Archive for the ‘ADHD’ Category

I am a 40 year old woman who has finally decided to do something about my ADHD. A psychiatrist has prescribed Vyvanse, but I haven't filled the prescription because of side- effect concerns.

Vyvanse is a new delivery system for a medication we have used for 70 years.  Extra precaution needs to be taken with CV issues like Mitral Valve Prolapse.  I’m not aware of a specific study with MVP, but a study was done at Harvard of patients with ADHD and high blood pressure.  The blood pressure was gotten under control first – then the patients were treated for ADHD and tolerated stimulants as well as patients with normal blood pressure.

Starting low and going slow would be essential with decreased dose or stopping if you have any side-effects that could be related to the drug, such as palpitations, dizziness, etc.

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I don't know why I am still on Adderall. I am so tired and depressed, unexcited, and don't even feel like reading the Bible, much less have the energy or passion to make the world a better place. I have been on Adderall for 14 years and I feel a little frazzled. Does long term use of amphetamines cause brain damage?

I have many patients who do great on 60-90 mg of Adderall per day and have for up to 13 years.  Anybody like yourself who is not doing well needs to make changes.  You need to start with a re-evaluation with a physician.

 

One simple option may be to change to the new Vyvanse and possibly just one/day (70mg).

 

Many of my patients require Tenex with Adderall.  Patients on Vyvanse are much less likely to need it.

 

One of the most important things I learned in training in the ‘60s – if what you are doing isn’t working, do something else, even if it is wrong it gets you unstuck.

 

Some important lifestyle issues to consider include:   quality sleep, exercise, bright light every day, good diet, omega 3 fatty acids, and possibly Cerefolin, and personality issues.  If you need medication work with your doctor until you find “the right medication at the right dose” for you.

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Is it safe for a 5 year old to wear the patch (Daytrana) and is it safe to cut the patch in half to reduce the dose?

I have just posted an article on preschoolers and ADHD:

test.askdrjones.com/2007/09/06/behavioral-treatment-for-adhd-in-preschoolers/

Most research in preschoolers is with methylphenidate even though it is only FDA approved down to the age of 6.  The patch works fine if cut in half.  Be aware that after six weeks of daily use blood levels may go up and the dose may need to be reduced further. 

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Behavioral Treatment for ADHD in Preschoolers

Brain functioning is genetically variable (polymorphic) and has plasticity – adaptability to conditions and experience.  When you learn a new skill  or habit – at any age  (though easier when in childhood) it changes your brain.  Neurons establish new connections.  Connections are strengthened – more receptors and nerve impulses are made faster and more myelin (insulation) is enhanced. 

Now new research is showing that giving more structure to a preschooler’s day can improve ADHD symptoms.  A recent study of treating preschoolers with medication found that the medication did help but not as much as in older kids and with more side-effects – leading to the conclusion that the need and potential benefits have to be greater in younger kids to justify use. 

Having behavioral alternatives is much more acceptable to most parents who worry that medication may not be the right answer.

I know you’re thinking, why not do the same thing with school age kids?  Probably the most elaborate research study in psychiatry ever was the MTA study.  Medication was unequivocally the superior treatment for school age children. 

MTA link:  test.askdrjones.com/

Although I don’t treat a lot of preschoolers I have treated a few and I generally recommend medication with the following conditions:

1.    If I don’t treat the kid’s ADHD I’m going to have to treat the parents and siblings for major stress symptoms

2.    If I don’t treat the kid no day care will keep them and mother (frequently a single parent) or father won’t be able to work and they’ll be standing in soup lines and bunking down at the Salvation Army

3.    Extreme impulsivity resulting in dangerous behavior like running out in the street

Ironically, methylphenidate has been the most studied in preschoolers but only dextroamphetamine is approved down to age three.

Estimates of incidence of significant ADHD symptoms in preschoolers are 1 to 4%.  The best test is to be in a room with them for a while – how bad do you need a drink or a Xanax afterwards?  The second best test is how much does mother look like the “before pictures” of the woman in the mattress commercials?  (Or in the case of the one with Lindsay Wagner even the after picture looks pretty haggard.)

