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Adderall, Prozac and Paxil: Problem not solution
Is Tom Cruise right?: are psych meds wrong?
November 24, 2006ADHD Medications: SSRI + Amphetamine Interactions Cause Serious Problems
November 25, 2006
Prozac and Paxil Create Problems Used With AMP
Drug Interactions Abound in ADHD Land
Some antidepressants and stimulants create significant problems together, period. Some of my colleagues disagree, and I'll tell you why in a moment. I'm certain of these findings as I've personally reviewed the literature, and with that guidance corrected many of my past mistakes before we even knew about 2D6. [Note: today, 10-4-15, this post is almost 9 years old.]
I've recommended this increased awareness in my medical presentations since 1996, and I include CYP 450 in our Testing Protocols at CorePsych. This type of genetic testing is not the entire answer, as recently pointed out in the Boston Globe, but it certainly is part of the answer for treatment failure based upon drug interactions.
Old News
The media has been buzzing this particular ADHD medication reaction topic up for years. This interaction is one reason psych meds are taking so much media heat. This post, if considered carefully, can save you much money, significant heartache, and that hopeless feeling when nothing you are taking to correct ADHD problems works. Young and old, you just won't be in so much medication-failure trouble.
Amphetamines [AMP]: Adderall, Vyvanse, Dexedrine, ProCentra, Zenzedi
In this post I'll tell you briefly about the pharmacological part of the problem, and the next post we can discuss how you can see it clinically, then ask the questions to unearth the gritty details.
Don't forget Concerta and MPH Products
This interaction problem is present, though less obvious, with MPH products like Concerta and Ritalin which also block 2D6 pathways.
These antidepressant and stimulant meds simply don't work together [rare exceptions, more about categorical thinking in a later post]: Prozac, or Paxil mixed with any amphetamine such as Adderall, mixed amphetamine salts, Dextrostat, or Dexedrine. Some may say it is “not in the literature,” but I have seen this clinically important and dangerous consequence hundreds of times, and have written about this common reaction with my son as lead author.
It's About 2D6 The CYP 450 Pathway
Video
See this 2D6 Video – Duration 4:49 min:
References
We will cover more details later, but for now just remember this: Prozac and Paxil both significantly block the pathway for the metabolism of Adderall and all the amphetamine products. [Wellbutrin and Cymbalta are moderate inhibitors, and can block 2D6 at higher doses.] If you take either of these two antidepressants together with an amphetamine, beware. You can significantly become overdosed on the amphetamine and suffer significant arousal side effects. Often this interaction can unpredictably occur several months later. The patient becomes toxic to the amphetamine, angry, irrational, can't sleep, can't eat, and can become dangerously destructive. The Adderall or Vyvanse often gets blamed. The Prozac and the Paxil are the problem. More about Adderall in a later post.
Reference: The Authoritative Drug Interactions Book
Many books document this challenging interaction, and this book turned my own practice around years ago: Drug Interaction Principles for Medical Practice: Wynn, Cozza and Armstong:
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The reason for the disagreement? The reason these abundant 2D6 interactions are missed? – This drug interaction often occurs much later – even months after the addition of the problematic mix – and therefore appears unrelated to changes in the meds.
Please do send comments if you have seen this interaction, let's talk about it.
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To Start ADHD Meds, Use Care: PDF on How-To Start Here
For More ADHD/Executive Function Video and Audio Details: PDF Here
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Press on…
cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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Book: New ADHD Med Rules: http://amzn.to/1zeDMga
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54 Comments
Hi,
I’m a 30 year old female diagnosed with ADHD. I was on adderall xr 30 with a 15 mg booster in the afternoon if needed. It worked for a while but became less effective over time. I took a few moths off and tried strattera and it was a disaster. I tried a month of Ritalin but it didn’t work well either. The main issue I have is that it wears off very quickly. The XR only seemed to work for 4-5 hours. So about a 8 months ago we switched to vyvanse. It lasted a little longer but after a month we added on the adderall rapid release 15mg. I’ve been on vyvanse 60 plus adderall 15 as needed in the afternoon for about 7 or 8 months. I’ve been struggling with depression and trying to manage it without additional meds for a while but I feel like it is getting worse. When my depression increases, my ADHD meds seem to be less effective as well. Im wondering what sort of options there are for adding an antidepressant to my current ADHD meds or if increasing them would help for now. I’ve made sure to take breaks from the stimulants when I can. I try to do 1-2 days a week off and then if I go on vacation or am away from work I stop for a week or so. So I don’t think it is an issue with tolerance but I’m really not sure. I know it is a rough cycle because when I’m more depressed the meds don’t work as well and then I’m less productive with work and more distracted and then I feel worse for not being able to keep up with my responsibilities.
Any suggestions are appreciated.
Lindsey,
The safest meds, and we do recommend this all the time, are those clean on [not inhibiting] CYP450 2D6 – Effexor, Pristiq, Celexa, and Lexapro. The problem, from the very distant sounds of things, is you likely have a comorbid metabolic problem. This set of videos can help consider options: http://corepsych.com/gi – Immunity is often the culprit and these are the tests we most frequently recommend: http://corepsych.com/tests
Hope this helps!
cp
Dr. Parker,
I am a 30yr Female just recently diagnosed with adult ADHD. Since being diagnosed I’ve been taking Vyvanse; currently I’m on 70mg as that was the best dosage both my pdoc and I found to be most helpful and I was doing much better both at work and home with little to no side effects. Now there is one thing I’ve noticed while taking Vyvanse and that is before my menstrual cycle I get severely agitated and anger; now I do suffer from PMS and these symptoms were all normal before medication but now taking vyvanse it’s gotten worst and I feel like my PMS symptoms are on overdrive. After mentioning this to to my pdoc the recommendation where: Prozac (generic) 90MG to be taken 14 days after my period for the 1st doze and the 2nd dose a week after to control my PMS symptoms. I’m concern taking this combo could cause an effect with my current medication and now that I’ve read your article I’m more fearful.
