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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 64. This is the beginning of the thread.
Posted by linkadge on January 13, 2007, at 10:39:16
If somebody says that a stimulant helps their depression, and would like to try a fixed dose to treat a mood disorder, then why is this person any less credable, and any more likely to abuse the medication than a person who needs a fixed dose for ADHD ?
Linkadge
Posted by Phillipa on January 13, 2007, at 11:09:43
In reply to If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 10:39:16
Well did they have a script for the med? If not maybe that's why. But a lot of others here say their ADD meds help with depression. Love Phillipa
Posted by Meri-Tuuli on January 13, 2007, at 11:45:57
In reply to If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 10:39:16
Link, I have no idea - its something I've wondered about too. Why is it so wrong for someone with depression being helped with stims?
Although here in the UK they're only just waking up to fact that adults can have ADHD too - seriously, adults here just don't have ADHD (its unbelieveable) in the eyes of the medical profession, let alone giving stims to no-ADHD folk. Personally, whatever helps, helps.
________________
Adult ADHD 'not treated properly'
Posted by Sebastian on January 13, 2007, at 15:49:29
In reply to If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 10:39:16
Posted by blueberry1 on January 13, 2007, at 18:20:45
In reply to If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 10:39:16
I'm going to run into this problem this week when I go see my doctor who I haven't seen in a long time. I've studied up on the symptoms of ADD and ADHD and I score pretty high on most of them. The problem is that so many of them could be brushed off by the doctor as symptoms of depression.
It is interesting to see at remedyfind that one of the very top rated drugs by users for depression is Adderall. Almost all antidepressants score in the 5.5 - 6.1 range. But Provigil, Adderall, and Parnate score in the mid 7's.
I would love to try Adderall and I mean this week! I'm going to have to really make my case. One thing in my favor is that this same doctor did prescribe me Ritalin and I still have the leftover bottle and pills with her name on it to prove it. Ritalin had too many ups and downs. The first dose of the day was good. Subsequent doses didn't do anything except bring on anxiety. I understand Adderall is supposed to be more effective and yet smoother with less anxiety.
I do believe there is a lot of overlap between ADHD and depression. Especially with the reward-deficiency symptoms. Inability to have pleasure. I wish doctors would be more open to stimulants for mood disorders because they have the benefit of doing a quick trial and error...if it will be beneficial it will be known from day 1 to day 7. But with any other drug you have to wait 6 to 8 weeks. To get the patient well faster, it makes sense to me to start with a drug that rates highest by actual users and that works fast.
> If somebody says that a stimulant helps their depression, and would like to try a fixed dose to treat a mood disorder, then why is this person any less credable, and any more likely to abuse the medication than a person who needs a fixed dose for ADHD ?
>
> Linkadge
Posted by laima on January 13, 2007, at 19:08:04
In reply to Re: If ADHD people are trusted, why mood disorder folk, posted by blueberry1 on January 13, 2007, at 18:20:45
Here's my speculation: when stimulants first work, they can seem almost euphoric. Obviously then, the depressed person is excited and elated, and tempted to up dosage. The temptation is strong because the perceived benefit is powerful, dramatic, and rapid. Eventually, the euphoric tendencies go away, and the benefit seems to come exclusively from ADD symptom relief and energy. I imagine there has been a problem with patients then attempting to up their doses to chase that feeting euphoria. I just about bet that the reason stimulants are not used more often is 1) high risk of depressed patients upping their doses, and 2) the higher the dose, the worse the possible crash as dose wears off. Cycle repeats.
I speculate that doctors figure the ADD population is less likely to get into such a cycle than the depressed population is. And of course, if a doctor's patients are abusing drugs, doctor's liscence is probably jeopardized.
And what's wrong with euphoria? Not natural, not lasting anyway. I mean, what good does it do to feel absolutely elated if a person has neglected their social life, bank account, other affairs? Isn't that how people get into trouble with drug abuse?
Posted by linkadge on January 13, 2007, at 19:33:28
In reply to Re: If ADHD people are trusted, why mood disorder folk, posted by laima on January 13, 2007, at 19:08:04
>Here's my speculation: when stimulants first >work, they can seem almost euphoric. Obviously >then, the depressed person is excited and >elated, and tempted to up dosage.
