- To Change Your Mind - Details Matter
Stimulants and Antidepressants: Why they don’t mix.
Pictures Tell the Story on Temporal Lobe Injuries
December 4, 2006Problems with ADD: Stimulants1
December 6, 2006
Misunderstood
Stimulants and Antidepressants for Children
– A frequently misunderstood topic, and Time says it's one of the most important issues of the medical year [from Depression on that page]
Researchers still don't understand why severely depressed teenagers are more likely than adults to commit suicide while taking antidepressant drugs like Paxil, but a major study out of UCLA concluded that the drugs do more good than harm. Starting in the early 1960s, the annual U.S. suicide rate held fairly steady at 12 to 14 instances per 100,000–until 1988, when the first of a new generation of antidepressants, the selective serotonin reuptake inhibitors, was introduced. The suicide rate has been falling ever since, to around 10 per 100,000. The investigators estimate that nearly 34,000 lives have been saved [Time 11/29/06]
This post is, of course, not research, but I do suggest some answers to this question on antidepressants for children. I've seen these answers not once or twice but hundreds, actually thousands of times over the years since 1996 when Adderall came out.
We're missing the comorbidity because we are thinking categorically. “Labels” become targets while the pharmacological complexity present in both children and adults remains overlooked.
Stimulants and Antidepressants: The Basal Ganglia Seesaw
One of the most frequently overlooked comorbid conditions with depression in children, and indeed adults, is ADHD. [More about the ADHD diagnosis in the next post.] Most important for this specific report is the fact that serotonin meds can significantly dysregulate [diminish] dopamine [all stimulants affect dopamine].
Serotonin is likely the most important and available treatment for depression [as noted in Time article], and it works, and is safe in most circumstances. More about SSRI side effects later, but for now the suicide rate is falling and SSRIs can significantly help with depression. But depressed kids and adults should NOT take SSRIs until after one carefully considers every other comorbid possibility. [Always look for every explanation, not just one.] SSRIs are frequently life savers used in the proper context with uncomplicated depression.
Serotonin lowers dopamine. Dopamine often lowers serotonin – thus the Seesaw Effect.
If the patient has an often unrecognized ADHD the SSRI will down-regulate, reduce, the already low dopamine in the prefrontal cortex. Adding an SSRI creates a Seesaw Effect, by dropping dopamine levels, with or without ADHD drugs. The most frequent outcome of this dopamine deficiency problem: abundance of thought, cognitive anxiety, increases impulsivity, the mind races [secondary to increased ADHD, not bipolar], the patient can't think, can't sleep, becomes cognitively less effective, more worried, more sleep deprived and wants to turn their brain off any way they can.
Many who think of suicide every day say on initial interview while taking serotonin agents without considering ADHD: “But I wouldn't do it.” Most reassuring…
The same interaction and subsequent depression often occurs when ADHD medication is used without considering associated depression.
Suicidal Thinking Matters
Death is a long-term solution to a short-term medication problem caused by missing the comorbid diagnosis of ADHD. ADHD is subsequently aggravated with the antidepressant, adding to the cognitive abundance and decreased control of thinking. Fix the ADHD at the same time as the depression and the problem very simply, disappears. This is precisely why I made the point on mixing meds for ADD and depression in my third CorePsych post.
I've been preaching about this clinical challenge around the country since 1996, and too many just don't get it.
Moreover, if you treat ADHD with an inappropriate bipolar drug, a mood stabilizer, the racing mind often does not stop. Sleep decreases, frontal lobe function deteriorates, impulsivity increases, and suicidal thinking increases. Suicidal and self-destructive behavior, cutting, head banging, hair pulling all can increase. Bipolar drugs do correct mood but can frequently aggravate cognitive imbalance, and corrupt thinking problems.
And, yes, if the underlying diagnosis is bipolar, and you treat bipolar with a stimulant it may aggravate the bipolar problem. And yes, bipolar can present with both ADHD and depression, we have seen it on SPECT brain imaging for years.
More comorbid conditions require more careful complex interventions.
This ADHD and depression problem is by far the most commonly missed comorbid presentation, and needs immediate attention every day in every office globally . Let's work together to address this challenging and easily fixable combination.