Would you recommend taking this combination or should I obt out from the Prozac?
Elizabeth,
Most docs don’t get the importance of drug interactions between those two. He/she is on the right track with considering an antidepressant as your estrogren changes pre-menstrually can aggravate the ‘touchy-mad-drop’ serotonin phenomenon. [see this video series: http://corepsych.com/drop ] Suggested: venlafaxine, 37.5 ER daily with your Vyvanse if your doc approves. It’s clean on 2D6 as noted in this posting.
cp
Dr. Parker,
I have a son who is almost 10 years old and has been on Adderall XR for approximately 2 years now. He currently takes 30mg. We did an in depth psych eval recently and they recommended we add an antidepressant too in order to help boost his mood. His pediatrician recommended we try Prozac at 10 mg 2 weeks ago. In the past four days he has had a lot of uncontrollable behavior. His behavior is as if he wasn’t on meds at all. His teachers have reported screaming, running around, throwing spit balls, climbing walls in the cafeteria, inability to focus whatsoever, and just being out of control. This is occurring in class and in gym. I have noticed uncontrollable behavior as well. Is this random defiance or is it a drug interaction? The only other change was that 2 months ago his insurance started allowing generic Adderall instead of name brand being required. Adderall alone wasn’t completely helping his behavior but it was more controlled than it has been in the past few days. I’d greatly appreciate your opinion on this. Thank you.
Amber,
Directly related to 2D6 interaction at CYP 450, no doubt. Usually it takes a bit longer, but if the dose of Adderall is a bit high anyway can arise in days. Videos to address this issue for you and your pediatrician: http://www.corepsych.com/2d6-video | http://corepsych.com/balance | http://corepsych.com/drop
I’m not telling you what to do – except get over there and change the med to Zoloft 25mg would be a suggestion for their consideration.
PS Don’t throw the Prozac down the toilet, the city dump will keep it out of our water systems.
cp
Thank you Dr. Parker! I will let his pediatrician know your advice. I’m so glad I decided to look into the behavior changes instead of assuming it was utter defiance. Hoping his days get better again or at least more ‘normal’ with the Prozac no longer being administered. I’ll let you know if further questions arise after speaking with his pediatrician. Thanks again.
Thank you Amber – all the best to you and your son, – and your pediatrician’s learning from this opportunity!
cp
Hi Doctor
im currently taking vyvance which has eliminated my severe bedrodden anxiety and repetative thoughts but i still suffer from the anxiety and depression in the AM and PM. My doctor phyciatrist prescribed both vyvance 30mg daily and Prozac 20mg daily. i asked him if there were any interactions i should be concerned about and he said absolutely not. Now that i know more about this thanks to you i have no confidence in him. i go back tomorrow morning for a follow up visit and i want to ask him for a different SSRI and i was hoping you could tell me which SSRI besides Effexor and Zoloft work best with stimulants and dont cause a back up.
Thank you
Daniel
Daniel,
Yes that would be a problem, often in the short run, but far more often in the long run as Vyvance is backed up in your system. This book Specifically nails down the research on that point. Facts beat denial everyday:
Definitive Drug Interactions Text – Amazon Global: http://geni.us/interactions
Try Lexapro, Effexor, Pristiq, all clean on 2D6, as documented in this book,
cp
Hey Doc,
I really appreciate everything that you have to say. Very much of this is new information to me. so glad I stumbled upon you. I have a question and I don’t know if anybody else has asked it I have been on Vyvanse and Prozac for years along with a Myriad of other things , what serotonin based antidepressant will work if there is any with Vyvanse?
Thank you for your time.
Sincerely,
Becky Kraker
Becky,
Many of them do not interfere with 2D6: Effexor, Pristiq and Lexapro are my favorites and they all come in generic except Pristiq. I fully expect they would provide improvement over your current mix – it’s worth a try if you do have side effects.
cp
Dr. Parker,
I was put on 20mg of Paxil for anxiety after a cross country move and career change at 27 y/o. After several months the Paxil didn’t seem to be alleviating much of my symptoms, so my psychiatrist determined that I had ADHD and added in 10mg of Adderall XR. It worked well for a few months then I started experiencing what I’ll call “mini seizures, severe headaches and cognitive impairment. I was on the combination for approximately a year. It’s been approximately a year since I ended both medications and I still suffer from severe frontal lobe headaches, teeth clenching and biting of cheeks, have no tolerance for alcohol or caffeine, severe depression, irritability, brain fog and cognitive impairment. None of these conditions existed prior to starting medications.
My question is, with your experience, can I ever expect to return to my normal self prior to taking Paxil or has this combination caused permanent brain damage.
Thank you.
Dave,
These findings are classic. They occur more often than not, in the 90% of the time range. Very likely your symptoms could be aggravated by an additional contributing factor which you could evaluate very simply with this first easy, very low cost Transit Time Test ;-): http://corepsych.com/ttt
And further testing considerations are detailed in this PDF: http://corepsych.com/tests
You will get better as you come to see and treat the entire picture.
cp
Hello!
I hope somebody can help me.
I have a problem. I have ADHD (ritalin doesn’t work) AND depression.
Now I wanted to try amphetamines. However, the only amphetamine product which is available for adults in my country contains DEXTROamphetamine.
When searching online for drug interactions I found many warnings that dextroamphetamine + SSRI or SNRI can cause serotonin syndrome!
I’m really worried now. This would be a real blow. This would mean that
even IF dextro should work for ADHD then I could forget about antidepressants. I really don’t know what to do now.
Unfortunately my psychiatrist has no experience with amphetamines.
Alexandra,
Do download this Special Report for your doc: 25 pages of fresh info on Predictable Solutions for diagnosis and some on drug interactions here: http://corepsych.com/adhdbook
Then do get over to my YouTube Channel for much more in several playlists: http://corepsych.com/youtube
The interactions between SSRI’s are mainly limited to Prozac and Paxil, almost every one of the others is clean. Dextroamphetamines are actually more efficacious – I have a video on MPH and AMP also. I hope they help. Press on.
