Question: I have been on Effexor XR 150 mg for 5-6 months now, but am disappointed with the weight gain – esp. around the belly. I was wondering if I can ask my doctor about Wellbutrin XL to help counteract that. What are your thoughts on that?

– Mona

Answer: All SSRI’s and SNRI’s can cause weight gain. Sometimes, increasing the dose of Effexor to 225 mg will make it easier to control weight, since it mainly increases Norepinephrine effect at the higher dose. Adding Wellbutrin is more likely to help (either 150 or 300 mg). Wellbutrin XL is probably better but not in generic. Taking Wellbutrin in a.m. and Effexor around supper time decreases overlap.

Question:  I am searching for help with an issue my adult son with a history of ADHD has run into.  As an adult, his physician put him on Paxil for his ADHD as other medications for ADHD were not as effective.  My son is functioning very well, has never been depressed, suicidal or any other issues associated with taking Paxil.  Seven months ago, my son had a flight physical by a certified FAA medical examiner, told the physician he was taking Paxil and the physician passed him, thus allowing my son to proceed with obtaining his private pilot’s license.  Now, seven months later, after he has completed all requirements, and has been flying the FAA sent him a letter stating they would not allow his medical exam due to him taking Paxil. 

My question is: Is Paxil used to treat adult ADHD?  What other drug could be used?  We have always been told that he does not produce enough dopamine therefore resulting in a chemical imbalance.  With the Paxil he is able to maintain focus and carry on a very normal, busy, independent life of a 32 year old single male.  Any information or help you may offer us would be greatly appreciated as we are going to try to fight this issue.  Personally I feel it is discrimination against ADHD. – S.B.

Answer:  Consensus of experts in the area of ADHD is that there are imbalances in the dopamine and norepinephrine brain systems, primarily due to genetics.  There are many sources of evidence to support this view.  There is disagreement as to whether the problem is primarily in the dopamine system or whether it’s primarily in the norepinephrine system or equally both.  It will probably turn out to be mainly dopamine in some people who are ADHD and norepinephrine in others and both in still others.   The problem is compounded by many factors, one of which is that dopamine and norepinephrine impact each other and may be high in some areas of the brain and low in others. 

There is currently no scientific evidence that serotonin modulators such as Paxil help ADHD.  Paxil has a very weak modulating effect on norepinephrine, but this is not believed to be clinically relevant (unless one takes very high doses).  Most SSRI’s, including Paxil, will actually lower dopamine levels.  Norepinephrine modulating antidepressants, tricyclics (desipramine, imipramine), Strattera (actually approved for ADHD but not depression, higher doses of Effexor (150 mg and above), Wellbutrin, and theoretically Cymbalta can help ADHD – though on average 1/2 as effective as stimulants. 

Your son benefits from Paxil.  What does this mean?  My guess is that your son is not ADHD, or at least that’s not what Paxil is helping.  Many other things can cause some of the symptoms of ADHD.  Sustained concentration requires ignoring distractions, either in the environment or from the mind (“What if …?”).  Anxiety means “danger” and danger means monitoring the environment more closely and thinking about all the relevant “What ifs.” 

Clinical depression involves deficiencies in one or more brain transmitter systems that frequently interferes with focus.  Also, calm, sustained focus activates more left brain functions, but stress, anxiety and depression activate the right brain more.  I recommend a complete reevaluation before any other steps are taken.  Dealing with the FAA reminds me of my days as an Air Force psychiatrist.  You can’t let logic or fairness cloud your thinking.  It’s all about the regulations.  How to deal with them would need to come after the evaluation.

Question: How do we cope with our ADHD/angry/grown-child who is living at home?

Answer:  Unfortunately, I frequently hear “ADHD/angry/grown-child living at home with no job for several months and parents feeling helpless.”  Blames you for ______ is also common.  Not taking responsibility for one’s problems and life situations may be immaturity.  ADHD kids are usually found to be at least 2-3 years behind.  In more serious cases, frequent blaming behavior can be part of a personality disorder, which is difficult to deal with and may persist, sometimes for life. 

One issue is leverage, or power.  When kids are little you have the “power of the pop.”  With teenagers you have “the power of the purse.”  When I did hospital psychiatry years ago, sometimes the only leverage I had was cigarettes – I know, pretty desperate, but when that was the only thing someone cared about that I could have control of, that was my only option. 

Question: Are the terms “antipsychotic” and “mood stabilizers” the same?

– R.M.

Answer: There is no consensus about the definition of mood stabilizer – but at the least, it includes helping either mania or depression without worsening the other.

The term antipsychotic at this point means medications that block certain brain receptors (D2) that have been found to be overly active during classic psychosis including hallucinations and delusions. Abilify is one exception in that it doesn’t block D2 receptors but modulates them, i.e. decreasing activity when too high but increasing activity when too low. The term “antipsychotic” was reasonable with the older medications like Thorazine, Stelazine, Mellaril, and Haldol. They are not considered mood stabilizers because although they can help mania they can worsen depression.

The term “atypical antipsychotic” is misleading because these medications (Risperdal, Seroquel, Zyprexa, and Geodon) have many uses in addition to helping psychotic symptoms. They are used for treatment resistant depression and Obsessive Compulsive Disorder. They are also used for agitation, extreme anger and aggression. They may be helpful for addictions. Clozaril is different in that it has potential severe side effects that limit its use. Abilify is unique as previously discussed. These medications meet the standard of helping mania without worsening depression.

