- To Change Your Mind - Details Matter
ADHD Medications: SSRI + Amphetamine Interactions Cause Serious Problems
Adderall, Prozac and Paxil: Problem not solution
November 24, 2006Science, Labels, Stuckness, Brain Diagnosis 2007
November 27, 2006ADHD Medications: SSRI Drug Interaction With Stimulants Matter 
The overall lack of appreciation regarding the seriousness of these interactions is creating a counterproductive buzz and often results in profound negative consequences for those who either need treatment or are currently taking stimulant meds [amphetamines] with some SSRI antidepressants.
The reference books in the previous post will be helpful, and if you want to really get more into it check out this one on the Cytochrome P450 metabolic pathways. Bottom line, think of pipes, working drains that take meds from one form to another more useful form.
[By the way these drugs are not “broken down” by these liver pathways, but are built up so they can be used, metabolized and excreted.] The amphetamines all come up through this one pipe, the 2D6 pipe [the CYP450 2D6 pipe]. Prozac and Paxil significantly block that specific pipe [and others]. Others that work well with 2D6, and don't block it are listed in this later post on Intuniv.
This dramatic cooling of the prefrontal cortex is what we have seen as a result of med interactions:
See below to consider what happens next in real life:
Blocking Spelled Out
If the amphetamine [Adderall, Dextrostat, dextroamphetamine] is poorly metabolized because the pipe is plugged by drug like Prozac or Paxil, or because of genetic variants [meaning you didn't get that particular pipe in the first place – more later], -if is not metabolized at all – big problems drift downstream, down our own inside stream.
You or your loved ones can become relatively toxic, either slowly in the first week or so, or can have a big ongoing problem months down the road. The drug slowly builds up because it isn't being burned properly.
It sneaks up on you, you start cycling, and what does everyone say… she's bipolar! How many have heard that one before? Most characteristic is the feeling of great over focus for short periods, getting almost too much done, and then it's as if the lights go out.
Can't think, can't complete sentences. Cognitive abilities are worse! Let's see, what should we do? Use more amphetamines? No, just change the antidepressant.
See these CoreBrain Training videos:
ADHD Meds Tutorial – Overview: http://bit.ly/medstutorial
ADHD Meds Dosage – http://bit.ly/dosevids
ADHD Meds Problems – Mind and Gut: http://bit.ly/mindgut
ADHD Meds & Allergies – Milk and Wheat: http://bit.ly/mawimmun
ADHD Meds & Allergies – Street Immunity: http://bit.ly/IorWJs
ADHD Meds Become Instructive – Learn from The PM Drop: http://bit.ly/7PMdrops
Yes the drugs are wrong, but not absolutely. They create the wrong mix. A different antidepressant will not block that path, the amphetamine product works perfectly, and no accumulation occurs.
Basic applied science, works almost every time. As you know nothing in medicine is 100%, because the complexities can turn the day. So why not master the complexities? Stay tuned.
cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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Complimentary: 23 Special Report: Predictable Solutions For ADHD Medications
47 Comments
Also I find the old dexedrine 5mg tabs to be the most effective, albeit dosing strategy plays a vital key. My current dose regimen is 60mg daily divided into 3 x 3 x 3 x 3 or 5 x 4 x 3 .. sometimes I will swap the dexedrine ir with Adderall xr 15mg x2 AM and boost with Dexedrine IR for PM drop.
I really like your idea of the therapeutic window. I find my body to metabolize amp really quickly and have had success with higher doses. My issue has been figuring out how to eliminate amp to sleep without adding other meds. I have tried mirtazapine, zoloft, trazadone, and Clonodine but all find they mess with the AMP effectiveness and create other unwanted sides.
Can’t one just take stimulants and live happily ever after without having to introduce an array of unnecessary medications that start up regulating and down regulating each other?
I am currently battling the zoloft and want it out of my body asap. I went from 100 to 50 and now want to just stop.
Also I smoke a pack of cigarettes a day and wondering if that is playing a role? I am in the process of quitting smoking as well. Even though the desire to smoke is more pronounced when dosing I find after the few first smokes I feel lethargic and unmedicated.
Please help!! I am a huge fan of your videos and show them to anyone I can! I just wish there was a way of finding out what my body really needs and not what I think, or my pdoc or other forum suggestions.