Contrary to all those reports the problem is not serotonin syndrome, but rather the accumulation of AMP by the SSRI blocking the metabolism so it accumulates.
cp
Benzodiazepines
Dr. Parker,
I came across you atricle regarding Prozac and amphetamine medications and saw some familiar issues reflected in my life that you describe as possible side effects and reactions.
To keep this fairly short I will “try” to shorten this thing currently called my life. Due to various life events and situations, at the begining of 2014 I had been prescribed a “cocktail” of medications to aid me with day to day life. Concerta (Methyphenidate ER) 108 mg daily, Prozac (Fluoentine HCL) 60 mg daily, Librium (Chloriazepoxide) 25mg daily, Klonopin (Clonazepam) 20 mg daily. Needless to say my physical health was suffering as well at this time. I was experiencing tachycardia and my blood pressure was going from high to very low. This caused a cardiologist to place me on heart medication in attempt to regulate the heart. (Total mess!)
In March I was given a “new” generic form of Concerta and after taking it for 2 days I suffered a terrible breakdown and though I had never had any sucidal thoughts before, I attempted an overdose. I do not recall those days leading up to this event or the event itself. Iwas told I had taken an overdose of 2 of my prescription drugs. After a quick trip to the local hospital, I was then commited (unvoluntarily) to a ” Treatment Center”, where this nightmare of my life continued. I was there aproximately 10 days and my medications were all changed or altered. Concerta 72mg daily, Prozac 60 mg daily, Trazadone 100 mg nightly, Abilify (2 days) unsure of the mg given, later changed to Wellbutrin 100 mg daily. Needless to say I in a constant state of haze. Upon leaving the center, I was placed back on the 108 mg dosage of Concerta by my doctor, along with the above listed medications. After 12 days of being on the Wellbutrin I began to experience moments of psychosis. I contacted my doctor immediately and was told to stop taking the Wellbutrin immediately. I knew down deep in side those stereo speakers could not being playing music, I had unplugged the stereo to be sure.
20 days after I was released I thought I was begining to adjust and I had taken the “new generic” form of Concerta again. Noted a major issue here was 2 prescriptions of Concerta in my house, no-one realized the pills in the bottles were different at this point. ( Not realizing it may have been the proverbal straw that broke the camels back) Therefore, I expereienced a horrific reaction to the “concerta” and knew I was in danger. The medication did not seem to dissolve in an extended release way and it felt as if all 108 mg of Concerta (Methyphenidate) hit my body at once. After my last visit to the local hospital landed me in a “Treatment Center” I was not about to return there for help. My family remained with me during this time and the following day when after being given the daily dose of my medications, the reaction became violent. I was hearing and seeing things, my heart felt as if it would burst out of my chest. All sensory nerves were in overload. My family again remained with me, I was still refusing medical assistance. (Not a wise decision on my part) The 3rd day was spent without any medications as I did not want any medication in my body, after this experience. I went to see my therapist and it was noticable that I was having a serious reaction. I consulted to a urine drug test and was told that the “quick test’ showed I had Benzodiazephines in my sysem and was informed it was an anxiety medication and quizzed regarding any drugs I was taking. At this point my family had all the medications I was prescribed and I had NOT taken anything other than what I was instructed to take. (Concerta 108mg, Prozac 60 mg, Trazadone 100 mg.) My family had done some research on the new generic Concerta and began to ask questions regarding the side effects and drug interactions. At this point my “doctor” became agitated stating this drug did not have any of the side effects I had or was experiencing and proceded to even state the incorrect dosage he was prescribing. After showing the 2 bottles of pills to the staff to verify the way this script was written, which turned out was more than the FDA recommended amount, he up and left the office telling the staff to inform me to just “stop taking the conerta then” when asked if stoping and not undergoing a weening process was wise, again it was stated to “just stop taking it”. Needless to say, I did just that, I did again as I was instructed and stopped. Today is day 96 without Concerta. The reason I state the number of days without is due to the terrible withdrawls I went through after stopping. I had been addicted to the medication.
Currently I am still working through this mess that I am in. I am still taking the 60 mg of Prozac under the watchful eye of my medical physician, (I no longer see the doctor who prescribed all the above mentioned medications) I would like to either try a new drug or just go off it entirely. Right now I am advised to not do so. Which I do understand as I am of sound enough mind to know I am not ready for that. Amazing clarity can be found without the drug in my system. I had been prescribed these medications and the dosages for several years. Now realizing I seem to have forgotten a lot of things and events during those years. Things I can never get back. My family has said I was a totally different person while taking the drugs. I still do not feel like my old self and work daily to find me again. I would like to know if the reaction I experienced was due to possible interactions and a not so well compounded generic medication. Have you heard of other people experiencing this type of reaction and importantly should the FDA be notifed of the violent reaction I had to the generic version? I look forward to hearing back from you regarding this. Any information would be greatly apprieciated. I would truely hate for someone else to have to go through this experience when it could have possibly been avoided.
Thank you
Renee,
Under the press of time and concern for you I will both try to answer and apologize for brevity.
I have repeatedly seen these reactions for years, and confess that in the 90’s I myself created some similar, though not so serious, adverse consequences before I understood CYP 450 implications with Prozac. I loved the apparent safety of Prozac before I discovered it’s significant interaction challenges. Denial regarding these interactions remains profound from the street to Harvard as I just started work with a patient in Boston who consulted with me because of similar interaction denial with an ADHD expert at Harvard [who said, quite officiously I’m told, that those interactions aren’t in the literature!]. Point being: Your doc is within the corrupted standard of care. Second point: It’s not only in the literature it’s in the package insert last time I checked.
Two important issues that you must add to your list of concerns that might remain alive today with your current mix:
1. Mixing benzos [BZ] with Prozac is also verboten. Not only does Prozac block 2D6 but it also blocks the 3A4 pathway for the BZ and all those withdrawal reactions likely had something to do with benzo withdrawal as well. I couldn’t assess that possible interaction in your notes as you focused on Concerta/Prozac and generic Concerta. Your problems for years lived downstream of both Concerta and Prozac, and if you were on birth control pills you likely suffered significant period problems as well with estrogen dominance from 3A4 blockage of BCs.