See this Dosage Playlist at YouTube below for more details: http://bit.ly/dosevids
cp
Dr Charles Parker
Author: New ADHD Medication Rules – Brain Science & Common Sense
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29 Comments
Dr. Parker,
I was prescribed zoloft (50mg) when I was diagnosed with an eating disorder at 14. I was malnurished and so preocuppied with restricting that nothing else mattered to me and I became depressed. The doctor said that the zoloft would help with the depression and the anxiety I had around food. I had always been shy and emotional but never to the point where it prevented me from socializing, having hobbies, going to school, getting enough sleep, etc until the eating disorder. I thought that once my body was able to get the nutrients it needed, I could go back to being myself again, without having to rely on a pill.
The Zoloft seemed to be helping. I was able to sleep more, eat more, and enjoy life more. However, I also had my first anxiety attack about two months later. They became a regular thing for me and most of the time, I didn’t even notice that I was anxious before they happened so they seemed completly random. I was never full, no matter how much I ate but I figured that was because my body was trying to get back to a healthy weight. I ate up to 10,000 calories a day and my stomach never hurt or felt full. I reached my pre-anorexia weight and eventually became overweight because I was still hungry all the time. Everyone was convinced that I had developed a binge eating disorder. I had began to suspect that the zoloft was preventing me from feeling full. I didn’t think I needed it anymore anyways so I lowered the dose very slowly but I still went through terrible withdrawals. I didn’t sleep for days, was extremely anxious, cried all the time and wanted to die. I told myself that I’d feel better once the zoloft was out of my system. The constant hunger went away but the severe anxiety and depression never did (although it was never that bad before I started taking zoloft!)
I forced myself to exersise, drank tons of water and ate extremely healthy. I tried supplements like HTP-5 and Saint Johns Wort and took magmesium and B vitamins but nothing worked.
I decided to take the zoloft again 6 months later when I felt like I couldn’t fight the guilty/racing/suicidal thoughts anymore.
I found that coffee surpressed my appetite. In fact, coffee seemed to help with everything. I began drinking coffee to help with my anxiety, sadness, headaches and sleep. I became more sociable and focused at school and I didn’t have as many anxiety attacks.
My mom told me that my dad, who has ADHD, drinks lots of coffee to help him relax and that many people with ADHD self-medicate with caffiene. She asked my counselor to test me for ADHD.
The counselor told my mom that I probably didn’t have ADHD because I get good grades in school. She was suprised when during the testing, I told her that I don’t listen in class and hate sitting still. I had almost every symptom of ADHD.
I was prescribed Concerta (27mg) to take with the Zoloft.
My stomach felt so perfect, like it finally wasn’t full of sadness and constantly in need of food. I could fall asleep easily and I was much calmer.
It’s been over 2 months and I haven’t had an anxiety attack or noticed a single side effect! But this week, I’ve felt like I haven’t taken any Zoloft or Concerta. Well actually, the anxiety and depression are less noticible once I take the concerta and drink a bunch of coffee but when it wears off, they are overbearing again and it’s very hard to fall asleep. I want to stop taking the zoloft because I think that the zoloft and the concerta are canceling eachother out and it seems as if the zoloft has done more harm than good. But I’m scared of facing the withdrawal symptoms again or that the concerta will not treat my anxiety and depression well enough alone and I’ll be stuck taking just the zoloft instead (since it probably isn’t good to take both). Should I stop taking the zoloft anyways? Thank you for your article and your reply!
Destiny
Destiny,
Sorry for the late reply was out of the office for almost 2 weeks. – As they say in the carnival of life, close but no cigar. Very likely the Zoloft aggravated, as does most SSRI meds, the ADHD: See this video: http://corepsych.com/balance
My experience with this combo of challenges is that you, any person with this collection of challenges, needs more specific testing. Your questions are born from not knowing, but a comment that arises from simple experience isn’t as accurate as real data that will drive specfic treatment objectives. See this PDF set of videos for testing: http://corepsych.com/tests I strongly recommend the first two on the second page and hope you could also so the 3rd, as that combo will give you significant useful info. I’ve seen many folks with eating disorders, and this testing will become the standard of care in the future – psychology is helpful, but a clear biological fix is indicated more than 95% of the time. Why hold back on the 5%? – Because some do respond without good measures.
cp
Hi Dr Parker, I was wondering if it’s safe for me to take 20mg celexa with either 27mg concerta or vyvanse 30 mg. which on has the least amount of interaction? For my antidepressant options I can switch to Effexor 75 mg for less interaction if that’s the case.
