DOCTOR, The STIMULANT Stopped Working! - 10 Points to Consider for Optimum ADHD Management

Join Dr. Sanil Rege in this enlightening episode of 'Psychiatry Simplified' as he dives deep into the complexities of ADHD management.
In this video, Dr. Rege explores a common issue in ADHD Management: When the Stimulant Medication Loses Effect!
Has it lost its effect or is there more to it?
He unveils the crucial aspects of ADHD treatment that go beyond just the prescription of stimulants. Understand the heterogeneity of ADHD, explore the neuroscience behind its management, and discover the ten essential points every clinician and patient should know.
Key Highlights:
1. Understanding ADHD's Complex Nature: Learn about the diverse presentations and the factors influencing response to treatment.
2. Beyond Stimulants: Insights into the roles of neurotransmitters like dopamine and noradrenaline in ADHD management.
3. Comprehensive Approach: Discussion on the importance of addressing comorbidities and optimizing treatment frameworks.
Dr. Rege emphasizes that effective ADHD management requires a multifaceted approach, considering psychological, pharmacological, and lifestyle factors. Whether you're a healthcare professional or someone on their ADHD journey, this video will equip you with the knowledge to understand the intricacies of ADHD beyond stimulants.
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Stay curious and informed about the latest in mental health. See you in the next video!
#ADHD, #MentalHealth, #Psychiatry, #Stimulants, #Neuroscience, #ADHDTreatment, #SanilRege, #PsychiatrySimplified, #MentalHealthAwareness, #ADHDAwareness#ADHDTreatment, #BeyondStimulants, #MentalHealth, #PersonalizedCare, #ExecutiveFunction, #SleepAndADHD, #ComorbidConditions, #ClinicalPsychiatry, #DiagnosticApproach, #LimbicSystem, #EmotionalRegulation, #ADHDmeds, #PatientAdherence, #Neuroscience, #LongTermCare, #SymptomManagement, #PsychiatryEducation, #PsychiatrySimplified, #DrSanilRege
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[@stepheno.2730]

Outstanding explanation Dr! Often, I ask myself: “Why is the stimulant not working?” The answer more often than not is multi-faceted encompassing components of anxiety, hx of trauma, physiological etiologies (anemia, OSA) ASD or developmental conditions, or a mood component. Further clarity of the entire clinical picture holistically often provides clues. Excellent work sir, thank you.

[@PsychiatrySimplified]

Yes correct 👍

[@skierprincessakify]

Well said! I am a psychiatric provider with ADHD myself and a few times in the past when chatting with my dad I have complained that I feel like my medication isn’t working….. he reminds me “Are you exercising? Are you sleeping and eating well or are you sitting there scrolling on your phone?” Ha, dads! He’s always right though, it’s when I’ve suddenly gotten off my healthy routines.

[@eirini98]

Dr. You always seem to be on the cutting edge of the questions and issues so many people have regarding ADHD and ADHD-related issues, including how the various medications actually work. Brilliant

[@PsychiatrySimplified]

Thank you for your feedback. The questions from the audience acts as material for the videos so it wouldn’t be possible without your curiosity and questions. Thanks 🙏🏻

[@stevenkeller49]

Thanks so much for helping me understand better about what I was asking I really appreciate how in depth you get on understanding treatment. It seems like the long term approach is the only true way to proceed with trying to treat this so thanks for giving me hope to be able to get some kind of normalcy in my life .

[@katharinaschmidt2384]

If stimulants stop working in females, it’s also important to check for changes in steroid hormones (like starting/changing hormonal birth control or menopause) as these modulate dopamine and serotonine. The high overlap of ADHD and PMDD/hormone sensitivity can lead to a huge impact of hormonal changes on ADHD symptoms. 
So changing /starting hormonal contraceptives might make a higher dose of ADHD medication necessary.

