Meridia (sibutramine) is FDA approved for weight loss.  It combines the effects of antidepressants like Effexor (at doses of 225mg or higher) or Cymbalta with dopamine effects like stimulants.  One possible side effect is increased blood pressure.

Years ago I tried Meridia for several patients and most of them didn’t like it enough to stay on it.  If you are looking for a medication that helps with depression and weight loss then I would recommend Wellbutrin.  www.askdrjones.com/2005/12/29/how-to-take-wellbutrin/  If you are mostly interested in the mood/anxiety effects I would recommend Effexor XL at least 225mg per day possibly in combination with Wellbutrin.  This would closely duplicate the effects of Meridia.  An alternative that might even be better would be Effexor and Vyvanse.

I am not crazy about long term use of Xanax (or any other benzodiazepine) for treatment of chronic insomnia because they don’t produce all the normal sleep states (esp. stage 4 deep sleep).  Whether this is the case in everyone and whether this effect persists indefinately has not been adequately studied.  My main concern is that lack of stage 4 sleep can be associated with less secretion of growth hormone and other restorative processes that occur during the deepest sleep states - e.g., maintaining the immune system.  There may also be some reduction of REM sleep - that might impair long term memory.  None of this is adequately studied.

Most of my ADHD patients do well and many if not most like being ADHD.  There are some who haven’t found the "right medication(s)", but there are frequently new medications that become available.  Within 4-8 weeks we will have Vyvanse, a new form of Dexedrine that has research benefit higher than currently available medications.

Sometimes it takes a combination of meds like Adderall XR or Methylphenidate + Tenex (Guanfacine).  Sometimes it takes a different form of medication (like the Daytrana patch) which is a form of Methylphenidate that avoids first pass metabolism in the gut and liver.  This is a plus for patients that are rapid metabolizers and don’t get enough of the tablet forms into their brain.  There are also people that don’t tolerate any of the stimulants except Desoxyn.

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

Another possibility is that you are not just ADHD.  At least 85% of people with ADHD have other conditions that have to be addressed.  You are 3 times more likely than the general population to have a mood disorder, an anxiety disorder, substance abuse issues, or impulse control disorder.

We already know 11 different gene variants that are more common in people who are ADHD.  All these possible complexities need to be addressed as well as basic health habits (especially sleep) to enable you to have the quality of life you want and deserve.  

Question:  I have ADHD, and it is ruining my life.  I can’t function like everyone else.  I keep making appointments to see a therapist, but I never go.  I don’t want to do this anymore.  I want to go to college, but everyone I know says it’s not a good idea for ME.  Can ADHD people succeed in college?

- Stacy

Question:  Why are you so down on Luvox?  It has worked well for me in the past.  Also, I use 1200 of Lithium and my creatinine is 1.2.  I have used it 10 years.  At what creatinine level should Lithium be stopped?  I would try Abilify but am diabetic. - John

Prolonged use of Lithium can lead to some type of kidney impairment, probably inflammatory.  It’s more likely if serum levels are higher (1.0 and above) and may be more likely in individuals that have frequent urination and thirst.  It usually develops after years of use, and so far in my experience, it has not progressed to be a severe problem. But usually the Lithium itself was stopped.

I don’t routinely monitor creatinine levels.  They only start going up if kidney function is reduced by 75% or more.  If that occurs, the serum Lithium will go up without a change in dose or decrease in sodium intake or excess sodium loss (e.g. taking diuretics, vomiting, or diarrhea).

As with all meds, the decision comes down to benefit vs. risks, and in your case, Abilify might be a good option.

Question: I recently saw a special on deep tissue stimulation for OCD. It worked in this patient. How does deep tissue stimulation work? - Lea

Answer: I have not seen anything about that.  However, I recommend the Brain Lock technique to all my OCD patients - preferably to listen to the audio tape version of the book.
In the book Dr. Schwartz describes a cognitive behavioral technique used in a successful study done at UCLA.  The most important step in the technique is to shift your focus to something else.  At any given moment your focus is in your mind, in the environment, or in your body.  When stuck in obsessive thoughts or compulsive rituals, you need to shift focus.

• In your mind: thinking about something else or visualizing.
• To the environment: listening to music, watching a movie, playing a video game
• Into your body: exercising, yoga, etc. 

Deep tissue stimulation at the least would help shift focus to the body.  If combined with breathing or other relaxation techniques, it could also facilitate a shift into a more relaxed state of brain activity (alpha rhythm - slower and bigger waves than the usual beta activity of the awake state).  In the alpha state, the mind is more creative and not distressed which facilitates more positive thinking and imaging.  The same state can be achieved through long aerobic activity like running or meditation.

So, I can see where deep tissue stimulation could be useful for anyone with stress overload symptoms.  The problem that I would expect to see is that it works that day and the benefit lasts for awhile, but next week or next month, significant symptoms may return and deep tissue stimulation may not be available or feasible.

Brain Lock

Question:

Answer:

Strictly speaking, there is no standard treatment for Fibromyalgia. I’m not aware of any treatment having formal FDA approval. Cymbalta does have some positive controlled studies and Eli Lilly may be applying for approval.

Low thyroid is a common problem associated with fibromyalgia (see Thyroid Facts and Myths).

Stimulants are frequently used for chronic fatigue although they are not FDA approved for this. You are on a good combination of meds. If you are taking Cymbalta early in the day, switching to bedtime might help.