A five year old study sponsored by the National Institute of Mental Health provided a range of behavioral therapies to135 preschool kids with severe ADHD:

1.    Families were given parent education classes only

2.    Or classes and home visits by researchers who gave individualized behavioral therapy for each child’s particular needs

After one year aggressive behavior and learning had improved by 30%.  One parent said the most effective technique was providing predictability, such as, we are going to be leaving the playground in 5 minutes, 4 minutes, etc.  (She didn’t mention having to use a lasso or pepper spray when it was time to actually leave).  She also thought it was helpful to praise the child for doing things like behaving during a boring activity, helping with cleanup, or other positive behaviors.  (This study was reported in School Psychology Review Sept 07).

Classic behavioral management principles of parenting are:

1.    Behavior you like and want more of (praise, reward)

2.    Behavior you don’t like but that doesn’t bother you or others particularly (so you ignore)

3.    Behavior you can’t stand or is bothering others (punish) 

Note: Time-outs work well.  They provide the first opportunity to use the power of the “pop” (e.g., when they refuse to go to time-out).

The problem is that classic parenting doesn’t always work so great.  As Dennis the Menace said in one cartoon, “by the time I realize the consequences of my action I’ve already done it”.     test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

 

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Only 1/3 of ADHD Kids are Being Consistently Treated: Why are we not taking better care of our greatest resource?

A study of 3,000 randomly selected kids ages 8-15 was funded by the National Institute of Health (with no pharmaceutical company support).  The main author was Tanya Froehlich, a developmental behavior pediatrician.   The study was published in Archives of Pediatric & Adolescent Medicine Sept 07.

Originally the objective was to see if ADHD in kids was being over diagnosed and over treated.  Actual findings showed only 3% of those without ADHD were receiving medical treatment – and they could have represented kids who had improved so no longer met criteria.  They also found that 9% of the 3,000 kids had ADHD of which only 1/3 were consistently being treated.

That finding or worse has been repeatedly found – the question is, WHY?

I believe the most common reason is that the patient has not taken “the right medication at the right dose”.

 In consulting with physicians in their offices a frequently mentioned problem is getting kids to take their meds.  My approach is to first redefine the problem for kids and their families.

ADHD is a type of personality that makes it difficult to focus on things that aren’t interesting.

Like what?  Like school mostly.  The cause is genetic (polymorphism).  Mother Nature doesn’t want ADHD kids or adults spending time with boring, repetitive stuff.  ADHD people are the explorers, challengers, and changers of the world.

One of the problems with being ADHD is that in order for us to go to the best schools and get the best jobs, starting with the 9th grade we need to perform well in school and keep up with boring details (and at work boring reports, etc.)

The GOOD news is that medication – especially stimulants make our lives better by giving us the ability to do well on the boring stuff.  It also helps us stay calm and still when appropriate, and in control.

THE GOAL

The goal is to find a medication that kids, teens, and adults like.  Their lives are easier – they’re getting things done effectively and side-effects from the meds if any, are minimal.  HINT:  The medication probably isn’t Strattera.

If medication makes kids feel bad they shouldn’t take it.  I worry more about kids/teens who take meds that make them feel bad or detached or flat or racy.  I worry about parents who keep giving kids the wrong medication or the wrong dose.

Another reason for poor consistent compliance with treatment is that usually at least one of the parents is also ADHD.  Only 10% of ADHD adults are being treated.  So the parents forget, lose the med, are running late, or don’t have time.  They can’t stay organized to keep up with getting refills, scheduling and keeping follow-up appointments, much less filing insurance forms, etc.

Again this year at the American Psychiatric Association annual meeting a group of loud marchers picketed the main conference center.  “Stop poisoning our children” and other banners were being waved.  They were mostly Scientologists who are a blend of idiocy and nuttiness.  They should be sentenced for life to be locked up with a hyperactive kid like our son was in childhood.

Unfortunately, some patients give up too quickly on one or more meds because they don’t understand all the nuances of dosing and side-effects.  But, fortunately, we keep getting better and better medications that are more effective and last all day and are safer with less side-effects.

 Newest med:test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

     

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What Is ADHD and What Causes It?

ADHD is a personality type that is determined mainly by genetics.  Survival of the group is enhanced by variability of its members.  We wouldn’t want everyone to be the same.   Ancient tribes for example, needed a look-out person who could patiently maintain watch in case something happened.  That wouldn’t be an ADD person.  The ADD person needs much more stimulation.

The diagram shows the range of stimulation within which everyone functions.  You are excited at the higher end and relaxed at the lower end.  Everyone also has a level of stimulation below which they are bored and above which they are overstressed.  People with ADHD tend to have a problem at both ends.  They need higher stimulation than normal people and are stressed more easily.  They have trouble separating important from unimportant and tend to have too much on their mind.

