Archive for the ‘Q&A’ Category



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Pristiq vs Effexor

Question: Now that Pristiq has been out for awhile, what has been the clinical response with your patients compared with the Effexor XR formulation? Rumors have said it is more tolerable and less sexual side effects, although I have tried some samples, and it doesn’t seem to be as calming as Effexor, and I am unsure what the Pristiq 50mg dose is compare to a similar Effexor XR dosage?

Also what SSRI/SNRI tends to have the fewest sexual side effects?



Pristiq and Cymbalta seem to have less sexual side-effects than Effexor
and if Pristiq at 50mg is an adequate dose it should have the least
sexual effects. 90% of the first 570,000 treated with Pristiq have
stayed with a 50mg dose. This dose has the same efficacy in control
studies as 75-150 of Effexor with better tolerability. The drop out
rate due to side-effects is essentially the same as placebo.

When most people (normal metabolizers) take Effexor – 70% of the benefit
comes from Effexor being metabolized so the effects are very similar.
Pristiq does have a slightly higher ratio of norepinephrine effect
relative to serotonin than Effexor and this could account for your
impression that it’s not as calming – that is most likely a temporary

Because Pristiq doesn’t require the same liver metabolism as Effexor
there are less issues with drug drug interactions and tolerability for
those people (7-10% of Caucasians) who are poor metabolizers. Poor
metabolizers don’t usually do as well on Effexor and don’t usually
tolerate doses above 75mg. Some people do better on 100mg of Pristiq.

Pristiq is also more cost-effective, especially at 100mg dose – since
there is a 100mg tablet – whereas Effexor frequently requires 225mg or
more necessitating multiple capsules.

Wyeth is also getting ready to launch a program where they will pay 1/2
of your cost (copay or cash) as long as you take it on a continual
basis for life if necessary.

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Panic and traveling

Question: Dear Dr. Jones, I treated with you about 15 years ago for agoraphobia–and was helped very much by your keen insight into this condition. Would you have time for a quick question? I’ve had a problem traveling long distances from home for most of my adult life. I’ve had periods of remission, lived well despite the condition, working as television reporter, etc. But the problem is, in short, I’ve always limited my travel fearing “the big one.” Now, I want to go to Europe before I’m too old to enjoy! Klonopin works well for me. Do you think if I just plain old up and flew off to Italy, I would not have a “breakdown” if I brought Klonopin?— even if when I got there, I became extremely panicked by facing such a long trip after a life time of fearing it? In case you advise to “work up to it” with smaller trips first–I do note that whenever I force myself to take a trip I always have some degree of panic/pain (although also enjoy the trip!) and one time I had violent panic one week driving 30 miles away–then, flew 1000 miles the next week with less fear! Then, came back and panicked again going 30 miles! For me, sucessive approximation doesn’t seem useful. Thanks so much for any information! Best,


Dear Kate,

Congratulations for not letting Agoraphobia/panic attacks control your life
to any large extent. Although I can’t make specific treatment
recommendations, there are several general principles that apply to your

First, panic attacks associated with travel in cars, planes, etc., are the
claustrophobic kind which are related to hypersensitivity to increasing
levels of CO2 in your blood – conditioned fear responses and anticipatory
anxiety results in shallow breathing and a build up of co2. The best way to
prevent this is to breathe properly – out first…see my website section on
panic attacks for the full technique. Practice this periodically and always use this technique when you
start to get anxious or panicky.

Klonopin is the strongest panic preventer but like most medications needs to
be taken in the right dose. Panic patients tend to take as little as they
can get by with instead of as much as they need. Usual daily dose is 2-3mg
but can be higher. It’s ok to sedate yourself on long flights if necessary.

Desensitization is situation specific – so that being able to fly 1000 miles
doesn’t mean you can necessarily drive long distances. Avoidance or using
escape makes you worse, as does hanging in there but having a horrible
experience. Using proper breathing and or adequate medication to get
through it makes you better. Some people need to add an SSRI or SNRI to
facilitate full desensitization. Positive self-talk and having distractions
can also help.

Good luck!
Dr. Jones

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Can stimulants permanently stunt growth in children?