There are multiple options that could help motivation and energy levels:

• Increasing Concerta
• Increasing Cymbalta
• Adding Wellbutrin XL

Of course, you would need to discuss options with your doctor. It’s usually best to make only one change at a time.

Good luck!

Dr. Jones

Question: I have bad stomach pain after taking a drug for a bladder condition. I was also on Prozac, Elavil and Lorazepam at the time, for bladder and depression issues. I stopped the Prozac because I wanted to take less drugs, because now I also have to take Prevacid. So, currently I am taking Prevacid, Lorazepam, and Elavil (lowest dose of each) Would cymbalta work for me for the stomach pain? The doctors are calling it nonulcer dyspepsia.

Answer: I’m not clear about whether you are still on a med for a bladder condition, but I’m presuming not. Meds that effect the bladder usually also have some effects on the stomach. I’m guessing that the bladder condition is interstitial cystitis, but there are several other possibilities.

Prozac can result in stomach spasms and pain, either when first starting it or when going off. Tapering Prozac more slowly would help if that was the case. Starting it back would initially help and then tapering at 1-2/week would be less likely to cause problems. Cymbalta has been found to help with pain of various types, but Elavil also helps by similar mechanisms. Increasing the dose of Elavil should be tried before adding Cymbalta, which shouldn’t be mixed with Elavil (i.e., Elavil would best be tapered off before adding Cymbalta).

Make sure you find out what was causing the stomach pain. Sometimes the cause remains unclear in which case you need to monitor any possible related symptoms or changes and be periodically reevaluated.

Question: If Effexor XR helps decrease the amount of serotonin and norepinephrine uptake in the case of GAD, then why does it feel like I am racing all the time?

– Ryan

Answer: Generalized Anxiety Disorder presumably is due to genetic vulnerability, personality traits, and stress. We know of one specific genetic variation that alters serotonin levels. Giving an anxious person meds that stimulate serotonin receptors or norepinephrine receptors (e.g., metabolite of Trazodone or Yohimbine) increases anxiety.

Giving Effexor, especially at higher doses, may initially worsen anxiety symptoms since it initially increases levels of serotonin and norepinephrine. But over a period of 2-3 weeks or more on Effexor, symptoms improve - presumably related to down regulation of both of these transmitters. 225 mg of Effexor usually works better than 150, and 150 works better than 75. At 225 effects on norepinephrine and serotonin are about equal. At 75 the effects are mostly on serotonin.

Some people with GAD do well on just an SSRI like Lexapro. You may be supersensitive to the norepinephrine effect of Effexor and would do better on Lexapro. Other possibilities include some bipolar gene that results in being overstimulated by an antidepressant.

Taking a benzodiazepine like Niravam might help with “racing.” Klonopin might be better if your thoughts are racing.

Anxiety symptoms can be associated with many conditions. Physiology of norepinephrine and serotonin are complicated, especially for serotonin, because there are more than 10 different types of serotonin receptors, any of which can be too high or low. Each of these transmitters also does different things in different areas of the brain.

In the future we will be able to better predict your medication response by looking at your specific genetic profile and other brain function parameters. For now, if you can’t find a dose of Effexor that helps without causing significant side effects, you need to phase off and try other meds. You may also need a reevaluation to look for other possible causes of your symptoms. The average person with a significant anxiety or mood disorder has a total of 3 different diagnoses. This phenomenon of frequent comorbidity is mostly due to the “blind men and the elephant” problem. We just don’t have the full picture yet of how the mind and brain work.

Question: I’m a 48 yr. old female with bipolar II disorder and have been taking 300mg/day of Wellbutrin XL and .25mg of Xanax on an as needed basis for anxiety. My depression and anxiety have increased significantly the past few months due to stress from a job change, death of my mom and an “empty nest.” I’ve also been experiencing some peri-menopausal symptoms such as irregular periods and occasional night sweats.

My psychiatrist would like me to try hormone replacement therapy before making any changes in my meds. My ob-gyn would like me to try Cenestin. I’m very nervous about HRT and would rather try adjusting my present med dosages or changing to another anti-depressant. How do you feel about the effectiveness of HRT for treating depression/anxiety for those of us with bipolar disorder?

– Maureen

Answer: Irregular menses and night sweats in a 48 year old woman is very suggestive of perimenopause. Perimenopause is a period of usually 2-4 years where mood symptoms are common, more so than during menopause. Presumably, the depressive symptoms are related to dropping estrogen levels. Decreasing estrogen results in decreasing serotonin levels in the brain. Lowering serotonin levels doesn’t necessarily cause depression, but in a woman with previous depression or certain genetic vulnerabilities, depression does frequently occur. Another possible mechanism for estrogen benefit is that it stimulates cell growth in the rapid access memory brain (hippocampus).

In bipolar disorder mood changes are more often related to changes in hormones, seasons, steroids or effects of medication than to psychosocial stressors. Estrogen is often the most effective treatment in this situation. For some women this is the only treatment I have found to work. Cenestin, Premarin by mouth, or Estradiol by patch or cream is the best way to take it. Low doses are better to start (.3 Cenestin or Premarin or .025 Estradiol patch or cream). Occasionally, treatment results in hypomania. Wellbutrin can also cause hypomania in bipolar II. Most patients with bipolar disorder need to be on a mood stabilizer (see Best mood stabilizers).

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