One final question, if I take Benadryl or doxylamin (NyQuil) will that cause an interaction with the adhd meds such as concerta and vyvanse?
Thank you so much Dr Parker for sharing all your knowledge
Daniel,
More often than not any of those combos will work well w each other. Celexa is a bit more interactive than Effexor, but not much. Both are predictably safe 95% of the time. I’ve seen interactions w Celexa and never have seen a verifiable [corrected when med was stopped] response from an Effexor interaction.
Either antihistamine can block 2D6 and should be used very rarely or not at all.
cp
[…] 6. http://www.corepsych.com/2006/12/kids-and-antidepressants-why-they-dont-mix/ […]
[…] […]
Hi Dr. Parker,
My son seems to be having SSRI discontinuation syndrome. He was prescribed Prozac for anxiety. He takes Quillivant (3.5 ml) and Amantadine (50mg 2x a day). He took half the lowest dose of Prozac for 3 weeks, then bumped up to full lowest dose. On the fifth day on the full dose, he had suicidal ideation. Doc said to lower back to 1/2 dose. After two days back at that level, my son had a violent meltdown that, at times, looked almost like a seizure. He had NEVER had any behavior like that before.
So we decided to stop the Prozac. Seeing that he was taking half the lowest dose, I felt like it was safe to stop it. Two days later, everything has hit the fan. My son is having these rage episodes daily — today he had SIX. I cannot calm him. They seem to be out of his control. He also complains of dizziness and nausea some.
Doc thinks it shouldn’t be withdrawal from prozac due to taking only four weeks and on very small dose. I do not know how else to explain a sudden and severe change in my child. Uncontrollable rages are NOT my child. He is 11 and been treated for ADHD for over 5 years.
I remembered you talk a lot about amphetamines and Prozac being a bad combination, so I came to your blog tonight hoping to find a clue. However, my son is not on an amphetamine — he’s on Quillivant and Amantadine.
Any insight you can give would be enormously appreciated. I don’t know where to go from here. Doc says we need a mood stabilizer if these episodes don’t subside, but my kid has never had mood issues before.
Thanks!
Penny
Penny,
I do agree w your doc, not likely to be discontinuation w that short time on Prozac. On the other hand, my own clinical experience remains firmly against Prozac as I’ve seen way too many “unexplainable” reactions due to interactions w Prozac. Amphetamines are most common, but have seen MPH back up Prozac creating significant toxicity by blocking CYP 450. A quick look at Google this AM didn’t turn up a specific references for you, but I can report that I’ve seen and corrected these reactions hundreds of times and simply don’t use Prozac period because of that experience… in spite of one paper this AM recommending that combo!
The real issue: what to do w your guy. My own thought, subject to approval of course w your doc, is to simply get off all meds and start over. Not so easy, but it certainly sounds like a toxic reaction to me. A serious contributory, mitigating circumstance could be a very slow metabolic rate based upon liver constipation downstream from IgG issues. Take a look a these posts and these videos to see if they might contribute to your medical teams next steps:
1. Articles: http://www.corepsych.com/2014/02/transit-time-explained/ and http://www.corepsych.com/2007/10/recipe-for-brain-function-measuring-transit-time/
2. Video Playlists: http://bit.ly/mindgut and http://bit.ly/mawimmun
Hope these help!
cp
Thank you so much for your insights Dr. Parker! I found this article on PsychologyToday.com late last night (http://www.psychologytoday.com/blog/side-effects/201107/antidepressant-withdrawal-syndrome) that described what has been happening with my son’s behavior exactly, especially this passage:
“When patients try to end treatment, even stepping down their dose very gradually, many of them (22% to 78%, according to Rosenbaum and Fava) find that the receptors in their serotonergic system–saturated artificially for months, even years–experience the drop to predrug levels as starvation. Some patients then find themselves at the mercy of hair-trigger symptoms that register as intense anxiety, aggression, and insomnia.
Several receptors–including 5-HT1A–aren’t especially malleable, moreover, and take longer to sprout anew after drug treatment ends, delaying the patient’s return to neuronal health. Indeed, some studies I consulted found that in certain patients those receptors fail to grow back at all, in effect leaving the patients worse off than before. (See for instance “Dissociation of the Plasticity of 5-HT1A Sites and 5-HT Transporter Sites” in Paxil Research Studies 19.3 [1994], 311-15.)”