[@PsychiatrySimplified]

@@katharinaschmidt2384 good points

[@Write_Charlie]

Like a lot of people, I thought my stims had stopped working, but then I was reminded of my behaviour before taking them and that "pills don't give you skills". I can't speak for anyone else, but that makes sense to me. Every other ADHDer I've met goes into this knowing there's no meds "cure", but still kind of expects one. It's rarely as dramatic as we hope. It's frustrating because the coaching so many of us need to compliment the meds is rarely available, either due to lack of funds or availability. There's no forward thinking from government. Put the help in place and I'm sure the increased productivity would more than pay for it in return. Total false economy thinking. But then it's understandable to a point when you see the rubbish coming out of Tik Tok, etc. Is it any surprise we're not taken seriously?

[@PsychiatrySimplified]

Good points! And nice quote. ✅

[@stevenkeller49]

@CastellanSpandex that’s the problem they don’t want use really figured out they want to through high pharma at us but the root cause unless it makes money or fills bed the don’t care but thanks so much

[@20081980bert]

Great video 🙏🏻

[@nawafpsy]

Much appreciated Dr. Rege! My doctor prescribing Methylphenidate 36 mg for my hypersomnolence which led me to make accidents. The med was successfully working on it but I developed tolerance to it. The problem is that it's the only legal stimulant in my country! I'm wondering what to do!

[@mikepie805]

Modafinil is also illegal? Maybe there is also phenylpiracetam? I don't know much about it, but it's also a DRI

[@PsychiatrySimplified]

Modafinil is legal. It is prescribed in many countries

[@PsychiatrySimplified]

Please have a look at the recent video where I discuss what should one consider when stimulant stops working

[@nawafpsy]

Much appreciated dear Dr. Rege! Modafinil is not available in my country and region (Arab Gulf). I will try to buy it from an international pharmacy. Thanks again dear Dr. Wishing you all the best

[@PsychiatrySimplified]

@@nawafpsy please discuss this with a doctor as there will be alternatives.

[@mikemirer8618]

An excellent video! Kudos to you. It is good for any level of practitioner. Thanks again.

[@PsychiatrySimplified]

Thanks for the feedback

[@111jennlynn]

Have there been any studies on it helping MS? Because I Would B GLAD to Answer Any ?'s about it! After 6 yrs (starting 2014) of testing/trying the normal treatments, I was not any better. Major cognitive & physical problems, NOT TO MENTION THE ON GOING 24HR A DAY PAIN! Nothing helped and I decided to stop all pharmaceuticals and treatments and took things into my own hands. I know what u r saying in ur videos is true. Again, I would love to speak with someone about this because, I believe it to work for other disabilities as well! Ppl w/non curable diseases r suffering in pain & most of the time stuck n a bed or worse in a chair for life. Left stupidly stunned as their bodies die daily! TYSM 4 Ur Studies, it means more than u know!

[@PsychiatrySimplified]

Thanks for the feedback. When you say it helping? What do you mean?

[@kevinrice7291]

Just taper down your daily mgs by 30% to 50% of what you were taking, deal with the symptoms for a couple weeks, and you should find that even your new lower dose is more effective than what you were retaking before. Then you can rinse and repeat indefinitely. Also, cool it on the caffeine.

[@PsychiatrySimplified]

Whilst this modulates the ‘feeling’ afforded by the stimulant - the aim of treatment is to have a situation of stability - where the individual is not driven by dose adjustments on a weekly or monthly basis - because this is salience - where the relationship with the stimulant is more engrained. Optimal treatment usually requires very minimal dose adjustment over the long term

[@PsychiatrySimplified]

No not feel necessarily but through evaluation of function. E.g ability to focus on task until X time. Able to fall asleep well , able to be motivated in tasks over the week - it’s an overall big picture functioning . And treatment should be evaluated over a period. If one focuses on feeling there is too much scrutiny which can confuse the picture. With feeling side effects are main aspects to be avoided - e.g persistent anxiety or mood swings etc

[@PsychiatrySimplified]

Yes that can happen. The optimum dose varies from person to person.