But are there any statistics to suggest that a depressed person is more likely to up the dose to chase a high than a person with ADHD? I mean, they are both euqally trustable patients, and I don't know if a depressed person is more susceptable to the possable euphoric effects.
In fact, there is probably a higher rate of drug abuse in those with ADHD (for whatever reason that is).
Linkadge
Posted by laima on January 13, 2007, at 20:23:16
In reply to Re: If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 19:33:28
I suspect it's actually just a stereotype that a lot of people believe, maybe a loophole. I mean, amphetamines were used and promoted for depression during the 60's, and some people abused them. Amphetamines stopped being promoted for depression... Later, amphetamines are back and promoted primarily for ADD/ADHD, not depression. A sort of "reinvention" for them.
> >Here's my speculation: when stimulants first >work, they can seem almost euphoric. Obviously >then, the depressed person is excited and >elated, and tempted to up dosage.
>
> But are there any statistics to suggest that a depressed person is more likely to up the dose to chase a high than a person with ADHD? I mean, they are both euqally trustable patients, and I don't know if a depressed person is more susceptable to the possable euphoric effects.
>
> In fact, there is probably a higher rate of drug abuse in those with ADHD (for whatever reason that is).
>
>
> Linkadge
>
>
>
>
Posted by Klavot on January 14, 2007, at 8:12:21
In reply to Re: If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 19:33:28
> >Here's my speculation: when stimulants first >work, they can seem almost euphoric. Obviously >then, the depressed person is excited and >elated, and tempted to up dosage.
>
> But are there any statistics to suggest that a depressed person is more likely to up the dose to chase a high than a person with ADHD? I mean, they are both euqally trustable patients, and I don't know if a depressed person is more susceptable to the possable euphoric effects.
>
> In fact, there is probably a higher rate of drug abuse in those with ADHD (for whatever reason that is).
>
>
> LinkadgeNot to mention the problem off school kids with ADHD who *SELL* their meds to their friends. I have *never* heard of any depression patients who sell antidepressants for extra pocket money.
Klavot
Posted by laima on January 14, 2007, at 10:18:42
In reply to Re: If ADHD people are trusted, why mood disorder folk » linkadge, posted by Klavot on January 14, 2007, at 8:12:21
That's for sure! Not a chance.
> Not to mention the problem off school kids with ADHD who *SELL* their meds to their friends. I have *never* heard of any depression patients who sell antidepressants for extra pocket money.
>
> Klavot
Posted by linkadge on January 14, 2007, at 12:35:35
In reply to Re: If ADHD people are trusted, why mood disorder folk, posted by laima on January 14, 2007, at 10:18:42
Well, to be fair, antidepressants don't have much/any street value. If they did, I don't see why certain patients wouldn't try to sell them.
Linkadge
Posted by psychobot5000 on January 14, 2007, at 15:47:59
In reply to Re: If ADHD people are trusted, why mood disorder folk, posted by linkadge on January 13, 2007, at 19:33:28
> But are there any statistics to suggest that a depressed person is more likely to up the dose to chase a high than a person with ADHD? ...and I don't know if a depressed person is more susceptable to the possible euphoric effects.
> LinkadgeAccording to one study abstract, copied below, it seems depressed people seem to be more susceptible to stimulant 'euphoria.'
