Sustained treatment effect in attention-deficit/hyperactivity disorder: focus on long-term placebo-controlled randomized maintenance withdrawal and open-label studies

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often persists throughout life. Approximately two-thirds of patients with a childhood diagnosis of ADHD continue to experience clinically significant symptoms into adulthood. Nevertheless, most of these individuals consider themselves “well,” and a vast majority discontinue medication treatment during adolescence. As evidence concerning the adult presentation of ADHD becomes more widely accepted, increasing numbers of physicians and patients will face decisions about the benefits and risks of continuing ADHD treatment. The risks associated with psychostimulant pharmacotherapy, including abuse, dependence, and cardiovascular events, are well understood. Multiple clinical trials demonstrate the efficacy of psychostimulants in controlling ADHD symptoms in the short term. Recent investigations using randomized withdrawal designs now provide evidence of a clinically significant benefit with continued long-term ADHD pharmacotherapy and provide insight into the negative consequences associated with discontinuation. Because many patients lack insight regarding their ADHD symptoms and impairments, they may place a low value on maintaining treatment. Nevertheless, for patients who choose to discontinue treatment, physicians can remain a source of support and schedule follow-up appointments to reassess patient status. Medication discontinuation can be used as an opportunity to help patients recognize their most impairing symptoms, learn and implement behavioral strategies to cope with ADHD symptoms, and understand when additional supportive resources and the resumption of medication management may be necessary.

Keywords:

• psychostimulant
• nonstimulant
• adult
• child

Acknowledgments

Shire Development LLC provided funding to Scientific Communications and Information (SCI) for support in writing and editing this manuscript. Under the direction of the author, Michael Pucci, PhD, an employee of SCI, and Karen Dougherty, PhD, a former employee of SCI, provided writing assistance for this publication. Editorial assistance in formatting, proofreading, copyediting, and fact-checking was also provided by SCI. Thomas Babcock, DO, and Ryan Dammerman, MD, PhD, both of Shire Development LLC, also reviewed and edited this manuscript for scientific accuracy. Although Shire Development LLC was involved in the topic concept and fact-checking of information, the content of this manuscript, its ultimate interpretation, and the decision to submit it for publication in Therapeutics and Clinical Risk Management were made by the author alone.

Disclosure

Dr Goodman has received research support and/or consultant fees from Avacat, Cephalon, Consumer Reports, GuidePoint Global, Healthequity Corporation, Lundbeck, Major League Baseball, McNeil, Med-IQ, Novartis, OptumInsight, Otsuka Pharmaceuticals, Prescriber’s Letter, Pontifax, Professional Studies LLC, Shire Inc, Teva Pharmaceuticals, and the American Physician Institute for Advanced Professional Studies. He has also received honoraria from Medscape, the Neuroscience Education Institute, Temple University, WebMD, and the American Professional Society of ADHD and Related Disorders. The author reports no other conflicts of interest in this work.