ADHD is not just about Stimulants! - Managing ADHD with a Broader Lens

[@koins9154]

Your videos are theriputic for me. Seeing a sense of understanding to the chaos I live with is very helpful. An Increased dose and or bad day can definitely throw me off for an extended period. Knowledge is powerful for someone like myself.

[@PsychiatrySimplified]

Glad you found it helpful. Thanks for the feedback 🙏🏼

[@ottife]

The best channel for this kind of info!

[@PsychiatrySimplified]

Thank you for your feedback 🙏🏻

[@jakebrookesactor]

Dr. Rege, thank you for covering the all of the variables that add to the complexity of dextroamphetamine/methylphenidate prescription treatment. Such variables I have often thought about but was unsure if I was on the right track.

[@PsychiatrySimplified]

Thanks for the feedback 🙏🏼

[@Nov19Th]

Thank you so much for such an excellent video. Increased knowledge of this condition is empowering.

[@PsychiatrySimplified]

Thank you for your feedback 🙏🏼

[@andrewreed4538]

Best information I have found. Newly diagnosed.

[@PsychiatrySimplified]

Appreciate the generosity. Also please have a look at the other video on when stimulants dont work as it helps to have the broad overview at the start. Wish you well

[@MrDcrules]

It’s fascinating that a patient with a cluster of symptoms-anxiety, jitteriness, agitation-could be seen by a group of doctors as having anxiety, ADHD, or even a mild form of hypomania. Or all 3. There seems to be a symptom overlap in many conditions in the DSM. Thank you again for this important channel. Best.

[@PsychiatrySimplified]

Thank you for your feedback

[@MrDcrules]

Fascinating and highly-informative; thank you Dr Rege. I wish we had more clinicians of your caliber.

[@PsychiatrySimplified]

Thank you for your feedback 🙏🏻

[@Sarai71788]

This is fascinating as an adhd, aspiring psychiatrist going back for my sciences classes after many years unmedicated. I got my bachelors with good grades but being unmedicated gave me burnout for many years. I’m going to do more research into serotonin’s effects on stimulant efficacy. I notice when I’m sad, not so much mad, that my medication doesn’t work. It’s like the adderall gets eaten up by my stomach more quickly when I’m serotonin depleted. It doesn’t keep me alert, focused or feeling like my normal, medicated self, it barely pushes the button that usuallly makes the car go 60.

[@PsychiatrySimplified]

Yes affective changes impacts cognitive function - hence the need to target Amygdala / ACC network which is what mediates the affective component - changing the appraisal of stimuli - pharmacological and non pharmacological aspects.

[@MrDcrules]

It would be interesting to see if someone who has been on SSRIs for decades for OCD, anxiety, depression and PTSD has undiagnosed ADHD; and adding and ADHD agent or removing the SSRI and then adding the ADHD agent actually improves outcomes; that's been my situation. Its very complicated and tricky. thank you again.

[@raginald7mars408]

...as a German Biologist - I see the main racing development in the unstoppable tsunami of constant total Dis Tracktion in all areas of Life. I try to counteract this with riding my Bicycle in dense Traffic, having my Nikon DSLR Camera with me for instant shots - and FOCUS on this Moment rigth Here. 1 Second total attention to the here and now in continuo. Never getting lured in any of the myriads of Distracktions. With utmost awareness and attention in the moment I meet most wonderful persons living the same way and principles. In the News are the persons with headphones walking into tramways, cars, trains - driving their cars into Shop windows... There are new ways of evolutionary Extinction processes Self Elimination... Surviving of the Non dis Trackted... as all natural creatures are...

[@rachanabananaful]

I understand this. 44 year old woman recently diagnosed with combined type ADHD but looking around this world with addictive smart phone use ... Seems anti human. Not good for wellbeing.

[@drsandhyathumsikumar4479]

Very helpful video ..thanks Dr 🎉

[@breonnabarker4222]

What are some things that can be done to help with the cognitive rigidity mentioned at the end of your video? You have great content. Thank you! ♡

[@PsychiatrySimplified]

Have a listen to the video on when the stimulant stops working. There are 10 points many of which will apply to your question.

[@AesthetimisticApproach]

Can stimulants helps treatment resistant depression

[@PsychiatrySimplified]

There is evidence for TRD however this depends on the nature of the depression. If used it’s used as augmentation strategy .

[@sonyaosullivan69]

Hi Dr. Rege, could you please explain in more detail what "127 Variations" means. Thank you.

