanna
perk up and listen to because I think
a lot of providers unfortunately get
this wrong, no fault of their own,
people that are well-intentioned.
At the end of the day, people need
to get familiar prescribing the
medication in order to, to see, so
there's some people trying out there
and other people that just have their
biases, and the people with their
biases have the worst practices, oddly.
So if people just open their mind a bit
more, that's such a weird irony there.
It's like the people that are
anti-ADHD, , can often have the
worst prescribing practices.
"Here's some immediate-release tablets.
Take some when you need."
You know?
But
That's it for today Thanks for
joining me on Actually ADHD, brought
to you by a psychiatric nurse
practitioner that won't sell you short