Stimulants help both problems.  They turn on the brain to enable concentration on the lower level stimuli.  They also allow focus on one thing at a time, which helps the ADD person to be less hyper and more relaxed.

If a kid with ADD is playing baseball and you put him in the outfield, when the ball is hit to him you may ask – where is he?  The kid with ADD can’t pay attention in case something happens.  He may be digging a hole, or playing with stuff in his pocket or visiting with someone on the side-lines.  This inability to focus and separate the important from the unimportant is also seen in schoolwork (and in the case of adults, paperwork).

Boredom with routine is related to inadequate dopamine levels in the part of the brain that controls drive and motivation.  Easy distractibility is related to inadequate norepinephrine in the brain cortex.  Impulsivity is related to inadequate dopamine in the cortex.

ADD people focus on things that are interesting rather than things that are important.  They need action.  They are often the explorers, innovators and challengers in our world.

test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

 

 

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Vyvanse: New Treatment for ADHD

 Vyvanse, the new ADHD medicine, has a unique prodrug delivery system developed to prevent abuse.  In addition to marked reduced abuse and misuse, studies have shown other major advantages over Adderall XR – the most prescribed medication for ADHD.  Vyvanse has been found to be more consistent in its effect, more effective, especially for attention, longer acting and to have less rebound symptoms in the afternoon.    

 How is Vyvanse different from Adderall?

  • Adderall is 75% dextroamphetamine (dexedrine) + 25% levoamphetamine (mostly effects norepinephrine) 
  • Vyvanse is 100% dextroamphetamine as the active ingredient but it is bound to an amino acid, L lysine.  Because the amino acid has to be removed by a protease enzyme located  primarily in the intestine before it works, it is designated as a "prodrug".

Note:  The additional norepinephrine effect of Adderall may help alertness and distractibility but it is also responsible for most of the risks and side effects of Adderall.  Many patients taking Adderall do better taking it with Tenex. test.askdrjones.com/  Men on Adderall XR are more likely to have erectile dysfunction and need Viagra type medication.  Some people, especially older men have trouble urinating when taking Adderall XR and may need Flomax.  Patients switching to Vyvanse have been less likely to have these side-effects. 

  Other side-effects related to norepinephrine include:

  • dry mouth
  • muscle tightness
  • nervousness
  • stomach aches
  • cardiovascular effect (so less risk of increasing blood pressure)

Vyvanse is much more consistent than Adderall XR from day to day and patient to patient.  Vyvanse consistently reaches peak blood levels in 3 1/2 to 5 hours at a concentration of 100-175 ng/ml for a 70mg capsule.  Adderall XR has 400% variability – it peaks anywhere from 3 to 12 hours at levels of 70-300 ng/ml for a 30mg capsule.

Acidity levels in the stomach and small intestine and levels of gastrointestinal motility significantly impact absorption of XR but not Vyvanse.  Food, especially fat in the stomach or intestine can delay Adderall XR up to 2 1/2 hours but maximum delay of Vyvanse absorption is less than an hour.  Since it takes 3 hours to digest a fatty meal, forgetting to take XR before eating can result in significant stretches of time with reduced focus and productivity.

Vyvanse may be more likely to increase insomnia, decrease appetite, and increase weight loss – probably because it has a longer duration of action.

In a study where patients took alternately Adderall XR and Vyvanse almost 75% did much better.  However, twice as many patients on Vyvanse did very much better.

"Effect size" is a statistical measure of efficacy when comparing different studies.  The effect size for Vyvanse was significantly higher than any other medication ever studied for ADHD.  Also, when tested in known stimulant abusers it was significantly less likable than oral or IV dexedrine which means it is less abuse prone.

I have tried Vyvanse in approximately 200 patients – these were mostly patients taking Adderall.  Almost everyone that switched prefers Vyvanse.  One woman said that Adderall made her nervous and jittery which caused her to smoke more.  On Vyvanse she’s not smoking.  I still have a few patients that prefer Adderall.  Some probably prefer the increased mood or likability effect.  Some probably need the norepinephrine effect.

My prediction:  Vyvanse will rapidly become the number one medication for ADHD.

 Related ADHD article: test.askdrjones.com/2007/09/06/only-13-of-adhd-kids-are-being-consistently-treated-why-are-we-not-taking-better-care-of-our-greatest-resource/

 

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How can I live like a normal person when I have ADHD?