[@kevinrice7291]

@@PsychiatrySimplifiedI absolutely agree, and I love that you emphasize that stimulants are not the only thing to manage symptoms. I have been prescribed dexamphetamine for 1 year now, and I have only had to taper down one time. I think if there’s a need to do that weekly or monthly then there is indeed a bigger problem with the treatment.

[@curtiskarner2190]

@@kevinrice7291 how much do you take ?

[@DennisBolanos]

Dr. Rege-my psychiatrist said that stimulants work better when combined with protein because protein enhances the synthesis of neurotransmitters. Is that true? 🃏🎱🎲

[@PsychiatrySimplified]

Certain amino acids / vitamins are essential for the production of key neurotransmitters e.g Iron for dopamine , Vit B 12 and folate for DA and NA , Other amino acids are obtained from diet . Tryptophan for serotonin. Tyrosine from diet. Zn, Mg and B6 for serotonin and melatonin. Zn also for Dopamine. So yes they are essential but they arent treatments on their own.

[@DennisBolanos]

@@PsychiatrySimplified Great, thank you!

[@PsychiatrySimplified]

@@DennisBolanos Thank you for your generosity! We appreciate it 🙏🏼

[@rocketlegs6933]

thank you for the ADHD content, I was diagnosed a couple weeks ago so this is perfect timing :) is it common for it to be comorbid with GAD & MDD?

[@PsychiatrySimplified]

Yes in the video I cover the domains of ADHD - if one thinks of domains for ADHD - cognition, activity and emotion are three domains in ADHD , depression and anxiety so one can see the overlap.

[@rocketlegs6933]

@@PsychiatrySimplified In your experience, have you seen people find relief from ADHD medication (stimulants) in the comorbid domains also? This is what I've heard from my clinicians. I am currently on ritalin & agomelatine. Do you see this as an effective treatment for ADHD comorbid with GAD & MDD, including traits of sleep disturbances (waking up at night multiple times for the bathroom - this has not been worsened by the stimulant, was there before). Also I understand your response is not medical advice and I should consult my doctors :) Also appreciate the awesome content from a fellow aussie :D

[@PsychiatrySimplified]

Yes when prescribed appropriately multiple domains are treated. Over the long term once medication is stabilised - significant changes are rarely needed. Can’t comment on the specific combination - because the best way of knowing if it works is to know if it works for you. Psychopharmacology is quite precise which essentially means that one is trying to address specific domains through specific mechanisms. So we often don’t treat MDD as an umbrella - we identify phenomenology and then use the tools to address the elements

[@rocketlegs6933]

@@PsychiatrySimplified Thank you very much for the detailed response!

[@Fryguystudios]

In my experience, the confusion isn't so much about the medication not working, but working inconsistently with the same dose. Some days it works, others it doesn't, and some days it's too strong.

[@PsychiatrySimplified]

Yes that unpredictability is also part of 'non response' or inadequate response.

[@WB-63]

Great video!!!

[@PsychiatrySimplified]

Glad you liked it !

[@hyperionsolomon8718]

Thank you, dr. Would you do a video on the differences between methylphenidate and mixed amphetamine salts. Peeing on Adderall makes me feel like I can take on a lot of tasks in the physical world but when I was on methylphenidate I could study for 12 hours straight. Adderall does not give me that.

[@PsychiatrySimplified]

We’ve done a video on difference between Dexamphetamine vs methylphenidate . Immediate release or extended release ? There are quite a few factors to take into account . Here is a play list kzbin.info/aero/PLV0KZkVDyoOEOaE9DoJgpXzCXi_0b4sZz&si=sZ1WGsfC_bsiOeMi

[@neomt2]

What happens if Adderall XR just makes you sleepy and offers minimal clarity?

