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.

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.

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.

Serious adverse rashes can occur with Lamictil but it is rare.  Most reactions are mild - they go away when the Lamictal is stopped and many people tolerate Lamictal okay when it is restarted.  If a week or more goes by before skin clears you have to start back at 25mg or even lower.

Severe reactions are rare but can include anything above the neck such as swollen lymph nodes,  lesions in the mucous membranes in the mouth, or under the eyelids.  Then it is not considered safe to try taking it again.

I can’t tell how severe your reaction was but on the face is worrisome and "vasculitis" doesn’t sound good.  You should probably discuss this reaction with a dermatologist before trying Lamictal again.    

Depakene even in the best form, Depakote ER, can have adverse effects on hormones - it would be one of my last choices.  Lamictal is the best tolerated mood stabilizer if it doesn’t cause a serious rash (very uncommon).    The main problem with Lamictal is that it has to  be built up slowly so it would need to be overlapped with Depakote or something else.  In general for most patients Lamictal is a much better medication.

If she is on birth control pills - which is not recommended for women with mood disorders - Lamictal doses need to be higher.  The NuvaRing is the best form of birth control in my opinion if needed.  

LAMICTAL (lamotrigine)

LAMICTAL (lamotrigine) is formally classified as an anticonvulsant drug.  However, it has been used for many years for migraines and pain.  It is also effective for treating bipolar depression.

WARNING: STOP THE MEDICATION IMMEDIATELY IF A RASH APPEARS.

Lamictal comes in scored tablets of 25, 100, 150, and 200mg. It is most cost effective to buy the larger sizes and cut them in half.

The dose may need to be increased to a total of 250-400mg.

SIDE EFFECTS

If significant side effects occur (e.g. dizziness on 25mg), the dose may be reduced even further. 

To decrease side effects (especially risk of rash) take each dose for 2 weeks.

What do we know about the cause of postpartum psychosis?

Hormones, especially estrogen, have a significant effect on mood. Estrogen raises serotonin. When estrogen drops precipitously, as it does premenstrually, postpartum, and at the onset of menopause - the brain serotonin levels drop. In women who are sensitive to low serotonin (because of genetics or previous episodes of significant depression) dropping the level will bring on symptoms of depression.

This principle can be demonstrated experimentally. By giving someone a drink of amino acid (from which tryptophan has been removed) the level of brain serotonin will temporarily go down. This is because tryptophan is the amino acid the brain uses to make serotonin. Only people with a vulnerability to becoming clinically depressed will show a depressive response to the serotonin level drop. This phenomenon contributes to premenstrual depression and menopausal (especially perimenopausal) depression.

Think about how dramatically hormone levels drop after child birth. This is why postpartum blues (brief symptoms of mild depression) is extremely common. The postpartum period is the highest risk period for full blown clinical depression.

Post partum psychosis is an extreme form of mood disorder in which underlying genetic vulnerability causes not only depression but a psychotic state. This fortunately only occurs in 1 out of 1000 births.

Psychosis is often confused with delirium. Delirium is a state of severe confusion and disorientation that can be brought on by toxins, severe infections, and many other causes. Every area of functioning is impaired. Psychosis means there is a distortion between conscious reality and external reality.

The most common symptoms of psychosis are hallucinations (seeing things or hearing things that aren’t there) or delusions (beliefs that aren’t true). A person can have one serious delusion that can affect their behavior but can be totally normal in other areas of functioning.

A woman who has had one postpartum psychosis is at a very high risk in any future pregnancies. It was for this reason that Andrea Yates was advised not to have any more children. So why did she and her husband ignore this? I don’t presume to know all the factors that they took into account. But I know she was never diagnosed as bipolar.  And they were never adequately educated about the physiology and medical science that we do have about what causes postpartum depression and psychosis.

Another factor in the Yate’s decision to continue to have children was their faith. They relied more on spiritual experience and counseling with their minister than medical advice. Unfortunately they had come under the influence of an extremist minister, and their medical advice was inadequate and not convincing.

Can they be faulted for not realizing all of this?  I think not. It is not unusual for a person of strong faith to at times feel caught between science on the one side and their faith on the other.

Many centuries ago St. Augustine showed more wisdom in this matter than many of our current experts. He said in effect science and religion aren’t in opposition. They are both ways of looking at and understanding one truth. When science and religion don’t agree we need to discourse and study so that the disagreement can be resolved - without feeling like you have to choose one or the other. Of course not all supposed science is valid and not all ministerial counsel can be trusted. Extremism of any type is dangerous.

Question: Can a series of major stress over a period of 3-4 years cause a person to become bipolar?

– Pat P.
Answer: If one has genetic predisposition, then a series of stressors can turn on the genes and induce depression, hypomania or both (mixed or dysphoric mania). Non-genetic personality factors and availability of social support also play a a significant role. In the absence of genetic predisposition, it takes a lot more stress overload to induce symptoms.
It’s analogous to the situation of high sodium diet and high blood pressure. It’s the combination of genetic predisposition plus high sodium that leads to hypertension, whereas neither alone do it.
For more info, see the blog on Jane Pauley and the overview of Bipolar Disorder.

It’s frustrating trying to figure out what happened in the Miami airport this Wednesday. For the first time in U.S. history, a passenger was gunned down on the jetway after he abruptly left the plane just before takeoff.

At first it seemed tragically clear cut. He had Bipolar disorder, was off his meds, and he said he had a bomb. He apparently refused to comply when the air marshals ordered him to the ground. He then reached into his backpack and the air marshals had no other option than to shoot.

Questions like couldn’t they have just wounded him or physically subdued him or used a taser gun have been fairly well answered as too risky, not safe enough or not decisive enough. The marshals did what they were trained to do.

So why isn’t that the end of the story? In today’s USA Today, it was reported that after having initially taken his seat on the plane next to his wife, he suddenly jumped up and ran down the aisle flailing his arms. A flight attendant reportedly told him he couldn’t get off the plane - to which he said, "I have a bomb." But also on today’s AP wire, two passengers close to the exchange between him and the flight attendant said emphatically they never heard the word bomb.

Did someone misunderstand what he was saying? His wife was running up the aisle saying he’s Bipolar and off his meds, although one passenger reported that the wife was speaking Spanish, saying, "He’s sick. He has a problem."

Why did he feel he had to get off the plane? The most common explanation would be that he was having a panic attack - very common in individuals with Bipolar disorder. 

Unfortunately, I have not been able to find any information from the wife about what he was saying. There are reports today that in the airport, before boarding the plane, he seemed agitated and was singing "Go Down Moses" as his wife tried to calm him. It was also reported by a passenger near him on the plane that he seemed very restless and suddenly said he had to get off.

Bipolar disorder, when not controlled, can lead to a feeling of agitation that makes it very difficult to sit still. It can also produce delusional ideas or hallucinations that direct a person to flee.

Adding to the tragedy and confusion are several reports about what a nice, gentle person he was. He was well liked at work and in his Orlando neighborhood. He and his wife had been married over 18 years and had just returned from a missionary trip to Ecuador where Mr. Alpizar had served as a translator for a group of dentists and ophthalmologists offering their services to poor communities.

Assuming he did say he had a bomb - what would have been his motivation? Was he using that as a threat so they would let him off the plane? We obviously need more information. But mostly, we can’t just say - "He was Bipolar and that explains his crazy behavior."

Why was he allowed to board the plane in the first place? Why didn’t his wife talk to someone and try to get help for him instead of boarding the plane? Hopefully, we’ll get some answers soon. I’m eager to hear your opinions on this story.