Which ADHD Medicine is Right for Me?

by Natan Schleider M.D.

December 7th, 2018

So you think you have attention deficit hyperactiviy disorder (ADHD formerly ADD) and you are considering medicine options. If you are like most patients I see, you’ve already queried friends, family, and the internet so you can tell the doctor what you think is best. I have no issues with educated patients so I’ve put together a list of medicines I use and why.

Note the family of stimulants (IE methylphenidate, Adderall, Vyvanse, and others) are the first recommended treatment in general for patients but that varies by patient and whether they have other medical or mental health issues.

Stimulants can be habit forming so considering a non-controlled medicine (bupropion aka Wellbutrin, Strattera) for ADHD may be a nice option as they are not habit forming although tend to be milder and less strong.

While discussing stimulants, let me add that I am often asked ‘Can’t I just drink a lot of caffeine for my ADHD?’ Caffeine is a unique molecule and while it keeps most people awake and is activating, it does NOT help ADHD symptoms.

The first question to ask when it comes to stimulants are whether your want a short acting medicine that can be used a few times a day or a long acting medicine taken once a day. This is patient preference as some like flexible dose options with a short acting medicine while others just like to take one pill a day.

So here are your stimulantmedicine options for ADHD:

  1. methylphenidate (best known as Ritalin) which is the oldest and comes as short acting (last 2-4 hours) and long acting (last 6-12 hours for Concerta or Focalin or Vyvanse–I find they last closer to 6 hours in most patients). Note Daytrana is a patch that lasts up to 10 hours
  2. Dextroamphetamine/amphetaime (Adderall) which comes as short acting or long acting (Adderall XR) and super long acting (Mydayis) at up to 12 hours.
  3. Dexedrine and Dexedrine Spansules are popular amongst a handful of my patients althugh they re hard to find at pharmacies.

 
And here are your non-stimulant medicine options for ADHD:

  1. Atomoxetine (Strattera) which takes about 3 days to kick in and dose can be adjusted from 40 mg to 80 mg (the standard dose) in 3 days.
  2. bupropion (Wellbutrin) is a very activating antidepressant approved for ADHD, tobacco cessation, and depression.

My patients tend to prefer Vyvanse which is the least speedy of the stimulants but every patient breaks the medicines down differently so it may take some trial and error to find the right choice.

When reviewing medicine options with patients I go over the above in detail. While talk therapy helps for most other mental health illneses, it is less effective for ADHD (but no harm in trying it).

If you have any questions or comments please reach out to me on Twiter or Instagram or facebook.

Thanks for reading,

Natan Schleider, M.D.

Do I Have Clinical Depression or Am I Just Feeling Badly Because Life Just Dealt Me Crap?

Do I Have Clinical Depression or Am I Just Feeling Badly Because Life Just Dealt Me Crap?

By Natan Schleider, M.D.

November 18th, 2018

So you just broke up with your fiancee, you or a loved one just got diagnosed with a serious illness, or you just started litigation. These are some of the most common reasons patients see me wondering if they are depressed.

So how do doctors and mental health care providers determine if someone is depressed and warrants treatment or is going through a normal grief reaction or ‘adjustment disorder?’

For me it is quite simple–as are the screening guidelines for depression.

A simple 2 questions (called the Patient Health Questionnaire 2 Screening Instrument for Depression or PHQ-2 for short) is all we need to screen for depression:

  1. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things [you normally enjoy]?
  2. Over the past two weeks, how often have you been feeling down, depressed or hopeless?

Not At All=Zero Points, Several Days=1 point, More than half the days=2 points, Most days=3 points.

A score of 3 or more would be a positive screen for depression at which point your health care provider should dig deeper with more detailed questions. I would not give a patient with a score of 2 a slap on the back and a lollipop and say ‘suck it up’ but the PHQ-2 helps catch at least 90 percent of depressed patients.