I agree that withdrawal from Prozac is unlikely, especially with a low dose and only a month, but my son has had many extreme reactions to many medications, especially antidepressants and trileptal and risperdal. He is very, very sensitive to medication, and even supplements and vitamins.
He does have some testing with an Integrative Doc (not the doc who prescribes my son’s meds) and found that my son has high heavy metals levels, MTHFR and COMT genetic polymorphisms, some minor “gut” issues, and slow metabolic rate (as you suspected). I believe this explains some of his sensitivities and certainly complicates his treatment exponentially. We also just tested for PANDAS, but his anti-bodies were low. I’m going to take a look at your articles on metabolic rate as well.
So far today, no rage episodes. I’m hoping the Prozac is finally out of his system. I will continue to work with his doctors to modify treatment and will not agree to an anti-depressant, especially SSRI (he’s had bad reactions to 3 now, although none even close to the Prozac), ever again.
Thank you so much for your response — I knew you’d have further insight.
One more thing, wondering if you are familiar with this program to treat aggression and what you think of it: http://hopefortheviolentlyaggressivechild.com/. Like I said prior, my son is not aggressive unless he is on a medication he doesn’t tolerate well, but this was sent to me by a friend when I describe the first rage several days ago.
Penny
Penny,
Not familiar w that program, but so many of these programs are quite excellent in a sea of lost folks w what-to-do-next on a cognitive level.
As I kid I hunted rabbits all over southern and central Missouri, then also in NE Indiana around Angola. We had two beagles that loved to hunt as much as I did in those days. Sometimes I feel like I’m one of those dogs sniffing around the underbrush for a hot trail, and when I find something I do start barking. Then, if I see an actual rabbit, right there on my nose, I bark even more.
With that picture: I am sniffing and barking on one of your casual remarks, and I know from years of experience it’s a meaningful trail: “minor gut issues.” From my perch there are no minor gut issues w a kid like this, period. Have your doc review IgG asap, and likely will need a urine organic acids test to hit that moving target.
cp
One other key point not spelled out in my previous two responses: A key issue downstream from IgG issues: neurotransmitter imbalances. So there are two issues
1. the offending allergens [foods] create cytokine blockage of receptor sites creating emotional dysregulation.
2. the neurotransmitters themselves often significantly diminish in the relative malabsorption – and need replacement whilst fixing the bowel.
IgG issues do confound the discontinuation syndrome and make it seem impossible, beyond the excellent points you raised about receptor morphology and downregulation.
cp
[…] condition on the planet. I’m just standing up to raise my voice against denial of multiple ADHD comorbidities [7 years of written commentary], insufficient precision with ADHD medication dosage, and misunderstandings regarding elemental […]
Thank you Dr Parker,
I have set up a telephone consultation with your very helpful assistants for Thursday. I will prepare the 2 questions – do you need these in advance of the 15 minute consult?
What is your opinion of Atomoxetine or Strattera used in combination with Vyvanse? I see Dr Brown of Yale and Dr Berkeley (the 2 prominent ADHD physicians other than yourself I know of) suggesting combinations can be useful – but surely this would lead to problems with the theraputic window and CYP2D6 blockage / competitive inhibition. My person experience of Strattera was that is fairly useless.
DS
D,
Do send your questions to Desiree and she will give them to me before we chat.
I completely agree that Strattera is quite useless and use it only when I am completely baffled and nothing else is working… and someone can’t afford to do the necessary testing to discover the underlying problems. With new info we’re often right on track.
No interaction between Strattera and Vyvanse other than occasional competitive inhibition.
Looking forward our chat.
cp
Hello Dr Parker,
I am following your blog from the UK and have found your recent ADHD medication rules book most interesting. I notice that you do not go into talking about whether or not tricyclic antidepressants affect the CYP 2D6 pathway. I am currently taking 30mg Vyvanse which has been titrated carefully but have just been prescribed Clomipramine (Anafranil) which is an anti-obsessive medication for my Depression and OCD behaviour.
Is Clomipramine an inhibitior of the CYP2D6 pathway when taken with Dextroamphetamine? Is it as bad as Prozac?
Any guidance would be greatly appreciated and I must say this blog and your advice/knowledge is fantastic.
How do you suggest I proceed?