I have not seen previous reports of permanent growth suppression from long-term use of stimulants during childhood.  Expert consensus and my clinical experience is that height may be slightly delayed but is genetically determined (assuming adequate nutrition).

The package insert for methylphenidate products (Ritalin, Concerta, Focalin, Daytrana, Metadate), cautions that daily use in a controlled study versus a controlled group did show on average 2cm less height after 3 years – but it is assumed to eventually catch up.

Kids who don’t take medication on weekends or during summer don’t show this delay.  The presumed mechanism of the delay is that norepinephrine (increased by methylphenidate) leads to a decreased release of growth hormone during deep sleep, (normally in the first 3 hours).  This suppression of growth hormone can probably be prevented by use of Clonidine or possibly Guanfacine  taken at bedtime.

In the reader’s comment amphetamines were referenced but the statement was also made that the person referred to was treated with methylphenidate.  Of course both are stimulants but are significantly different.

The package insert on amphetamines (including Adderall and Vyvanse) cautions about below average weight gain over a one year period of daily use.  In the Vyvanse study the evidence was that at the beginning of the study the average child was at the 62nd percentile of body weight – since food is a natural booster of dopamine in the nucleus accumbens, patients on amphetamines are less likely to eat out of boredom and they usually lose weight.

In fairness, we do have more studies using methylphenidate in kids than amphetamines.  The longest controlled study ever, the MTA study was also predominantly methylphenidate.  Intuitively it would make sense that amphetamines would raise norepinephrine levels even more since they increase release in addition to blocking reuptake.  Empirically however, methylphenidate is associated with increased excretion of norepinephrine and amphetamines are associated with a decrease.  Presumably amphetamines are more likely to down regulate, ie, modulate norepinephrine levels.

The hardcore science for all of this is in its infancy.  We will undoubtedly find that there are “outliers”, but at this time with all the evidence I know of the long-term benefits outweigh potential risks for the spectrum of Attention Deficit Hyperactivity Disorder.

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I am switching to Vyvanse from Adderall and I am also trying to lose weight. Which of these meds suppresses appetite better?

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I took Adderall for ADHD. I then switched to Vyvanse for 2 months. It stopped working. I have anxiety and moodiness on it…which makes the ADHD worse. I can’t concentrate and am going back to the doctor. What do you recommend and should I take Tenex?

What does it mean when stimulants stop working and/or start causing anxiety or moodiness?  Stimulants usually have a stronger effect when they are first started and then the dose has to be increased to achieve a good response.  Some patients will become tolerant to at least some of the stimulant effects and have to increase the dose gradually over time.  This is not a major problem as long as the total daily dose doesn’t exceed the maximum.

Dosing chart:

Your problem may just be an inadequate dosing issue.

The anxiety and moodiness that you are having may be a side-effect or a rebound effect depending on when it is occurring.  If your mood symptoms are at their worst between 3 1/2 to 5 hours of taking Vyvanse it is probably a side-effect.  If they are  occurring later it more likely is rebound and you need a second dose – probably around lunch time.  Rebound symptoms are more likely with Adderall XR than Vyvanse – short acting Adderall or Dexedrine tablets are even worse.

The majority of my patients have done better on and preferred Vyvanse.  There are some patients however who do better on Adderall XR, presumably because they need the added norepinephrine effect.  More patients on Adderall need to add Tenex, but it can also be helpful with Vyvanse.

Anxiety and moodiness starting after taking stimulants for a while can also be due to underlying genetics of mood disorder, especially bipolar.  Any significant family history of major mood disorder increases the risk.  Patients with ADHD and bipolar genetics do best on a combination of a mood stabilizer and a stimulant.

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My doctor prescribed methylphenidate for weight gain from Effexor and Lexapro. It makes me sleepy/drowsy. Is there a better drug for appetite suppression?

There are occasional patients who become sluggish or sedated with methylphenidate for reasons that aren’t clear.  If you are taking Effexor or Lexapro in the am then these could interfere with the activating effects of the stimulant.  Lexapro and Effexor are usually taken in am when first started, but after a few weeks they generally work better taking them at night (Lexapro) or supper (Effexor XR), and this is especially true when combining with stimulants. 

