Treatment for ADHD is multimodal in nature and should always be discussed with your doctor and mental health professionals you’re working with. In order to decide if medication is right for you, and if you should be taking a stimulant or non stimulant ADHD medication, you and your care team should take into account your goals for treatment, your medical history (including history of stimulant use and how it affected you), the potential side effects of the medication, as well as other medications you are taking.
What Is a Stimulant vs Non Stimulant?
The two main medications used to treat ADHD include stimulants and non-stimulants. While they both work to increase concentration and attentiveness and decrease impulsivity seen in ADHD, one may be a better fit for certain individuals than others. Stimulant medications have been shown to be the most effective medication for symptom management in ADHD and may be a good initial treatment.1
The major difference between stimulant and non-stimulant medications are their mechanisms of action, their side effect profiles, and their interaction with other medications that patients may be taking.
Stimulant medications work by increasing the amount of neurotransmitters such as dopamine, norepinephrine, and serotonin sent to the brain, as well as stopping them from being degraded. Non-stimulant medications can work on similar neurotransmitters by decreasing their degradation in the brain. Many of the non-stimulant medications are used as an off-label treatment for ADHD, which means that they do not have approval by the FDA, but have been shown to be effective in some patients with ADHD.
Stimulants for ADHD
Stimulant medications work through two main mechanisms. In both ways they increase the amount of neurotransmitters in the brain. They are used as the first line medical treatment for patients with symptoms of ADHD. Children under six years old, however, are advised to work with a behavioral therapist rather than stimulant medication.
Stimulants are a good first line treatment that help alleviate common symptoms seen in adults with ADHD as well as adolescents, including restlessness and hyperactivity.
However they are a controlled substance and should be taken with caution. Patients who have a history of heart conditions, arrhythmias, blood pressure, and tic disorders should take stimulants with caution.
Patients should speak to their doctor about the side effects of overdosing, and have emergency contact information readily available. Stimulants should be kept away from children and stored in a safe area.
Common stimulant medications to treat ADHD include:
- Adderall (mixed amphetamine salts)
- Ritalin (methylphenidate hydrochloride)
- Concerta (methylphenidate hydrochloride)
How Quickly Do Stimulants Work?
Stimulant medications come in two forms, short-acting and long-acting, and vary in how quickly they take effect. Research has shown that stimulants work very quickly, usually less than one hour, and their effects last 3-4 hours. Because they only last 3-4 hours, however, it requires patients to take stimulant medication multiple times during the day.
Long-acting stimulants were invented later as a solution to patients having to take their medication multiple times during the day. They also act rapidly, typically in less than one hour, but their effects usually last up to 10 hours. 1
Short-Acting Stimulant Medications
Common types of short acting stimulants include Adderall, Ritalin, and Dextrostat. They act immediately or within one hour of administration. Their effects usually last 3-4 hours. They may be used for patients that need symptom control during the morning and afternoon, but not in the evening such as children who are in school. 2
Long-Acting Stimulant Medications
Common types of long acting stimulants include Concerta, Adderall XR, and Vyvanse. Similar to short-acting stimulants, they act immediately and effects are felt within one hour, however these effects last up to 10 hours. This allows patients to take much fewer pills throughout the day. These are better options for patients who may have trouble remembering to take medications throughout the day.
Side Effects of Stimulants for ADHD
Stimulants have a number of side effects including appetite suppression, weight loss and dry mouth. More severe side effects seen with stimulant medication include chest pain/palpitation seen in patients with pre-existing heart conditions (this requires prompt attention from a physician or emergency services). For children, growth restriction and appetite suppression should be closely monitored with height and weight checks at their pediatrician’s office. Women may have side effects related to menstruation or complications with pregnancy. Patients should always let their physician know about any side effects they may have from their ADHD medication.
Common stimulant side effects include:
- Appetite suppression
- Nausea/vomiting
- Dry mouth
- Weight loss
- Abuse potential
Note that stimulant medications are controlled substances by the DEA due to its abuse potential and as such should be taken with caution.
Stimulant medications for ADHD carry a black box warning for drug abuse and dependence, and the risk of sudden death and serious heart events due to misuse. A black box warning is the most serious warning from the FDA.
Benefits of Stimulants
In clinical trials, 70% of patients with ADHD have improvement in distractibility and attentiveness after beginning stimulant medication. 1 Studies have also shown that children diagnosed with ADHD who are treated with stimulant medication have improved decision making skills and school work productivity. 3
Stimulants are the best medical treatment for patients of all groups including children six years or older, teens, and adults. For children under six years of age, it is recommended that behavioural therapy be implemented.3 Doctors begin treatment for ADHD for both adults and children when their symptoms impede their quality of life 3. This includes in the workplace, school, or personal relationships.