Christian,
Sorry the balance principle works more often than not, easily. But you can always look at biomedical testing to chase down the underlying reasons for the neurotransmitter challenges. http://corepsych.com/tests
Other than that, think two easy pills because you likely have two easy targets!
cp
Dr. Parker,
First and foremost I must thank you for your videos and blogs. They are very helpful and informative.
I miss the old motivated self I used to be on dexedrine / Adderall before I started augmentation therapy with Zoloft and Clonodine. Even though 2D6 is clean for Zoloft why are there many websites pointing to a drug drug interaction and possibility of serotonin syndrome? Even if clean, I find the zoloft hampering the positive effects of the Adderall and it just makes me want to sleep all day. I want to stop cold turkey without tapering. Also could clonodine be adding a diminished effect?
Is it not possible to just take a stimulant without augmenting other meds to counter sides? Magnesium + Vitamin C + Melatonin at night? I find dimenhydrinate helps as well with comedown. Less is more , is it not ?
I wonder what your secret cocktail of meds are that make you so perfectly balanced? I have taken the IGG food allergy test but yet to really follow it.
Please shine some light and bring me out of the dark. God bless you!
Christian,
OK my friend, there is the IgG answer – right there in your hands. You really can’t have it both ways. I’ve seen people in my office psychotic on milk… – so tough up, make it your new summer program, and get off the offending antigens. You will very likely become a happier camper. And many thanks for your kind remarks. If you appreciate these notes you will love CoreBrain Journal!
cp
Hello my name is Anne wow wow wow I can not believe I found this info!!!! I hope you can help me!!!
Ok quick back story I have severe ADD I was the quiet girl who never got any attention in class. I also have learning Disabilities. dyslexia dysgraphia! I also have sever depression. I also have 4 and a hafe years clean from everything.
I take Adderall 20mg 2x aday
Welbutrein 300 MG xr
neurotion 300mg at night
I TRYED to get off completely but It didn’t go that great so I just take 300.
and Zolft 20mg
So here is the strange part. I was on Adderal before and NOTHING else. I stopped bc I thought it was making me paranoid but it was the WEED!!!!! NOT the Adderal. I could listen good clean super fast act NO BRAIN FOG.
So now that I am on the other meds with the adderall I don’t really feel like it help that much. I still feel like I can’t focus on people talking constantly go from thing to thing. when clean lose stuff
I FEEL LIKE I HAVE BRAIN FOG 24/7
I kept asking my dr and phrimasist about the ssri with the aderall and they just said “it’s possable to make it not work as much”.
So please let me know what you think
Anne,
Some possible issues to research and discuss w your doc:
1: Wellbutrin can back up Adderall also, to a lesser extent, and you may be building AMP up, and coming out the top of the Therapeutic Window: http://corepsych.com/tw
2: It sounds very much like you may suffer from a metabolic problem as well.
– First see this Transit Time Tool, & measure your time- it’s likely off: http://corepsych.com/ttt
– Then visit this page to look at possibilities for further Tests: http://corepsych.com/tests
– Every time I hear Brain Fog I automatically think of Candida: http://corepsych.com/candida
– Candida leads to Biofilm awareness and direct interventions: http://corepsych.com/biofilm
All of the metabolic challenges always create medication unpredictability. In those measurements you will, more likely than not, find the answers to your dilemma.
Zoloft is 50, not 20 and is not a problem.
Hope this helps,
cp
Hi. This is very helpful and interesting stuff.
Would you be happy to answer some questions I have?
I live in the UK and was diagnosed with ADHD and anankastic personality disorder nearly ten years ago. It took me nearly 8 years to find the right treatment and I was wondering if you could help explain some of the problems I’ve had with medications, particularly with antidepressants.
I’m trying to work out why I might have had problems with a sertraline and dexamphetamine combo, and then later with venlafaxine.
Problem #1.
While I was on dexamphetamine a few years ago, I was prescribed sertraline to counteract anxiety. It worked well for two weeks, then my dose was raised. 7 days later, I woke up in the morning with what felt like a really bad attack of hay fever.
At lunch time, while my wife was driving us home, I passed out in the passenger seat of our car.