2. Concerta, a methylphenidate product, does interact also with Prozac but in a different way. It blocks 2D6 the pathway for Prozac, and I’ve seen very serious reactions repeatedly occur with that interaction as well, tho not from the same dynamic – of Prozac blocking 2D6 [because it doesn’t come up through 2D6].
My best advice to anyone with a similar situation is immediately get off the Prozac and replace with one of the several clean antidepressants out there. Interaction is interaction – not maybe interaction. [Effexor, venlafaxine, Pristiq, Lexapro, & Celexa are all quite clean on 2D6].
Though you haven’t mentioned the other details hinted in the background I do strongly recommend that you have a comprehensive workup for a variety of metabolic challenges that might impede your progress following years of these mixes – see this pdf with tests listed: http://corepsych.com/tests14
Best, must run,
cp
Dear Dr.Parker,
I found your video on the 2D6 pipeline fascinating regarding the relationship to Adderall and Prozac, and the build up of the Adderall due to the blockage of the 2D6 pipeline by the Prozac. Does this occur solely with Adderall and Prozac? Does this also occur with Methylphenidate, and other stimulant therapies as well, like Focalin combined with Prozac?
I am highly interested in this because I was taking Adderall XR and IR 70-80mg for a year and a half along with 20 mg of Prozac (2005 to early 2007). I was doing very well on Adderall for the first year or 15 months.
After a year and a half I experienced a major psychotic event and I was taken completely off of the Adderall. At the time of the event I was also dealing with a tremendous amount of stress in my life taking care of both of my elderly parents who ultimately passed away within 6 months of one another. This coupled while trying to simultaneously work a highly while stressful job in addition to caring for my parents. I was not sleeping very well in the last few months prior to the onset of the psychosis.
I was then taken completely off of the Adderall and placed on Risperdone but the psychosis still lasted gradually, finally subsiding after 6-8 months.
Fast forward to 2012. I am totally off of the Adderall and my Prozac was bumped up due to increased depression from 20-40-mg daily. I then encountered a second episode of Psychosis, albeit a much less severe case than my 2007 episode. I was started on Abilify which worked wonders alleviating the psychosis. Since starting the Abilify I have stayed on a low dose( 5mg of Abilify) and my Pdoc has since started me on 400 mg of Provigil and 30 mg of methylphenidate.
I am a fast metabolizer of drugs and even though the 30 mg of methylphenidate coupled with the 400 mg of Provigil has helped my inattentive ADD symptoms to a degree, I am still tired at times and often unfocused and aloof. The stimulants have helped greatly but I think the dosage is to low to reach the adequate therapeutic levels and effect that my body requires to completely control my primarily inattentive ADD symptoms.
My question is what role do you think Prozac might have played in my psychosis since I had a second episode without and stimulants onboard? Secondly, since I have stayed on the 5 mg dose of Abilify and stimulant medication has subsequently been added and gradually augmented I have not had any psychosis or any paranoid thoughts whatsoever.
ADD has really impacted my life regarding work, relationships….etc. I would really like to get my ADD under control, but I certainly don’t want to have another episode of Psychosis. Do you think that I should come off of the Prozac and find an alternative anti depressant, or possibly an additional mood stabilizer in to the abilify like Lamictal which I read help also with depression?
I would really appreciate your thoughts and comments. Thank you for your all of your help. and comments
Sincerely,
Brian
Brian,
I can’t render an absolute opinion, but can make some general remarks:
1. Prozac builds up in your system, as it does everyone, because it interferes w it’s own metabolism through 2D6. Prozac could add to your problems period, simply by itself. Many in the field call that phenomenon “Prozac Stupid” – a prefrontal cognitive compromise. I’m not the only psychopharmacologist who’s repeatedly seen this interaction.
2. Prozac and MPH do interact, have seen it multiple times, but the interaction is different as MPH also blocks 2D6, thereby adding to the 2D6 metabolic burden. I saw an adolescent from Scotland [parents both MDs], clearly toxic on the MPH [Concerta] and Prozac combo. We cleaned that interaction up and she did well after.
3. My own opinion: absolutely get off the Prozac as it has interactions with 3A4 as well as 2D6, and can interfere w the atypicals you’re currently taking. And beware, you can become psychotic on antipsychotics if they become toxic.
4. The buildups do occur over time – I created those problems for patients repeatedly in late ’90s because of my innocence at the time w Prozac, and learned how to identify those challenges.
5. Regarding which mood stabilizer: that determination will come from your response and work w your doc – yes, off the Prozac.
6. If you look carefully at your history before the first Adderall/Prozac psychosis you could likely in retrospect see it coming over months [in spite of the stress] – but, as many do, it’s subtle until you’re over the hill.
cp
Good morning Dr. Parker,
I can’t thank you enough for your detailed comments back and your ultra quick response too my questions. I look forward to buying your book.
Two quick follow up questions:
1. I don’t have an appointment with my doctor until 7/1, in your opinion should I just stop the Prozac (cold turkey) immediately now prior to my 7/1 appointment? I really appreciate your comments regarding the MPH and Prozac 2D6 interaction as well.
2. I also greatly appreciate your comments and experience regarding abilify and Prozac. Is there an anti-depressant that you would recommend that does not interfere with both 2D6 and 3A4 with the atypicals?
Once again, I can’t thank you enough for you comments and advice. I hope that you have a great Father’s day!
Sincerely,
Brian
Brian,
1. It’s inappropriate for me to make medical recommendations without a personal eval, so I defer on that inquiry. The good news: when you do switch, there is no discontinuation most of the time w Prozac as it is stored in brain fat and 95% of the time takes many days to eliminate.
