You Mean I'm Not Lazy, Stupid or Crazy?!: The Classic Self-Help Book for Adults With Attention Deficit Disorder (51 page)

Long or Short Acting—Which Is Better?

The answer is: it depends. In the old days, before there were more reliable longer-acting stimulants, we complained about the need to take medicine every few hours. Rebound was a major issue, as was remembering to take those “middle of the day” doses. Many people do very well on extended-release preparations, but others have a better response to short-acting stimulants.
Still others need to be on a combination of long-and short-acting stimulant medication. Again, it is a trial-and-error process that also needs to take into consideration your particular needs for focus during the course of a day.

Medication for Work or Medication for Life?

Your life doesn’t stop when you leave the office. Your home life, your friendships and leisure-time activities will benefit
if you
are more present as a result of taking your medication. Factor this in as you work with your physician on dosage and timing.

Managing Side Effects

As we mentioned before, the most common side effects of stimulants are appetite and sleep disturbance, rebound, anxiety, cardiovascular changes, stomach upset and headaches. It is important to inform your doctor of any health changes, of course,
and to work closely together on side-effect management. We are, however, offering some words of wisdom, tips and strategies for dealing with the most common problems.

Appetite Disturbance:
This one does not tend to be a big problem for adults. On the contrary, many people are rather disappointed when the hoped-for side effect of weight loss fails to materialize. Generally, a loss of appetite
is temporary and short-lived. If you do experience a diminished desire to eat, don’t panic. Continue to drink ample fluids, with the addition of protein shakes. You can also eat a hearty meal in the morning, before your medicine kicks in, or when your medicine wears off.

Sleep Disturbance:
For most people, this effect is also temporary. The remedy is similar to that for appetite disturbance:
ride it out until your system adjusts. Of course, you are allowed to whine and complain in the meantime—sleep deprivation is no fun! Often, changing the timing of your medication will solve the problem. There is an optimal time window for getting to sleep when you are taking stimulant medication. Most people can get to sleep when they have enough stimulant in their systems, and also when the medicine
has worn off. The problems come when you try to get to sleep during that in-between period, when the medicine is in the process of wearing off. The solution for this is to work with your doctor on timing so that your medicine has either worn off or is still onboard at your regular bedtime. Sometimes a small evening dose will do the trick.

In the realm of the strange but interesting, we know an
ADDult who has had severe sleep difficulties all her life. Her body clock appeared to be on something like a twenty-six-hour cycle. Well, since there are only twenty-four hours in a day (contrary to what many of us wish to believe), her sleep and wake patterns moved around the real time clock constantly. She could not keep appointments or do anything consistently at a given time. Finally, she found
someone who was willing to experiment with her hunch that taking twenty-four-hour stimulant medication would help. She now takes a bedtime dose of a long-acting stimulant medication and has regular sleep and wake patterns for the very first time in her life. Go figure.

Rebound:
This is perhaps the most annoying of the side effects. When your medicine is wearing off, your symptoms come back in
a temporarily exaggerated fashion. You are more antsy, distracted, edgy, than you are when off meds. The solution is careful timing of dosages so the level of stimulant doesn’t fall too much during your waking hours. Some people, however, still experience some rebound. If this happens to you, you will need to manage your life so that your symptoms don’t get you into trouble. Take a break from work,
people or general stimulation when rebound hits. You don’t even have to invoke the ADD word; just tell your boss or coworkers that you are dealing with afternoon slump. If a total break is not possible, downshift to tasks that require less mental power.

Other Side Effects:
Work with your doctor if you experience anxiety, stomach upset or headaches. Sometimes these are also just temporary changes
as your body adjusts to the medicine. Cardiovascular changes can be more serious, so it is important to immediately report any changes in heart rate or blood pressure to your physician. Anxiety may be alleviated by switching to a different medication or adding another medication. Strattera, for example, is often helpful to those with anxiety.

Is It Really a Side Effect or Just the Experience of Tuning In?
Sometimes a side effect is not really a change at all but the result
of getting feedback from your body that you never paid attention to in the past. When your brain is more awake it is more tuned in to the signals from your body, as well as the data coming in from the outside world. That muscle tension or clenched stomach may have been there all along, but you failed to notice the
stress signals your body was sending you. Try some stress-busting techniques like exercise and/or meditation.

Nonstimulant Medications

Generally, these medications are considered to be second-line treatments for ADD. In other words, they are used when the stimulants don’t work, don’t work well enough or produce intolerable side effects. They are also used for some people with additional psychiatric
problems or medical conditions.

Strattera (atomoxetine):
This is currently the one exception. It is basically an antidepressant that increases the availability of the neurotransmitter norepinephrine. It has been approved by the FDA for treating ADD in children and adults. One advantage of Strattera is that it is not a controlled substance. Therefore, it is possible to get refills and a prescription
over the phone. This is a definite advantage for ADDers who have trouble keeping track of the monthly prescription routine. Strattera does take longer to take effect than the stimulants do—several weeks versus an hour. A major disadvantage of Strattera is that it may not be as effective as the stimulants. Limited studies suggest that Strattera and the stimulants are similar in effect, but a
number of professionals who specialize in treating ADD are not convinced that this is the case. In our experience (admittedly limited, as Strattera has been on the market for less than three years as of this writing), Strattera alone has not been as helpful to our clients as Strattera plus a stimulant. We have a concern that inexperienced physicians may lean too much in the direction of Strattera
with their ADD patients. It is tempting, as the hassles and concerns of prescribing a controlled substance are not an issue. Another concern is that Strattera can interfere with sexual functioning.

