We have been able to help thousands of patients who were previously resistant to treatment through the new brain-based model given in this book. Although treatment failures are less common using this model, sometimes treatment doesn’t seem to work or doesn’t seem to alleviate a patient’s symptoms completely. Patients who do not get well, and those who get a little better but who continue to experience significant symptoms in spite of what appears to be good treatment, are known as “treatment resistant patients.” The most common reasons for treatment resistance can be grouped into six categories: problems with the diagnosis; medication issues; interfering factors; poor patient follow-through with treatment recommendations; trying to cut corners; and those things for which we do not have an explanation.
When a condition is misdiagnosed as ADD, treatment will be ineffective and often makes things worse by delaying treatment of the underlying illness. A classic example is thyroid illness. Hypothyroidism is a condition in which the thyroid gland is underactive. The decreased amount of thyroid hormone available to the body causes symptoms that mimic decreased focus, fatigue, and lack of motivation. This condition can be easily mistaken for ADD and will not respond to stimulating supplements, medication, or neurofeedback. On the other hand, an overactive thyroid gland can cause symptoms of anxiety, agitation, and increased heart rate that resemble hyperactivity or anxiety disorders.
The list of medical conditions that affect brain function and attentional issues is extensive and crosses all specialties from cardiology to dermatology. Medical conditions should always be excluded as the underlying cause of symptoms before a psychiatric diagnosis is made.
Comorbidity is the presence of more than one condition, and it is one of the more common reasons for poor treatment outcome. Substance abuse disorders are one of the most common comorbid conditions we treat. Marijuana, inhalants, pain medications, and alcohol abuse interfere with the action of medications or supplements used to treat ADD. Substance abuse disturbs brain function and can disrupt brain development. Almost everyone knows this is true for babies exposed to substances during development, but most people don’t realize that teenagers and young adults are still vulnerable because the brain is still developing into young adulthood.
Self-medication with drugs and alcohol is a vicious cycle. Emotional and physical pain cause people to abuse substances or misuse prescription medications in an attempt to get relief, but intoxication and withdrawal states only aggravate the underlying conditions. Substance abuse issues must be dealt with for treatment to be effective.
Finally, doctors do not always get all the information necessary to make a correct diagnosis or to make treatment decisions. Sometimes patients do not tell us about underlying medical conditions, substance abuse, other medications they are taking, or the amount of stress they have in their lives. The reasons people withhold information are as unique as the people are themselves. Many times people feel shame over things in their past; think we won’t treat them if they have a substance abuse problem; are embarrassed by their thoughts; believe they will be judged if they reveal they are HIV positive; are concerned about what will be written in the medical record; and so on. Other times people forget about a prior head injury or cannot remember the names and dosages of the medications they are taking. All of this information is important for the accurate rendering of a diagnosis and formation of an effective treatment plan.
Think of your treatment plan as a recipe and your supplements or medications as one of the ingredients in the recipe. If you leave things out, make additions or substitutions, or if your timing is off you may not get what you planned for. But if you follow your recipe, you will have a better product. Medications and supplements work best when they are taken on schedule. They work less well if they are taken randomly. And they don’t work at all when doses are frequently missed. Why do people miss doses of medications or supplements? Complicated dosing schedules are sometimes a problem, and this is the reason we try to use medications and supplements that can be taken once or twice daily. We also try to minimize the number of medications or supplements a person is taking to further simplify things. The very young, very old, and people with ADD may not remember to take all their doses. Teenagers sometimes skip doses intentionally, and unfortunately, some parents who are divorced or separated victimize their children by withholding medication to get back at the other parent.
Medications and supplements must be taken at the correct dose to be effective. Every day in our practice we are amazed by the number of “treatment resistant” patients who are simply underdosed on their medications or supplements. Taking only half the dosage necessary to help your brain will not work any better than using half the heat necessary to bake your bread. Additionally, many doctors who are not specialists in the field of psychiatry do not prescribe high enough dosages of supplements or medications.
Other prescription medications, over-the-counter drugs, and herbs and supplements can interfere with the action of supplements and medications prescribed to treat ADD. Examples of medications that may cause such interference include: some of the antihistamines, asthma medications, and medications used to treat heart conditions. Caffeine is known to aggravate some of the stimulant side effects. Medications used to treat high blood pressure cross over into brain tissue and worsen mood issues. It is extremely important to always inform all your doctors of every medication and supplement you take.