2. Effexor, Celexa, Lexapro and Pristiq are all clean on both pathways.
Thanks for your kind remarks – if I’ve helped you please help me pass along these fresh perspectives any way possible.
cp
Dr. Parker,
I apologize for the delayed response back. The information that you provided is extremely helpful. I have been suffering tremendously from inattentive ADD, Depression, and Anxiety. Since my first major episode of psychosis I feel as though my ADD has gotten worse because my Pdoc has been reluctant to prescribe stimulant therapy. Stimulants calm me down and helps me focus. The stimulants also help my anxiety and my depression. I can’t thank you enough. I have been trying to solve this puzzle for 7 years. I am very eager to read your book. I hope that you enjoy the rest of your weekend.
Sincerely,
Brian
Thanks Brian,
Best to you, with that old med mix change sounds promising!
cp
Hi Dr. Parker,
I apologize if you are receiving this message twice as I originally tried to email you via my iPhone and I am not sure if it went through. I would be very interested in having you evaluate me or a consultation. Unfortunately I am located in Massachusetts. I realize that you are located in Virginia is that even feasible given the proximity. How do you conduct medication management with your out of state patients? If this is not feasible given my situation would you know of any doctors that you might be able to recommend here in Massachusetts?
Sincerely,
Brian
Hey Brian,
We talk to people in S Africa so I’m sure we can work out a phone consult w MA. We must see you down here for 1 [the first] visit to actually write meds, and after that can send prescriptions to you in MA. Alternative plan: phone consult and we send recommendations for a doc there to write if they will cooperate. Most often psychs will not cooperate, often GPs do.
If you do come down our policy is once a year face to face, but that necessity often fades as the person turns around. Talk soon, looking forward!
cp
Good morning Dr. Parker,
Thank you again for getting back to me. I downloaded and read your book yesterday afternoon. I found it to be fascinating. In terms of an evaluation with you, how soon could that potentially happen? I have Blue Cross Blue Shield HMO Blue of Massachusetts as my insurance carrier. Do you accept that insurance? It is not a deal breaker if you do not. I am currently unemployed, but I have been successful in business for many years and I can pay out of pocket if need be, as this is extremely important to me. I would also be willing to come down to Virginia if I can afford it to get myself on the right track. I look forward to hearing back from you to discuss the next steps.
Sincerely,
Brian
Brian,
We don’t do insurance, but give you a bill to file. Desiree is the person who keeps my schedule, and we can fit you in likely w/in two weeks. She’s the one to make it happen: http://corepsych.com/services. If you set up a brief chat we can quickly review if testing would help even before coming down – to get it all done in one visit?
Talk soon!
cp
Dr. Parker,
Thank you again. I left VM message for Desiree as I would be interested in setting up a phone consultation and a potential visit. I am sure Desiree is inundated so I have yet to hear back from her. I have three additional questions that I would be very interested in your opinion.
1. How knowledgable is the Psychiatry community in general of drug-drug interactions for patients taking multiple therapeutic agents for co-morbid conditionsin your opinion? Is this in general overlooked and a problem?
2. Do you recommend the utilization of an online drug/drug interaction calculator, like Medscape’s online calculator?
3. In you book you talk about the therapeutic window of the effectiveness of ADHD medications which makes a lot of sense to me. I would imagine that many factors play into that TOE contingent upon how a person metabolizes certain ADHD drug? I came across this link and wanted to get your thoughts or if there are tests that you do to ascertain how each patient metabolizes ADHD medications, or is it completely subjective? I have pasted the following link:
http://www.consumerhealth.com/services/NewGeneticTestsHelpDoctorsPrescribetheRightMedicineforYou.php
Thank you again,
Brian
Brian,
1. The psych community continues to grow in it’s awareness of drug interactions – but there remains a long way to go.
2. There are several drug interaction sources of info… I didn’t look at this one, but most of them support knowing more vs denial, and therefore I encourage any of that dialogue.
3. There are many companies that provide testing for CYP polymorphisms – we have used several. We don’t ask the person to spend money however unless we’re completely stymied because more often than not we simply pay attention to those details in the first place.
cp
Good morning Dr. Parker,
My apologies for the delayed response back, but since our last correspondence I have gotten a second opinion (yesterday), from a leading Adult ADHD Harvard Psychiatrist here in the Boston area. Quite frankly after spending over two hours with this clinician I came away even more confused, and I don’t have an actual diagnosis, or certainly I feel a very it is a very nebulous one at that. I have been playing phone tag over the past few days with Desiree and I hope to be able to set up a consult with you soon once I connect with Desiree.
I have the following questions coming of my confusing second opinion. With feeling very much that my inattentive ADD is my major current problem area that needs to be addressed this particular specialist recommended that I increase my current Abilify dose from 5mg to 10mg to address my ADD? This seems a bit unconventional from what I have read, but I certainly wanted to run this by you?. During my long appointment the doctor did not address to my satisfaction the topic of drug to drug interactions.
I copied my medication list with the top 3 of the 12 DDI for you to review:( I even showed this list to the doctor during the appointment and he did not find the list to be alarming in any way, or suggest that I get off of the Prozac)
12 Interactions Found
Current list of medications:
aripiprazole
• Abilify
modafinil
• Provigil
propranolol
clonazepam
• Klonopin
fluoxetine
• Prozac
methylphenidate
1. Serious – Use Alternative
fluoxetine + aripiprazole
fluoxetine will increase the level or effect of aripiprazole by affecting hepatic enzyme CYP2D6 metabolism. Possible serious or life-threatening interaction. Monitor closely. Use alternatives if available.
2.fluoxetine + propranolol
fluoxetine will increase the level or effect of propranolol by affecting hepatic enzyme CYP2D6 metabolism. Possible serious or life-threatening interaction. Monitor closely. Use alternatives if available.
3. Significant – Monitor Closely
modafinil + aripiprazole
modafinil will decrease the level or effect of aripiprazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Significant interaction possible, monitor closely.
I realize that you have not evaluated me but I just wanted to get your general thoughts, and if you augment Abilify often to address inattentive ADD?
