ADD: Overdosing the Big Guys

What's the biggest problem with psych meds for big guys?

Easy answer: Overdose.

Adjusting meds by body weight was fine in the 50's and even late into the 60's and early 70's. Now body weight as a factor in dosing stimulant meds is very old news, and simply doesn't work. Metabolism is determined by many issues, from acid base balance in the bowel, to transit time of food, to genetic polymorphisms. Just because they tower over us, does not mean they need more meds.

The most common problem I see with the moose guys: they come in stoned on meds, -prescribed stimulant meds, that is. The reasons are several and simple:

1. They are big, big, and they  can appear scary. -Have an ex Navy officer, was submarine XO [have no idea how he fit in down there], big as a house, solid, Naval Academy Graduate, looms over my 5'10" frame like I am a sparrow under a condor. Came in stoned [more specifics in a minute], almost couldn't talk or focus, on 100mg Adderall XR, Risperdal 4mg at bed, Depakote 500mgER 2x/day. Diagnosis: you guessed it, bipolar. He was a slow burner, took very little to achieve good brain concentration, and after much juggling he has been on 40mg XR for > 2 years, and 150 Effexor XR, with Desyrel 50mg to sleep. Still has to duck coming in the door, no problem with impulsivity or focus, the meds blew him out the top of the therapeutic window.
2. They are often big and smart: Very big African American adolescent, 13 yo, weight about 270, also did the tower drill with me, about 6'3" tall, imposing and glaring when he first came in. Stoned. Not a drug user, snapped out with the early fast titration of meds, is now on a dose of 30mg XR. Had a low dose of antidepressant 30mg Celexa. Now leader in his class, funny, yet still awkward with the way people react. Smart is also intimidating if the answers are coming too fast. -Thus the med rush. Big and smart, go for the Rx…
3. Docs go up too fast just because of size, or just because they have a cookie cutter strategy, and don't stop to ask duration of effectiveness [DOE]. "First we go to 20mg, then to 30 and will check you at 40mg XR." No room to accommodate to the new meds. Unacceptable.

The way you can tell the stimulants are too much:

1. With amphetamines [Adderall etc]: Anger, racing thoughts, over focused, bitter and short, moods either up or down, often crying when no history, can't sleep, don't eat.
2. With methylphenidates [Ritalin, Focalin, Metadate etc]: Dull, can't think, staring in space, just not doing well, tho doing better, shorter flash points, but more often will say "I feel stoned."

So let's watch out for the big guys and give them a fair shake. They appreciate straight talk, no psychobabble, and basic listening to their observations.

My plan with all the folks I see, big or small, is simple: I will teach you how to tell me what to do, – then you can tell me what to do, and we will both be happy. Basic, and much more interesting.