By Rajnish Mago, MD (bio)
Question from a Member:
(Skipping) stimulant doses on the weekend or over holidays for a “break”… should this be recommended to adults?
Also, some people feel that this practice helps protect against building tolerance and prevents people from requiring higher and higher doses of a stimulant. Do you think this is true?
The issue of stimulant “holidays” in children is discussed on another page on this website (see Related Pages below). Here, I’ll address our Member’s question about whether stimulant holidays may be helpful in adults.
There is virtually no research on this specific topic (as of January 2020), so the comments below are based on my own clinical experience, review of Practice Guidelines, and discussion with a leading expert on the pharmacological treatment of ADHD.
First, let’s note that the clinical term “stimulant holiday” can refer to either SHORT holidays (e.g., for a weekend or a few days) or LONGER holidays (e.g., for anything ranging from a month to several months). First, let’s look at the pros and cons of SHORT stimulant holidays.
It is not clear to what extent patients on a stimulant develop tolerance. The concerns that patients with ADHD who are on a stimulant will commonly require higher and higher doses of a stimulant are exaggerated. But, individual patients sometimes do report decreased benefits from the stimulant medication over time. There are many possible reasons for this.
Before we assume that “tolerance” to the stimulant medication has developed, we should ask the patient about which symptoms or problems are not being helped as much as they previously were. Sometimes we find that the improvement in attention is still there but the improvement in energy and mood has diminished (Canadian ADHD Resource Alliance, CADDRA, 2018).
In patients with ADHD in whom the benefit has clearly decreased, an alternative to increasing the dose of the stimulant medication may be to taper the stimulant off for a week or more and then restarting it. When the stimulant is restarted, the original benefit often returns.
This was recommended in one Practice Guideline (Canadian ADHD Resource Alliance, CADDRA, 2018), which noted:
“Some patients report loss of effect from stimulant treatments over time. In some cases, taking breaks from stimulant treatment intermittently has reportedly allowed for the maintenance of effects at lower doses.”
“Some clinical reports state that some individuals find that taking breaks from the stimulant medication may have a “rejuvenating” effect. This phenomenon is not well studied, but it is advisable to have patients take such breaks rather than to increase dose in a previously effective treatment” (emphasis added).
In adults, it is much less common than in adults to have the problem of undesired weight loss due to a stimulant medication. Most patients either don’t loose weight or lose weight only to a desirable extent.
But, we occasionally see adults with ADHD who have low body weight at baseline and develop appetite suppression after starting a stimulant. In such situations, we can advise the patient to do the same thing that we do more often in children—to take a lower dose on weekends or even to skip the stimulant on weekends.
If short stimulant holidays are not enough to prevent weight loss in such persons, we can, of course, add something to stimulate the appetite, e.g., mirtazapine (my favorite for this purpose) or cyproheptadine. For a set of strategies that can help in managing loss of appetite/ weight due to a stimulant, please see the following article on this website:
Ability to relax
I have had several patients who prefer to not take stimulants on weekends and while on vacation (or to take a lower dose) because they find that the helpful focus from stimulants can have a dark side—difficulty relaxing and “just chillin'”. For this problem, taking a lower dose of the stimulant or, if needed, skipping it altogether, can be helpful. Of course, in such situations, we should assess the patient to make sure that that the dose of the medication is not too high i.e., even on weekdays.
What about longer breaks from taking a stimulant medication (weeks or months)? What are the pros and cons of such longer stimulant holidays?
Longer periods of being off a stimulant (or at least on a lower dose) are a good idea because they allow us to assess whether a stimulant is still needed and at what dose. Some clinical practice guidelines (Bolea-Almanac et al., 2014) specifically recommend that for ADHD in adults,
“Drug holidays may be useful to ascertain the need of continuation of treatment“.
Here are my tips on how to use stimulant holidays most effectively, for this purpose:
– Decide in advance, in collaboration with the patient, how long the break will last, at least in approximate terms.
– Thoroughly and systematically assess the ADHD symptoms before starting the stimulant holiday and then repeat that assessment after the patient has been off the stimulant for several weeks. On another page on this website, I will discuss tips on how to systematically assess ADHD-related symptoms in adult patients.
What I mean by my suggestions above is that the stimulant holiday should be considered to be a systematic trial or “experiment“. We should structure it so that at the end of the trial period, we have some answers, one way or another. We should be able to draw definite conclusions as to its benefits and drawbacks rather than having only vague impressions about how how the stimulant holiday affected the symptoms. To the extent that we don’t have clear answers at the end of the stimulant holiday, the trial was essentially wasted.
Increased risk of non-adherence?
A potential disadvantage of taking a long break from the stimulant medication, at least theoretically, is that it may give the patient the message that we want them to “get off” the medication. So, it is important that we discuss with the patient our reasons for recommending a longer break from the stimulant medication. We may unintentionally encourage non-adherence to the medication.
Optional to read:
PubMed search done on December 7, 2019, using the strategy: (“Central Nervous System Stimulants”[Mesh] OR stimulant* OR methylphenidate OR amphetamine*) AND holiday*
Stimulant “holidays” in children and adolescents with ADHD? (COMING SOON)
Bolea-Alamañac B, Nutt DJ, Adamou M, Asherson P, Bazire S, Coghill D, Heal D, Müller U, Nash J, Santosh P, Sayal K, Sonuga-Barke E, Young SJ; British Association for Psychopharmacology. Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: update on recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2014 Mar;28(3):179-203. PubMed PMID: 24526134.
Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON;
Carias E, Fricke D, Vijayashanthar A, Smith L, Somanesan R, Martin C, Kalinowski L, Popoola D, Hadjiargyrou M, Komatsu DE, Thanos PK. Weekday-only chronic oral methylphenidate self-administration in male rats: Reversibility of the behavioral and physiological effects. Behav Brain Res. 2019 Jan 1;356:189-196. doi: 10.1016/j.bbr.2018.08.014. Epub 2018 Aug 24. PubMed PMID: 30149034; PubMed Central PMCID: PMC6317517.
Faraone SV, Spencer TJ, Montano CB, Biederman J. Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care. Arch Intern Med. 2004 Jun 14;164(11):1221-6. PubMed PMID: 15197048.
Hugtenburg JG, Griekspoor JE, De Boer I, Heerdink ER, Tso YH, Egberts AC. Methylphenidate: use in daily practice. Pharm World Sci. 2005 Jun;27(3):197-201. PubMed PMID: 16096887.
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