Thank you,
Brian
Brian,
If he’s the same leading Harvard psych he’s likely the one I personally told about all these interactions more than 10 years ago. Not to worry – Harvard didn’t decide that Adderall was a drug they could even write about, research, until about 5 years after it was ordained as a national best seller by patient satisfaction w no significant challenges.
Over time we’ve become more careful – and remember this: those days were typified by complete disregard for any ADHD Medication Rules, and almost complete innocence on how to use them correctly. Now we’re all making progress w how to use these meds thoughtfully, with more clear treatment objectives, more effectively.
If you [the public] can addendum these interactions with a very small effort to a website posting, it seems like that doc at Harvard should buckle down, read my book, and look more carefully at the research.
cp
Dr. Parker,
As a follow up to my earlier email today both my primary Psychiatrist and the Psychiatrist that I received a second opinion from yesterday that recommended I increase my abilify from 5-10mg have flat out told me that I am not Bipolar.
Thanks,
Brian
Brian,
Cool, excellent to have the home team on track.
cp
Hello, I am a 20 year old female currently prescribed Prozac 20mg, Adderall 50mg (though in all honesty due to former abuse of both amphetamines/methamphetamine, after discontinuing the methamphetamine my tolerance to Adderall had skyrocketed and it was very hard to function at school – I need to take about 100mg+, usually an average of 120mg, just to feel “baseline” concentration, motivation, and focus), Lamictal 200mg (100mg twice per day), and Clonidine 0.5mg for sleep aid (though I rarely take it).
I also take many supplements which I spent a great deal of time researching in order to protect my body and mind from higher doses of Adderall, as well as recover my brain from harder substances. I’ll admit I’m ignorant to the effectiveness/safety of all of these together, but so far many seem to have helped especially considering my diet has been poor. I recently stopped seeing my former psychiatrist who was ignorant about vitamins/supps as well.
Here are the ones I take daily: ≈4g Fish Oil (6:1 ratio EPA:DHA, has helped with depression I believe), 400mg Chelated Magnesium (200mg x 2), Multivitamin, B-Complex, Vitamin B-6 100mg, Vitamin B-12 500mcg-5000mcg, CoQ-10, Alpha Lipoic Acid 200mg, Acetyl L-Carnitine, L-Arginine, L-Theanine, Niacin 1000mg (Vitamin B3), Milk Thistle 200mg (1-3 x daily), Gingko Baloba, Panax Ginseng, Choline, Tumeric, Tonalin CLA, GABA 600mg (night). Not as consistently, but often I take: Inositol 650mg, Chromium Picolinate, Melatonin 5-10mg (night for sleep), Vitamin C (night), L-Glutamine (rare), L-Tyrosine (occasional), and L-Phenylalaine (occasional). In addition, I typically take about 400-800mg of caffeine per day (caffeine pills) and at least 81mg of aspirin for the headaches I’ve been getting.
Now for some background – I’m sorry this is so long! I have been diagnosed primarily with ADHD, anxiety/panic disorder (anxiety is chronic; bi-weekly panic attacks began after stopping meth in January, haven’t had one in 3 or 4 weeks), depression, and PMDD. I had major depressive disorder with suicidal ideation 4 years ago, speculated to be partially from the acne medication Accutane. The depression became less severe, but I developed anorexia and mild substance/alcohol issues in the couple years following that. After therapeutic treatment, I had achieved stability and no longer felt depression, only some anxiety and my ADHD symptoms. Summer of 2013, I was prescribed Adderall which changed my life and finally made the fog and chaos of ADHD clear from my mind. I could perform socially and academically better and my jumbled/obsessive thoughts improved. Around the same time, I was once again prescribed Accutane and took the risk of mood changes to heal stubborn acne.
A couple later during my 1st semester of freshman year of college, I developed some dysphoric feelings that progressed to a consistent cycle of aggravated depression (tended towards aggression), chronic anxiety, and feelings of loneliness/emptiness, extremely impulsive behavior (I am impulsive to begin with, but it was exaggerated). I needed more Adderall to regain any stability in school and within my mind, so my dose increased to ≈60-90mg per day. I began trying other drugs again, sleeping every other night, taking even more Adderall because I feared sleep, and finally falling into a 3 week cycle of consistent crystal methamphetamine abuse. I stopped this, and other drugs, mid-January of 2014. When I restarted my Adderall, it barely worked and it took at least 100mg to feel anything. At this time, I was only prescribed Lamictal.
Delusions and paranoia, panic attacks, fatigued depression, along with recurring episodes of high excitability, either of an aggressive or manic nature. My PMDD became much worse, with more volatile mood swings, crying, and hopelessness. I was consistently being prescribed higher doses of Accutane, up to a final dose of 80mg/day in April. I was much happier in February and March due to positive social changes, but April brought an especially bad week of PMDD followed by worsening depression. I had more panic attacks, uncontrollable crying episodes, unrelenting thoughts of extreme guilt and shame, racing thoughts of paranoia and fear, and finally brief thoughts of hopelessness/suicidal ideation. I stopped the Accutane immediately once I made the connection that it might be causing the depression. I started the supplement regimen, and was prescribed 20mg of Prozac for depression and PMDD.
The Prozac helped TREMENDOUSLY with depression, despite the fact that SSRIs/SNRIs did nothing for me 4 years ago. I felt much more like myself again and much more positive/motivated within two weeks, and finally felt less tense and aggressive. I was able to start taking a bit less Adderall, as it worked better. Unfortunately, the panic attacks were stubborn to go away – Xanax helped me most, but I was only prescribed five low dose Ativan pills to get me through 8 panic attacks per month. They were extremely debilitating, but the depression was still better. In addition, my PMDD symptoms were alleviated almost entirely – the first good month I’ve had in a long time.