[@PsychiatrySimplified]

Needs an evaluation with dose adjustment. Sleep disorders to be ruled out which are highly comorbid.

[@neomt2]

@PsychiatrySimplified ty, i was severely under dosed, that's why I was so sleepy all the time

[@PsychiatrySimplified]

@@neomt2 great! You got to the bottom of it!

[@jsonbourne9799]

Thank you for explaining, Dr Rege. Does point 9 at 15:03 (avoiding sensitization cycles) mean that "stimulant holidays" are a bad idea? I am currently taking 18 mg 12h MP 5 days on, 2 off because I don't want to have to increase the dose later on. Is this likely to have the opposite effect of what I was hoping for?

[@PsychiatrySimplified]

I can’t comment on an individual basis but the aim of treatment is to reach stability - it’s about asking what is preventing one from 1. Taking a stable dose over the week ? 2. Are all domains of ADHD reasonably well controlled 3. The stimulant holidays in children are used to manage certain side effects appetite and growth but in general a stable dose throughout provides homeostasis - balance. 4. Stimulant holidays are used in adults - for the ‘extra boost’ after a gap - the aim of ADHD treatment is not to provide that boost but for sustained functioning. To kick the motivation process into gear so it’s self sustained with the medication assisting it. Hope that helps. Ps not advice.

[@ronlalk32]

Please tell me more about add adhd

[@bronsonblood637]

How so you only have 63000 subscribers.

[@PsychiatrySimplified]

Im taking that as a compliment. 😃. I'll keep sharing information ( good content i hope) and over time that number should increase.

[@sunshinevalley0]

What should someone with add/adhd look for in a adhd therapist?

[@PsychiatrySimplified]

ADHD coach or therapist you mean? Depends on what one is looking to achieve. Important aspect is what is one trying to change? 1. Clinical goals - symptoms e.g sleep, attention etc 2. Personal goals - job, achievement etc 3. Functional goals - relationship, finances. Housing , work Based on this one has to identify what are the barriers that are preventing one from achieving the goals . Then one can based on that identify the kind of therapist that will best suit them.

[@candicewallace3553]

Females in general weighing less may affect the lower dose required.. mgs per kgs is my motto, and the principle of medication tolerance is routinely overlooked if even thought of by many.. It's after all the cornerstone of the success of the cartels lucrative black Market . Tolerance to illictly aquired meds is pretty much inevitable on the roads to ruins .

[@AlluraGrim]

When tachyphylaxis does occur (as in it worked yesterday but not today), what are the primary causes? Dosage too high? Nutritional deficiency?

[@PsychiatrySimplified]

Have a listen to this - kzbin.info/www/bejne/b4LFc6hjq6mki7ssi=HGlSVzLD1Ey6HKNG

[@MarcelNeculae]

Hello Dr. Rege, what pharmacological plans do you use in ADHD patients with no comorbidities that don't get a steady response in the long-term? For example I feel that both my Prozac+Concerta are less effective after 18 months even if the dosages are increased. I tend to cycle off them for 3 months and then they start working as expected, though I'm not a fan of the withdrawl effects during those months. Is there another SSRI you tend to pair with Concerta to replace Prozac, without a need to take complete breaks from the medication? I've tried all common SSRIs except sertraline but they do nothing compared to Prozac. Also tried bupropion (😅) with Concerta but together I have no benefit, they seem to do their job only alone. I plan on bringing up a switch to sertraline on my next appointment, but I was curious on your input based on previous experience. Any "energizing" SSRIs (or maybe ADHD non stimulants) with long half lifes that would mimic the pharmacology of Prozac&Concerta? 🤔

[@PsychiatrySimplified]

The answer to this question and finding the appropriate pharmacological combination is in understanding which or what domains of ADHD is one trying to treat. In the video have a listen to the domains. Then have a look at the other video on diagnostic understanding of ADHD . The optimum treatment is best derived after an understanding of the symptom domains and formulation . Because ADHD is not one entity. Sorry I couldn’t give a specific answer because there is no generic answer to your question which is a good one and a common one which prompted me to do this video.