_______
Probing brain reward system function in major depressive disorder: altered response to dextroamphetamineArch Gen Psychiatry 2002 May;59(5):409-16
ABSTRACT
BACKGROUND: The state of the brain reward system in major depressive disorder was assessed with dextroamphetamine, which probes the release of dopamine within the mesocorticolimbic system, a major component of the brain reward system, and produces measurable behavioral changes, including rewarding effects (eg, euphoria). We hypothesized that depressed individuals would exhibit an altered response to dextroamphetamine due to an underlying brain reward system dysfunction reflected by anhedonic symptoms. METHODS: In a double-blind, placebo-controlled, randomized, parallel study, the behavioral and physiological effects of a single 30-mg dose of oral dextroamphetamine sulfate were measured. Forty patients with a diagnosis of DSM-IV major depressive disorder who were not taking antidepressant medications (22 assigned to dextroamphetamine and 18 to placebo) were compared with 36 control subjects (18 assigned to dextroamphetamine and 18 to placebo) using validated self-report drug effect measurement tools (eg, the Addiction Research Center Inventory), heart rate, and blood pressure. RESULTS: Multiple regression analysis showed that severity of depression as measured by the Hamilton Rating Scale for Depression correlated highly with the rewarding effects of dextroamphetamine in the depressed group (model R(2) = 0.63; interaction P =.04). A subsequent analysis categorizing the depressed group into patients with severe symptoms (Hamilton score >23) and those with moderate symptoms revealed a significant interaction between drug and depression (P =.02). Patients with severe symptoms reported rewarding effects 3.4-fold greater than controls. CONCLUSIONS: The results suggest the presence of a hypersensitive response is present in the brain reward system of depressed patients, which may reflect a hypofunctional state and may provide a novel pathophysiologic and therapeutic target for future studies.
http://www.biopsychiatry.com/dextroamphetamine.htm
Posted by laima on January 14, 2007, at 16:05:36
In reply to Re: Depressives' sensitivity to stimulants! » linkadge, posted by psychobot5000 on January 14, 2007, at 15:47:59
Well, I've got another theory. If a stimulant can boost a depressed person's mood rapidly and dramatically, the temptation to abuse will obviously be high. And the higher the dose, the more severe of a crash is possible. So if a person ends up taking high doses and feeling great, and then crashing pretty bad, the end result isn't going to be good. Rollercoaster of extremes. Some crashers might not even realized why. Again though, I'm sure that physicians are looking out for themselves as well as for their patients.
Posted by med_empowered on January 14, 2007, at 16:48:54
In reply to Re: Depressives' sensitivity to stimulants!, posted by laima on January 14, 2007, at 16:05:36
I think, like a lot of things in psychiatry, the stims for add, but not for depression practice isn't based on good science. Stims can be good antidepressants. Since the 40s, they have been used widely, and often safely, for depression. I think psychiatry has taught that antidepressants are meds "specifically" for depression (but not very good ones) and stimulants are "specifically" for ADHD. The problem is, psychiatry isn't like real medicine, where you have discrete disorders that respond to specific medications. You're dealing with a whole person here--feelings, thoughts, past, present, a whole brain--so there's going to be a lot of variability in terms of what works and what doesn't.
Also, I think part of the problem is that in the 60s speed was so abused and over-rx'd that psychiatry wanted to get away from its "Valley of The Dolls" image into what I guess it is now--docs are slow to prescribe "addictive" substances, and patients continue to suffer while paying out $$$ for ineffective treatment.I think it boils down to this: psychiatric patients get screwed. If you're a heart patient and your medication s/e suck, your doc works with you. Depression? Bipolar? Schizophrenia? Stick with it. If you're in chronic physical pain, a reasonable doc will work with you, possibly with very strong, potentially addictive meds. Psychic Pain? Can't leave the house? Too apathetic to function? Too damn bad. Take your Paxil and shut up.
That, I think, is the problem: shrinks really don't respect or value their patients.
Posted by linkadge on January 14, 2007, at 17:10:12
In reply to Re: Depressives' sensitivity to stimulants!, posted by med_empowered on January 14, 2007, at 16:48:54
But who says depressives want to be high? A number of people with depression just want to feel normal. I think there needs to be a certain type of personality (perhaps thrill seeking) that would compromise a healthy state for an unhealthy one.
It may be true that depressives are more sensitive to stimulants, but one could argue the other way, that because they need less to get an effect, that they'd be *less* likely to abuse it, like a cheap drunk isn't doesn't drink more than a expesnive drunk, because they get drunk on less alchohol.
Nevertheless, I still don't see how somebody with depression would be looking for a "high" any more than somebody with just ADHD.
Linkadge
Posted by linkadge on January 14, 2007, at 17:15:06
In reply to Re: Depressives' sensitivity to stimulants!, posted by med_empowered on January 14, 2007, at 16:48:54
I can see how stimulant crashing might be more dangerous for a depressed person.
