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ADHD Medications: Use The Therapeutic Window – CorePsych Radio
ADHD and TBI: Hopes, Cautions, Medication Protocols: CorePsych Radio
April 13, 2009ADHD: The Therapeutic Window via Indiana and NYC
April 26, 2009
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ADHD Meds are Predictable:
Use The Therapeutic Window For Best Results
Tune in to CorePsych Radio Thursday 4PM EDT and download the Program Outline here.
If you simply pay attention to these basic details the possibility of the biggest two problems with ADHD medications are almost naturally corrected – no more frustration, no more fear of adverse effects. This program is a summary of several articles already published at EzineArticles on the Therapeutic Window
__________________________________________________
I Overview: Sides, Top, Bottom: The big picture.
7 Tips To Recognize The Window at the Outset
1. The Sides: The Entire Problem with Stimulant Meds can be summarized in two ways- Too Much, or Not Enough – the Therapeutic Window is the correct dosage, not too much, not too little, lasting exactly the right duration through the day. Stimulant meds don't last all day, thus the problem with timing. Everybody is built different metabolically, thus the problems with dosage.
2. The Therapeutic Window is specific for each individual adult or child
3. Stay away from the Top of the Window:
4. Watch for the Bottom of the Therapeutic Window: 5. Watch for the Sides to find the DOE, Duration of Effectiveness: Each stimulant medication lasts only a specific duration. If you are under that expected duration and the sides do not cover it properly as noted in the “Sides” article, you are underdosed. If you go past that expected DOE, you are on too much.
6. Drug Interactions do occur and may cause unpredictable diminishing. – More here on 2D6, an important metabolic pathway.
7. Denial of the Importance of The Window: If you don't think about it, if you don't know it's there, you simply cannot target it. If you don't target the ‘Window' you are either shooting geese at night, or simply throwing cans of paint at the barn door.
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II The Insufficient Bottom:
Often ADD/ADHD medications aren't targeted, or dialed carefully in, for the Entire Day, but rather set for an inadequate objective to just “get through work or school.” This problem has been with us since much before the 1960s – is Paleolithic – and simply does not address the ‘bewitching hours' of 4-8 PM.
7 Tips to Find and Correct Insufficient Dosage
1. Look for that longer objective: It may sound simple, but with the new drugs we can significantly change our PM objectives. The new drugs such as Vyvanse and Daytrana will last 13-14 hrs easily, but just take some time to ask the questions carefully and then adjust the dosage.
2. DOE, ‘Duration of Effectiveness,' evaluation must come up at every medication check. If your doctor doesn’t ask about it, you must think about it anyway to encourage the discussion.
3. Know The Characteristic Subsets of the PM Drop: – Each medication reviewed in detail for DOE and characteristic drop in PM.
4. How Vyvanse covers 12-14 hr: Increase it carefully with 10 mg increase in the AM will add about 2-4 hrs on the PM bewitching hours.
5. How Daytrana can cover 12- 14 hr: I like both of these medications because compliance goes up with less afternoon dosing, and there is no need to remember that PM dose.
6. Other Meds: Adderall XR, Concerta, Focalin XR, Metadate CR Durations:
7. Teach the children at the outset: It is harder for them to know what to look for setting these PM treatment objectives. Spending just a little time at the front end will help them feel like part of the team.
_______________________________________________________________________
III The Toxic Top
Simply stated: The Top is too much, the Bottom is too little.
7 Tips to Find and Correct The Toxic Top
1. The Reasonable Objective – No side effects
2. Recognize Too Much
3. Toxicity Timing: All Day Problems – Toxicity may appear as absolute: All day buzzing.
4. Toxicity Timing: On and Off Problems -Toxicity may appear as cyclical, mercurial — off and on — with hyperfocus and subsequent inability to focus.
5. “Drugged” Is Too Much: Simply feels like you are toxic; it's just too much. You shouldn't feel stoned or drugged.
6. More Symptoms at the Top: Confusion, disorientation, cognitive stress, anxiety, are all increased, while self-expression diminishes.
7. Different Stimulant, Different Tops: Stimulants Adjusted Incorrectly: If you feel these kind of symptoms for the first couple of days after starting a new med, usually no problem. ____________________________________________________________________
III The Understandable Sides
The 7 Tips For The Sides of The Therapeutic Window
1. The Sides of the Window Are Based Upon Time: The Expected DOE – Duration of Effectiveness
2. Know the Medication DOE Expectations from the Outset:
3. Measure Precisely the Time DOE At Every Meeting: Easy questions: “When did you take it and when does it stop working?”