When I woke up, my wife informed me I had just had what looked like a seizure and had called for an ambulance. My blood pressure was very low, my heart rate was very high, I had an uncontrollable tremor in my hands and was soaked in sweat. I had a second seizure shortly after arriving at the hospital and was put on IV fluids and oxygen for 48 hours. I was eventually discharged with a diagnosis of a vasovagal syncope caused by a chest infection which was never actually identified, only diagnosed on the basis of inflammation markers. My GP later suggested it could have been a panic attack.
Questions #1.
Do you think it’s possible that the episode I described could have been serotonin syndrome? It was never diagnosed as such, but every description of serotonin syndrome I’ve read since then seems to correlate with my experience.
I should add that I had taken a decongestant tablet containing pseudoephedrine shortly before I initially passed out. Could this have been a trigger?
I remained on sertraline and dexamphetamine for some time after that, but felt very poorly the whole time.
Problem #2.
A couple of years after my experience on sertraline, I was given venlafaxine in the form of Venlalic XL 75mg. It helped my symptoms a little, but I felt very tired. I also noticed was that my cholesterol had become quite elevated, which had never happened to me before.
I came off venlafaxine in order to try alternatives, first modafinil (didn’t help my ADHD), then bupropion (caused me to completely stop defecating) and then amitriptyline (felt too much like sertraline.) These didn’t help, so I decided to give venlafaxine a second try. I was off the amitriptyline for a long while before I started the venlafaxine again.
A couple of months later, a nurse noticed during a routine check that my blood pressure had risen sharply. In the weeks that followed, I was getting readings averaging around 180/160, often higher, and it wasn’t dipping at night. My cholesterol went up again.
A few weeks later, I was shocked to discover during another routine check-up that I had become diabetic. My blood sugars had been fine just 6 months prior to that.
Questions #2.
What could explain getting such severe hypertension on just 75mg of venlafaxine? I was told by my GP that it wasn’t possible on such a small dose, but I am convinced that venlafaxine that caused my hypertension. Is this not reasonable?
Furthermore, is it reasonable for me to think that venlafaxine might have triggered the onset of my diabetes? Diabetes is on the list of side-effects on the venlafaxine leaflet but I can’t find any information about this.
Could all this be because I’m a poor metaboliser for CYP2D6?
Thankfully, I’m now on lisdexamfetamine 50mg. 70mg seemed to exacerbate my chest problems (bronchiectasis and asthma) and loss of libido. 50mg works well enough without side effects. My hypertension eventually resolved after I stopped venlafaxine, as did my elevated cholesterol. Sadly, I am still diabetic.
Sorry that this is so long-winded. I’ve broken it up into headings to make in the hope that it will be easier to read.
Hope you can help. Thanks in advance.
Daniel,
You have many symptoms that sound much like serious comorbid metabolic/immunity issues: HBP, asthma, syncope attacks – just as a quick review.
Yes, 2D6 Polymorphism could add additional complexity to the meds you mention… all of them run through 2D6.
With complexity like yours I’m strongly suggesting you consider further testing and look at these various links to move you further down the biomedical line – as very likely you have several issues:
Overmethylation: See this page for video and more details – http://corepsych.com/walsh-resources
Mind Gut Issue: See this playlist – http://bit.ly/mindgut
Serotonin/Dopamine Balance Issues: This Video – http://corepsych.com/balance
Testing available outlined with videos and references here: http://corepsych.com/tests14
Solve your mystery with more precise a more precise biomedical reviews – wherever you are,
It’s inappropriate to add to speculation, but reasonable to seek more information through lab data.
cp
Thank you for replying to my message. I know this was from nearly a year ago, but the reason it took me so long to reply was that I received a new and rather unexpected diagnosis a few days after you replied to me which took my attention.
I was diagnosed with hemochromatosis, and promptly started venesections to reduce my serum ferritin levels which were brought to within normal range within a few months. I then received an email out of the blue from a liver specialist advising me that my ceruloplasmin was low at 14 mg/dL and that I should get checked out for Wilson’s Disease. My urine copper was tested normal, and a penicillamine challenge was also normal. I tested negative for Kayser-Fleischer, and a liver biopsy tested negative for excess copper, but revealed a fatty liver with some siderosis and fibrosis.
No-one has been able to tell me why my ceruloplasmin was quite so low. I did wonder if I might have a kidney problem, but urine tests I had to investigate that showed no signs of that whatsoever.
