Archive for the ‘Blogs’ Category

My brother is 16 and he has ADHD. What is the right starting dose for medication?

It is usually better to start low and increase until no additional benefits or side-effects.

Weight can be used to determine maximum dose, 2mg/kg for methylphenidate and 1.5mg/kg for amphetamines.  The following chart was published by Biederman and Wilens at the Harvard department of psychiatry.

More people prefer amphetamines.  Only 16% prefer methyphenidate.  This fits my clinical experience over the past 40 years.  The following chart shows a meta-analysis study that was done that confirms this.

So, if your brother weighs 150 pounds (or 70kg) he may need doses of methyphenidate up to 140mg, or Concerta 54mg 3x per day, or 1-2 Daytrana patches, or 90-150mg Adderall, or Vyvanse 70mg 3x per day for optimal effect.

Over the past several weeks I have tried Vyvanse in over 300 patients, many of whom were previously on Adderall.  The majority of patients prefer Vyvanse – they report that it is smoother, has less side-effects, less rebound in the afternoon, and more efficacy throughout the day.  Vyvanse has less risk to blood pressure or the cardiovascular system and has a mode of action that prevents using it to get high.  There are still some patients that prefer and do better on Adderall.  The lowest dose of Vyvanse is 30mg, which is equal to 10mg of Dexedrine or 20mg of Ritalin (methylphenidate).

How much medication should your brother take?

Enough, not too much.   It takes time and trial and error to find the best dose for each individual.

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How can I prevent recurrence of depression and what do I do if the depression does come back?

Depression runs in my family and I’ve been on the same medicine for a while with no episodes of depression.  About two weeks ago I woke up feeling not myself and contributed it to getting my period on top of coming down with a respiratory infection.  Still not feeling well after two weeks I think it might be depression because I feel tired, confused thinking, can’t focus, etc.  I’ve called my doctor and he told me to up my medicine 100mgs.  My question:  

Since I have not had an episode of depression in quite some time could it have been brought on by me not feeling well?

 


 

Dr. Jones’ reply:

I’m not sure what antidepressant you are on – but it was possibly Zoloft or Luvox since they can be increased by 100mg increments, but not SNRI’s (Effexor, Cymbalta) or other SSRI’s (Prozac, Celexa, Lexapro, Paxil).

Women with a family history and or prior history of depression who respond to an SSRI or SNRI can have return of symptoms if their serotonin level is reduced (as it is premenstrually, post partum, or during perimenopause).  Being ill can also contribute to relapse by disrupting sleep or normal thyroid function.

Previous studies have shown that:  "the dose that gets you well keeps you well", but even then the relapse rates are:  20% of patients have recurrence within 3 years,  50% relapse if the dose is lowered, or 80% relapse if medication is stopped.

Recurrent depression not only causes distress and possible short term impairment, it can also increase your vulnerability to future episodes and decrease your responsiveness to treatment.

There are several things that can help prevent recurrence:

  1. Good sleep – 7-8 hours every night (Lunesta, Ambien provide normal sleep)
  2. Physical activity – daily vigorous activity for at least 30 minutes (a 2 mile walk or equivalent)
  3. Omega 3 fatty acids – take twice daily.  (I trust Cooper brand the most)
  4. Bright light daily 
  5. Thyroid – make sure thyroid levels are good  test.askdrjones.com/ 
  6. Cognitive behavioral therapy – if needed
  7. Other medications – other medications may help such as alprazolam, atypicals, stimulants
  8.  L Methylfolate – (Deplin,  Cerefolin, or Cerefolin NAC)  – these contain a form of folic acid that gets into the brain cells.  Deplin was recently approved by the FDA as an add-on treatment for depression.  Cerefolin also contains B12 and Cerefolin NAC has a third ingredient that increases glutathione (a powerful brain cell antioxidant).  These medications not only can improve mood, but improve cognition and energy.  Caution:  taking Deplin if your B12 level is low can be harmful.  It is safer to either check your B12 levels or take Cerefolin. 
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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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Pictures of Addiction

These scans looking down on the brain are measuring dopamine activity in the nucleus accumbens and reflect levels of interest, drive and motivation.