Finally, we are to the present moment! Thank you for bearing with me. About 3 weeks ago, I had a particularly bad episode of hopeless/depressive and anxious/paranoid PMDD, followed by a few big relationship/living changes and a near-death experience, which were traumatic and drastically reduced my state of wellbeing. This week I have been more depressed than I’ve been in a while, and once again need at least 120mg of Adderall to deal with the stress in my life. I have been crying quite a bit, mood swings, some irrational thoughts of guilt/shame/loneliness and mistrust, choosing not to sleep once again, fear, and hopelessness. It’s not the worst I’ve ever dealt with, but it’s the worst in a while. My OCD, and to a lesser extent bulimic eating disorder symptoms, are also not improving. I ended up taking an extra 10mg of Prozac last night after deciding that I want to try increasing my dose to 30mg for the depression and OCD issues. This morning, after staying up all night working and still on a high dose of Adderall, I felt very bad nausea and some dizziness, head pressure again, and slight anxiety.
FINALLY, here are my biggest medical/pharmaceutical questions and concerns based on the previous description of my situation:
1) This Prozac/Adderall interaction is very legitimate based on your research. Considering I am taking, and have been for the duration of the ≈6 weeks on Prozac, over 100mg of Adderall per day with 20mg of Prozac, is it even safe to increase to 30mg of Prozac if I haven’t run into significant issues?
The only problems I seem to have are headaches, some nausea that passes, and occasional tachycardia (though ironically the slight heart issues have gotten better on Prozac even with extra stimulation). What is the highest dose of both medications that has proven to be safe and effective on someone with a history of surviving many drugs that affect this pathway (like meth, some cocaine, and heavy alcohol use)?
2) At what point should one consider upping the dose of Prozac? If I am experiencing PMDD/depression symptoms strongly again, even if due to life changes, are my chemicals altered enough that it would taking more would benefit me like it did before?
3) How does Lamictal interact with these two medications? Would it be wise to get off of it?
4) What about the supplements? Are they helping or hurting; preventing oxidative stress or heart damage or side effects?
5) Specifically, will Milk Thistle help my liver to metabolize the high doses of Adderall better while on Prozac?
6) Overall, since both Prozac and Adderall immensely help me, do you think it’s possible to take the two in higher doses together?
Those are my main questions/concerns. Please let me know if anything else comes to mind in advising me. I appreciate your time reading such a long response and admire your work – I hope to pursue the same path of study in the next few years, because I find it fascinating.
Thank you!
Vanessa,
It’s clear you would like some answers, and I would love to give them to you. But, as you may not know, I am far to serious about data to speculate with all the variables at play here. Your descriptions encourage a far more comprehensive review.
What to review:
IgG: Your excellent supplement regime, your medications [right or wrong], simply won’t work predictably w IgG imbalances. I know I’ve tried repeatedly.
Yeast: With someone as absolutely unpredictable in response as you are you need the OATS and Yeast Questionnaire included in this download: http://corepsych.com/tests14. Do look at the video from Great Plains on Candida under the OATS info.
Yeast questions also here: http://www.corepsych.com/2014/04/yeast-candida-matters/
Stay sober, hang on, get data, don’t speculate!
Best,
cp
Dr. Parker,
Thank you very much for your response. I’ll try to stay brief in this reply, though first I must say I’m impressed by your prompt response to such a long post from me!
Now I just have a couple brief follow up questions:
1) I live in Massachusetts. Are you ever open to new clients/have any currently who live further away, or perhaps even speak on the phone? I feel that at least a consult with you would highly benefit both me and someone close to me suffering from an unresolved amphetamine related issue currently.
(I’ll add that the side effects from my medications have just about gone away, fortunately. I am now on 30mg Prozac/day and around 100-120mg of Adderall/Dexedrine combinations, as well as the 200mg/day of Lamictal and daily birth control. I still do take the supplements as well which I will begin to reevaluate. As for my other question…)
2) Perhaps the most urgent combination question I’d love to get an answer on is should I be taking a form of milk thistle (and if so, must it be the most bioavailable/potent one?) to cleanse my 2D6 liver pathway of the Prozac/Adderall combination? Will this do anything to prevent future rebound side effects or damage? I have the most concern about this after seeing your video about the interactions.
3) A new question that crossed my mind: if it is possible to have a narrow 2D6 liver pathway, unable to metabolize amphetamines well, is it ALSO possible to have a wider than average one, therefore requiring a HIGHER dose of medication to achieve desired efficiency? My father was prescribed 90mg of Adderall for 30 years without trouble, and I seem to also be able to take upwards of this much even at my age and weight with the same effects as people I know who can only tolerate 10-30mg.
To be more concise, is it possible to require an abnormally large amount of amphetamine (60-90+mg of Adderall, for example) because of a “wider” liver pathway and still be healthy?
I truly appreciate your help and your work!
-Vanessa
Vanessa,
We see people all over the world, and repeatedly from MA. Phone would be easy, see the protocol on http://corepsych.com/servies – we can do testing and report results to you up there, just can’t write for meds unless you ‘pop down’ for an office visit in person.
Milk thistle alone won’t help 2D6 per se, but it can certainly help w any metabolic problems secondary to immunity and bowel issues… it’s one of several supplements we regularly recommend.
2D6 has 4 main polymorphisms – just SEARCH on this site w that term, many posts. Yes, about 7% are “Ultra-rapid metabolizers” and require a higher dose, but managed care has no appreciation of that fact – yes, not a prob, only a prob w standard of care, $, and insurance.
Prozac, more often than not, will make you feel like you need more because you’re blowing out the top of the Therapeutic Window, search here for that term and see my video playlist on dosing at YouTube: http://bit.ly/dosevids
Good luck!
cp
Hello , Thank you so much for looking into my case in advance.
Are there any issues ( as small as they can be) with combing Paxil (10mg) at night, and Amphetamine in the AM (10 mg). My doctor wants to me to increase Paxil to 20 mg after a week.
here is some history!