As I see that you have written elsewhere about the significance of copper in relation to ADHD, I figured you might be able to shed some more light on my situation and point me in the right direction.
Are you aware of any reason why my ceruloplasmin would be low when my copper is showing normal, and could it be significant for my ADHD and/or general sense of fatigue? Are there tests could you recommend in light of my new diagnosis and recent negative tests for Wilson’s? If so, are you able to offer these tests for people living in the UK?
I’m still taking 50mg lisdexamfetamine, which helps my sleep pattern and fatigue to some extent but doesn’t give me a great deal of mental clarity any more. I’d like to get to the bottom of this if I can.
Thanks again so much for your kind advice.
Daniel,
For your best biomedical review I do suggest the following:
1. Review these brief remarks at Wikipedia on the causes of low ceruloplasmin: https://en.wikipedia.org/wiki/Ceruloplasmin
2. For testing on the nutritional side I strongly recommend the first three tests [IgG, Walsh, OATS] and the Tissue Mineral Analysis [TMA] on the second page here: http://corepsych.com/tests – These results may not directly change your ceruloplasmin but very likely would help the chronic deterioration you’re experiencing with firm foundations regarding underlying medical imbalances. The TMA is a good way to evaluate trace elements and heavy metals.
3. Yes we do consult across the Pond on video consults – explained here: http://corepsych.com/services
Hope this helps!
cp
How do you treat someone with genetically ‘Impossible Pipes’ as you mention in your book that 8% of Caucasians have?
Is Modafinil a reliable alternative?
Juggernaut,
MPH is metabolized differently than AMP so often not a prob. Modafinil is an alternative -“reliable is a bit of a stretch IMHO.
cp
Dear Dr. Parker:
I suffer from severe adult ADHD, Major Depressive Disorder, and OC traits. I have struggled to find a balance between the proper dosage between both a serotonergic medication and a stimulant. For instance, Adderall XR just about cures my ADHD, but in time, my serotonergically-related issues are exacerbated, leading to severe and debilitating major depression, obsessive-compulsive behavior, delusional thinking, panic, and other disabling symptoms. That said, I have tried both Lexapro and Zoloft SSRI medications, both of which completely obliterated most all of my serotonergic issues. However, it seems that even the lowest dose of an SSRI medication not only makes my ADHD a billion times worse, but it also renders the otherwise effective stimulant medication completely useless. I have attepted to self-medicate with more stimulant drug as a means to simply “get by” and be able to pay some attention in my college courses; this had also proven ineffective. Interestingly enough, the efficacy of even an extremely low dose of Adderall XR (10mg) is completely restored post discontinuation of the SSRI medication. That said, could it be that Lexapro and Zoloft are creating metabolic issues with breakdown of amphetamine? If so, should I try a different stimulant, or talk to my psychiatrist about a different SSRI, or perhaps another class of AD? Thanks so much for your time and for reading this lengthy comment. Sincerely, Michael.
Micheal,
One never knows but these are some quick options to discuss w your doc:
1. Easy trial: Effexor, Venlafaxine often works when those other two don’t.
2. With these kinds of unpredictable results I always get into metabolic problems as your trace elements and neurotransmitters could all be off – and these tests might help better assess the problem:
-> http://www.corepsych.com/tests14
3. Take a look at these videos to see if they take you a bit further down where I think you likely must go:
-> Mind and Gut: http://bit.ly/mindgut & ADHD Meds & Allergies –> Milk and Wheat: http://bit.ly/mawimmun
Best,
cp
Thanks for the prompt reply! Do you think cymbalta may be more effective? It’s my understanding that Effexor acts as an SSRI until one reaches a higher dose, whereas cymbalta has greater effects than Effexor at the lower end of the dose? Also, given that I experienced a loss of personality and emotional blunting while on both Zoloft and Lexapro, do you think the odds are high that the same may occur on another drug that inhibits SE neuronal reuptake as part of its action? Lastly, what are your thoughts on a tetracyclic such as remeron? Thanks again!