4. The First Side Objective – AM Onset: All meds should be working in 30-45 min after taking the medication.
5. Regulating the AM Onset: Protein Breakfast is Essential
6. The Second Side Objective – The PM Release – When They Stop Working:
7. The Mystery Objective: The PM Release with Vyvanse
See ya there!
cp
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37 Comments
[…] 8 short videos by Dr. Charles Parker – about ½ hour in total – Matching Article: Finding the Therapeutic Window *TOP tips – Open a regular dialogue with your patients and measure the effectiveness of the […]
Hey Dr. Parker. I just listened to the chapter in your Audio Book version of New ADD Rules about hitting the top of the therapeutic window and I have a question. My doctor and I have me taking 60mg of Vyvanse at 5:00am and then another dosage of 30mg of Vyvanse at 12:00 noon and this seems to help me be in the therapeutic window for all waking hours. At first my doctor, Dr. Richard Winer (I think you guys might know each other, by the way) had me take the second 30mg at 9:00am but it didn’t seem to get me through to the evening hours so we adjusted it twice to where now I take the 30mg of Vyvanse and 12:00 noon. So all seems to be good but around 1:15ish till about 3:00pm and I feel more more stimulated (and good, euphoric-ish)…but focused and without negative side effects than the other hours of the day. So my question is feeling good hitting the top of the therapeutic window? I waver back and forth between thinking that the way I feel in those few hours is how I should feel all day to thinking that that is too much because I feel good. I don’t feel stoned or drugged in that my brain does not work as well but it actually seems to work better than all day during those times (with some euphoria). Does that sound like I am hitting the top of the therapeutic window?
Chad,
I’ve had several folks over the years stop Vyvanse because they worried it was so unnatural after years of suffering to perform so well. My use of the Therapeutic Window concept is to at once identify problems, going over that too-much line, and feeling so good you become completely out of sync with the world – and on the other hand simply good because your improved in your capacity to function to deal with real world changes. My sense of your report, and I do recall meeting a Dr Winer [but can’t remember which town at this moment], is that your doc is doing an excellent job of listening to your DOE reports [see this Duration of Effectiveness video: http://www.corepsych.com/doe ] and that your should rest reassured that your outcome meets the criteria of working effectively, not working ineffectively from both dosage and it’s associated DOE.
My shorthand: working well is inside the window, not working well is coming out the top with side effects and associated indications of too much.
Sounds like you hit your target with the good doc,
cp
Thanks Dr. Parker for your reply and the information you provide. It has been so helpful today! So to summarize: I take 60mg of Vyvanse at 5:00am and then 30mg at 12:00pm. After reading your site yesterday, I paid attention to exactly how I was feeling today from the the period of time I was concerned about (from 1:00 pm to 2:20ish) and I do think I felt a little “stoned”, “drugged”, a bit intense, a little anxious, and a little not quite right so I am thinking that I have hit the top. What I think I will do (I left a message with Dr. Winer to see what he thinks) is push the 30mg dosage back to 1:00pm, 1:30pm, or 2:00pm to see if that does the trick. I say 1:30 because I felt that way from about 1:00pm to 2:20pm and I am thinking that pushing it back an hourand a half will push it past whatever is happening at that time period (maybe another strong wave from the first dosage of Vyvanse happens at that time?) So anyway, thank you for the site and all the information you have put online that was not available online before! You are a God send! I would not have know what to look for had you not specifically said, “stoned”, and “drugged”. Also what you said about being out of sync with the world helped. Also, what do you think of my plan? And if you think pushing it back is a good idea, do you think I should push it back 1 hour, 1.5 hours or 2 hours?
Thanks again!
Chad,
On the right track, and may even go down further with just a small dose of immediate release Adderall if you need just a touch in the PM. Find the right trim based on your personal Therapeutic Window and you’ll be in the right place at the right time.
cp
I think moving the second dosage of 30 mg of Vyvanse to 2:00 pm instead of 12:00 noon hit the sweet spot (as you put it). As long as I can sleep tonight, I think that adjustment was a perfect adjustment for now. Thanks again!!!
Chad,
Hope it works – makes sense.
cp
Side note: If I am correct about hitting the top, the good news about Vyvanse is that it doesn’t feel good! Why would anyone want to take too much of it makes them feel bad? cg
You got it Chad!
cp
Dear Dr.Parker
After reading your book and reading a lot of articles on your website about metabolic/immune issues, I am choosing to get my IgG and neurotransmitter testing done.
I have a question regarding the neurotransmitter testing though. Would the results be affected due to the fact that I’m currently on Wellbutrin and Vyvanse or does it not matter at all?
Faisal,
Yes the results might differ, but the experienced reader can ‘read through’ the meds without going off. Good question!
cp
Dr. Parker,
I bought and read your book and really enjoyed it. I have a question: is 45 mg dexedrine ER at one time considered a high starting dose?
I have been on 72 mg Concerta and 30 mg ritalin ir for a few years, however have never tried another medication.