There is inadequate research to determine whether the “atypical” antipsychotics meet the stricter definition of mood stabilizer – help mania, help depression and help prevent future episodes of both – which means beyond 6 months after an episode. Seroquel has one good study for helping Bipolar depression. Abilify has evidence for preventing relapse up to 6 months. Zyprexa also has an indication for maintenance. At this time Lithium has the most supporting evidence as a mood stabilizer – but it’s been studied for 50+ years (on the U.S. market for 35 years).

Risperdal in the U.S. has FDA approval for mania and mixed episodes (mania and depression) but it doesn’t have controlled studies for Bipolar depression or maintenance. As I discussed in my article Ranking the Mood Stabilizers, my issues with Risperdal have to do with moderate risk for weight and metabolic problems and frequently elevation of the hormone prolactin. Since prolactin lowers hormones (estrogen and testosterone) it can cause decreased libido, increased risk of long term osteoporosis and possibly many other long term problems. Of course if it’s working well with no apparent side effects and other medications haven’t worked then on the basis of benefits vs. risks it makes sense to take it on a long term basis.

There are other options for treatment resistant depression. Making sure thyroid, estrogen and testosterone levels are good is important. Thirty minutes per day of vigorous physical activity and at least thirty minutes of bright outside light exposure are also important. Cognitive therapy can also be helpful. Sometimes adding a stimulant like Adderall, Concerta, or Provigil can be extremely helpful especially if there are problems with motivation, interest, and focus. Wellbutrin XL can be combined with an SSRI or Effexor or Cymbalta. Combining antidepressants or adding a stimulant have greater long term safety than most of the atypicals.

It’s important that you are getting adequate (7-8 hours) quality sleep(See sleep articles) but avoid excessive sleep because this can worsen depression. Of course all options need to be explored by your physician.

FAQs: Comparing Meds

Question:  What causes ADHD?

Answer:  Personality is thought to be 1/2 temperament which is primarily genetic.  But personality disorders are thought to be primarily learned, maladaptive, and mostly deficits in character development. ADHD on the other hand has been found to be 75% genetically determined.  Studies include comparing ADHD identical vs. fraternal twins and studying individuals who have been adopted at birth.  The likelihood that they will turn out to be ADHD primarily correlates with the presence or absence of these traits in their biologic parents not their adoptive parents.  This is much less true for personality disorders or character. 

So whether we are ADHD is mainly (75%) determined by how we choose our parents and the luck of the draw.  What about the other 25%?  Several things have been found to increase the chances that ADHD traits in childhood will continue into adult life.  This includes early childhood trauma and neglect which increase risk/severity of ADHD symptoms.  Early exposure to television correlates with increased severity of ADHD symptoms also.  Undoubtedly being exposed to high stimulation such as computer games, or maybe even computers themselves will result in brain adaptations that might make it harder to focus in low stimulation settings.  Modern lifestyle with the demands for multi-tasking will be more difficult for “all or none” ADHD personalities. 

Question:  Can any physician diagnose and treat ADHD in kids, or does it have to be a specialist?

Answer:  Most pediatricians are comfortable at least screening for ADHD in kids and in many cases will try at least a couple of medications before referring to a specialist.  One problem with being treated by a non-specialist is that studies have shown a lower success rate.

In the largest most comprehensive study MTA Study , patients that were treated in the community did not fare as well as those treated by specialists using a set protocol.  The kids treated in the community on average ended up on lower doses of medication per dose and fewer doses per day (of short-acting medication).  Most striking was that after medication was initially stabilized the patients in the community were seen on average 15 minutes every 6 months.  Those treated by specialists were seen every 3 months for 30 minutes.

Question:  What is genopharmacology?

Answer:  It is the interaction of gene variations with specific medication treatments.  Although some people inherit both the subtypes of ADHD the majority of the time this is probably not the case.  There are already over a dozen gene variations (polymorphisms) that have been found to be more common in ADHD.  Last week a new study was reported in which one gene variation was found to respond very favorably to one type of stimulant (in 60% of these patients) but another gene variation was found to not respond at all to the same medication.  The use of genotypes in predicting treatment response is coming soon.

Question:  Why do most ADHD individuals have symptoms of different subtypes?  

Answer:  Models have been developed to show how a person can inherit one subtype of ADHD and develop symptoms of the other over time.  This helps us to understand the fact that the majority of ADHD patients have some symptoms of both.  Problems with focus, attention, and concentration can be associated with both types.  In one the brain won’t turn on – “not interested”.  In the other there’s too much noise and the individual can’t focus on the important because of too many unimportant distractions.

Question:  Are there different types of ADHD?

Answer:  Yes.  Recent research shows that there are two genetically distinct subtypes of ADHD symptoms.  One involves the need for higher levels of stimulation for the brain to work well.  There is lower level of functioning than normal when reward is delayed.  There are problems with being bored in settings that are not particularly stimulating like school classrooms, doing homework, or adult’s typical work setting.  Frequently there are problems listening to conversations if the ADHD person is not acutely interested in the topic being discussed (not great for marriages).

The other subtype of ADHD involves deficits in executive functioning.  One of the main functions of our highest brain centers is to inhibit our instinctual or emotional reactions.  What response or course of action is compatible with our values and long term plans?  I have a Dennis the Menace cartoon where he says, “by the time I realize the consequences of my action I’ve already done it!”  That’s the problem with impulsivity – act first, think second.  The problem with hyperactivity is excessive arousal and “noise” in background brain activity.  It is hard to focus on the important things when the brain is being constantly bombarded with the unimportant.  This subtype of ADHD results in being easily stressed or having too much on the mind at once.

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