Michael
Michael,
I do prefer Effexor, have seen that reported NE effect w Cymbalta occasionally, but don’t like the 2D6 inhibition w Cymbalta with stim meds. Remeron is good for sleep, not so reliable as antidepressant. The way they are not-working for you it’s possible that you have some metabolic molasses going on.
cp
Once again, thanks for the reply! As an aside, I have just purchased (and have pretty much finished reading) your “New ADHD Medication Rules” book, and I must say, it is an excellent and informative read. The main reason I inquired about cymbalta is because Effexor supposedly doesn’t have bad withdrawal symptoms if one needs to quit taking it, but rather THE WORST withdrawal symptoms as far as most AD’s go. What are your thoughts on Pristig (desvenlafaxine)? In general, I am an extremely athletic, 20 year old male, and I metabolize everything very quickly. However, I do show some signs of gluten sensitivity that I am also addressing. Lastly, all of the meds I have tried worked extremely well for their intended purposes while exacerbating other issues (the whole dopmaine-serotonin seasaw effect). The issue I have, for instance, is when I start, for instance, an SSRI, executive functions go out the window and ADHD Sx become unmanageable, even at the lowest doses of those serotonin meds. I will definitely keep gluten out of the diet for a while and see if that helps. In the meantime, should I ask about Effexor or Pristiq? Thanks again!
Michael
Michael,
Pristiq is very similar to Effexor in efficacy, and both have characteristic discontinuation [DC] syndromes, as does Paxil, for example. Over time one theme emerges about correcting discontinuation: get the underlying metabolic challenges corrected – most especially the deficiency of neurotransmitters [NTs] in the first place. Having measured NTs for many years now, and then treated the imbalances, I can report with certainty that most improve in their DC symptoms when sufficient with NTs. The underlying problem is metabolic, nutritional, leaky gut and immunity, not Effexor or Pristiq.
cp
Dear Dr. Parker,
I took Ritalin sr 20 mg (adhd with a CAPITAL H) plus 40 mg paroxetine (as prescribed by my psychiatrist) for over two years. The paroxetine was added when I moved back from the UK to Germany after college and had problems adjusting and applying for jobs due to very low self-esteem. Within two months of the treatment with paroxetine my personality changed horrifically: I have never been “so well adjusted to society” before, I got a job in communication for big multinational company, a job and environment I knew I hated from day one. But I thought I needed “to grow up”. I felt numb, but sensed “great horror underneath”, however “logically” I finally “succeeded in life” if that makes any sense.
In order to keep the suicidal thoughts that arose quickly after starting the paroxetine, at bay, I spent 10-14 hrs/d at work in order to stay busy and to be under “surveillance”. I was very successful and managed to become head of a (smaller) department within these two years. I thought about suicide every day, self-harmed 2-4 times a week and developed a mild bulimia (binged/purged once a day in the evenings). I went from a creative wild vibrant communication design student to a corporate robot with a very good income within a short time. I had had episodes of depression from the age of 14 onwards, but I never had these severe suicide ideas or self-harm behaviors BEFORE I took the paroxetine.
After two years I stopped all medication from one day to another, as the abstract sensation of wasting my life started to cover every concept, idea, feeling, activity, and the suicidal thoughts (paradoxically?) worsened. I dealt well with the withdrawal (brain zaps, dizziness etc), as I was soon able to see and smell the world’s beauty and most of all hear music again. I left the job. Took a year out. Wrote a novel. Was too insecure to even look for an agent after two rejections. Recently I applied for an MA in creative writing in the UK, I just got accepted. But it is a ridiculous, pointless career. I still struggle. Also with depression. But I will never touch an SSRI or one of its ugly relatives again. Although the suicidal thoughts, the self harm and the bulimia have stopped as if by magic after I stopped taking the paroxetine, I have the feeling I am an utter failure. My self-confidence is even lower than before the short career in management. Of course I did go back to the stimulants (I am not that crazy yet), currently I take Elvanse (Vyvanse) the best so far, but I am still struggling with the dose, I never know when it’s too low or too high. I feel quite hopeless to ever be normal or to function again and I am terrified I have wasted my life although I simply cannot regret the decision to have left the job.
Two questions:
Could have taking 40 mg/d of paroxetine (combined with the methylphenidate) for two years have caused any irreversible brain damage?
Regarding the Elvanse/Vyvanse: Is being too relaxed (“lazy”) and really tired 1.5 hrs after taking the med a sign of a too high or too low a dose?
It’s Sunday and obviously I haven’t taken my meds (see, is this a sign of having turned into a hopeless case????), so I do apologize for this post.
Thank you so much for your great work.