I tried Vyvanse, and seemed to get a little benefit out of 60mg, but I didn’t like 70mg. I went back to the methylphenidate combo, and am now on week two of dexedrine.
I used to think Vyvanse wasn’t for me because it would ‘work’ for a bit in the morning and then very quickly ‘come down,’ leaving me with a foggy brain and feeling antisocial and down for the rest of the day. However, I’ve heard many people say that with any of the dextroamphetamine medications, the goal is to not really feel anything different, simply to have more symptom control. So, I’m now wondering if perhaps the problem with Vyvanse was that the dose was always too high–that is, rather than ‘working’ for a few hours in the morning, I was feeling the physical effects of too much medication and then went out the top of the window, which was the effect I was feeling for the rest of the day.
AJ,
Thanks on New Rules!
I always start low and go slow [slower that you did] when switching from MPH to AMP, but it sounds like it wasn’t a prob for you. 45mg of Dex isn’t a large dose if the other MPH doses worked fairly well, I’m just exceeding careful not knowing the 2D6 polymorphism for AMPs.
Completely agree w your thinking on the “working/feeling” concept, have seen it hundreds of times. My guess from your remarks, it that you weren’t on enough of the Vyvanse because of what you described, but may have also have chased the feeling thing and missed the actual symptom control. It’s hard to tell just from these few remarks – and is often hard even on a med check. When you say you ‘didn’t like’ the 70mg sounds like the dose may have popped out the top of the Therapeutic Window. I’ve seen many who can take Dex or Adderall and not take Vyvanse… I have no idea why at this moment.
cp
Thanks for the quick response! I’m actually thinking the dexedrine may be too high, which perhaps means the methylphenidate was also too much (perhaps the medication was ineffective and I was trying to compensate by seeking a higher dosage?). I took 30 mg of spansules today and even that seemed to push me to a point where I felt kind of anxious and cloudy-headed, and fuzzy–it was harder to concentrate after two hours than it was when I first woke up. I see my psychiatrist tomorrow so will see about starting over perhaps taking one spansule in the morning and monitoring how that works. I think I’m so used to the more peripheral/physical effects of methylphenidate that it has been harder for me to notice the effect of too much dexedrine. I’m also diagnosed with generalized anxiety, which I am treating through CBT and psychotherapy with a clinical psychologist, so perhaps too high of a dose compounds that?
AJ,
With GAD, often more associated w serotonin imbalances, it can be amplified by DA products, no doubt. You’re thinking like you should now it’s time to see in the context of the multiple variables down the road.
cp
I am 57 and have struggled somewhat successfully through life ( got through college, became a teacher, stayed married,) with ADD without meds. Now I find myself having anxiety over not being able to think clearly (very typical) but to the point where depression has set in. I had a work up from our family therapist to verify my ADD and depression so that I could approach my family doctor with some verification of need for meds other than my anecdotal complaints. He is reluctant to put me on stimulant meds for heart reasons even though I have no health risk factors. After seeing your videos on treating comorbid conditions such as ADD and Depression I am unsure if I should be asking my doctor for two medications (one for each condition) or starting with my acute depression. I know the depression is related to my feelings of inadequacy stemming from my ADD but it is also situational in that I have had a lot of family trauma this last year. Where do I start. I am seeing my doctor tomorrow 7-23-13. I don’t expect you to answer this that soon but I will certainly value your input even after the fact of seeking a prescription from my doctor. I was thinking of asking for Vyvanse for ADD and Lexapro (or similar) for the depression. I have been insatiably pouring over your videos and blogs and websites trying to glean as much info as I can. I feel enlightened but not certain or confident. Please steer me.
Kent,
You likely have, without an eval, valid symptoms of both issues: Depression and ADD. The problem you face, as many do, few medical folks are informed about these issues as they present either separately or, most especially, together. For more complete answers you really should read my book – far more precise answers are there that might help you with whatever medical professional you use.
Many docs simply don’t know what to do or how to medicate ADD, and too many don’t appreciate drug interactions. Vyvanse and Lexapro have no interactions, and work well together.
Quite frankly you do need to speak to someone familiar w ADD and ADD meds. It shouldn’t fall to you and someone on the Internet to help the doc come up with the correct mix for you, and if the mix doesn’t work, what then?
I do long distance evals through the Services page here and would be happy to provide more info if you set up a consult.
Hope this helps,
cp
[…] a 7 or more, and all else appears well, consider their progress to correlate with remission. As I commented in this post years ago, numbers make more sense than […]
Hi Dr. Parker,
You are the man! I am consuming your blog posts and YouTube videos. This is exactly the kind of information I have always wished I could be privy too. This is enlightening!