We have also seen generic medications cause treatment problems and confusion, and we know generic medication works differently from brand-name medication. Sometimes it works better, sometimes worse. For example, one of my daughters responded very nicely to a specific generic for Ritalin, but not others.
One factor that few physicians consider is the difference between how females and males process supplements and medication. Very few drug trials involve women, and therefore finding the therapeutic dose for women is often a process of trial and error. Hormonal factors affect the action of supplements and medications in women. Many women also have a higher percentage of body fat than men and that may affect drug distribution. These and other factors mean that women may need a different dose of the same supplement or medication we use to treat men, or else an altogether entirely different protocol.
Your treatment plan is a prescription for health, and when prescribed lifestyle changes are not made, the entire plan can be sabotaged. We prescribe dietary changes to help brain function, boost supplement or medication effectiveness, and to normalize energy levels. Patients eating a high-carbohydrate diet will continue to experience blood sugar and insulin level fluctuations that aggravate their mood, energy levels, and ability to concentrate. Excessive caffeine and any nicotine use will interfere with the action of many supplements and medications, including stimulants. Because the effects of caffeine and nicotine are so short-lived, they cause people to be irritable and sometimes more unfocused. Citrus juices slow down the ability of the body to process some supplements and medications.
A problematic or difficult environment (such as at home, work, or school) also contributes to treatment failures. You can have the right diagnosis and right treatment protocol, but if you are in a chronically difficult marriage, have difficult parents or teachers, or have siblings who are abusing you, treatment will appeared flawed and frequently fail. The environment needs to support the treatment.
One of the most important aspects of the treatment plan is the therapeutic relationship. The doctor-patient relationship is in itself an instrument of healing. Patients work hard to find care providers who are not only experts in their field, but who are also good communicators. Conflicts and miscommunication in doctor-patient or patient-therapist relationships lead to poor outcomes. Patients need to inform all medical providers of any change in their medical or psychological status and report any medications, supplements, herbs, and over-the-counter medications they are taking.
Lack of patient follow-through with treatment is what doctors and therapists call lack of compliance. Doctors spend a lot of time trying to figure out why patients become noncompliant with treatment protocols. We’ve compiled our own list of common reasons:
To increase the likelihood that our patients will derive the best possible benefit from treatment, we stress the importance of strict compliance with the full treatment plan. A full treatment plan is a prescription for health that encompasses many areas of your life and requires your active participation on a daily basis. Communication with your doctor about your concerns and to modify the plan as needed is essential. Patience and persistence are keys to success.
Impatience and thoughtlessness can have dire consequences.
We’ve all heard the phrase “you get what you pay for.” Unfortunately, we usually hear it after we’ve written the check for something we were sure was a good bargain only to realize we had a “lemon” on our hands the day after the warranty ran out. No one wants to spend money needlessly and everyone wants to make a good investment. The best investment you can make is in your health, especially your brain health. This truly is an investment for life—your own life and the lives of your children.
Most of us complain less about the cost of clothing, food, and automobiles than we do about the health care we purchase. Many of us spend money excessively on entertainment, large homes, vacations, and even things that are not good for us—such as cigarettes, excessive alcohol, and too much food.
Some patients are treated by nonspecialists and do fine on generic drugs. But if you are among those who are becoming frustrated because you are not getting better, you need to see a specialist. You might benefit from technology that can image your brain and guide diagnosis and treatment. You might need a more sophisticated combination of supplements and medications. This might require some people to pay out-of-pocket, or go outside their insurance plan. The cost of a consultation with a specialist, with or without tests, and getting the correct treatment prescribed is enormously less expensive than the costs of repeated visits to other doctors, medication trials and errors, and long-term disability resulting from poorly treated symptoms.
Poor compliance, premature discontinuation of treatment, active substance abuse, and untreated medical illnesses are some of the factors that contribute to the risk of continued symptoms of ADD. Untreated sleep disturbances are known to increase the risk of cognitive impairment. Every patient has the risk of relapse or recurrence, yet it is higher for patients who are treated only until their symptoms respond as opposed to those who are treated until their symptoms are in remission. In other words, patients who discontinue their treatment on their own as soon as they start to feel better are at much higher relapse risk than those who remain on treatment until they complete a full course (usually several years). Further, once in remission, the chance of relapse and recurrence can be further reduced by maintaining a healthy lifestyle.
There are countless factors that influence the neurochemical state of the mind and body. We are only beginning to understand some of these influences and there is much we do not know. I look forward to the continued development of imaging techniques to study the brain, to guide treatment, and to follow the course of treatment.