I have had anxieties mostly from taking exams, and also have had trouble focusing on studying specially in public areas. So for the anxiety last year i was put on Zoloft last year, that i couldn’t finish taking for more than 10 days, They say all the SSRI takes 4 weeks for it work. So I stopped. 6 months after ( now) the problem of both anxiety and difficulty in focusing still persist. I just feel that i have been very emotional person easily distracted by any sound or voice. So Just last 10 days i was put on Paxil for the anxiety part and Amphetamine 10mg for focusing. The doctor wanted me to start Paxil 1st week with 10 mg , then increase to 20. So i did the 1st week with 10 mg, it was already so powerful that messes with everything, the 1st week i experimented to see weather i should take at night or in the AM. Taking it in the AM was the worst choice so i started to take at bedtime last night was my 1st trial. Still was so hard to get out of bed feeling very drowsy, but once I tool the amphetamine i became more stabilized , awake and functioning. So my question is do u see any short or long term health problems with this combination? or do you suggest a better combination to treat both anxiety and focusing. Many thanks for your time and support
Sean
Video: Yes, there are several problems and they are likely manifested in what appears to already present as an interaction problem. See this Amphetamine, Paxil and Prozac Video for a quick review of the problem.
Article: See this article written in ’08 on Vyvanse and Amphetamines for more info. Just search this website on the front page for many more articles on these details.
cp
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First off i apologize for reopening this but i have seen too many varying opinions in regards to prozac and adderall. I will try and make this brief…
I am a male 195#. I have been on many different anti depressants over the past ten years. Paxil effexor wellbutrin and a few others. I was put on paxi first for anxiety and it worked well. I would always be up for hours in bed worrying about everything. After the anxiety was “cured” i was diagnosed with depression. Thats when i was put on welbutrin and i had to quit immediately because of severe depression and suicidal desires. Eventually i came off paxil, had alifestyle change and all seemed well except for the frequent occurences of depression. I was put on various antidepressants over the years but none of them seemed to help. I was put on adderal xr about 4 years ago because i tested positive for add it worked great but i came off of it a few months later because i was crashing hard like 5 hours after taking it. But as far as i can remember it treated my depression symptoms pretty well. Then the dics trued me on prozac and i have been off and on it since. My last dosage was up to 60mg a day. To be honest it wasnt doing anything for me but i kept taking it. The past six months i have been horrible about taking the prozac. Completely quitting the prozac and then re titrating myself back on it over and over again. About 3 weeks ago i saw my regular physician and told her about the added stress and complexity of my new job. I told her about my motuvation and concentration issues as well as my memory. I told her i needed to try something, be a guinea pig even lol. I told her about adderal that a previous doc had prescribed and asked if i could try it again and if it didnt work move to the next prescription. She also upped my prozac to 80mg. This was one of the times where i was restarting the prozac on my own. I started at 10mg of xr and the first day was freaking amazing. Everything seemed so clear and i could focus and was motivated to do anything regardless of how boring it seemed. The next few days were nice as well. But i soon started with this wavy feeling. I would feel great and then out of nowhere i could feel some darkness taking over. I literally felt a cold wave come over my back and shoulders. Soon after the good feeling would come back. It would cycle like this for a while. I then researched prizac and adderall interactions and found some negative info so i quit the prozac. Im still having the waves but they seem ti be more subtle now. I know that prozac has a long half life so could this be causing theae waves? Is this a typical feeling when mixing the two drugs? Also i can feel the 10mg xr wearing off around 4-5 hours later. Honestly i just want that initial motivation back. I want to enjoy working but most of all i want the depression waves to stop. I know ive rambled on for a while and ive kind of forgotten my original question but i was hoping to get some insight about what is going on. I know this is asking a lot through the internet but what would you do if i walked into your office with this story? What should be my next step? What should i talk to my doctor about? I thought i had found something to help with my depression but just like before it seems too good to be true but the adderall is the first drug that made me feel normal which is all i really want. Just so you know any help is greatly appreciated.
Charles
Charles B,
Gotcha on this… and do think it’s likely that the “waves” were related to the interaction — from the sounds of things on this brief report you should talk to your doc about depression, but I would get on a clean antidepressant like Effexor, Celexa, or Lexapro. With far less interaction possibilities.
cp
And one other point… the problem is Prozac, not the AMP, as Prozac is the metabolic blocker, the drain stopper.
cp
Mary,
That Adderall and Prozac has been on my books for years – have been talking about it for more than 14 years, writing about it here since the start of the blog… just SEARCH that topic and you will see many good references on the links in those posts – some in the Prozac package insert.
cp
My son is 12 yrs old. His doctor had started him on 2mg of intuniv. my son is on ablifiy 15mg aday. will these 2 meds work ok together.
thank you
Crystal,
Yes, absolutely, they work well together, – and keep an eye out for the strong possibility that over time you might be able to decrease the Abilify – but no drug interactions there. See this series of posts on Intuniv [summarized in the first paragraph of this CorePsych Blog post], – including one on drug interaction possibilities.
cp
Michael,
Many antidepressants can cause discontinuation syndrome.. a phenomenon that is caused by up-regulation, re-awakening of downregulated serotonin receptors. This reaction is preventable by simply going off slowly, and if anyone has difficulty going off the SSRIs the first rule is to do it slowly, but the immediate second, and most important rule is to ask the question:
What is the metabolic problem presented here?
Most folks with DCS Disconinuation Syndrome have associated metabolic issues – too many to cover in this brief note.
Thanks for your observations.
cp
My name is Michael Smith and i would like to show you my personal experience with Paxil.
I am 40 years old. Have been on Paxil for 5 years now. Please be careful if coming off, i started to wean myself with out doctors help couldnt afford it. I went from 20 mgs to 10 mgs for a month, then 10 mgs to 5 mgs for a month. Because the 20 mgs were way to strong took 20 for 5 years and was always on edge. After about 1 month on 10 felt a little better. I stopped for 7 days completly and man did I feel like shit man I didn’t want to leave the house , shop! I just started back on 5 mgs to get it back in my system. Who know what is the right amount you have to be the test subject on yourself!
I have experienced some of these side effects-
Headaches, tremors, emotional wreck, just the blah’s when I 1st started takin wasnt bad, cause I also way taken klonopin.
I hope this information will be useful to others,
Michael Smith