When Stimulant Medication Doesn’t Seem to Work: A Guide to Next Steps
Stimulant medications like methylphenidate and different mixtures of amphetamine are the treatment with the best evidence base for treating symptoms of ADHD. They can significantly improve quality of life and can improve any and all of the 18 symptoms of ADHD, and some of the associated features, such as emotional dysregulation and irritability. However, medication doesn’t offer a one-size-fits-all solution. There is no way a doctor can tell what chemical will have the best effect (methylphenidate or dexamphetamine here in New Zealand), and at what dose. There isn't a mg/kg formula for dosing as there are for some medications. It all comes down to trial and error and titrating the dose to maximise treatment effect while minimising side effects.
You may have come across accounts from individuals who've taken medication, describing significant positive changes in their symptoms. Yet for a minority of people, despite following a treatment plan, they find that the medication isn't having the desired effects on symptoms, or is even having some significant negative effects. This is something I come across in my adult ADHD clients. I tell my assessment clients it can take several months to get medications right. And by this, I mean that's the time that may be required to find the right chemical and formulation, at the right dose, and for enough hours a day.
For my son, it took around 18 months to get on the right combination of stimulant meds, and his dose has also been increased over time. While it can be very disheartening and can increase imposter syndrome when things aren't going the way a person thought they would, there is much room for medications to be optimised, and this blog post looks at some of the signs that things aren't right, and what to do about them.
Signs Your Medication May Not Be Working Well When effective, stimulant medications should offer significant symptom relief, helping a person focus better, reducing impulsivity, and making it easier to complete daily tasks. Any side effects should be minimal and tolerable. Common, tolerable side effects may include mild appetite loss or changes in sleep patterns. For some people, these persist over time and for some, they reduce over time or can be managed with behavioural modifications or changes in timing or formulation of medication used (e.g. fast or long-acting formulations).
Minimal or No Clinical Improvement One of the primary indicators that your medication might not be working is a lack of noticeable improvement in your symptoms. If your focus, impulsivity, or other symptoms haven't improved, despite an increasing dose, this could be a sign that another formulation or chemical is needed. I have had a number of clients whose doctors have pushed their dose of methylphenidate to the recommended maximum daily dose and who have felt no change in symptoms at all, and a subsequent change to dexamphetamine has led to the kind of good symptom improvement that they had been hoping for from the start.
Unpleasant Side Effects If a person experiences side effects that are bothersome or disruptive, like extreme irritability, sleep disturbances, or significant appetite and weight loss, it's essential to talk to the prescribing doctor and see if a formulation or chemical change is needed.
I have seen a number of people who receive only a partial effect of medication, such as minimal symptom improvement, or for many fewer hours than would be expected for the formulation they are on. This could be a dose issue, or it could be a formulation issue. I have clients who tell me they avoid taking their medication unless they absolutely have to as they don't like the way it makes them feel. People have told me about feeling tense, having a tight jaw, increased anxiety, clenching their jaw while sleeping, turning bright red for four hours a day (a new one to me), sweating profusely, or feeling uncomfortably stimulated. It's not supposed to be like this! This is a sign that your meds aren't right yet, it is not something you simply have to put up with. If a person is avoiding taking meds due to side effects, that is a reason to talk to their doctor about making a change to dose, formulation, or chemical.
What to Do If Your Medication Isn't Working The first step in addressing concerns about your medication's effectiveness is to consult with the healthcare provider who prescribed it. Open, honest communication about your symptoms and side effects will allow them to make informed decisions about your treatment. Sometimes, a simple adjustment in dosage or switching to a different formulation of the same medication can make all the difference. This fine-tuning is a standard part of the treatment journey. The client I mentioned above who turned bright red for four hours a day ceased having this problem when they switched to a different formulation of methylphenidate once they consulted their doctor about it.
Conclusion Treating ADHD is a highly individualised process. If you find that your current medication isn’t providing the relief you expected or is causing some nasty side effects, don't lose hope! There are various formulations and two main classes of chemical available, each with their potential benefits and drawbacks, and no one can predict what will work best for an individual. It really is a trial-and-error approach. The key is to maintain open and honest lines of communication with your prescriber, working collaboratively to find the treatment that’s right for you.
Remember, you're not alone on this journey. Lots of other people have to spend quite a bit of time getting their medication right. I see them often in my practice. Then, the dose or formulation may change in the future due to other life factors like changing task demands, having children, ageing, pregnancy, or menopause, and it's entirely okay to seek adjustments in your treatment. Remember, stimulant medication is the best evidence-based treatment for ADHD, so it's important to optimise it.
See my blog post ADHD Medications Available in New Zealand Part 1: Stimulants for an up-to-date list of all the stimulant meds available, and how each formulation is designed to release in the body.
Clinical psychologist Dr Thomas E. Brown discusses how to optimise and troubleshoot stimulant medication: The ADHD Medication Stopped Working! How to Troubleshoot Treatment. Note that many of the medications in this article are not available in New Zealand, so compare it to the medications listed in my stimulants blog post to see what you may have access to.
Here's an excellent one-hour podcast about ADHD meds and how to optimise them, presented by ADHD expert psychiatrist Dr William Dodson.
Click here to see a psychiatrist explain how methylphenidate and dexamphetamine work in the brain.