[@PsychiatrySimplified]

I've touched on this in the video. The permutations and combinations with the different domains woukd lesd to multiple variations more than 127. It's to highlight that one size does not fit all

[@sonyaosullivan69]

Thank you Dr. Rege 🙂

[@douglasman100]

Why would someone change in response? Like if someone previously tolerated them and stopped tolerating them? Does some cataclysm event need to happen for this change to happen?

[@PsychiatrySimplified]

Because there are brain changes over the life span and life stressor changes which may change response. E.g increased stressors or sleep disturbances or even positive changes such as a promotion ..

[@AndrogenReceptor01]

Hi Dr, sort of unrelated but I’m about to be prescribed Adderall for ADHD but I’ve been reading that it can cause serotonin transmission. Can it safely be used with an SSRI like fluvoxamine? Obviously this is a discussion I’ll have with my psych but I would love your opinion

[@PsychiatrySimplified]

The product information highlights caution with this combination for the reasons you mention. The risk is greater with CYP2D6 inhibitors and substrates fluoxetine , paroxetine while fluvoxamine is CYP1A2 - so there are two aspects to consider 1. Pharmacokinetics I.e enzyme interactions 2. Serotonergic increase. Hope this helps with the discussion. Ps not advice

[@EmperorPenguinXRemas]

Hey Sanil, curious what your take is regarding this case. Lets say I am diagnosed with a dissociative disorder, anxiety, depression in the past, and sleep problems (late falling a sleep). Over the years symptoms remained consisten with not a substantial response to meds, e.g., anti depressant, anxiety medication, anti-epileptica and so on. There was always some remaining symptoms with a profile like ADD. A hetero anamnese is not possible, due to family circumstances, and lack of conclusive school reports for evidence. Current symptoms score high on ADD scales and measures so the suggestion was made to take methylfenidate. Let say the response is enormous, so improvement of sleep even when taking stimulants in the evening, improvement concentration, planning and more. Anxiety decreases over time, but was initially higher due to side effects. Sensitivity to stimuli is decreased. Would you at this point be confident to conclude there is most likely ADD? Even though it would be impossible to conclusive differentiate between the dissociative symptoms, anxiety, depression, etc. comorbidities.

[@EmperorPenguinXRemas]

And also less sleepy during daytime, but intially way more.

[@PsychiatrySimplified]

A ‘better’ way to think of this would be that methylphenidate as a NDRI targets a range of symptoms. A response to MPH should be evaluated in the short and long term. In such a case the decision is made by the clinician based on the framework and risk benefit analysis. The diagnosis may be either retrospective or a differential. MPH is evidence-based in conditions beyond ADHD - e.g depression, targeting fatigue etc. Another example - a patient may have a provisional diagnosis of ADHD but finds MPH too activating - this person still has ADHD it's just that their repsonse is heightened in such cases agents lower on the dopaminergic hierarchy should be considered. On the other hand someone without a clear diagnosis of ADHD may respond well to MPH to target cognition as part of a depressive syndrome. The clinician may decide to prescribe off label under the right framework. Hope this helps. Ps not advice

[@TheStealthPawn]

Why do stimulants cause emotional blunting in some people (ADHD or not)? Similar to the effect of SSRIs. Is it from noradrenaline? Are some people just over sensitive to NE? What can be done if stim-blunting occurs even at low doses? It would be weird if it was due to dopamine which normally increases reward. Is modafinil/armodafinil better for such cases to avoid NE pathway more?

[@PsychiatrySimplified]

This is in most cases typical emotional blunting as with SSRIs due to reduction of ventral striatal reward dopamine. This ‘emotional blunting ‘ a feeling of being flat occurs after the reduction of emotional arousal and hyperactivity. Most individuals with ADHD are used to a heightened arousal which is associated with distractibility and hyperactivity which can feel like a blunted state. Usually time should be allowed to understand the repsonse. Ultimately it should be linked to function as activity itself can increase arousal which can treat the ‘blunting’ . Often the treatment of ADHD should move from the feeling aspect to evaluation of activity

[@InspiredHorizons-01]

@@PsychiatrySimplified How to restore ventral striatal reward dopamine caused due to SSRIs ?

[@PsychiatrySimplified]

If strictly neurobiologically speaking then agents such as Bupropion, stimulants do this. Agomelatine at milder levels.

