Stimulants and ADHD medications — cross-table viva · Psych Vivas

Prompt

Examiner draws columns: Class / Target / Onset / Killer monitoring. Cards: MTA, Cortese NMA, Newcorn, Volkow PET, Cooper, Habel, Hennissen, Wilens SUD meta, Sallee GXR, Michelson ATX, lisdexamfetamine prodrug.

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect mechanism → dose → trial name → safety without marketing slogans.[3]

Core questions and model points

Map classes to targets. Methylphenidate → DAT blockade (Volkow PET extracellular DA); amphetamines → catecholamine reverse transport/vesicular effects plus reuptake; atomoxetine → NET; guanfacine/clonidine → alpha-2A + autonomic.[1][10][9]
Onset discriminator. Stimulants: hours/day at adequate dose. Atomoxetine: weeks (Michelson). Alpha-2: days–weeks with early sedation.[3][10]
MTA in 30 seconds. 14-month carefully titrated medication management (± behaviour) superior for core symptoms vs behaviour alone/community care; quality of titration matters; long-term between-arm differences fade.[2]
Cortese 2018 one-liner. Most meds beat placebo short-term; stimulants largest average effects; age strata inform preference talk.[3]
Newcorn. OROS MPH more efficacious on average than ATX, but differential responders — sequential trials legitimate.[4]
CV package. Hennissen: small BP/HR rises. Cooper/Habel: serious events rare without clear large increase in large cohorts. Still take personal/family cardiac history and investigate syncope/chest pain.[5][6][7]
GXR dose scaffold. 1 mg start, +1 mg/week, often 1–4 mg; monitor sedation/BP/HR; taper after prolonged use.[9]
SUD myth bust. Wilens meta: stimulant treatment of ADHD not shown to increase later SUD; diversion still needs formulation safeguards.[8]

Discriminators examiners reward

Names lisdexamfetamine as prodrug; states MAOI contraindication; distinguishes absolute CV event rarity from mean BP/HR change; refuses to diagnose or prescribe from a single questionnaire.[3][5][8]

Common fails

Fails that lose marks include claiming atomoxetine works in 30 minutes; asserting stimulants always cause heart attacks without absolute-risk literacy; claiming stimulants create addicts against Wilens meta-analysis; and brand-only answers without mechanism or monitoring.[10][5][6][8]

References

[1]Volkow ND, Wang G, Fowler JS, et al. Therapeutic doses of oral methylphenidate significantly increase extracellular dopamine in the human brain J Neurosci, 2001.PMID 11160455
[2]The MTA Cooperative Group A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder Arch Gen Psychiatry, 1999.PMID 10591283
[3]Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis Lancet Psychiatry, 2018.PMID 30097390
[4]Newcorn JH, Kratochvil CJ, Allen AJ, et al. Atomoxetine and osmotically released methylphenidate for the treatment of attention deficit hyperactivity disorder: acute comparison and differential response Am J Psychiatry, 2008.PMID 18281409
[5]Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults N Engl J Med, 2011.PMID 22043968
[6]Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults JAMA, 2011.PMID 22161946
[7]Hennissen L, Bakker MJ, Banaschewski T, et al. Cardiovascular Effects of Stimulant and Non-Stimulant Medication for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis of Trials of Methylphenidate, Amphetamines and Atomoxetine CNS Drugs, 2017.PMID 28236285
[8]Wilens TE, Faraone SV, Biederman J, et al. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature Pediatrics, 2003.PMID 12509574
[9]Sallee FR, McGough J, Wigal T, et al. Guanfacine extended release in children and adolescents with attention-deficit/hyperactivity disorder: a placebo-controlled trial J Am Acad Child Adolesc Psychiatry, 2009.PMID 19106767
[10]Michelson D, Allen AJ, Busner J, et al. Once-daily atomoxetine treatment for children and adolescents with attention deficit hyperactivity disorder: a randomized, placebo-controlled study Am J Psychiatry, 2002.PMID 12411225

Core questions and model points

Map classes to targets. Methylphenidate → DAT blockade (Volkow PET extracellular DA); amphetamines → catecholamine reverse transport/vesicular effects plus reuptake; atomoxetine → NET; guanfacine/clonidine → alpha-2A + autonomic.[1][10][9]

Onset discriminator. Stimulants: hours/day at adequate dose. Atomoxetine: weeks (Michelson). Alpha-2: days–weeks with early sedation.[3][10]

MTA in 30 seconds. 14-month carefully titrated medication management (± behaviour) superior for core symptoms vs behaviour alone/community care; quality of titration matters; long-term between-arm differences fade.[2]

Cortese 2018 one-liner. Most meds beat placebo short-term; stimulants largest average effects; age strata inform preference talk.[3]

Newcorn. OROS MPH more efficacious on average than ATX, but differential responders — sequential trials legitimate.[4]

CV package. Hennissen: small BP/HR rises. Cooper/Habel: serious events rare without clear large increase in large cohorts. Still take personal/family cardiac history and investigate syncope/chest pain.[5][6][7]

GXR dose scaffold. 1 mg start, +1 mg/week, often 1–4 mg; monitor sedation/BP/HR; taper after prolonged use.[9]

SUD myth bust. Wilens meta: stimulant treatment of ADHD not shown to increase later SUD; diversion still needs formulation safeguards.[8]

Common fails

References

[1]Volkow ND, Wang G, Fowler JS, et al. Therapeutic doses of oral methylphenidate significantly increase extracellular dopamine in the human brain J Neurosci, 2001.PMID 11160455
[2]The MTA Cooperative Group A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder Arch Gen Psychiatry, 1999.PMID 10591283
[3]Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis Lancet Psychiatry, 2018.PMID 30097390
[4]Newcorn JH, Kratochvil CJ, Allen AJ, et al. Atomoxetine and osmotically released methylphenidate for the treatment of attention deficit hyperactivity disorder: acute comparison and differential response Am J Psychiatry, 2008.PMID 18281409
[5]Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults N Engl J Med, 2011.PMID 22043968
[6]Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults JAMA, 2011.PMID 22161946
[7]Hennissen L, Bakker MJ, Banaschewski T, et al. Cardiovascular Effects of Stimulant and Non-Stimulant Medication for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis of Trials of Methylphenidate, Amphetamines and Atomoxetine CNS Drugs, 2017.PMID 28236285
[8]Wilens TE, Faraone SV, Biederman J, et al. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature Pediatrics, 2003.PMID 12509574
[9]Sallee FR, McGough J, Wigal T, et al. Guanfacine extended release in children and adolescents with attention-deficit/hyperactivity disorder: a placebo-controlled trial J Am Acad Child Adolesc Psychiatry, 2009.PMID 19106767
[10]Michelson D, Allen AJ, Busner J, et al. Once-daily atomoxetine treatment for children and adolescents with attention deficit hyperactivity disorder: a randomized, placebo-controlled study Am J Psychiatry, 2002.PMID 12411225