1.5 years ago I was diagnosed with ADHD (Inattentive) and I was prescribed Adderall IR liberally (eventually 90mg/day). I also complained of depression and anxiety, so I was prescribed 10mg Lexapro (I have taken antidepressants before and preferred Lexapro) and 30mg Propranolol. I found that taking 20mg of Adderall IR 3 times a day was best for me. I complained about anxiety with every visit, but rejected Xanax for fear of physical dependence.
Then I went psychotic. Yes, psychotic! My first (and hopefully only) time. I thought I was being followed, surveillanced and harassed. Scared family members got me to see my psychiatrist immediately.
Everything was discontinued except the Propranolol. I started on 10mg/Zyprexa and was tapered down slowly over the course of more than a year to 2.5mg/day. I love Zyprexa because it solved my anxiety and makes me rather happy, but I gained 80lbs and my blood pressure went up.
One day, tired of being overweight, I decided to switch from 2.5/day to zero, for about two months. I know — naughty. I noticed I was more depressed. Now I am taking 1.25mg/day Zyprexa and plan on informing my psychiatrist the next time I see her.
Three questions:
1. What does my reaction to the Adderall say about my health? Am I likely bipolar? I do have a history of depression.
2. My psychiatrist wants me to take 2.5mg Zyprexa indefinitely. She said I am not bipolar, “but the disease process is still there.” I wonder if she was just letting me down easy. I would like to know if I am bipolar because I want to switch doctors one day.
3. My psychiatrist suggested the following: 2.5mg Zyprexa,
20mg Lexapro, and unknown dosage of Guanfacine for ADHD. Thoughts? That is what she wanted to prescribe, but I just told her I did not want to make any changes yet.
Does anything in my saga astound you?
Anyways. Thanks for listening, and running this informative website, making videos, publishing a book, all of it!
Toby,
Nothing astounding, rather: typical and interesting. Sounds like you went too high on the Adderall, and as you know from reading here I never make a diagnosis pronouncement here, don’t even like to make one in the office without more data –
But having said that I would look carefully at diet, ability to metabolize AMP, and your pre-existing state from a biomedical perspective – like immune system dysregulation and GI dysfunction. Bipolar may be what you appear, but highly unlikely that’s what you are intrinsically. Do the Transit Time to see if you have a slowing of bowel. Easy test, find the pdf here thru the search.
cp
Anna,
Sorry to get this out so late, just the summer activities popping in!
cp
Hi Dr. Parker.
I’ve watched several of your videos and read a bunch of your articles. I’m glad I came across your blog; thanks for publishing such useful information.
I
I’ve been on Adderall for a little over 2 months and am getting frustrated trying to figure out the best dosage & schedule for me. I’m seeing a family Dr. who was recommended to me by my counselor. I hope to start seeing a psychiatrist by the summer (I’m not atm due to cost reasons).
I just recently found out I have ADD and taking Adderall has made a lot of positive differences in my life so far and once I get on a correct dosage & schedule I feel as though I’ll be able to function normally and lead a productive life.
Just to give you a short summary of me (I have a specific question I’ll save until the end):
I’m a 26 year old male and my main issues are:
1. No motivation what-so-ever. It’s difficult getting up and dressed. Up until last Fall I only left my house to get food and to do essential things. I forced myself to start taking classes at my local college last Fall. This is the only time I ever leave my house. I’m not depressed at all (I’ve analyzed it over and over–I’m positive on this). The only time I get depressed is when I sleep all day and/or isolate myself for 3 days or more. I’m majoring in Psychology and I think I remember learning that low epinephrine causes a lack of motivation. I mean its hard for me to do anything (dishes, take dog for walk, etc). For years all I would do is sleep most of the day because I could never muster the motivation to do anything.
2. Tiredness & “Mental Fog.” Everything I’m listing ties into each other. No matter how much sleep I get (8, 10, 12) I’m always tired and have this mental fog hanging over me. I’m constantly in stupid mode. It got to the point where I started seeing a sleep specialist (due to me be tired all of the time and having Zero motivation). I had two sleep tests done and the doctor said everything was completely normal w/ some minor issues (not enough to cause the tiredness and lack of motivation I was describing).
I’ve been having sleep issues since I was a teenager. At least twice a month I sleep in way too long (like until 2pm-5pm) and this ruins my sleeping pattern for up to a week. (I don’t do this as much w/ Adderall because I know I’ll be able to function 30 min. after taking it.) I’ll enter a period of sleeping during the day and being awake at night. If I try to pull an all-nighter to get my sleep back in line I have a decent chance of having a night-terror (which hasn’t happened in over a year to my knowledge) and I am guaranteed to have insomnia-sleeping for 3 hours and not being able to fall back asleep until the sun comes up. My sleep doctor gave me Klonopin for this, told me I was too anxious (which I was because I was trying so hard to convince him there was something wrong–which there was–only it was ADD and not a sleep disorder). He also told me to see a psychiatrist.