See how to take Effexor:

The most effective stimulant for appetite suppression and weight loss is Dexedrine (Vyvanse is the most effective form).  Adderall is the next best.  Methylphenidate is the least effective for appetite/weight.

In general, using stimulants to lose weight needs to be a long term commitment.  If the stimulant is stopped the weight is almost always regained – usually with 5 extra pounds for good measure.  This is not usually the case if weight gain only occurred on an antidepressant and the antidepressant is no longer being taken.  All antidepressants except Wellbutrin are sometimes associated with weight gain, but may not occur until several months of being on the medication.  Weight gain is partly due to changing set points for serotonin receptors that help regulate carbohydrate intake.  Another possible mechanism is that serotonin up regulation by antidepressants can down regulate dopamine and eating is one way to stimulate the dopamine system.  Stimulants, especially amphetamines (Dexedrine, Vyvanse, Adderall) increase dopamine release to counteract the serotonin effect.



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I have had chronic sleeping problems for 10 years. I am a 58 yo woman going through menopause. My mother is 90 and still on sleeping pills. Could my condition be hereditary? Which pill will give me 7 hours of sleep leaving me refreshed the next day?

See the Do’s and Don’ts of sleeping habits on my site:

Make sure you are doing all the cognitive and behavioral things you can do to optimize sleep. 

You are in a high risk group for insomnia.  Sleep problems are more common in women than men, increase with age, and are aggravated by menopause.  The onset of your insomnia coincides with perimenopause.

Estrogen has many more potential benefits than risks for most women – especially brain benefits.  Unfortunately, if you still have your uterus you have to take some progesterone.  There are options like long acting intrauterine forms of progesterone that can minimize side-effects.  I am totally opposed to oral estradiol such as Estrace.

  Premarin or synthetic Cenestin by mouth and or estradiol cream/gel or patch is the best form.  The WHE study 5 years ago scared a lot of women about estrogen replacement therapy but the women in the study were on average 10 years post menopause and never used estrogen – that puts women at greater risk and may apply to you especially if you smoke.

One milder option is prescription DHEA which in women mainly turns to testosterone (good for bone and muscle) but then in the brain is converted to estrogen – avoiding the increased risk of estrogen related breast cancer.  

There are occasional women who benefit from natural progesterone (Prometrium) at bedtime since it has a natural benzodiazepine like sedative effect.  I recommend that you don’t take synthetic progesterone like Provera.  

Any form of alcohol can contribute to sleep problems because it causes arousal as it wears off.  If you do drink alcohol make sure it is not within 3-4 hours of going to bed.

We are fortunate to have very effective sleep medications that provide normal sleep.  The mildest, shortest acting is Sonata, usually 10mg-20mg lasts 4-5 hours.  Benzodiazepines such as Xanax, Klonodine, Ativan, etc., shouldn’t be used at bedtime because they decrease stage 4 sleep (the most important type of sleep), but they can be used for early awakening with inability to get back to sleep – since we get all our deep sleep in the first three hours.

Lunesta (2-4mg is needed) for sleep but may cause a bad taste in 15-20% of people (less likely if taken with orange juice).

In general, Ambien CR is better than Ambien tablets because they frequently don’t last long enough.  The generic form is probably weaker.  The CR form is not as strong as the tablets for inducing sleep but lasts longer.  Some people have to combine CR with the short acting tablets to get to sleep.

All of these sleep medications work better on an empty stomach – combined with good sleep habits as I stated earlier.

Circadian rhythm problems can also contribute to the problem.  Morning bright light and or evening melatonin or prescription Rozerum may also help. 

Adding Tenex or Clonidine, or occasionally Prozosin can be helpful.  Trazodone, Seroquel, or low dose Doxepin may help.  Neurontin (up to 800mg) or Lyrica also induce normal sleep.

Chronic insomnia can be very resistant because of all the anxiety and conditioned negative expectations.  It is harder to treat initially and gets easier as fear of insomnia subsides.  When problems persist a sleep study can help identify problems such as restless legs, myoclonus, or sleep apnea.

When all else fails there is a medication that usually works, Xyrem.  It is highly regulated because of previous misuse of it as GHB.

Because good sleep is so essential you have to persist until you find what works for you.  Don’t give up until you find the right medication at the right dose.    

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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 
  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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