DS
D,
As insurance companies press for generic antidepressant products over here we see a rise not only in the notorious Paxil and Prozac interactions but do regularly see practitioners using more TCAs – Tricyclic Antidepressants as you describe – raising concerns.
TCAs including Anafranil, are metabolized by 2D6, goes up through 2D6, and don’t block it. Therefore Vyvanse is not a problem except in the odd, much less common presentation of competitive inhibition, as both meds are trying pass through the same pathway and if it’s genetically smaller [4 basic sizes] the competitive inhibition process might show – about 5-10% of the Caucasian population.
Bottom line: no interaction in more than 95% of the time. Not to worry. Always look for the metabolic rate and DOE anyway, as that is your guide to correct dosing strategies.
Many thanks for your kind remarks!
cp
Dr Parker,
I very much appreciate your comments, advice and would like to thank you for coming back to me so quickly.
A final question would be that I am a type 1 Diabetic with Gilbert Syndrome and wanted to ask if this could affect the metabolic process or some of my ADHD symptoms.
I follow a low carbohydrate diet and maintain an HBA1C of 5; with well controlled blood sugar levels. I appreciate you are not a diabetes specialist but do you have any advice on this matter.
How can I go about booking a telephone consultation? I would be more than happy to pay the necesarry amount for a longer discussion with you. I am based in the UK, do you offer this service for oversees patients?
I have found your information on drug interactions most useful; its quite startling that many UK based psychiatrists are unaware of the interactions. It explains why I had poor experiences on Duloxetine/Cymbalta while taking Vyvanse.
Many Thanks
DS
D,
Absolutely consult internationally – just hook up w Desiree by email or phone and set a time. If you schedule an hour I’ll be much more able to review your materials, questions and make some solid recommendations so you can get the best value. @ http://corepsych.com/services
Yes, have seen the Cymbalta problem many times as well as Wellbutrin, not appreciate by many, but quite often a problem. Denial of Reality is not a good thing 😉 .
Suggest get on this list for the next Reality series – a guy like you will love it – and if you are enthusiastic enough to promote it we can hook you up as an affiliate.
Strongly recommended for you: Grain Brain, by my buddy David Perlmutter – you will love it, it’s all about you.
cp
Sorry D,
The ADHD Reality Series is here: http://corebrain.org/reality
tnx,
cp
Dr. Parker,
After reading your book I felt a lot of renewed hope for finally finding the answers to our long search in the treatment of ADHD and depression that plagues several members of our family, so I began trying to implement what it taught me in our family.
My daughter had been on both fluoxetine and adderall before I read your book. She was put on the adderall approximately 6 weeks before school was out, but she did not feel like her adderall was working. The pediatrician wanted her to try to wean from her fluoxetine this Summer to see how she did, so after school was out she began that process while trying an increased dose of adderall. She was a completely different person–extremely irritable, combative, anxious, and depressed. During this time I read your book and became concerned that the seesaw effect was occurring in her–that the fact that she was taking adderall while being off the SSRI was making her depression even worse. I was also concerned that the SSRI she was on previously was fluoxetine and that it had probably been blocking the 2D6 pipeline which made the adderall seem ineffective. I scheduled a follow up appointment to discuss all of this; I was hoping to get my daughter on Celexa to treat the depression while keeping the 2D6 pipeline clear and to continue the adderall a while longer to continue to try to figure out the appropriate treatment. (My daughter had been off of the fluoxetine for over a month when we had our follow up appointment. She still did not notice the adderall working even when she was off of the fluoxetine, but I wondered if the depression symptoms were overpowering everything else so she wasn’t able to think clearly about more subtle symptoms.)
The doctor acted as if I was crazy for thinking that the seesaw effect might have been occurring previously. He said that the only interaction the two meds would be having is a synergistic effect, and he showed me the screen on his computer that indicated that the interaction would increase serotonin levels. He decided that the fact the adderall didn’t seem to be working meant that my daughter didn’t need adderall, and so he discontinued it. He didn’t try her on another stimulant (or any other medication) for ADHD because he believes that if one doesn’t work the other won’t work either; it is my understanding that this is not true. He also put my daughter back on fluoxetine instead of trying her on Celexa or another clean SSRI because he already knew that it works for her. I was frustrated with this because I am not convinced yet that she does not need the adderall or another stimulant, but she doesn’t like to feel like she is “broken” and is, therefore, more than happy to stop taking the med. I am frustrated because I know that untreated ADHD can cause her additional problems, and I want to make sure she has the necessary treatment in order for her to have the best chances for success.