3. Extreme social “awkwardness”. I’m not sure I’d call it anxiety (although I def. have it at times). I just feel so lethargic and have this mental fog hovering over me that it makes me not want to interact with anyone. And then when I do my thoughts can’t get together and I dont know what to say and look stupid. I feel like everyone is always watching me when it public too…and analyze almost every move I make at times.
4. Concentration/Focus. This is already getting pretty long. In the general sense. I forget what people say 3 words after they say it. Cannot follow directions and have to ask people multiple times for their name which I’ll still forget unless I really get to know them. I also have trouble finishing tasks. I never finish anything I start.
I can think, imagine, dream big, get myself pumped up over an idea or something I want to accomplish. I start certain things with enthusiasm but can’t maintain focus and soon give up/put it on hold.
II What Adderall has done for me so far:
I have ZERO social problems. I talk talk talk. At first I thought it was a problem but then I realized its been years since I’ve really talked or connected about anything. While on this medication I just love being around friends and family for once–even strangers. I mean my closest family barely knows me–I never open up and talk just seems cheap and meaningless…but with this I can actually define and express my true thoughts and emotions. It’s bringing me closer to my family (when on medication). It makes me want to go out and do things with PEOPLE and live life. I honestly never do ANYTHING. Whatever I do I always do along. So far while being on Adderall (for two months) I’ve hung out with my half-brother for the first time in wow..10 years (he’s 23) and am still getting to know him, hung out with my half sister for the first time EVER since we were both little kids , I’ve bought tickets to 2 concerts, made a few plans with people I haven’t spoken to in awhile…and lots of other things. What I’ve found is that I can make plans while under the benefits of Adderall but I also feel like I would def. need adderall to participate in the plans I make. If I didn’t take it I’d probably cancel and spend the night alone–or force myself to go and feel socially awkward the entire time.
To sum the social improvements up: in a less meaningful (than above) sense I’m able to think about what I want to say and actually say it. I don’t have an empty mind anymore. (I’ve always been able to articulate my thoughts in writing–go figure right?–just not spoken words)
I havent had a job in 5 years (since 2006). I went from job to job and I always quit for the reasons mentioned here. Being alone in my room on the computer has always been my safe spot. I truly do not feel depressed. When I’m alone I’m actually quite happy. When I’m w/ people all I can think about is getting back to my room. Adderall takes away this problem and gives me the opposite; I crave social interaction to the point I think I’m actually going to start making friends (shocker).
I didn’t plan on this being so long. In one of your videos you talked about people who thing about things too much–this is def. me–although only certain things. And yes I am thinking way too much about my current situation and finding the proper dose of adderall. Its only because, I feel crazy saying it, the drug has been a literal miracle. I almost gave up on ever getting help. I couldn’t define my problem. In a way I thought the sleep doctor was my last hope.
Here is the main reason I wanted to leave you a comment. If you respond to anything (if this long ass message still has your attention) please let it be this:
I was started on 5mg of Adderall IR (which did nothing) and then was bumped to 10mg.
10mg works wonderfully but it only lasts 90 minutes. I can time it. 2 to 2.5 hours after taking the medication it feels like all of the benefits are gone and then this weird tiredness starts to creep up on me and hits hard 3-4 hours after first taking it. It’s a bad feeling. I’m tired, stupid, and ADD ten-fold.
I’ve tried 7.5 2x daily (not effective enough) and 15mg at one time. After calling my Dr. gave me permission to experiment w/ up to 15mg per day to find what works best. The few times I tried 15mg it works great–better than 10mg. The only thing was I definitely had Euphoria the first 45 minutes. I don’t do illegal drugs but I was definitely “high”. 15mg lasted 30-45 minutes longer than 10mg but the “crash” feeling was worse. I just met with my Dr. yesterday and told her I thought 10 was enough.
I am now on 20mg Adderall XR. Today was my first day.
It lasted about 4.5 hour…right around then I started getting tired and felt less into what I was doing. This feeling lasted a few hours. It’s mostly gone at the moment. I’m writing this very long comment out of desperation, but a part of me wonders if the adderall is helping as well. Maybe both. I just know I couldn’t function properly in public and am safe in my room.
I’m coming to a close I promise.
I have two theories as to why the medication isn’t lasting as long as it’s supposed to. I’d really like your opinion. I really feel like its up to me to figure out the best dosage/balance to report back to my Dr.
Theory 1.
10mg IR (or 20mg XR) is the right dosage but I have a weird body and metabolize the medication faster than I’m supposed to. I should talk to my Dr. about taking 20mg XR in the morning and 1-2 10mg IR during early afternoon & late afternoon. (or just two 20mgXR which wouldn’t give me the flexibility of only taking 1 10mg IR on days I might not need a second dose.
