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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by stargazer on August 3, 2006, at 9:17:52
I'm not sure if I have ADD or not. I've been referred to an ADD clinic to verify this based on my own uncertainty. I did take Adderall for awhile and I think it was helpful for energy and focus. It recently was discontinued along with Celexa and Wellbutrin (stopped working), which helped for awhile. I wanted to try Marplan so I had to stop everything else due to interactions. I told my doc I thought the lack of Adderall was causing me to be less focused and more tired. He disagreed and is keeping me on Lamictal and Risperdal with Marplan. I feel tired and unforcused. Can I take Adderall with Marplan or what stimulant might help if I cannot take Adderall?
Thanks for any feedback...SG.
I'm still wondering if the Adderall helped becasue I have ADD or if it works to give you energy adn focus without the diagnosis.
Posted by Tomatheus on August 3, 2006, at 14:14:44
In reply to Does Adderall work if you don't have ADD?, posted by stargazer on August 3, 2006, at 9:17:52
SG,
You should know better than anybody else whether or not you're feeling too unfocused and too tired. I can see why your doctor might be of the opinion that your fatigue and difficulty focusing aren't being caused by a "lack of Adderall." But if I were your doctor and you told me that you were having difficulty with fatigue and focus, I certainly would have taken your concerns seriously and would have offered to do *something* to try to help alleviate the symptoms that you reported. From your post, it sounds like your doctor just dismissed your concerns about feeling too tired and unfocused, and that just doesn't seem right.
One thing you might want to consider if you haven't done so already is lowering your dose of either Lamictal or Risperdal (under the guidance of a doctor, of course). Both meds tend to be associated with increased fatigue and difficulty focusing. I'm not necessarily saying that the symptoms that you've described aren't true manifestations of your psychiatric disorder, but it could be the case that taking Marplan by itself might be enough to help you feel more focused and less fatigued and that the Lamictal and Risperdal are interfering with Marplan's therapeutic effects.
Of course, it is possible that the addition of Adderall or another stimulant to your medication cocktail might just provide the boost that you need. However, I personally think that it would be best to first try reducing the Lamictal and/or Risperdal (if you haven't tried this already) to see if that might help you feel more focused and less tired without having to take a fourth medication.
Adderall is officially contraindicated with MAOIs, but several anecdotal reports (including some on this board) suggest that low-dose Adderall can -- in some cases -- be safely combined with an MAOI. It is also my guess that your odds of experiencing a hypertensive crisis as a result of combining Marplan with Adderall would probably be reduced if you keep Lamictal and Risperdal in the mix. But considering the fact that Marplan and Adderall are indeed contraindicated, it might be difficult to find a doctor who'd be willing to prescribe you Adderall. If you still think that adding a stimulant to your combo would be the way to go, you might want to consider asking a doctor about modafinil. Based on what I've read about modafinil, it tends to increase alertness and concentration in most individuals without causing too much edginess and agitation. And unlike Adderall, it's not contraindicated with MAOIs. It's actually been used successfully to combat residual fatigue induced by other medications.
I can't say for sure that you'll find my suggestions to be helpful, but hopefully what I wrote will give you something to think about, if nothing else. Please let me know if you have any questions about anything that I've written.
Tomatheus
> I'm not sure if I have ADD or not. I've been referred to an ADD clinic to verify this based on my own uncertainty. I did take Adderall for awhile and I think it was helpful for energy and focus. It recently was discontinued along with Celexa and Wellbutrin (stopped working), which helped for awhile. I wanted to try Marplan so I had to stop everything else due to interactions. I told my doc I thought the lack of Adderall was causing me to be less focused and more tired. He disagreed and is keeping me on Lamictal and Risperdal with Marplan. I feel tired and unforcused. Can I take Adderall with Marplan or what stimulant might help if I cannot take Adderall?
>
> Thanks for any feedback...SG.
>
>
> I'm still wondering if the Adderall helped becasue I have ADD or if it works to give you energy adn focus without the diagnosis.
Posted by rjlockhart on August 3, 2006, at 14:15:57
In reply to Does Adderall work if you don't have ADD?, posted by stargazer on August 3, 2006, at 9:17:52
No,
MAOI's dont go with stimulants, it is dangerous. Your doctor i dont belive would prescribe you adderall and marplan, both together because of the so many things you can not take with maoi's, like cheeze, avacado's, amphetamine, something to do with the tyramine building up too much.
Here is the website.
http://health.yahoo.com/drug/d04035a1/
What should I discuss with my healthcare provider before taking amphetamine-dextroamphetamine?
Do not take amphetamine-dextroamphetamine if you
have heart disease or high blood pressure;
have arteriosclerosis (hardening of the arteries);
have glaucoma;
have taken a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), tranylcypromine (Parnate), or phenelzine (Nardil) in the last 14 days; or
have a history of drug or alcohol abuse.Very danger reaction, hospitization would be required, varies.
So just to keep you safe. Have you asked about Parnate? It is a stimulating energizing MAOI, similar mild effects to amphetamine.
Talk to your doctor.
Matt
Posted by Maxime on August 3, 2006, at 14:28:11
In reply to Re: Does Adderall work if you don't have ADD?, posted by rjlockhart on August 3, 2006, at 14:15:57
You can take Adderall with a MAOI. It is contraindicated but it can be done. I took Adderall with Parnate ... no problem. Mind, it might be a problem for someone else ... you don't know how you will react.
Anyhow here some info to back up my statements.
Maxime
1: J Clin Psychopharmacol. 1991 Apr;11(2):127-32.