Linkadge
Posted by laima on January 15, 2007, at 0:19:09
In reply to Re: Depressives' sensitivity to stimulants!, posted by linkadge on January 14, 2007, at 17:15:06
I agree, I think the concern about a depressed person experiencing a crash from stimulants is probably the most legeit reason doctors might want to not use them, but the thing is, I don't think a crash is guarenteed. I don't think I experience this from the low doses I use. Have they plain forgotten then about how useful stimulants can be? I think they should decide patient by patient, not just forget about them altogether.I'm interested to hear about when ADD and ADHD were er, "discovered". Were these disorders first organized before or after stimulants fell out of favor for depression? I mean, I believe in them, I identify with the innattentive type attention deficit, but I'm curious about how the history sorts out. I also think there might be some overlap with the symptoms, ie, innattentive and frustrated due to depression, or attention deficit?
> I can see how stimulant crashing might be more dangerous for a depressed person.
>
>
> Linkadge
Posted by linkadge on January 15, 2007, at 9:02:37
In reply to Re: Depressives' sensitivity to stimulants!, posted by laima on January 15, 2007, at 0:19:09
I agree, I didn't really crash from ritalin when I was depressed. Infact I felt ok at the end of the day because I had got more done, and that I had dug myself a little futher out of the hole.
Linkadge
Posted by SLS on January 15, 2007, at 10:27:31
In reply to Re: Depressives' sensitivity to stimulants!, posted by med_empowered on January 14, 2007, at 16:48:54
> I think, like a lot of things in psychiatry, the stims for add, but not for depression practice isn't based on good science.
Bad science then? It seems to be based on something.
> Stims can be good antidepressants.
For what percentage of people suffering with MDD or BD do you think they would be good antidepressants?
> Since the 40s, they have been used widely, and often safely, for depression.
Why did they stop?
> I think psychiatry has taught that antidepressants are meds "specifically" for depression
I can see this. Remember, though, that it was the old-timers like Nathan Klein who got to see the differences in efficacy between amphetamine and imipramine who helped establish a trend in thought that these newer drugs better target affective disorders.
> (but not very good ones)
When they work, they can be miracle drugs for those who had suffered.
> and stimulants are "specifically" for ADHD.
There are plenty of doctors who have open minds when it comes to the use of psychotropics. I have seen quite a few. I think you'll find, though, that the majority have found through experience that amphetamine monotherapy does not produce a persistent antidepressant response for MDD and BD. If the clinical experience of experts represents bad science, I am often inclined to respect it. And yes, I have tried amphetamine monotherapy. I experienced an antidepressant effect for the first 3-4 hours after my first dose. That was about it, despite continued treatment at 20mg.
> The problem is, psychiatry isn't like real medicine,
Would this include diagnosis?
> where you have discrete disorders that respond to specific medications. You're dealing with a whole person here--feelings, thoughts, past, present, a whole brain--so there's going to be a lot of variability in terms of what works and what doesn't.
Most definitely. I'm glad to see that we are in agreement that there are treatments that do indeed work.
> Also, I think part of the problem is that in the 60s speed was so abused
Yes, it was.
> docs are slow to prescribe "addictive" substances,
Why the quotation marks given your above statement?
> and patients continue to suffer while paying out $$$ for ineffective treatment.
The only treatments that are ineffective are the ones that don't work. Sorry. But that's the state of the art - best guess trial and error. You don't think that deciding between Spiriva and Advair for COPD isn't an exercise in trial and error? Why should psychiatry be singled-out in this regard?
> I think it boils down to this: psychiatric patients get screwed.
Perhaps you are - not me, thanks.
> If you're a heart patient and your medication s/e suck, your doc works with you.
Ok.
> Depression? Bipolar? Schizophrenia? Stick with it. If you're in chronic physical pain, a reasonable doc will work with you, possibly with very strong, potentially addictive meds. Psychic Pain? Can't leave the house? Too apathetic to function? Too damn bad. Take your Paxil and shut up.
This has not been my experience with psychiatrists, and I don't think I could agree with such a generalization. If you have been treated this way, then you have not been given a fair opportunity to achieve wellness. You might consider using the Internet as a resource to find a competent and professional doctor who cares and is willing to work with you. There are plenty of them.