Theory 2.
10mg at a time is not enough and increasing it would make it last longer than 90 minutes (eg: 15mg). The euphoria I felt the few times I tried 15mg would eventually go away once my body got used to it. I should talk to my Dr about 30mg XR once per day.
Anyway. Thats it. I’d just like to figure out the dose that will let me function all day. I’m finding the Brand XR much calmer/smoother than the Generic IR I was on before. I don’t have insurance and this is expensive…so I might have to switch back to IR until I can earn some money.
I have no idea if you’ll read this mammoth of a text–but you’re awesome if you do! lol At least it will add text/keywords to the page and increase traffic slightly 🙂
You seem like a really good/knowledgeable Dr. I wish I lived closer!
Scott,
My man, you are a complete riot. It was great fun reading your note, but wish you would have dropped ADHD in there a few more times for SEO! 😉
To answer your two questions, yes and yes, gotta go now – just kidding.
1. You do have a metabolic problem as you have all the signs of a Narrow Therapeutic Window – I know you aren’t loosing your memory, but just a tad more takes you into relative toxicity.
2. Increasing the dosage will only work for a little while as the man titration problem is secondary to metabolic issues, tho you don’t give any hard or soft evidence for it!
cp
Hey Scott,
Reading your message just blew my mind. Every single thing you have described is me.. the motivation problems, messed up sleep schedule, liking to be alone, social awkwardness, starting things I’m really excite about and never following through, and even the problems with medication. I am actually close to speechless.
I was diagnosed with ADHD a few months ago after years of people just suggesting depression (which I’ve always been certain was not the problem) and being told to “go to bed earlier and make a to-do list” a if I’ve never tried those before but I’ve never met anyone or heard a story so close to mine before.
I have been taking Vyvanse since the diagnosis which started out wonderfully – my life was changed! I’m slowly working up my dosage as the medication wears off much quicker than it is supposed to, and I notice that I start getting really tired a few hours in, and at that point I start reverting to my old ways – wanting to be alone, slacking on doing necessary and easy tasks and generally not accomplishing much. The few hours that it’s there are good, though an I have no complaints either than this.
Just wondering if you have any updates on your situation, I’d be interested in hearing them if you do.
Thanks — I got your message.
Why did my post go away?
Theresa,
I approved every comment before publishing them on this blog, and have been behind with opening the DC office this next week. I will send you an offline note as well.
cp
Dr. Parker,
How do you correct the metabolic difficulties? I have no known allergies, occasional indigestion (3x a month at the most I think — used to have it a lot more, but a changed diet helped), generally a bm once/day, occasional incomplete/difficult to pass bms (one or two days a week maybe?), very mild and occasional discomfort or itchiness…but none of it interferes much with anything else and I’ve never been able to establish any pattern.
I make sure I get protein, fiber, and whole grains (in addition to fruits and veggies) daily. I drink as much water as I possibly can, and generally I’ve been exercising 4-6 days a week.
I do take adhd meds now (started around 3-4 months ago), even though I question it almost constantly. Would they be less effective on days when I have those issues….? What about during my menstrual cycle, would they be less effective then too?
I feel like I worry more now than I used to, but what I actually think is that I’m more aware of it or identify it as worrying – rather than as a necessity to be able to do anything.
My biggest problem/FRUSTRATION right now: I struggle so much with time management and I’ve been setting alarms to limit what I’m doing (let’s say on the computer, as one example). Usually when I’ve taken the meds, I can stop myself when it’s time much more easily than when I wasn’t – even though I’d always told myself I had to do whatever else instead (I didn’t start using alarms until I started meds). Sort of like that hyperfocus.
But two days now in a row, I haven’t been able to stop (whatever the impulse is) — despite my alarms and my repeated telling myself that I had to. And this has been while the meds have supposedly been effective. It’s not that I don’t want to do what I need to, I do. The problem is, it is so hard for me not to see this as a lack of discipline/effort which is what I’ve always equated it to. So when it was better with the meds, it helped me to not see it that way.
But now I don’t know. and I’m frustrated with it and angry with myself for not sticking to my schedule yet again …but I don’t understand why. (it’s been 3 days now, in a row, that I haven’t done my exercise or gotten to bed when I actually needed, and tonight will be another one already!) If the meds aren’t going to help me with that (among other things), then I don’t want to do it! — but at the same time, they were at one point and overall I guess they are. These are two evenings we’re talking about, and I do take the meds also in the evening.
I’ve been taking this stimulant for a while now (about a month or so) and although the formulation and the dose have changed slightly every now and then to try to find the optimal scenario, it’s basically been the same. But when this kind of thing happens where I take it and it doesn’t help where/when it needs to or I expect that it should based on previous experiences, I don’t have a reason for continuing to try to find the right times/combinations!!!! Especially when I already have enough doubts as it is!!! (However there is no pattern I can find for when it’s not helping but I think it should be).
