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.

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: http://www.askdrjones.com/2005/12/29/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.

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

 http://www.askdrjones.com/wp-content/uploads/2006/06/sleep_dos_and_donts1.pdf

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.  http://www.askdrjones.com/2007/04/28/say-goodbye-to-the-pill-ladies/

  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.    

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.

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  www.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. 

I don’t use Risperdal because of the increased risk of neurological side-effects, and increased prolactin interfering with hormones, including estrogen.  Lexapro is good for anxiety, obsessiveness, and depression, especially sadness, but if your daughter is manic depressed/bipolar the Lexapro can make her more emotionally unstable.  Effexor XR is a broader spectrum medication with potential advantages but would also destabilize if she is bipolar.

How thorough was her examination?  What family history is there for anxiety, depression, or bipolar?

If your daughter needs a mood stabilizer or something to "glue" her thoughts I have had the best luck with Abilify or Seroquel. www.askdrjones.com/2005/02/14/ranking-the-mood-stabilizers/

Age fifteen is such a critical time developmentally so you need an experienced clinician and you need to be seeing some improvement.

Recovery from agoraphobia requires a good understanding of what it is, proper breathing www.askdrjones.com/wp-content/uploads/2006/06/Anxiety_Handout.pdf and complete desensitization.  SSRI’s/SNRI’s are not required unless you are unable to progress with CBT, breathing correctly, and benzodiazepines - including as needed extra doses.  Some patients do better on Clonazepam, or Xanax XR, or Niravam.  If SSRI’s/SNRI’s are needed you have to start with a very low dose - the lowest I ever gave a patient was one granule of Effexor XR.

Treat agoraphobia like a bully that wants to run your life.  If you give an inch it will take a mile.  It’s okay to stop, breathe, take extra medication or call a support person, but don’t leave or avoid. 

Geodon is a medication with a lot of issues so that it is not one of my first choices.  It is a good antimanic mood stabilizer if taken in higher doses (120-160mg).  At lower doses it can destabilize mood.  It is not an anti-anxiety medication.  It usually requires twice daily dosing and wears off fast if doses are missed and if not taken with food.  It only has a 50% absorption.  It is relatively benign from the standpoint of weight gain and metabolic syndrome.  It is not acutely effective for insomnia.  Dosing is more complicated because it is in capsules. 

Abilify is in tablets that can be easily broken in half at the 2.5 and 10mg doses,  has the longest duration of this class, and can be started low and slowly increased.  www.askdrjones.com/2005/02/14/ranking-the-mood-stabilizers/  Both medications are pricey.

Vyvanse has less effect on the cardiovascular system than Adderall but all stimulants have possible cardiovascular side-effects.  You should stop taking it and see if the symptoms go away.  If not you need to see your cardiologist or internist.  If the side-effects do go away you may want to discuss options with your doctor. 

Generic Tenex helps with distractibility www.askdrjones.com/2006/11/07/tenex/ and can be taken with Toprol if it doesn’t lower the blood pressure too much.  You may tolerate a lower dose of Vyvanse, possibly with Tenex or you may do better on one of the forms of methylphenidate, or possibly Provigil.

Addiction means continued use in spite of negative consequences.  In this sense Benadryl addiction is not known to be a common problem.  Since it can cause weird reactions at high doses I guess that is possible.  People who abuse downers are usually trying to be somewhat emotionally “numb” - so that’s a possibility.

Many people confuse physical dependence with addiction.  This results from taking something long enough or in high enough doses that  you become physiologically adapted to it - then if you just stop it you can have withdrawal symptoms.  In the latter case you just need to taper it slowly - it could take a few weeks, depending on how long you have taken it regularly.

The other issue would be what were you taking it for?  Is there a condition that needs to be treated?