Most of my ADHD patients do well and many if not most like being ADHD.  There are some who haven’t found the "right medication(s)", but there are frequently new medications that become available.  Within 4-8 weeks we will have Vyvanse, a new form of Dexedrine that has research benefit higher than currently available medications.

Sometimes it takes a combination of meds like Adderall XR or Methylphenidate + Tenex (Guanfacine).  Sometimes it takes a different form of medication (like the Daytrana patch) which is a form of Methylphenidate that avoids first pass metabolism in the gut and liver.  This is a plus for patients that are rapid metabolizers and don’t get enough of the tablet forms into their brain.  There are also people that don’t tolerate any of the stimulants except Desoxyn.

test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

 

Another possibility is that you are not just ADHD.  At least 85% of people with ADHD have other conditions that have to be addressed.  You are 3 times more likely than the general population to have a mood disorder, an anxiety disorder, substance abuse issues, or impulse control disorder.

We already know 11 different gene variants that are more common in people who are ADHD.  All these possible complexities need to be addressed as well as basic health habits (especially sleep) to enable you to have the quality of life you want and deserve.  

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Is ADHD Being Overdiagnosed in Adults?

ADHD and to a lesser extent anxiety disorders are frequently unrecognized and untreated.  As a result millions of adults in the U.S. have a reduced quality of life and chronic stress symptoms that gradually take their toll on physical health.

Adults who have mood and anxiety disorders can also be ADHD.  The National Comorbidity Study (NCS) found ADHD occurs in

  • 32% of  patients with a depressive disorder
  • 21.2% of patients with bipolar disorder
  • 9.5% of patients with an anxiety disorder

However, a large managed care data base reported the following treatment rates for co-occurring ADHD in adults with mood and anxiety disorders:

  •  2.5%   in patients with bipolar disorder
  •  1.7%   in patients with a depressive or anxiety disorder

New diagnoses for mood and anxiety disorders =

  • 12,036,905 new depressive disorders
  • 6,573,576 new anxiety disorders
  • 1,148,175 new bipolar disorders

New diagnoses for ADHD = 900,897

This means that of 12 million patients diagnosed with a new depressive disorder almost 4 million also were ADHD but only 200,000 were being treated (4%) of the total here.  Approximately 100,000 of 600,000 patients with an anxiety disorder were being treated for ADHD (16%).  Only 250,000 bipolar patients (11%) were being treated for ADHD. 

test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

The National Comorbidity Study (NCS) directed by Dr. Ronald Kessler is accepted as the most reliable study of the U.S. population.  Two hour assessments of all adults in selected households were randomly chosen from all over the country to establish prevalence. 

The NCS also found that anxiety disorders were the most prevalent mental health problem.  Social anxiety disorder was the single most common (8%) of the population followed by post traumatic stress disorder, generalized anxiety disorder, panic disorder and OCD.

Since anxiety disorders are 50% more prevalent than depressive disorders the managed care data base reflects that 2/3’s of anxiety disorders were not being treated.  The most likely explanation is that they usually weren’t diagnosed. 

If anxiety disorders are more common, how do you explain the fact that almost twice as many patients in the managed care data base were treated for depressive disorders (12 million) than anxiety disorders (6.5 million)? 

Other studies have found that doctors, including psychiatrists are much less likely to recognize and treat anxiety disorders.  This is partly because patients don’t have insight into the nature of their symptoms, or, especially in social anxiety and OCD, they are too embarrassed to bring it up.  Many doctors are not proactive in asking about each group of symptoms.  In managed care, reimbursement is a set rate.  It’s more economically effective to keep it simple and focus primarily on the presenting complaint. 

The saddest reality is that the success rate of treatment is appallingly low.  The NCS found that in any given year 30% of Americans will suffer from a mental health disorder, and those with a disorder will have on average 2 co-occurring disorders.  Successful treatment requires identification of all the existing problems and understanding of how each relates to the others.

It’s ironic that ADHD is the most frequently missed diagnosis since it is the most easily and effectively treated.   Anxiety disorders are probably the second most missed.  Although harder to treat than ADHD, they are not as complicated as depressive disorders, especially bipolar type.

The managed care data base didn’t include alcoholism and drug abuse.  Addictive disorders have the highest rate of co-occurring ADHD, but doctors are  reluctant to give the most effective treatment (stimulants) to this group of patients – even though studies show that usually they are safe and effective.

Change begins with awareness.  Our medical system is broken.  The impetus is going to have to come from the people suffering the consequences of the system.