P
ROS

Not a controlled substance

Prescriptions can be refilled over the phone

Another option for people who have not had a good response to stimulants

Works continuously, contrasted to 3-12 hours
for the stimulants

Preliminary evidence shows it may be helpful for ADDults who experience anxiety

C
ONS

May not be as effective as stimulant medication

Takes longer to take effect—weeks versus an hour or less for stimulants

Can cause sexual dysfunction

Second-Line Medications

These preparations are not as effective as the stimulants, but they are useful when stimulant medication cannot be
used for some reason. If your physician prescribes a second-line drug first, ask (respectfully) to be told the rationale for doing so. There may be sound medical reasons for the decision, and you need to be informed. In some cases, however, the physician is inexperienced or generally reluctant to prescribe stimulants.

Bupropion (Wellbutrin):
Bupropion is an atypical antidepressant that increases
both dopamine and norepinephrine levels. It is helpful in relieving the symptoms of ADD but is not as powerful as the stimulants. A major advantage of this medication is that is does not cause sexual dysfunction, which is a side effect of the other antidepressants currently available. If you have a history of seizures, this drug is not a good choice, as it lowers the seizure threshold.

Tricyclic Antidepressants:
Desipramine and nortriptyline both significantly increase the availability of the neurotransmitter norepinephrine. They can reduce the core symptoms of ADD but not as effectively as the stimulants. One advantage of the tricyclics is that they provide twenty-four-hour coverage. They take several weeks to take effect, however, and include some potentially serious side effects, such
as cardiac problems.

Monoamine Oxidase Inhibitors:
This category of antidepressants increases the availability of the neurotransmitters norepinephrine and dopamine. They are rarely used to treat ADD since a special diet is needed to avoid serious side effects (hypertensive crisis). Not a great option for those who tend to be impulsive.

Venlafaxine (Effexor):
This antidepressant increases the
availability of norepinephrine and serotonin. Currently, a few non-controlled studies have indicated that it may be helpful for treating ADD adults. Please note that it is important to taper off this medication gradually—stopping abruptly can cause very uncomfortable side effects. In any case, it is important to work with your physician when making any medication changes.

Modafinil (Provigil):
Currently approved by the FDA for treating narcolepsy. Its main effect seems to be indirect activation of the frontal cortex. There is some evidence that it may be helpful for ADD adults, particularly for improving sleep cycles.

SSRIs:
This is not a specific medication but a category of medications—the selective serotonin reuptake inhibitors. The net effect of these drugs is to increase the amount
of serotonin available in the brain. They do not help wake up the brain like stimulant medication, but they do decrease impulsivity and alleviate depression. They are often used in combination with stimulants to manage the symptoms of ADD. Medications in this category include, but are not limited to, Prozac, Paxil, Celexa and Lexapro.

Caution: Labels can be misleading—medicine is not for everyone, and is never the whole answer.

Mood Stabilizers:
These medicines are first-line treatments for bipolar disorder. Some ADDults have a combination of ADD and bipolar disorder. As mentioned before, taking stimulant medication alone can be risky if you have or someone in your family has a history of bipolar disorder. In this case, your
physician
will prescribe a mood stabilizer before adding a stimulant. Medications in this category include, but are not limited to, lithium, Depakote, Lamictal and Tegretol.

Alternatives for Waking Up the Brain

For those of you who can’t or prefer not to take medication for your ADD, we are including some alternatives. This is by no means an inclusive list. Do a Google search for “ADD and natural
remedies” if you really want to be confused. There are scads of Web sites devoted to nutritional and other nonmedical solutions for the problem of ADD. Folks in the medical establishment are skeptical about the claims that herbal remedies or nutritional supplements are effective for treating ADD. They want to know about the scientific studies done to back up those claims. We choose not to participate
in that particular debate. Many established medical treatments have not been studied all that well either.

On the other hand, our personal and professional experience has been disappointing when it comes to nutritional/herbal interventions for ADD. Both of us went through a period of experimenting with herbals and supplements. Some of them seemed to help, but not as much as the stimulant medications.
Our clients who started out on natural preparations and later switched to stimulants experienced a profound difference between them. The natural remedies were much weaker in effect. Peggy’s experience was that some of the supplements worked well for a time, and then stopped being effective. She has not had that experience with stimulant medication.

That said, we are aware that this is just our
experience, and certainly not the whole story. In the interests of conserving space, we will discuss a few alternatives, and refer you to
Delivered
from Distraction
, by Edward Hallowell and John Ratey, for a balanced discussion of nutrition and ADD. In particular, they have included an entire chapter on the omega-3 fatty acids, a
promising form of dietary supplementation for people with ADD.

Neurofeedback

This interesting and controversial treatment for ADD is based on the idea that we can retrain our brains. Meditators have long known that this is possible, but did you know that scientists are beginning to look for evidence by studying the brain images of Buddhist monks? One such preliminary study used EEGs and MRIs to observe the brain effects when six monks meditated on compassion.
These monks had greater activity in the left frontal cortex of the brain than research subjects who were not practiced in meditation.