Louisa,
1. My experience and discussion with many colleagues over the years on the brain damage question: No. Without evaluating you, only speculating, it’s likely that your mind isn’t working the way it should anyway, more likely due to metabolic issues as you can’t find your therapeutic window: make sure you see these vids on Dosing at YouTube: http://bit.ly/dosevids – and watch carefully to determine your PM drop: http://www.corepsych.com/7videosPMDrop thus understanding more of your comorbidity.
2. I can’t tell from your info on the second question, could go yes or no. If you feel buzzy and depressed it could simply be that your serotonin side is not adequately addressed http://youtu.be/Wsj219F9M2Q – Quite honestly, without knowing you I can tell you’re smart and on it but your self esteem, your Whatever factor is high on the clinical list and you, my friend are exceedingly fixable. Hang tough, stay tuned. Look at my videos, much truth in there. This will give you serious hope: http://corepsych.com/galileo – direct from my friend, Galileo 😉 . Watch your DOE on Vyvanse that will tell you more.
3. Never, never think of yourself as odd or hopeless. You are only mismeasured and misunderstood, not unrecognizable, not on another solar system. Get out some rulers and move forward. Critical thinking is your next step. Evidence is your flashlight out of the woods.
Never apologize, I appreciate the opportunity to pitch in and know you can turn around. You had to have considerable sauce to get in, now, with some training you can get back on the horse and write that novel, yes!
Thanks back, hang tough,
cp
Dear Dr. Parker,
Thank you so very much for your kind, helpful and more than prompt reply. I watched and read carefully (with meds). As far as I have understood only amphetamine products interact with paroxetine. I wonder what went wrong in my case, as it was methylphenidate and paroxetine combined! Probably I am one of those who do not respond well to SSRIs (suicide-ideas, self harm) in general.
So in case I need to be treated for depression, what medication is saver regarding this reaction?
I water titrated my 30 mg Vyvanse today, took a dose as low as 10mg and will continue to take it on the same time for 4 consecutive days and see what happens. I feel less tired and less “lazy” and got things done. I also think that there are a lot of issues I need to tackle in my life, but I guess I can only really deal with them plus I can also only find out what precise comorbidities there might be, once I have got my dosage right. My best friend, who was diagnosed as a kid shortly after me and is fine on Concerta and Ritalin (she “flew” through high school and med school once she got on her medication) and who is training to be surgeon now (I am sometimes almost envious they got it right in her case immediately) said she had already suspected that I had some metabolic issues as I always seem to be “too anxious & too calm at the same time” or “simply not medicated at all”. I am a “picky eater” but I normally go through approx. 2500-3000 kcal a day without gaining weight (BMI 18.5) ever, so I though I was “a fast metabolizer”…
Could it still be that a very low dose can be effective in my case? 10 mg seem to work better than 30! And if the 10 mg should wear off after 9 hours, does that mean I have to increase the dose slightly? If so in what increments? 1 mg every 4 days?
Dr. Parker, I must say I am very impressed with your commitment and body of work! I simply cannot believe with how much care you reply to every single comment. I will surely recommend your work/books to my best friend as well as my psychiatrist. I am tempted to book an appointment with you (you must be overbooked for years!!!) and fly over to the US just to get proper treatment, as I am paying a lot for my treatment anyway (even the good private insurances in Germany just cover methylphenidate products and only certain doctors for adults with ADHD and I take Vyvanse and still see my child psychiatrist).
Thanks a lot! In case you are interested I will let you know how my Vyvanse adjustment went after a couple of days. And if you find the time please let me know which antidepressant you would recommend to those who struggle with the issues named above.
Best regards,
Louisa
Louisa,
You are very kind, appreciate your support and insightful remarks. Re: dosage would, working w your doc look at 20 mg, probably would work well, and the med options are detailed in this post: http://www.corepsych.com/2009/12/intuniv-for-adhd-avoid-drug-interactions/. You likely would, based upon your remarks here, benefit from an IgG as you do seem to manifest both a Narrow Therapeutic Window [Search here for details and on YouTube] and a challenge w DOE.
The MPH reaction is more based upon MPH blocking 2D6 w accumulation of Paxil and subsequent marked PFC deterioration. Thanks to your comments here will go back and add this link to the article.