A recent research finding is that people who are born with below average receptors (D2) in this area are more likely to develop behavioral and/or substance addictions.

Conversely, people born with above average numbers of these receptors are relatively protected from developing addictions.

The function of this area of the brain is to learn what is pleasurable and then fire to activate our systems of pursuit.  Mother nature wants us to be motivated to eat and have sex.  These are natural activators of the nucleus accumbens.

In addictions this part of the brain is “hijacked” by some behavior, like gambling or alcohol/drugs.

Tolerance frequently develops to addictive substances and results in a depletion of dopamine.  Low dopamine causes craving for substances that have powerful effects on the dopamine system – like speed, cocaine, or alcohol.

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Are You Prone To Addiction?

One of the major themes of this year’s APA was the neurobiological basis of addictions. 

First it was schizophrenia, then manic and depressive disorders, then the anxiety disorders, then attention deficit disorders – These all became much better understood not just as abnormal behavior or feelings but as complex medical disorders with genetics and physiology. 

Science of mind is making possible much more effective treatments – not to replace psychological and social dimensions but to enhance them. 

Most recently, advances in understanding the science of addiction is beginning to help us treat these disorders more effectively.  How many D2 receptors were you born with?  It makes a difference. (see pictures of addiction)

One of the personalities that stood out at this years APA was Dr. Nora Volkow, Director of the National Institute of Mental Health Division for Addictions.  Dr. Volkow is a wiry, hyper, opinionated woman with a strong Germanic accent which seems to add force to her dynamic personality.  Her favorite thing to say is, "I like to be provocative."  She occasionally apologizes for dominating the stage and microphone but is not able to stay silent very long. 

One of her lectures was titled "Addictions and Free Will."  Free will is one of the things between stimulus and response.  Is this response a good idea?  What happened last time?  What are the possible consequences, options…etc.?

Unfortunately, the addictive brain may not access these thoughts.  Control is reduced or absent.  Fortunately we’re starting to understand why, and we’re starting to find treatments that give addicts new controls and options.

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Brooke Shields, John Nash, and the national APA meeting

Two thunderous standing ovations highlighted this year’s APA meeting. They were as different as you could imagine. An intimate conversation with Brooke Shields about her battle against nature’s cruelest mood disorder – postpartum depression – and Dr. John Nash (A Beautiful Mind) reading a paper he wrote in which he describes his battle against schizophrenia through metaphors of economic theory and the complex mathematics of game theory (for which he received a Nobel prize). Each presentation was in front of hundred’s of physicians and other professionals. One was alternately funny and gut wrenching.  The other was a mind twisting exercise in obfuscation.

What they had in common was each individual had the courage and strength to open their heart and soul to the professional world so that their stories could help us help others.

Dr. Nash’s presentation was interesting at times and touching at times but mostly unemotional.  I wish he had been interviewed in front of the audience instead.

He likened becoming psychotic to part of his mind going on strike. The most provocative thing he said was that to him his new insight into mathematics and his paranoia were both novel ideas not shared by anyone.  The only difference was that one was true, was labeled genius, and was rewarded with the Nobel prize.  The other was not true, was labeled insanity, and got him committed to a locked psychiatric ward.

The schizophrenic mind can’t tell the difference. Of course sometimes ideas are true but sound crazy.  And for various reasons society is not ready for them and may even persecute those who dare to challenge the current version of truth (like the earth is the center of the universe).

I was the most moved by Brooke Shields. Maybe because I have helped women who struggle with postpartum depression for over 40 years. 