I hate this part and I want to give it up. But at the same time, it has made a big difference overall in almost all the areas…so I’m afraid to go off it because I’m so much better now than I was before, but I hate being on it because of the uncertainty and occasional inconsistencies.
Can you help me? Offer any words of advice or encouragement? My next appointment is in two weeks. This entire process has been such a struggle and I just want to understand better, or something. So much for my schedule tonight….this was a desperate post, so if you can help in any way, I would be forever grateful.
Plugging along anyway….
Thank you,
Theresa
Theresa,
Sorry to be so late getting back when you are in turmoil… you, my friend, do need more information. Frustration arises when matters on the front end are not correctly identified, and then, in my office when they need more tweaking as the initial intervention hits a wall. You have way to many variables on your plate and do need a complete review with solid evidence to get into that next recovery phase.
cp
I am scared to ask my doctor for a new dose of vyvanse. My dose has already been uped from 20 to 50mg. I feel like I am very close to getting the correct dose. Last time my doctor mentioned that if 50 did not work she would have me spilt my dose up into 2 a day. I have read that this is not effective. Any thoughts?
Jenny,
Please take a moment to rectify your uncomfortable feeling with your doc. If he doesn’t work with you, you are the customer, make your feelings known. Yes, he is the doc, the suggestion is not a bad one, just that you are quite right using the DOE that 60/70 might be a better dose with better compliance if dialed in correctly.
See the last chapter in my book ADHD Medication Rules for notes on dealing with your doctor effectively, and for the titration strategy using the DOE for careful/precise symptom resolution.
cp
Long post here, but I think you might find it interesting.
I would have loved to have heard all you said today on CPradio, but I was distracted…
What little I heard (MES had tech probs until 4:30 and then cut you off mid-sentence at 5 pm) was interesting and relevant. Gonna watch Eastwood specially tonight. Was it High Plains Drifter?
Just like you said “suicidal thoughts” should trump “distracted at school” it seems that depression should be treated before ADD (and sleep problems–restless legs/Mirapex–before anything else.)
When my depression–really, irritability and cynicism–colors my responses, the people around me dismiss my words as “bad attitude.” Consequently, my cognitive abilities are ignored and my relationships don’t get past first impressions. Of course, I’ve been unemployed for 13 years, since I left the military.
You’re right about military structure. As an enlisted man, being told what to do and when to do it, I performed really well: lots of promotions and medals. As an officer at remote locations, I was on my own. I was often praised for outstanding performance under pressure, but often chewed out for being unreliable.
It was quite normal for me to stand in front of a general officer while he says, “Listen carefully, this is vitally important…” and then hear him say, “… so those are your orders. We’re counting on you!” Umm. Oops. Huh?
Although I’m really a fine upstanding law-abiding good citizen, I’ve faced the barrel of a gun several times in my life and even been read my Miranda rights a couple times as a result of my impulsive actions. (I once told my troops to burglarize a top-secret vault because we couldn’t find the keys to the radio codes. In hindsight, I suppose I should have gone through channels, instead.)
Prior to the service, I got plenty of structure from the counselors during two years at the Ozanam Home for Boys and from the nuns at Bishop Hogan High School. (I ran away from home at 14, and now I know I was quite fortunate to have been jumped by an off-duty plain-clothes cop. If I had had time to pull my pistol, my last structured environment would have been a pine box.)
Now that I’m diagnosed (I recognized myself while watching my little boy), my wife and I accept the fact that, if I set out to do something simple, even important, I’ll totally forget it within seconds, and get caught up in something else. I often have no idea if I’ve paid the bills, and my kids have become accustomed to being forgotten at the bus stop.
Today, I really hoped to listen to your show, but instead, I got up for a cup of coffee, forgot to put the water in the pot, did a yard chore, and finally realized your show was half over. So it goes.
My big question: Instead of stimulants, couldn’t Effexor address both the cynicism/irritability and the inattentive ADD? (I’m wary of stimulants only because, after 2 years of Ritalin, I noticed my resting heart-rate was over 100.) Is this the “burn out” part of the Therapeutic Window you referred to?
Should irritability really be called depression? I’m not overly sad, I’m just easily pissed. The sadness and lethargy components of my depression are easily explained by the isolation of long-term unemployment. I’m really quite lucky that my wife can put up with all this.
You mentioned metabolism: I have irritable bowel syndrome. I’ve been a gaseous guy all my life. A standard meal goes from front to back in 19 hours, but long ago I learned never to drink coffee with filet mignon: as soon as steak and coffee mix, my butt explodes within seconds! (Always happy to share.)