[@InspiredHorizons-01]

@@PsychiatrySimplified if someone take agomelatine for SSRIs induced emotional blunting. Then after 6 or 7 months of upregulating the melatonin receptors will cause severe downregulation of melatonin receptors when the agomelatine withdrawn occurs. This would caused insomnia and sleep disturbance just like SSRIs downregulate the serotonin receptors in brain .Means one have to sacrifice their sleep or melatonin receptors for restoring the others 😟

[@TheStealthPawn]

But aren't stimulants (which are NDRIs) increasing dopamine? So how would there be a reduction in ventral striatum DA as with SSRIs? I wish this phenomenon was discussed more as its very counterintuitive to what NDRIs would do for most people, as they are even prescribed off label for anhedonia symptoms. Personally, for me I find MPH is more emotionally blunting however Armodafinil actually helps my blunting/anhedonia. I presumed its just because this one avoids NE but its probably more complex. I also wonder if its due to increased neuroinflammatory load from regular stims whereas the -afinils actually lower neuroinflammation in some studies. I do not tolerate SSRIs similarly either so thats interesting. @@PsychiatrySimplified

[@mihiranand2916]

Hello, how can I book consultation with you?

[@PsychiatrySimplified]

Sorry due to medicolegal reasons can't provide online consultations.

[@mihiranand2916]

​@@PsychiatrySimplified I understand sir. However, I must say you are an absolute marvel of a psychiatrist. Being a medical student, I hope to become like you one day 🙏

[@PsychiatrySimplified]

That's high praise, Thanks for the feedback. Pick up lots of wisdom from different people and create a unique you as a psychiatrist 😁.

[@zezezep]

Really interesting and well presented ☑☑☑☑ Subscribed

[@PsychiatrySimplified]

Thanks for the feedback

[@Davey-TheDJ]

Doc you trying to simplify it too fast 1 2 3 4 5 6 I'm like wait a minute slow up here my Adderall might be working at 65% at the dose I'm taking this 15 mg twice a day but I have memory problems so I have to rewind and start over rewind start over. Cuz I'm taking notes I suffer from a host of mental health conditions but I have a great desire to learn all I can now I have the dsm-4 big book and the DSM-5 small book but I like to get all the information I can about everything mental and medical if I went to messed up in the head if I was normal I'd be Internal Medicine Physicians specializing psychiatry cuz my narcissistic says that that's the only position I would take PS I like being narcissistic borderline used to be my favorite when I was in my growing up teenage but I didn't get first diagnosed with anything until I took my first overdose when I was 18 when I was a kid I used to write those S Notes I don't want to say the word cuz I don't want to trigger anybody

[@PsychiatrySimplified]

Try slowing the video down. Sometimes it takes a few views to consolidate rhe information. Sunday will be releasing another video on stimulants and non response so that should help as well

[@AndrogenReceptor01]

You know it’s very strange you mention hedonic drive…I assume it’s an integral part of learning and for accomplishing goals but as someone with MDD, specifically with a brutal anhedonic aspect, I’m afraid stimulants won’t work for me. I can ingest 800mg of caffeine (do not do this please) and I feel absolutely nothing. No heart rate elevation or drive. I’m guessing my dopamine receptors have been severely desensitized. Hopefully stimulants work and allow me to pull-off an academic comeback but I’m afraid it might not happen

[@PsychiatrySimplified]

Important issue you raise Anhedonia has 3 components. 1. Anticipatory anhedonia 2. Consummatory anhedonia 3. Motivational anhedonia . Depression involves all 3. ADHD predominantly number 3. Each component has different parts of the brain involved. 1 and 2 involve appraisal systems and emotional circuits limbic circuits. Hence why stimulants alone don’t work in depression especially the melancholic types ( and ofcourse adjustment etc ) . To explore more I’ve done a video on the neuroscience kzbin.info/www/bejne/pV6lZaOkhtyWldUsi=MbYOkc1jrknO5zBc the video on melancholic depression will also help in the principles of management.

[@user-sk4xo8yn9f]

@PsychiatrySimplified Dr.rege I also suffered from very severe anhedonia for over 10 years, and recently took methylphenidate prescribed, but it did not help much in anhedonia, motivation, concentration, etc. However, when I took cyproheptadine together ,because I thought it would help with loss of appetite due to methylphenidate, I experienced various emotions (It felt like i have came back alive after being dead for a very long time.) that I had never experienced for more than 10 years. At first, I thought the effect of methylphenidate was just belated, but while taking cyproheptadine, it was not very consistent, but I still felt that anhedonia had improved, but after stopping taking cyproheptadine, I feel that there is no difference between taking methylphenidate and not taking it. So my hypothesis is that cyproheptadine's 5ht2a and 5ht2c antagonism increased dopamine activity in the prefrontal lobe in combination with methylphenidate's dopamine norepinephrine reuptake inhibitions. Under this hypothesis, I am thinking of using mirtazapine, which has a similar mechanism to cyproheptadine, with methylphenidate, and I wonder what you think about it.

