When going to a doctor, you mostly aim for two things to happen: one, you want the doctor to tell you what kind of disorder you are currently suffering from and two, you hope for him or her to give you adequate treatment. While most people are able to follow their physician’s instructions well enough when they have to take medication like antibiotics for a few days, the longer the therapy needs to be, the less likely they are to “adhere”.

Adherence is a term to describe to what extent a person’s behavior in taking medication corresponds with agreed recommendations from a healthcare provider1. This means that after a physician has informed you about possible treatment options, you decide together what kind of treatment you are going to receive². Afterwards, if you stop taking the medication or choose not to take some of it, your behavior might be classified as non-adherent. Said non-adherence has significant impact on treatment effectiveness, individual suffering and health care costs³. If prescribed medication is secretly not taken, doctors might increase doses or switch to different substances as they suspect the current drug is not working properly.

A recent study explored adolescents’ health beliefs and subjective opinions relating to psychotropic medication, and statistically linked them to reported medication adherence. Adolescents age 12-17 answered a series of interview questions regarding their personal perceptions of their own course of disease, experienced symptoms and physician–patient relationship. Additionally they reported on their individual appraisal of positive effects from psychotherapy and/or medication, thoughts on adverse events, and thoughts on disease-related interactions with their friends and families.

Authors found that patients classified as non-adherent could be characterized as more likely to report feeling worse after taking medication, to describe a lower sense of self-efficacy concerning the improvement of their symptoms, and/or to perceive a less trustful physician–patient relationship. Furthermore, non-adherent patients were more likely to state that their attitude toward medication worsened after experiencing “side effects”, that they subjectively felt less support from their relatives, and/or they had fewer individuals in their family who were fully informed about their condition4.

In summary, if the medication you are taking is making you feel worse than you did before, if you feel like you have little or no control over your own symptoms, if you distrust your physician or if you feel your family isn’t supporting you (enough), this might lead you to stop your medication – possibly without telling your physician about it.

What can we learn from these results?

Health care providers can learn how important it is to repeatedly talk to their patients about their feelings towards the medication and encourage them to speak openly about medication-related doubts or worries. They can also learn how important their interaction with patients is, as even the best drug can’t work properly if it isn’t taken.

As a patient, one might realize that not wanting to take prescribed medication is a common occurrence, and one shouldn’t feel embarrassed or guilty about it. What is important, though, is to openly talk to the treating physician about it and find a solution together.

REFERENCES:

1  World Health Organization: Adherence to Long-Term Therapies. WHO Library Cataloguing-in-Publication Data, 1–211. 2003. www.who.int/chp/knowledge/publications/adherence_full_report.pdf

2  Ahmed, R., & Aslani, P. (2014). What is patient adherence? A terminology overview. Int J Clin Pharm, 36(1), 4-7, 2014.

3  Julius RJ, Novitsky MA, Jr., Dubin WR: Medication adherence: A review of the literature and implications for clinical practice. J Psychiatr Pract 15:34–44, 2009.

4  Niemeyer, L., et al., “When I Stop My Medication, Everything Goes Wrong”: Content Analysis of Interviews with Adolescent Patients Treated with Psychotropic Medication. J Child Adolesc Psychopharmacol, 2018. 28(9): p. 655-662.

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Loss of appetite is among the most common side effects of stimulant for ADHD. Across studies, approximately 20% of patients with ADHD who were treated with stimulants reported a loss of appetite [1,2]. Weight loss is also quite common, as are digestive problems [3]. Together, such side effects are often referred to as “gastro-intestinal adverse events”. But why do stimulants change the way we go about eating? And what could this tell us about ADHD itself?

Appetite can arise in response to physical cues, such as an empty stomach or low blood sugar. Psychological cues can also influence our appetite; for instance, we may get hungry when we watch other people eat, or when we are bored. For most people, eating is a pleasant and rewarding activity. In the human brain, pleasure, reward, craving and, thus, appetite, have everything to do with dopamine. More specifically, with dopamine levels in the striatum, a cluster of neurons at the very base of the forebrain. The striatum is strongly connected with the prefrontal cortex. The prefrontal cortex exercises cognitive control over the urges of the striatum: when we’re hungry, the striatum makes us crave high-caloric, high-fat, or sweet foods; at the same time, our more rational prefrontal cortex helps us make responsible food choices.

Interestingly, ADHD also has everything to do with dopamine and the striatum. Dopamine levels in the striatum are slightly ‘off’ in individuals with ADHD. As a result, people with ADHD feel a higher urge to seek pleasant experiences, and less prefrontal control over this urge. Impulsivity, a prominent feature of ADHD, can be viewed as a failure to sufficiently activate the prefrontal cortex. Finding a balance between pleasure-seeking on the one hand, and rational decision-making on the other, can be difficult for all of us. However, for people with ADHD whose dopamine balance is slightly off, making healthy, non-impulsive decisions about what to eat may be even more challenging. Indeed, overweight, obesity and diabetes seem to be more common in people with ADHD compared to people without ADHD [4].

Stimulants such as methylphenidate and dexamphetamine can restore the dopamine balance in the brain. This may result in less craving for food (as well as for other pleasant activities) and more control over impulsive urges. It is thus not very surprising that stimulant medications may cause a loss of appetite or even weight loss. Interestingly, stimulants are sometimes used to treat obesity and certain eating disorders as well. Especially for eating disorders involving impulsive eating, such as bulimia nervosa and binge-eating disorder, stimulant treatment could be promising. [5]

There is one other interesting angle on stimulants, dopamine, and eating. Did you know that most of the dopamine in your body is not located in the brain? In fact, a substantial proportion of all dopamine-related processes in the human body take place in the gut. Throughout the gastro-intestinal tract, dopamine receptors are abundant. Therefore, in addition to the indirect effects described above (i.e., via craving and/or impulse control), stimulants may have direct effects on eating behaviours as well. Unfortunately, we know very little about such direct effects.

REFERENCES
[1] Storebø, Ramstad, Krogh, Nilausen, Skoog, Holmskov et al. (2015). Methylphenidate for attention-deficit/hyperactivity disorder in children and adolescents: Cochrane systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. Cochrane Database Syst Rev (11):CD009885. doi: 10.1002/14651858.CD009885.pub2

[2] Storebø, Pedersen, Ramstad, Kielsholm, Nielsen, Krogh et al. (2018) Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents – assessment of adverse events in non-randomised studies. Cochrane Database Syst Rev 5:CD012069. doi: 10.1002/14651858.CD012069.pub2

[3] Holmskov, Storebø, Moreira-Maia, Ramstad, Magnusson, Krogh et al. (2017) Gastrointestinal adverse events during methylphenidate treatment of children and adolescents with attention deficit hyperactivity disorder: A systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials. PLoS One 12(6):e0178187. doi: 10.1371/journal.pone.0178187

[4] Cortese, Moreira-Maia, St Fleur, Morcillo-Peñalver, Rohde & Faraone (2016). Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. Am J Psychiatry 173(1):34-43. doi: 10.1176/appi.ajp.2015.15020266

[5] Himmerich & Treasure (2018). Psychopharmacological advances in eating disorders. Expert Rev Clin Pharmacol, 11(1):95-108. doi: 10.1080/17512433.2018.1383895

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