Risks of Stimulants
Life threatening risks to be aware of include stimulant overdose, cardiac side effects of stimulants, and serotonin syndrome, especially when taking antidepressant medications. They all present with racing heart rate, sweating, tremors, agitation, and increased blood pressure. They require emergency intervention and patients should be advised to call 911 or go to their nearest emergency department.
Non-Stimulants for ADHD
Non-stimulant medications for ADHD include antidepressant medications and previously used antihypertensive medications. They are typically used for ADHD when patients are either not able to take stimulant medications or when patients have not benefited from stimulant medications. They work to increase the neurotransmitters in the brain by inhibiting their reuptake.
Non-stimulant medications are used to treat the same symptoms as stimulant medications. However, the difference is in how well they manage those symptoms. One size does not fit all for these medications, and while most patients will respond to stimulant medication, some may respond better to non stimulants instead. The FDA has approved three non-stimulants for the use in teenagers. These include atomoxetine, guanfacine, and clonidine.
Non-stimulant medications, such as atomoxetine, should not be used in patients that are taking other types of antidepressants or anti-anxiety medication as they may increase your risk of serotonin syndrome. Non stimulant medications should not be used in conjunction with stimulants as that can also increase the risk of serotonin syndrome.
The most common non stimulant medications to treat ADHD include:
- Strattera (atomoxetine)
- Intuniv (guanfacine)
- Wellbutrin SR and Wellbutrin XL (bupropion hydrochloride)
How Quickly Do Non Stimulants Work?
It can vary based on the medication. Atomexetine has been shown to take weeks to reach full effect in the treatment of ADHD 4. Bupropion has shown to reach a therapeutic effect in adults within one month 5.
Side Effects of Non-Stimulants for ADHD
Serious side effects of non-stimulant medications include serotonin syndrome, especially when combined with other antidepressant or anti anxiety medication. Patients that have tremors, seizures, sweating, increased blood pressure, and palpitation should call 911 or go to their nearest emergency department. Atomexitine carries a risk of increased suicidal ideation in teens. Patients should be monitored closely in the first month of treatment.
Common non stimulant side effects include:
- Nausea or vomiting
- Headaches and dizziness
- Abdominal pain
Non-stimulant medications for ADHD carry a black box warning for suicidal thoughts and behavoris in children, adolescents, and young adults. A black box warning is the most serious warning from the FDA. Intuniv (guanfacine) does not carry this black box warning.
Benefits of Non Stimulants
The major benefit of using non-stimulant medication is that they are not a controlled substance and therefore do not carry a risk of substance abuse with them. Additionally, they are a great choice for the 10-30% of patients with ADHD who do not respond to stimulant medications. 1
Risks of Non Stimulants
Patients should be aware of the risk of serotonin syndrome with wellbutrin and atomoxetine. Additionally teenagers and children can have increased suicidal ideation in the first month of treatment and should be monitored closely during this time. Patients should call 911 in any emergency situation.
Is a Stimulant or Non Stimulant Better for Treating ADHD?
The choice of non-stimulant vs stimulant medication is a personal decision between doctors and patients and requires shared decision making. While stimulant medications have been shown to be more efficacious for ADHD treatment for symptoms such as agitation and concentration, it is up to the doctor and patient to come to a consensus on what the best treatment is on an individual basis.1
Some reasons you and your physician may choose a non-stimulant over stimulant medication include:
- Treatment failure with stimulants
- Minimal risk of substance abuse
- Intolerable side effects of stimulant medications
- The risk of interactions with other medications you are taking
Regardless of which medication (if any) you decide to take, it’s also recommended that patients should also attend therapy, such as CBT for ADHD, as part of their treatment plan. Patients may benefit from finding a neurodiverse therapist, who can work with them to learn their individual strengths.
For children under six years old, the best treatment for management of ADHD symptoms is behaviour management therapy.
Questions to Ask Your Health Team About Stimulant vs Non Stimulant ADHD Meds
Patients should have an active role in their treatment plan for ADHD. It is important that you know what type of medication you’re taking and why, the dosage of that medication, and common side effects to watch out for. Similarly, you should know what type of therapist to look for and speak with, and have a clear idea of the goals of that therapy.
Questions to ask your care team about before taking medication for ADHD include:
- What is the mechanism of action of the medication I am taking?
- What are common side effects?
- What are more serious side effects?
- What is the dosage of the medication?
- How often should I be taking these medications?
- What is the goal of my therapy sessions?
- How soon should I expect to see resolution in symptoms?
Final Thoughts
ADHD treatment is varied and multimodal. Different patients respond to different medications and therapy styles. It’s important to speak with your doctor to determine whether stimulant or non stimulant medication to treat your ADHD is right for you.
For Further Reading
- ADD.org
- Mental Health America
- Take a look at this list of the Best Books About ADHD
Stimulant vs Non Stimulant ADHD Meds Infographics