Really appreciate your intelligent review, many thanks! And do please keep us posted!
cp
Thank you kindly for this info. I just discovered your site today after being (finally) diagnosed last month. I have been on an SNRI for over a decade, and start my taper plan tomorrow. I have never felt like this was the correct medication for me, but also felt that there was no alternative. After being on Adderall for over a month, the changes are much more significant (and positive) as compared to these drugs. I look forward to learning more from you.
Daisy,
Thanks… and don’t forget to watch for and understand the possibility of a PM drop http://bit.ly/7PMdrops – If the SNRI worked that long you always want to consider that you might find a drop w/o it on the stimulant.
cp
I’m getting the drop now (I’m still trying to find my right dose) – not mood-related, it seems to the “what” drop that you talk about.
Daisy,
So reassuring to know which one it is, as it tells you the next step!
cp
That URL for the PM Drop Playlist is broken, here’s the new one:
http://www.corepsych.com/7videosPMDrop
I had never heard of Executive Function until you brought it up. My life was put together with post-its before Adderall. My friends even gave them to me as gifts! Thank you.
Daisy,
Once identified the lights go on, and proper treatment can take you out of your darkness.
cp
How about luvox? Its pretty uncommon it seems as ssris go, but seems alot like paxil. I take 100 mg luxox and 40 ir of adderall. It seems to be hug elpful but it’s only been a coup’ll e.months. I have adhd and multiple anxiety disorders/odd
Michelle,
No interaction w 2D6 for Luvox, but it does interact w a variety of other meds thru 3A4 [birth control and estrogens] and 1A2.
cp
Dear Dr.Parker,
Thanks for all the value you provide on ADHD and psychiatry in general and I am really grateful for it. I have read your book ‘New ADHD Medications’ and it was really eye opening for me in helping me know that I suffer from Thinking ADHD. I have been diagnosed with ADHD and social anxiety for a few years now but only started on medication this year (Vyvanse) and it was really great! However I still have a question about my ADHD, social anxiety and SSRI’s.
I am underweight and follow a gluten/dairy free diet (I guess that gives away the fact that I’m a picky eater lol). My doctor started me on 30 mg of Vyvanse, which was a high dose for me even though I felt motivated, focused, energized and basically euphoric more than I have ever felt in my life, I was not taking any action because my Thinking ADHD increased even more where I was obsessing on thinking about taking action rather than taking it and I basically felt a little drugged up. It also gave me a faster heartbeat. The dosage was then reduced to 20 mg and it was better now, I do not feel drugged up anymore and my medication has a good DOE of 13 hours. However I still have the symptoms where I just think a lot and don’t take action until the last minute, and my social anxiety is still persists. Interestingly, the only time I feel no social anxiety and take the most action is when I have taken Vyvanse earlier in the day and the hours that follow after I had a few drinks of alcohol.
After stating this to my doctor, she thinks that it would be better to add an SSRI to reduce anxiety and so added Zoloft 25 mg to take along with my Vyvanse 2 days back. I’m not sure if I understand it fully yet but by reading your book, and from your videos, it seems like my Thinking ADHD would actually get worse if I start taking an SSRI, right? I have not started taking my Zoloft yet because I was not so sure about it but is that something you would recommend to someone who’s symptoms of Thinking ADHD has not disappeared with Vyvanse alone?
Fally,
Good questions:
1. Zoloft has no drug interaction w Vyvanse.
2. It is likely that with your weight and picky eating you have a significant, contributory metabolic problem – as further confirmed by the fact that you appear to be a very slow metabolizer, going back down to 20 mg after going out the Top of the Therapeutic Window.
3. Two issues – may be separate or combined: a: the dose may still be too high for your inordinately slow metabolism and b. you very well may have, as your doc correctly considered, a related serotonin issue.
Serotonin and affect: feeling somatically [in your body], vs just thinking [in your head]. It sounds to me with just this little info that both issues arise together, and if neither works out you do need to consider IgG testing, qualitative, not quantitative.
Hope this helps!
cp
Thank you for your kind help Dr.Parker.
I have read your reply and started taking my Zoloft 3 days back and I think I’m going through some of the side effects right now where I’m sleeping more than I should be (10+ hours) and feeling a little forgetful but hopefully it reduces as the medication settles in.
I also have my IgG testing coming up next week so it shall be interesting to see how that plays out. I’ll let my doctor know that I want it to be qualitative. Is that how slow metabolism is usually diagnosed and treated?