[@coffeeortea547]

Doctor, can you make a video about stimulant medication and erectile dysfunction? Why does it happen and what ways are there to mitigate such effects?

[@laurencerosenthalwinckler4439]

venvanse 70mg matches with viagra hahaha was going to say its a hard truth but then... hard? Not really.. It was one of the factors that made me go back to 30mg... At this range the collaterals are more manageable, but the effects are also diminished, specially once tolerance raises.

[@zmb5501]

I get realy strong fatigue and anxiety and elevated hr. Doesnt help with my focus cuz i feel so bad.

[@PsychiatrySimplified]

Worth discussing this with the doctor

[@zmb5501]

@@PsychiatrySimplified already did. Now I'm not on any adhd treatement and focus is horrible.

[@PsychiatrySimplified]

Not advice but one doesn’t need to consider all or none - the anxiety or activation can be counterbalanced by augmentation or synergy. E.g stimulant plus clonidine - One example Not advice. Please see video on clonidine

[@zmb5501]

@@PsychiatrySimplified thank you I will look into it.

[@callmate9102]

Stimulant stopped working means in 9/10 cases that the dopaminergic euphoria stopped, increasing dosages or adding other dopaminergics will just cause addiction and more side effects...

[@PsychiatrySimplified]

Yes partially true as you are describing the concept of desensitisation

[@nireeburr]

So with what’s said in mind… I’m 50 female .. who’s gone thru C-PTSD, The loss of mother after caring for her due to rare cancer .. Family rejection due to not understanding circumstances such as ADHD …;& all other labels stamped To my name.! No I’m also going thru menopause.. Currently procrastinating is so bad that I’m unable to leave home during the day .. I can but it takes a week of stuffing around doing tasks . I’m totally isolated alone and struggling to meet new people including professional help. I can’t make appointments on time so they ditch me. It’s not out of laziness. The mental chatter is beyond understanding why . I’m so desperately aching for social interaction at same time have social anxiety . If ur able to assist me in any way? The last 4years have taken its toll physically on my body.. nerves , thyroid, AND hormonal changes. I’m due for blood testing .. to get there and to fast.. is impossible atm .. I need help to do this .. but where to get help . Not many people understand any of this and just end up triggering me. Oh and the kankles , swollen knuckles . I hope some one can see this and able to help me., before loneliness does.. ❤pls help. It’s just me and my dog.. Australia

[@theluckyman74]

Studies found certain very low precursors can have a major effect I would imagine certain heavy metals in the body can mess this thing up . Thankfully it is possible to test these things. Also Studies found certain parasites can have a major effect

[@justgaleeri]

@@PsychiatrySimplified also called tachyphylaxis👍🏼

[@PsychiatrySimplified]

@@justgaleeri Tachyphylaxis is one component of non-response. But true tachyphylaxis is not as common. A significant proportion of tachyphylaxis is due to incorrect prescribing or other aspects not ruled out.

[@redsolaris1]

No mention of questioning the patients recent history of alcohol use?

[@PsychiatrySimplified]

Subsumed under comorbidities. the video is a broad overview. there are multiple comorbidiies that one could bring up ; aim is to prompt individuals to think of comorbidities.

[@saintessa]

I've seen people discussing dose splitting on reddit. Say they're prescribed 60mg and halve it to 30s - is this a method GPs have ever suggested?

[@PsychiatrySimplified]

BD dosing has been mentioned in literature. Its not common practice. Ultimately the aim is to achieve full day cover

[@Winona-c1q]

😊

[@asimkhan6919]

Hello sir can you 🙏 please reply to me as soon as possible I'm meth drug user if I'm going for visa medical test it will caught in my blood tell me sir

[@simplexone6686]

Stop taking hard drugs I can’t believe people still do this