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I’m glad to be back! We have had technical issues with our site for several weeks. Everything should now be operational.

FYI, in case you didn’t catch this before,  I’m a “sport bitcher”.  I love complaining, and being sarcastic, especially  about “the system”.  After 52 years of observation and study of neuroscience there is only one thing I know for sure…if the government is involved it’s screwed.  (This is to be continued later.)

In order to bitch convincingly I stay well informed through informal as well as formal study every day.  I realized many years ago that every patient is a teacher,  so I spend many hours in the “classroom” every week.

To me the most important knowledge is where science meets practical day to day reality. The best medication in the world is irrelevant if it’s not available or it’s unaffordable.  Making the best possible treatments  happen or getting as close as we can is part of the art of medicine.

As I try to answer questions for my patients, as well as those that inquire on my website, I draw on many sources of information.  My facts will almost always be right.  Some of my ideas, assumptions, and beliefs may turn out to be wrong, but looking back at the the things I’ve written over the years I’ve found most of it is still right on target using the current scientific data and my own clinical observations!

I believe that the foundation of medicine/psychiatry is empiric science. That means we gather information and observations, and then develop hypotheses…and ultimately theories to explain them.  One thing that characterizes scientific ideas is that they can be proven wrong. We are constantly modifying our understanding of how things work.

When we look back 100, 200 years at what philosophers/scientists thought, we think, “are you kidding me?”  Well, guess what? …one hundred years from now we are not going to look so bright.  Unfortunately, the more we learn, the more we realize we don’t know.  An example within the last century is that we have gone from the solar system, to the galaxy, to billions of galaxies – each with greater and greater complexity and mystery.  As we have expanded outwardly we have explored the seemingly infinite micro-diversity of each cell and atom.  To paraphrase Socrates, what I know best is there are a lot of things I don’t know.

I see my job as educating patients about the pros and cons of each option and then let them make the decisions that effect their personal lives. Time will tell if we are going the right direction, and we will expect to make adjustments along the way.  As circumstances change, new insights are developed, new studies are conducted, and new options are available we will be better able to meet the needs of  each individual patient.  This should be very encouraging for those that are struggling to function well, feel good, and live better lives.

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Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.

Russell Barkley, Ph.D., is considered by many professionals to be the most authoritative expert (researcher), on the cognitive/behavioral aspects of ADHD.
In his book, Adult ADHD (2010), he details a study where he followed a group of non-ADHD young kids to age 30 and compared them to a group of ADHD kids. There were about 100 kids in each group.
The most striking finding in this study is that untreated ADHD impairs functioning in every area of life. They are less likely to be employed, and if employed, make less money, have had more jobs, have less education, worse grades, or took longer to get through school. They were also in greater debt, had more relationship problems, worse health, more traffic tickets, and other legal problems.
In my clinical experience over the past 40 years I have seen more people’s lives dramatically improve with ADHD treatment than any other mental health condition I treat, usually by prescribing a stimulant.
Long-term adherence to treatment is a problem with all medical and mental health problems, but many times it is because patients did not get the right medication(s) at the right dose(s). Sometimes cost is the primary problem but adequate generic medications and sometimes patient assistance programs can solve that issue.
We ADHD personalities are driven by interest rather than importance. We tend to be easily distracted and have way too many things on our mind at any given moment. ADHD medications can help us be calm and focused, and not only cope with our rapidly changing modern world, but actually thrive.

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Best Medications Revisited

In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company.  They asked me if I could have only five medications to prescribe which ones would I choose?  Since I have a cash only practice I have to go with the most effective medications long term.

Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement).  These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication. 

It is only through extensive clinical experience that we can learn which medications are best.

I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc.  If the medication starts working on day one that is a bonus. 

Great medications help you feel better, function better, be less stressed and help protect your overall health.  Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival.  You think – I wish I had this medication a long time ago. 

The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.

In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great).  I have patients that have taken them for over three decades.  I haven’t seen any long term problems from taking them.

I was initially trained in the 60’s.  One of the most helpful things I was taught – “if what you are doing isn’t working, do something else.  Even if it is wrong it will get you unstuck.”  This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.

Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry.  Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008.  Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc.,  not to mention a certain intimidation is felt by doctors.  By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.

My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications.  For now it consists of the following:

#1     Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines).  15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.

#2     Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice).  Clonazepam, especially Klonopin wafers are a  close second.  

Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians.  Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.   

#3     Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems).  Both of these meds work great for most people.  They are both approved for long term use and provide normal sleep.  Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta.  Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.

No sleep medications were in the top 10 meds prescribed by doctors in 2008.

#4     Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin.  Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch).  But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.

Cymbalta is the other antidepressant in this category.  It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine.  I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster.  Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone. 

#5     Mood stabilizers – Abilify/Seroquel.  There is no perfect choice in this category.  I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.

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