> That, I think, is the problem: shrinks really don't respect or value their patients.
Another generalization. How can such things be so universally accepted as fact? Bad science.
- Scott
Posted by linkadge on January 15, 2007, at 13:20:44
In reply to Re: Depressives' sensitivity to stimulants! » med_empowered, posted by SLS on January 15, 2007, at 10:27:31
Not, med empowered, but I am going to comment on various comments.
>For what percentage of people suffering with MDD >or BD do you think they would be good >antidepressants?I think it was interesting that on remedy find, a stimulant was more highly rated than all other antidepressants. Like was mentioned, some of those people had been on one for years.
>Why did they stop?I think they stopped because they found a drug that couldn't get you high. Antidepressants aren't really in the patients best interest, they are just more practical.
>I have seen quite a few. I think you'll find, >though, that the majority have found through >experience that amphetamine monotherapy does not >produce a persistent antidepressant response for >MDD and BD.
To be fair, many of the doctors willing to experiment with stimulants are probably dealing with treatment resistant patients. Treatment resistant patients aren't a fair way to compare drugs, since they have often failed conventional treatments too. Stimulants are never prescribed first line.
>Why the quotation marks given your above >statement?Just becasue a substance has a potential for abuse, doesn't mean that it always leads to abuse.
The benzos are a good example. There are people who have used theraputic doses for years. I don't think a doctor should cut off a trial of a benzodiazapine just because it has abuse potential.The SSRI's have become the treatment modality for anxiety disorders to replace the benzodiazapines for the express reason that they are less addictive. This doesn't imply that the SSRI's are any more effective for anxiety disorders, only thay they are perhaps safer (or at least they are promoted as being safer). Another example would be how the SSRI's have replaced the TCA's dispite any significant proof of superior efficacy.
>Perhaps you are - not me, thanks.Well it seems SLS, that you have had some of the most open, understanding, and experiementive doctors available. If your doctor said, I won't prescribe an MAOI because they are unsafe, then you would have been screwed.
>Too apathetic to function? Too damn bad. Take >your Paxil and shut up.Its true. With depression, doctors just reach a point, then they conclude you are a complainer and that your suffering is somehow your own fault.
>This has not been my experience with >psychiatrists, and I don't think I could agree >with such a generalization. If you have been >treated this way, then you have not been given a >fair opportunity to achieve wellness.There are a lot of people who have not been given a fair opportunity to achieve wellness. 3-5 minaute psychiatris appointments once every 6 months would be a perfect example.
> That, I think, is the problem: shrinks really >don't respect or value their patients.I would agree. I think they just get tired of hearing people complain, esp. since they know most of their drugs are placebos.
Linkadge
Posted by psychobot5000 on January 15, 2007, at 15:12:56
In reply to Re: Depressives' sensitivity to stimulants!, posted by laima on January 15, 2007, at 0:19:09
> I agree, I think the concern about a depressed person experiencing a crash from stimulants is probably the most legeit reason doctors might want to not use them, but the thing is, I don't think a crash is guarenteed. I don't think I experience this from the low doses I use.
>______________Me neither. Been prescribed amphetamines and several formulations of methylphenidate, and never experienced any sort of 'crashing.' The benefit merely recedes, and I move back to baseline, usually feeling better because I'm more accomplished. 'Crashing' does not seem to happen to the majority of patients, as far as I can tell. Though certainly a substantial minority.
>
Were these disorders (ADD) first organized before or after stimulants fell out of favor for depression?
>_______________...As for why docs generally stopped using stims for depression, I think the primary reason (besides bad publicity for stims, and the headache of dealing with meds that have abuse-potential) was the creation of conventional ADs. I've read that amphetamine was referred to as "the antidepressant" in the 1940s, but the better efficacy (for many patients) of tricyclics seems to have led to its downfall as a first-line treatment.
> I mean, I believe in them, I identify with the innattentive type attention deficit, but I'm curious about how the history sorts out. I also think there might be some overlap with the symptoms, ie, innattentive and frustrated due to depression, or attention deficit?