What can possibly be a more joyous time than having a new baby – looking into your eyes, cooing, and responding to your love?  What can be more painful than when you as a mother feel nothing, or rejection, or thoughts of harming this poor helpless creature?  What could be more shameful and guilt producing? 

Everyone is saying how cute and precious your baby is, and you’re thinking "I wish you would shut up," or maybe even, "Please take this baby with you."  And if you do share that you’re not feeling right they say, "Oh, it’s just ‘baby blues.’  It will pass. it’s normal." 

And you’re thinking, "You don’t understand. I want to die. I feel empty, hopeless, inadequate, overwhelmed."  Or if they suggest medication, what you hear is you’re weak or crazy or both!  When you’re a celebrity with fame and fortune, a loving husband, and all the trappings of a perfect life, but you feel like a total failure, you see no hope for even being o.k. again and thoughts of suicide come to mind.

As Brooke Shields discussed this torturous beginning to motherhood, the pain of her experience was palpable throughout the ballroom.  The first turning point occurred for her when she had sent her husband to get a changing table, but he returned empty handed.  He sat on the bed and broke down.  She had never seen him cry.  He said "I went to the store and there were all these mothers and babies and families, and they were so happy.  Why aren’t we happy?" 

I almost lost it, in fact it took several tries before I could comment to my wife without getting choked up.

She went on to describe how she got on an antidepressant and felt better.  She went back to California and stopped the meds and crashed again.  She describes driving in her car with the baby in the back and thinking, "I could speed up to 80 mph and run into a concrete wall and all this would be over."  Fortunately she called a girlfriend and told her how she was feeling, and her girlfriend made a date with her for lunch the next day. She said her girlfriend was so manipulative because she knew Brooke was compulsive about keeping her commitments and would have to wait until after lunch tomorrow to drive into a wall.  

Brooke called her  doctor who asked if she had stopped her meds.  She said yes and he asked, "Why?"  She thought, "Did I sleep through my 4 years at Princeton?"

So, she went back on meds, had some side effects, changed meds, and eventually, everything was okay. 

3 years ago she went through a 2nd pregnancy without all the stressors of her first pregnancy, which included 7 in vitro fertilizations, miscarriages, death of her father (prostate cancer), an emergency C-section, being away froms support people, and being clueless with expectations of being the perfect mother. 

She described how different this 2nd experience was.  When the OB handed her the baby in the delivery room, her husband was thinking "Please don’t start sobbing," but she felt joyous, relieved, then elated.  She said, "I started telling my girlfriends they could have some of my husband’s sperm (in vitro) if they needed it."  A happy ending.

She tells her story in the recent book Down Came the Rain.  She has done way more than her share in making women aware of what can happen and that treatment is available.  I felt so much respect and appreciation for what she has done.  Then I thought about Tom Cruise (see previous article). I wondered how many women were on the fence about mood disorders, psychiatry, and medication.  How many were influenced by him to not seek help?  How many mothers suffered unnecessarily, and how many babies didn’t bond with their mothers during those early critical developmental weeks and whose lives will be adversely affected forever?

At the same moment I wanted to sing Brooke Shields praises and kick Tom Cruise’s ass.

 

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Say Goodbye To The Pill Ladies

I am now completely against birth control pills. I’m also against hormone replacement with oral estradiol. Estradiol (in every birth control pill) taken by mouth goes through the liver and causes problems with thyroid, testosterone, and the most effective form of estrogen.

In anyone with a history of depression and/or stress reactivity, this can be a major contributing factor to their functioning and quality of life.

For premenopausal women the NuvaRing seems to be the best option. This is because the hormone blood levels are about 1/3 of what they are with the weakest birth control pill.

Controversy continues regarding hormone replacement in postmenopausal women. However, for most women, the benefits outweigh the risks – especially for brain function (mood & memory). Using the right types of hormones and the right dose is essential. The best options are Premarin or Cenestin tablets and/or estradiol by patch or gel.

Remember, estrogen x thyroid x brain transmitters = mood in women.

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