I called our pharmacist after that appointment to get another opinion on the fluoxetine/adderall interaction. He told me that the interaction warning for the two medications was that it could cause a serotonin effect due to too much serotonin.
I don’t understand why these practitioners are saying that there would actually be an increase in serotonin when there would probably be a decrease in it because of the seesaw effect. I don’t understand why it is believed that adderall, which is a norepinephrine and dopamine reuptake inhibitor, would have the effect of increasing serotonin.
This is just one of my family members’ story. There are several others of us that I am trying to figure out. I felt renewed hope after reading your book, but now I am becoming discouraged because it seems like I am being stopped from implementing the suggestions. How do you suggest I proceed?
Susan,
Just quickly, go in and Google 2D6 and Prozac… how they continue to make that mistake is beyond me – and yes I’ve heard it from many folks, and have then heard that Effexor blocks 2D6 which it doesn’t. This is a tough call, as to try Zoloft, perhaps he/she is uncomfortable w Celexa. Take a look at the links in this posting – any drug interaction book has these fully on board.
Beg?
cp
Dear Dr. Parker,
If only other child psychiatrists had the insight you have, there may be some hope in this world. As a teenager suffering from severe headaches, time-management trouble, procrastination, and sleep issues, I was labeled as “depressed” by my psychiatrist. Furthermore, when I tried to convince her my headache wasn’t just me “somaticizing” anxiety/depression (it had a sudden neurological onset), no amount of mindfulness/exercise was helping, and that my memory/cognition had become exceedingly worse on increased doses of sertaline, she ignored me. Every time we would up the dose, the medication would work for the first week (improved concentration, mood, etc.), and then I would crash, become severely apathetic, depressed, lethargic, and my headache increased in intensity (Symptoms much worse than before starting the Zoloft).
I then told my psychiatrist that I had begun to notice weird symptoms on 150 mg of the Zoloft; I couldn’t “shut my brain off” before going to sleep and couldn’t sleep for more than 4/5 hours a night. I began to feel my obsessive planning and overabundance of thoughts come back, and I could no longer focus or read novels. My eyes jumped over the lines in boredom; this was the first time in my life this happened. (Before the headaches and associated symptoms that led me to seek treatment, I was ranked number one in my class.)
My pdoc believed my cognitive impairment to be residual symptoms of depression despite my incessant pleas that my cognition/memory was much better prior to SSRI usage. When she refused to listen to me, I read her numerous studies on over-achievers with ADHD; I fit the bill from childhood. I even tried to convince her that I was more likely to have ADHD because I suffered from enuresis until the age of 13, but she kept arguing we needed to “stabilize” the depression first (the depression Zoloft caused). She also believed I had SSRI-induced hypomania, but if you read on, you’ll find that assertion far from correct.
She then prescribed me lamictal, and later abilify on which I then proceeded to become extremely confused/distracted and got into a car accident. My headache pain and associated light/sound sensitivity became excruciating as well. She was still worried about bipolar so she put me on wellbutrin instead of a stimulant; I reacted to bupropion by becoming sedated and anxious/angry (sleeping 10 hours a day instead of 4/5 on zoloft).
After refusing to up the dose of Zoloft to 200mg, she finally agreed to try Vyvanse. Within hours of taking the medicine, I felt very calm and relaxed. The piercing, knife-like headache over the front, right side of my head disappeared completely! The associated light and sound sensitivity disappeared as well. ( I should note that this headache had appeared out of the blue about one year ago and was accompanied by increased forgetfulness, increased somnolence, light/sound sensitivity, difficulty/slowed processing, and trouble memorizing and normally I am a great student. No triptans, anti-seizure medications, or migraine preventatives worked on this painful headache.) I was so thankful for it to have finally disappeared!
On Vyvanse, my jumpiness, anxiety, anger went away, and I felt that I could control my emotions much better. In neurofeedback, I was able to focus without developing a headache and/or feeling fatigued, and was no longer producing an excessive amount of theta waves (I tried to tell my psychiatrist my excessive theta wave activity was indicative of ADHD). Also, the troublesome akathisia I developed on Zoloft disappeared after one dose of Vyvanse. That night, right before I went to sleep, I took my daily dose of 150 mg of Zoloft. I felt sleepy and did not have to force myself to sleep for once. I awoke abruptly at 12:30 AM to my heart racing, a tightened jaw, too many thoughts, painful muscle spasms, etc. (the exact opposite of my reaction to Vyvanse during the day). I couldn’t sleep for five hours due to those symptoms.