Still, I love protein, ever since a dietician said my magnificent omentum is due to my body not handling carbs well. At 5’8” I’m a good looking guy, except my beer gut and consequent 194#) gives me a BMI of 29! (I’ve got Lipitor, aspirin and Lofibra on-board, to prevent me from following my multiply-infarcted father into the dementia clinic.)
Been googling in vain for the Kelsey scale you mentioned. Is there a better name for it? Which Kelsey?
I realize I’m taking your time. But still, I’d be grateful for your considered opinion, as you seem to be the smartest guy on the subject. I hope you found this life story interesting. I do, every day.
Hey Mike,
Great comments, almost a post in itself.
1. Clint Eastwood: Yes, The Stranger in High Plains Drifter
2. Kelsey: He was Jeff Kelsey MD, PhD in Atlanta, formerly with Emory, died about 4 years ago now, and that reference may have never been published as he became sick, and died of Leukemia. He was a good friend of mine on the teaching/speaking circuit for Wyeth with Effexor. Did a study, and he was a perfectionist comparing the HAM-D to the scale of 1-10, and found highly correlated [statistically significant] the remission of =/< 7 on the HAM-D with 7 or more on his 1-10 scale. Use it all the time… comes closer to actual testing.
3. I don’t use Effexor for ADHD tho there may be one or two papers that have seen some significance – I just don’t. I treat the ADHD unto itself and that plan works well over 95% of the time.
4. Stimulants do the trick best, and if you can take an AMP, then you are a candidate for Vyvanse, started slowly regardless of any previous AMP dose.
Got a kick out of your writing about your mil experience… almost like I was there with you.
Thanks for your great comments – give the stims a try with Effexor if you have comorbid depression, depending on what your doc says.
cp
Hi Dr. Parker, since i’m not sure the best way to reach you these days (there are SO many choices – twitter, fb, feedblitz, corepsycblog, myexpert, etc!) – i’ll post here too. I was very excited to hear your therapeutic window program today, but what ran was half (starting at 4:30pm est) of your previous depression program! Everything ok?
Jackie,
Program on Therapeutic Window was recorded as i was flying to Indiana on Thurs – heard about this problem Fri when I checked my email, left a VM at the station, and will post you back on what happened when we correct the situation. Thanks for trying!
cp
Thanks for your helpful posts.
I’m a 53-yro ADDer diagnosed only after 20 years of military service. (Boy! When you can’t pay attention to even the most important military orders, it’s a real career killer.)
Now, after 13 years of Zoloft and a few tries with Adderal (sometimes made me hyperactive), Ritalin (elevated my heart rate after 2 years), Wellbutrin (instant skin itch on the first day), Strattera (no effect whatsoever) and Effexor (nice antidepressant), I’ve settled on some facts about timing. I get angry at my kids far too easily during the first hour after taking a Zoloft. Now, my best results with mood control are to take 100mg Zoloft at bedtime, then 3×37.5mg Effexor mid-morning.
Just today I discovered the invention of SNRIs for ADD, so I’m hoping to increase my Effexor dose to see what happens to my ADD symptoms.
Any thoughts?
Mike-
Yeah, if you had it bad in the military you were either in some very unstructured assignments – or… I don’t need to tell you. Most often the military and structure helps with the ADHD.
On the meds: My take on SNRI queston: I don’t mix apples and oranges: for ADHD they are ‘helpful,’ but not as consistently corrective as stims. I love Effexor and Pristiq, both SNRIs, but use them for the affect [anger, depression, anxiety] not the cognition, and they may very well help with the anger you describe. I use the Kelsey scale for anger/depression and rate the problems from 1 being the very worst to 10 perfect – you want to be at a 7 or more. Using that simple scale can take much of the guess work out of titration for affect with antidepressants.
For the Adderall and Ritalin probs: Burn out is usually diet, and especially protein/diet related. If they are not dialed in correctly they will cause side effects – thus this radio program and this detailed post. Everyone should be using this Therapeutic Window concept with every med check. Too much Adderall = out the top. Insufficient = out the bottom. If no breakfast with protein the likelihood of toxic like med problems is high – 70-80%.
Stay tuned here for all the material coming soon on ‘neurotransmitter precursors’ and their important relevance in med management. At CorePsych we measure these specifically and augment with specific amino acid precursors for the burnout, and for proper balance on the front end, if indicated.
Finally, it does sound like you have some chronic metabolic issues, and since we are here on line I won’t ask you how many times a day you go #2, – but if your transit time is either too long or too short – I can pretty well guarantee long term problems with psych meds, all/any of them.
Try correcting these items, and do carefully review the Therapeutic Window topics, something just wasn’t right with the stim meds – and the reason was biologic, i just don’t have enough additional info to suggest other specifics.
Hang in there,
cp