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_donts.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 like 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. 

Brain functioning is genetically variable (polymorphic) and has plasticity – adaptability to conditions and experience.  When you learn a new skill  or habit – at any age  (though easier when in childhood) it changes your brain.  Neurons establish new connections.  Connections are strengthened – more receptors and nerve impulses are made faster and more myelin (insulation) is enhanced. 

Now new research is showing that giving more structure to a preschooler’s day can improve ADHD symptoms.  A recent study of treating preschoolers with medication found that the medication did help but not as much as in older kids and with more side-effects – leading to the conclusion that the need and potential benefits have to be greater in younger kids to justify use. 

Having behavioral alternatives is much more acceptable to most parents who worry that medication may not be the right answer.

I know you’re thinking, why not do the same thing with school age kids?  Probably the most elaborate research study in psychiatry ever was the MTA study.  Medication was unequivocally the superior treatment for school age children. 

MTA link:  www.askdrjones.com/

Although I don’t treat a lot of preschoolers I have treated a few and I generally recommend medication with the following conditions:

1.    If I don’t treat the kid’s ADHD I’m going to have to treat the parents and siblings for major stress symptoms

2.    If I don’t treat the kid no day care will keep them and mother (frequently a single parent) or father won’t be able to work and they’ll be standing in soup lines and bunking down at the Salvation Army

3.    Extreme impulsivity resulting in dangerous behavior like running out in the street

Ironically, methylphenidate has been the most studied in preschoolers but only dextroamphetamine is approved down to age three.

Estimates of incidence of significant ADHD symptoms in preschoolers are 1 to 4%.  The best test is to be in a room with them for a while – how bad do you need a drink or a Xanax afterwards?  The second best test is how much does mother look like the “before pictures” of the woman in the mattress commercials?  (Or in the case of the one with Lindsay Wagner even the after picture looks pretty haggard.)

A five year old study sponsored by the National Institute of Mental Health provided a range of behavioral therapies to135 preschool kids with severe ADHD:

1.    Families were given parent education classes only

2.    Or classes and home visits by researchers who gave individualized behavioral therapy for each child’s particular needs

After one year aggressive behavior and learning had improved by 30%.  One parent said the most effective technique was providing predictability, such as, we are going to be leaving the playground in 5 minutes, 4 minutes, etc.  (She didn’t mention having to use a lasso or pepper spray when it was time to actually leave).  She also thought it was helpful to praise the child for doing things like behaving during a boring activity, helping with cleanup, or other positive behaviors.  (This study was reported in School Psychology Review Sept 07).

Classic behavioral management principles of parenting are:

1.    Behavior you like and want more of (praise, reward)

2.    Behavior you don’t like but that doesn’t bother you or others particularly (so you ignore)

3.    Behavior you can’t stand or is bothering others (punish) 

Note: Time-outs work well.  They provide the first opportunity to use the power of the “pop” (e.g., when they refuse to go to time-out).

The problem is that classic parenting doesn’t always work so great.  As Dennis the Menace said in one cartoon, “by the time I realize the consequences of my action I’ve already done it”.     www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

A study of 3,000 randomly selected kids ages 8-15 was funded by the National Institute of Health (with no pharmaceutical company support).  The main author was Tanya Froehlich, a developmental behavior pediatrician.   The study was published in Archives of Pediatric & Adolescent Medicine Sept 07.

Originally the objective was to see if ADHD in kids was being over diagnosed and over treated.  Actual findings showed only 3% of those without ADHD were receiving medical treatment – and they could have represented kids who had improved so no longer met criteria.  They also found that 9% of the 3,000 kids had ADHD of which only 1/3 were consistently being treated.

That finding or worse has been repeatedly found – the question is, WHY?

I believe the most common reason is that the patient has not taken “the right medication at the right dose”.

 In consulting with physicians in their offices a frequently mentioned problem is getting kids to take their meds.  My approach is to first redefine the problem for kids and their families.

ADHD is a type of personality that makes it difficult to focus on things that aren’t interesting.

Like what?  Like school mostly.  The cause is genetic (polymorphism).  Mother Nature doesn’t want ADHD kids or adults spending time with boring, repetitive stuff.  ADHD people are the explorers, challengers, and changers of the world.

One of the problems with being ADHD is that in order for us to go to the best schools and get the best jobs, starting with the 9th grade we need to perform well in school and keep up with boring details (and at work boring reports, etc.)

The GOOD news is that medication – especially stimulants make our lives better by giving us the ability to do well on the boring stuff.  It also helps us stay calm and still when appropriate, and in control.

THE GOAL

The goal is to find a medication that kids, teens, and adults like.  Their lives are easier – they’re getting things done effectively and side-effects from the meds if any, are minimal.  HINT:  The medication probably isn’t Strattera.

If medication makes kids feel bad they shouldn’t take it.  I worry more about kids/teens who take meds that make them feel bad or detached or flat or racy.  I worry about parents who keep giving kids the wrong medication or the wrong dose.

Another reason for poor consistent compliance with treatment is that usually at least one of the parents is also ADHD.  Only 10% of ADHD adults are being treated.  So the parents forget, lose the med, are running late, or don’t have time.  They can’t stay organized to keep up with getting refills, scheduling and keeping follow-up appointments, much less filing insurance forms, etc.

Again this year at the American Psychiatric Association annual meeting a group of loud marchers picketed the main conference center.  “Stop poisoning our children” and other banners were being waved.  They were mostly Scientologists who are a blend of idiocy and nuttiness.  They should be sentenced for life to be locked up with a hyperactive kid like our son was in childhood.

Unfortunately, some patients give up too quickly on one or more meds because they don’t understand all the nuances of dosing and side-effects.  But, fortunately, we keep getting better and better medications that are more effective and last all day and are safer with less side-effects.

 Newest med:www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/