[@AndrogenReceptor01]

@@user-sk4xo8yn9f Firstly, I'm glad to hear that you've experienced various emotions you haven't in over 10 years. That quite amazing. I would do anything to have my emotions back--even if the emotions were painful. I have heard of cyproheptadine but haven't researched it much. I do know that it works somewhat like agomelatine in that it antagonizes certain serotonergic receptors used in the treatment of SSRI-induced sexual dysfunction and melancholic depression. That seems quite promising for people like us who need this avenue of treatment. Unfortunately, I cannot quite recommend the use of methylphenidate in concert with mirtazapine simply because I'm not a medical professional in any capacity. However, I'm not sure about combining histamine antagonists with drugs that cause transmission of histamine (methylphenidate). In general I'd ask your prescriber

[@PsychiatrySimplified]

Cyproheptadine is used in PTSD to address hyperarousal and to treat nightmares. The combination is similar to using clonidine and MPH. 5HT2A antagonist also has a antidepressant and anti anxiety effect - Mirtazapine is also a 5HT2A antagonist.

[@PsychiatrySimplified]

Cyproheptadine is used in PTSD to address hyperarousal and to treat nightmares. The combination is similar to using clonidine and MPH. 5HT2A antagonist also has a antidepressant and anti anxiety effect - Mirtazapine is also a 5HT2A antagonist.

[@Hgtp2_Hat]

I like your thinking, there is a lot of merit, but I think you’re oversimplifying things & drawing distinctions arbitrarily. As a psychiatrist who has adhd & also treats adhd, the most usual reason for stimulants not working is tolerance, varying dose or having a few days off really helps, I agree that hormones are a big factor for some, and environmental stress, relationship problems & negative experiences work against medication. Totally agree that medication alone is not enough. And sometimes stimulant plus other meds needed plus psychosocial interventions. My worry is you are trying to give clarity where there is none & drawing distinctions that don’t exist.

[@PsychiatrySimplified]

Thanks for your comment. This video was simple - to talk about the concept. Im releasing another specific one on why stimulants stop working. Perhaps that covers things in more detail. Of course for YT it's different - keeping things broad and simple. For clinicians it's lot more depth in teaching 13.5 hrs - www.academy.psychscene.com/courses/clinical-excellence-in-adult-adhd-a-comprehensive-curriculum/

[@TT-ww8vv]

Memantine is really picks up the slack

[@PsychiatrySimplified]

Good medication

[@DennisBolanos]

Dr. Rege-why do different methylphenidate brands have different maximum doses (despite the active ingredient being the same)? In Spain, the upper limit for Concerta is 108 mg/d, yet for Rubifen SR it’s 60 mg/d. 🐫🌴🏺

[@PsychiatrySimplified]

Rubifen is different from Concerta - their release mechanisms and duration of action are different. E.g Rubifen ( Ritalin) has two peaks during the day 4 hrs apart, Concerta one peak at 6 hrs. Concerts is a OROS release mechanism 22% IR and 78% slow release. Ritalin has shorter duration of action, concerta longer. Hope this helps. Appreciate the gesture 🙏🏼

[@DennisBolanos]

@@PsychiatrySimplified Ah I see. Thank you!

[@kimsherlock8969]

The choice of medications 💊? You chose they can't. Your the prescriber. When you prescribed you must realise One drug isn't a miracle of life and has limitations in many situations Where it has been prescribed for treatment of ADHD brain chemistry For the wrong brain chemistry of those whom have possibly been mislabelled 😮 I know this is not uncommon, missed diagnosis can cause serious problems. Its too easy to box a mind , even though many minds can't be boxed This is not possible because of the nature of variation in each other.

[@PsychiatrySimplified]

I understand

[@redsolaris1]

No mention of the importance of diet and exercise in this condition? No mention of stimulant medication tolerance?🤔

[@PsychiatrySimplified]

Thanks for your feedback. Tolerance has been mentioned. A lot of tolerance encompasses what I've covered : The aim of this video wasn't to give a complete management perspective. But to highlight a ‘natrower’ perspective of response to stimulants. There are other videos where I've covered the diagnostic assessment and management.

[@andrewconnor4429]

Sanil you have been so tolerant on twitter you are a god. The antipsychiatritry stuff you engage with... Bro i couldn't do it. You have my complete respect

[@PsychiatrySimplified]

😃