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How To Take Adderall (Amphetamine-Dextroamphetamine)

ADDERALL XR (amphetamine-dextroamphetamine)

ADDERALL XR is a mixed salt amphetamine approved by the FDA for treatment of Attention Deficit Hyperactivity Disorder. Mixed salt amphetamines have been studied and used clinically to treat ADHD since the 1930’s.

Amphetamines, as a class of stimulants, increase activity of the brain’s natural stimulants, Dopamine and Norepinephrine. Dopamine regulates interest, motivation, energy, concentration, pleasure seeking and movement. Norepinephrine regulates alertness, focus, energy, and vigilance. Adderall’s effects on Norepinephrine are about equal to its Dopamine effect.

ADDERALL XR comes in 5, 10, 15, 30, 25, and 30 mg slow release capsules. The cost is the same for all 6 sizes. Total duration of effect for the XR form is 7-12 hours. Half of the dose is absorbed immediately, and takes effect in about 30 minutes. Half is absorbed in 4 hours.

ADDERALL tablets (scored) come in 5, 7.5, 10, 12.5, 15, 20, and 30 mg sizes. Duration of action for the tablets is 3 ½ – 6 hours. Tablets are more likely to have rebound side effects, and doses are more likely to be missed or delayed.

Unlike most prescriptions, ADDERALL cannot be called into the pharmacy. By state regulations all stimulants require written prescriptions, which MUST BE FILLED WITHIN SEVEN DAYS. This means a prescription written on Monday must be filled by Sunday.

HOW TO TAKE ADDERALL XR

GUIDELINES

DOSING

  • STARTING DOSE is 10mg in am for adults, 5mg in am for children.
  • Increase dose by 10mg every 1-4 days until symptoms are under control.
  • Dosing needs to be individualized for optimal benefit but is in the 20-90 mg range for most people. Maximum total daily dose is usually 2/3’s body weight in pounds. (Do not go above prescribed dose without doctor’s approval.)
  • Higher doses last longer and can be effective up to 10-12 hours.
  • If nervousness or over-stimulation occurs, always REDUCE the dose.

SWITCHING FROM ADDERALL TABLETS TO CAPSULES (XR)

If switching from ADDERALL tablets to capsules (XR), total the daily dose of tablets in mg and take half as often. For example, if currently taking 30mg tablets twice daily, switch to 60mg XR in am (two 30mg XR capsules). If taking 15mg 4x per day, take 30mg XR twice per day.

MANAGING SIDE EFFECTS

Most side effects are mild and occur mainly in the first two weeks of starting medication. In studies, very few people stop medication due to side effects. If side effects are experienced to a bothersome degree, decrease the dose.

POSSIBLE SIDE EFFECTS
Side Effect Children <13 Adolescents Adults
Decreased appetite
Insomnia
Emotional lability    
Abdominal pain  
Weight loss  
Dry mouth    
Headache    

May aggravate tics.

Side effects that peak around 6 hours from dose are most likely due to the medication. Dose needs to be reduced.

Irritability and tiredness/fatigue that occurs more than 6 hours after last dose are more likely due to medication wearing off (rebound effect). Dosing may need to be adjusted by adding an extra dose or by increasing the dose.

Many side effects are well controlled by Tenex (Guanfacine).

APPETITE SUPPRESSION

Eat a good breakfast 15-30 minutes after the morning dose. A nighttime snack such as ice cream is also recommended. Appetite usually improves over time, but if not, other methods of management can be used. Weight loss is common especially in people who are overweight. This is usually not due to appetite decrease but to a decreased tendency to eat due to boredom or stress.

Tenex may help taken a.m., evening, or both.

Remeron (Mirtazapine) helps sleep and appetite. Start very low (7.5 mg or lower). Remeron can cause morning drowsiness, especially when first starting.

SLEEP DISTURBANCE

First, shift dose to earlier in the day. If earlier does not work, take dose LATER in day. This may be caused by a “rebound” of ADD symptoms. Sometimes, medications that provide normal sleep are needed.

NOTE: Blood pressure should be monitored especially if any of the following is used on a regular basis with Adderall. Tenex is the first treatment option since it directly counteracts the effects of Adderall and these medications on blood pressure.

  • Caffeine-large amounts
  • Appetite suppressants
  • Thyroid
  • Some asthma meds
  • Wellbutrin XL
  • Effexor XR
  • Tricyclics
  • Cymbalta

For full information, see package insert or prescribing information.

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