Again, thank you so much for your time and help!
Faisal,
The IgG measures the immunity response to food. If you are allergic to foods they can cause inflammation, malabsorption and neurotransmitter imbalances – and all of those issues can also be measured by yet other tests.
cp
so venlafaxine is ok with DL-amphetamine?
Noubamofi,
Of many choices it’s most often the best.
cp
Dr. Parker,
I find your work to be very interesting and very informative. I have a question for you regarding amphetamines and their metabolism that would be right up your alley. I am a 41yr old male and I was taking 20mg of Pexeva and 300mg of Wellbutrin. The psychiatrist added 20 mg of Dexedrine Spansules per day. I have never used amphetamines before. I seemed to get no positive effects from the medicine and discontinued after 1 week. There was no increased focus, motivation, or energy. It was befuddling. The only thing I did get was horrendous side effects in the form of extremely high BP and very high heart rate.
I have been on Ritalin before and had some decent results. Could the lack of therapeutic effects be due to the medicine combo I was on. Also, I noticed you said that Zoloft does not have a negative effect on the 2d6 pipe. The drug information on various web sites says it does. I have seen various drug info web sites and Wikipedia say that it does have an effect. Any reason why they would say that?
Kenneth,
You must be from out of the USA as Pexeva is not a brand here, so look it up and tell me the generic. It could be the med combo, just look it up or call your pharmacy, drop me a note and I will get back.
Regarding other interactions: I frequently get calls from pharmacies because other SSRIs are on the list in their computers, but show no real evidence in the drug interaction books. Zoloft and Effexor are often sited, but those two have been clean on 2D6 as far as I can see from my perch.
Actually I am glad that people are talking about these reactions, even if they aren’t a major problem… Prozac and Paxil are major problems and Wellbutrin, by the way, is often a problem with moderate inhibition at the 300mg range. The feeling on interaction is usually [with an AMP like Dex] one of irritation and mind racing.
cp
I don’t get it. “these drugs are not “broken down” by these liver pathways, but are built up so they can be used, metabolized and excreted. The amphetamines all come up through this one pipe, the 2D6 pipe [the CYP450 2D6 pipe]”
How are they built up? This idea is new to me. What is amphetamine built up to? Or is it adminstered in a form that is not active amphetamine.
Karen,
They are ‘broken down’ in the sense that they can be metabolized and excreted. The process of metabolism, the breaking down process, actually involves a biotransformation process that adds to the molecule making it more hydrophilic, less lipophilic. In a water solution it can be excreted more easily than when bonded with fat.
I’m using the 2D6 liver and pipe line metaphor to help picture the plugged and unplugged phenomenon that can prevent the biotransformation and will, over time encourage an accumulation taking the person out the top of the therapeutic window. The CYP 450 is like the size of the drain, big drain = fast drainage, small or no drain with drug still coming on board = overflow. Size in 2D6 is often genetically determined, all of which makes this subject so much more interesting!
Just to confuse matters: new research does indicate that ‘neurotransmitters’ [Dopamine, Norepinephrine] are both broken down and actually created in the proximal tubule of the kidney – an entirely different matter relating to a different set of variables regarding neurotransmitter precursors.
Hope this helps!
cp
Is this a problem with Zoloft (sertraline) as well? I take Zoloft and Vyvanse daily and have never heard of this possibility before.
Laura
Laura,
No prob with Zoloft, clean on 2D6.
cp
Thanks for your kind words! Multiple places to read about brain and gut, and will be posting several blogs and podcasts on this subject in the near future. In my offices my colleagues call me the poopmeister with these dramatic stories, and when I give a presentation I try to get the poop out of the way before dinner even tho it’s often a medical audience. Book: The Second Brain by Mike Gershon, MD. More in the very next post.
It was the colon – brain connection that hooked me… can you tell me where you discuss that?
This is a great example of a really juiced up blog with gobbs of features, well-written and easy to read stories and resources all over. Very well done!!
DD
Oh, yeah, and I’ll be back to see what else you have share. The people I know need to see this.
Thank you so much for all of your help and multiple insights! Just back to your site and look forward to working more together.
Thanks for making this easy to read and easy to understand! Makes sense to me, and I’m not an MD. Looking forward to reading more.