>___________
The symptoms of 'depressive pseudodementia' are near-identical to 'innattentive ADD,' and many of the pdocs I've met have been aware of this similarity. The DSM-IV specifically states that one of the criteria for diagnosing ADHD is that the ADHD symptoms not be caused by another psychiatric disorder, and I think that the similarity to many depressive states is part of the reason why.There is also some bias in theory, I think, as today's docs sometimes prefer to think that depression is dependent on serotonin, and stims don't affect it as much as DA and NA. Also, conventional ADs could be interpreted (because they produce a steady state of mood-elevation and such) as resolving the underlying problem of depression, whereas the withdrawal of benefit from the patient (from stims), as the blood-levels recede, seem to suggest that stimulants only treat the symptoms without treating the cause.
I can understand practitioners' reasons for being wary, and their desire to use other meds for first and second-line treatments, but I think they should be more open to them thereafter, especially for treatment-resistant depression, and as adjuncts to other treatment(MAOis included).
Posted by blueberry1 on January 15, 2007, at 16:10:20
In reply to Stims vs conventional ADs, no crashing, AD theory » laima, posted by psychobot5000 on January 15, 2007, at 15:12:56
I say give the patient a stimulant sooner rather than later. It offers the potential of immediate benefit vs a 6 week wait. If it doesn't work in 1 week, forget it. No big loss of time compared to switching or starting antidepressants.
It also takes the whole overlap theory stuff between ADHD, ADD, anxiety, and depression off the table. Either the stim will help the patient or it won't, plain and simple. Most important, win or lose, it is a FAST trial. Even the most ill patients can afford one week. But 6 weeks can be an eternity.
In the fear of abuse, that is easy for doctors to monitor with careful prescribing practices (for example, instructions to the pharmacy to only issue one week's worth of the prescription at a time). In terms of tolerance or poopout, that happens with some people and not others. Just like every other conventional med on the market. For a very skeptical fearful doctor, they could at least let a patient who likes a stimulant use it at first while starting an antidepressant and slowly withdraw it as the antidepressant takes over. In the end if the antidepressant alone doesn't do the job, at least everyone knows what will.
Mileage obviously varies. Some people get horribly depressed on stimulants. Go figure.
Posted by laima on January 15, 2007, at 16:11:12
In reply to Re: Depressives' sensitivity to stimulants!, posted by linkadge on January 15, 2007, at 9:02:37
Me too! A sense of satisfaction to relish.
> I agree, I didn't really crash from ritalin when I was depressed. Infact I felt ok at the end of the day because I had got more done, and that I had dug myself a little futher out of the hole.
>
>
> Linkadge
Posted by laima on January 15, 2007, at 16:17:05
In reply to Re: Depressives' sensitivity to stimulants!, posted by linkadge on January 15, 2007, at 13:20:44
Isn't it true though, that if a doctor goes crazy writing prescriptions for stimulants, and a number of patients end up abusing them, selling them, depressed patient has a hard crash--or who knows what- doctor's liscence is in jeopardy? That may be a motivation for exercising restraint in writing these prescriptions. Doctors may understandably prefer to first try non-abusable precriptions first.
Posted by laima on January 15, 2007, at 16:27:14
In reply to Stims vs conventional ADs, no crashing, AD theory » laima, posted by psychobot5000 on January 15, 2007, at 15:12:56
Thanks for all of the interesting information.Yes, I think most of us are aware that the DSM changes from edition to edition, with new disorders , such as "internet addiction" being added, and some, such as "homosexual" being removed. There were some articles in the New York Times late last fall about the malleability of the existing disorders, too. As for that seratonin emphasis, I can't help but wonder if the emphasis wasn't invented or exaggerated by the marketers of SSRIs- I mean, if only it were that simple for all of us.
As for the assertion that stimulants only treat symptoms not causes, I'd have to protest. I don't mean it's not at all true, I actually think the same claim could be made for many antidepressents. And if a stimulant prompts a lethargic person to get up, socialize, and get involved with activities and life in general, leading to a sense of satisfaction and engagement- whose to say that it is "only treatingt symptoms"? I think it's fuzzy.
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