CNS stimulant potentiation of monoamine oxidase inhibitors in
treatment-refractory depression.Fawcett J, Kravitz HM, Zajecka JM, Schaff MR.
Department of Psychiatry, Rush-Presbyterian-St. Luke's Medical Center,
Chicago,
Illinois.We report on our clinical experience with a combination of a CNS stimulant (either pemoline or dextroamphetamine) and a monoamine oxidase inhibitor (MAOI) for treating 32 depressed patients (mainly outpatients) refractory to standard
antidepressant pharmacotherapy. This combination, though not approved by the FDA, appears to be safe and effective. Twenty-five (78%) of these patients experienced at least 6 months of symptom remission with a stimulant + MAOI combination. Many patients required adjunctive antidepressant treatment, including tricyclics and lithium. Side effects were not excessive, though 6 patients (3 unipolar and 3 bipolar) cycled to mania (N = 1) or hypomania (N = 5). None developed hypertensive crises. With properly motivated and complaint patients and careful clinical monitoring by the prescribing psychiatrist, stimulant potentiation of MAOIs may be a viable option for treatment-resistant depressed patients.PMID: 2056139 [PubMed - indexed for MEDLINE]
2: J Clin Psychiatry. 1985 Jun;46(6):206-9.Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression.
Feighner JP, Herbstein J, Damlouji N.
Patients with "treatment resistant" depression who do not respond to standard methods or relapse over time have a moral and legitimate right to innovative
therapy. Combined treatment with monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and stimulants has been resisted by practitioners because of hypertensive and hyperthermic crises noted in certain cases. This paper reports a case series demonstrating the safety and efficacy of adding a stimulant to an MAOI or to a combination of TCA and MAOI in the treatment of intractable depression.PMID: 3997787 [PubMed - indexed for MEDLINE]
MAOIs in high doses and with stimulantsDate: Sat, 1 Apr 1995 13:33:03 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Non-response to tranylcypromineThe commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine . Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Posted by Jost on August 3, 2006, at 16:29:02
In reply to Does Adderall work if you don't have ADD?, posted by stargazer on August 3, 2006, at 9:17:52
I've taken adderall with am maoi, and had no problem. Adding the adderall to the maoi, after your've reached a consistent dose level, and know whether you're particularly reactive to other things.
It depends on dose and your individual reactions to the particular maoi.
Adderall generally increases energy and concentration, even if you don't have ADD.
Jost
Posted by Phillipa on August 3, 2006, at 16:59:19
In reply to Re: Does Adderall work if you don't have ADD?, posted by Maxime on August 3, 2006, at 14:28:11
Maxie you sure are doing some researh. Wow that's awesome. Love Jan
Posted by Maxime on August 3, 2006, at 19:39:10
In reply to Re: Does Adderall work if you don't have ADD? » Maxime, posted by Phillipa on August 3, 2006, at 16:59:19
> Maxie you sure are doing some researh. Wow that's awesome. Love Jan
Nope. I DID some research ... a couple of years ago and kept it.Maxime
Posted by Maxime on August 3, 2006, at 19:40:38
In reply to Re: Does Adderall work if you don't have ADD?, posted by Jost on August 3, 2006, at 16:29:02
> Adderall generally increases energy and concentration, even if you don't have ADD.
>
> Jost*nods in agreement*
Maxime
Posted by mike lynch on August 3, 2006, at 19:45:11
In reply to Re: Does Adderall work if you don't have ADD? » Jost, posted by Maxime on August 3, 2006, at 19:40:38
Posted by stargazer on August 3, 2006, at 21:48:34
In reply to Re: Does Adderall work if you don't have ADD? » Jost, posted by Maxime on August 3, 2006, at 19:40:38
Wow, great to know so many people really know their stuff and that someone (Maxime) kept all of those MAO + stimulant emails which suggest that I could take Adderall w Marplan. I can print them out and bring them with me to my pdoc. I'm only on 0.25 of the Risp. so I don't think that is causing much problem but it sounds like the Lamictal might be and this is what I thought too. I went from 200 to 150 today to see if this might reduce the lethargy going on, although I'm not supposed to change my dosages without letting him know. Oh well.
Do you think I should bother with an actual workup for ADD at some clinic my new PCP just gave me? If insurance covers it I'd be interested in whether or not I have ADD since I've always had what I would consider attentive deficit, i.e. can't retain written or verbal information. I have no hyperactivity, more like hypoactivity.
SG
Posted by Tomatheus on August 6, 2006, at 1:34:55
In reply to Thank for all advice, very helpful, posted by stargazer on August 3, 2006, at 21:48:34
> Do you think I should bother with an actual workup for ADD at some clinic my new PCP just gave me? If insurance covers it I'd be interested in whether or not I have ADD since I've always had what I would consider attentive deficit, i.e. can't retain written or verbal information. I have no hyperactivity, more like hypoactivity.
SG,
It would probably be a good idea to follow through with the workup at the ADD clinic that you referred to, assuming that you can get your insurance to cover at least part of it. Even though I don't personally think it makes a difference whether your attentional difficulties are said to be the result of ADD or another disorder -- what I find to be most crucial is that your docs recognize and treat your attentional difficulties no matter how many DSM-IV diagnoses you qualify for -- doctors obviously tend to prescribe medications that are indicated for specific diagnoses. So in other words, if you do receive a diagnosis of ADD in addition to the diagnosis(es) that you've already received, you'll probably have a better chance of being prescribed Adderall than you do now.
I hope this helps.
Tomatheus
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