Then, went down to 100 mg of Zoloft and felt better, but still had odd symptoms including napping right after Vyvanse kicked in (my pdoc found this bizarre though I tried to tell her I was too relaxed). In addition, I had insomnia/overthinking after taking my evening dose of Zoloft. I even had a brief episode of confusion were I felt very spacey (happy but slightly confused). I proceeded to self-taper my dose of zoloft under the guidance of my therapist, although my psychiatrist had warned against it.
Today marks two weeks off zoloft, and I’ve never felt better. With Vyvanse, my sleep cycle has regulated perfectly, my head feels pain-free, I’m in the best emotional state I’ve been ever (I pause before reacting), and my memory/cognition/problem solving abilities are slowly returning.
The next step is convincing my psychiatrist I need an IR Booster because dexedrine is not completely effective (it takes three hours to work and then wears off in six hours, on higher doses I notice no change in effectiveness-only a decrease in motivation).
I wanted to tell you my story, because I feel that you are a doctor who listens to his/her patients, and I find your work to be very inspiring. While most psychiatrists like to make everything black and white, your blogs reveal you think on a neurochemical level. Hopefully more pdocs will chose a science-based approach to psychiatry, so the atypical cases can find some relief!
Thank you for your time,
S. Gill
S,
Thanks for your important observations and documentation of a process I’ve seen in my own practice and second opinions for the last 16 years. I’ve made that same mistake so many times I had to go back and ask myself the same questions, based on my own self doubt, and concern that I might activate an odd bipolar presentation… until I came across clear documentation that the 5HT Serotonin down regulates DA Dopamine .
Your comment here will likely help others along their way, and I do hope your open remarks encourage some of those others to step forward on this important challenge. Some become so dysregulated they can suffer with either potential or real suicidal thinking/actions.
cp
[…] work-up of a patient. From his experience, Dr Parker writes that Attention Deficit Disorder is underdiagnosed and notes that the SSRI’s can dysregulate dopamine levels with potential clinical implications. […]
Thanks for pinging on this – one of the most important points out there!
cp
Dr. Parker,
I am a parent of a child who has been diagnosed with ADHD. This isn’t surprising as my husband and myself both have ADHD. I know first hand the trials and tribulations one can go through trying to find the right medication. My son started on Ritilan and was being slowly titrated up. At week 2, he had a minor hallucination at night. I chalked it up to nerves and fatigue…until 10 days later, he had a very intense auditory hallucination. The voices weren’t threatening, but no the less, very scary. We stopped the med immediatly. My concern, is this a situation where the stimulant is aggravating an underlying disorder? Is this a common side effect? Everything i have read says this is a very rare side effect.
Thank you for your reply!
Christine
Christine,
Very unusual problem with the hallucinations, not necessarily characteristic of every stimulant, but might be [you might see it again on a different stim].
The second issue in question is the reason I am writing this blog – yes I would wonder and seek more evidence on any symptom such as this with specific neurotransmitter testing to start, and perhaps more testing depending on the results of that first foray into measuring one aspect of his neurophysiology. Take a look at this Neuroscience page for much more information on these issues, and do check out the CD by Laponis under ‘Brain and Immunity’ on that page.
cp
[…] work-up of a patient. From his experience, Dr Parker writes that Attention Deficit Disorder is underdiagnosed and notes that the SSRI’s can dysregulate dopamine levels with potential clinical […]
Gina,
You know how it is, many are simply waiting for someone to write *definitive research* on the comorbid diagnosis issue discussed in this post. Depression and ADD are very commonly found comorbidly.
For now, my patient numbers with this seesaw finding are in the thousands, with long term [many more than 5 years] follow up numbers to match.
I appreciate your comments and do hope these posts raise awareness to this oft overlooked critical diagnostic and treatment challenge – and the dangerous consequences of not drilling every ADD presentation precisely on these important questions.
Many times the seesaw drug interactions will raise a big yellow caution flag on the first visit as others have missed that essential point and the client is deteriorating without the correct combo of meds.
Thanks for your remarks,
Chuck