I am commonly asked: ‘Since I know the cause of my depressed mood, do I really need further evaluation or treatment?’ The answer is: nearly all of my depressed patients know why they are down, if they have clinical criteria for depression such as changes in sleep, interest deficit, guilt (hopelessness, regret, etc), appetite changes/weight changes, psychomotor retardation (trouble coordinating and concentrating), and/or suicidal thoughts or plans treatment is indicated.

That does not mean the patient is committing to a pill for life–a common fear. Talk therapy, herbal medicines like St.John’s Wort, and other non pharmaceutical treatments are available.

If you are feeling down and think you may be depressed, you are not alone–about 8 percent of the US population is depressed.

If you enjoyed this article and have questions, comments, or concerns please let me know via this blog or twitter or facebook or instagram.

Thanks for reading!

Natan Schleider, M.D.

SOURCE: AMERICAN FAMILY PHYSICIAN V.98 NO.8 OCT 15TH, 2018

Ten tips to be sure you have been prescribed the right antidepressant?

Ten Tips to be Sure You Have Been Prescribed the Right Antidepressant

By Natan Schleider, M.D.

October 15th, 2018

‘So my mood is much better,’ said my patient last week, ‘but I can’t get it up.’

Antidepressant medicines (not a great name for what they do since many also treat anxiety without depression, nerve pain, fibromyalgia, etc) come in many families and varieties. Choosing the right one is difficult, espcecially since many share the same common side effects like weight gain and sexual side effects.

If you have been prescribed an antidepressant for any reason, always consider whether possible side effects outweigh potential benefits and ask ‘Am I on the right antidepressant for me?’. Here are some tips on how to do just that:

  1. If you are concerned about weight gain, the Selective Serotonin Reuptake Inhibitor (SSRI) family, the Tricyclic Antidepressant Family TCA), and some other antidepressants like mirtazapine (Remeron) can cause weight gain. I find escitalopram (Lexapro) weight neutral, that is, most of my patients do not gain weight with it althoug it is an SSRI.
  2. Sexual side effects like poor libido or trouble obtaining or maintaining an erection can occur with TCAs and SSRIs
  3. The SSRIs tend to be one of the most common first choices doctors prescribe as they are inexpensive and have a pretty good safety profile; however, they are not all equal in action. Some are more activating and I use these with patients who are depressed, apathetic, oversleeping and overeating. Others are more sedating, good for someone also suffering from poor appetite, and feeling wired or anxious. Here is a list from most activating to least activating (although some patients will react to them differently): fluoxetine, sertraline, paroxetine, escitalopram, citalopram, fluvoxamine (an interesting SSRI not FDA approved for depression but anxiety).
  4. If other symptoms are present that the antidepressant can help with, why not kill too birds with one stone. For example duloxetine (Cymbalta) can be used for depression and/or anxiety and/or nerve pain and/or fibromyalgia.
  5. If you or a first degree relative have had success with a particular antidepressant in the past, that would be a reasonable one to trial
  6. If you are good at remembring to take your pills daily, great. If not, I would avoid venlafexine (Effexor XR) which is broken down quickly in the body and leave you in an uncomfortable withdrawal if not taken at the same time daily.
  7. If you have had side effects from one family of antidepressants, good chance you will have them from all medicines in that family so consider switching to a different family.
  8. If your mood can be managed without a daily medicine, for example talk therapy why not go for that first?
  9. If you are on other mental health medicines, double check there is no interaction between them. Most medicine labels may read do not take your antidepressant with alcohol–this is a common question. textbook answer is ideally don’t drink while on mental health medicines as they can confuse the diagnosis or medicines effect, especially if you like your medicines with a mimosa every morning.
  10. If you have failed the older families of medicines, try some newer antidepressants like vilazodone (Vybrid), Vortioxetine (Trintellix), or levomilnacipran (Fetzima).

Hope that answers some questions! Questions, comments, concerns? Contact me:

Twitter: @DrSchleider