Stimulant vs nonstimulant AD(H)D meds? Specifier: anxiety

January 26, 2021 7:06 AM

Grain of salt for armchair diagnostician bullshit. I do not have an ADD diagnosis but I have a lifetime of history that suggests it. (Stupid irony: Kaiser makes you fill out a 40 page packet to even start the process of getting diagnosed. Guess whether I finished it.) Anyway I am thinking about pursuing this again esp after reading an article saying "lots of people get convinced they don't/didn't have ADHD because they did well in school." Blah blah tldr; I would like to spend some portion of my life not feeling 100% unable, many days, to do simple components of my job. I am curious about meds.

Now, in grad school, I got someone to prescribe me one of the stimulant meds. This was during the worst year of my life and the first time I had panic attacks, so I didnt' give it much of a shot because it made me jittery and I wasn't really sticking with anything right then anyway.

I am reasonably functional! My panic disorder is fairly well contained in my life. But my tendency toward anxiety means for instance I almost never have more than a cup of tea worth of caffeine because it's somewhat likely to make me spend the next few hours twitching, my mind running in teeny circles.

So I'm curious about basically I think Strattera, a nonstimulant ADD med for adults and whether people have had good experiences or whether, if I can get my doctor to just let me try something without sending my parents a questionnaire about what I was like as a kid, I should just try the regular ones, if they're not going to just feel like a huge cup of coffee and make me spend most of my time on the ceiling.

Thoughts?

posted by less of course to Health & Fitness (28 answers total)

I had the exact same situation: late diagnosis because I was good in school, horrific experience once with meds that put me off stimulants for a very long time. I will say that the biggest shift for me in terms of ADHD symptoms was getting my anxiety under control with Zoloft; once that was in hand I was much more capable of dealing with the worst of the ADHD with lifestyle changes. That said, I recently had the somewhat absurd experience of discovering that my allergy medicine, Claritin D, treats my ADHD symptoms as a side effect, and while that’s technically a stimulant, I think, for the first time I felt what people meant when they said that for ADHDers, a stimulant can actually slow you down: no buzzy uncomfortable rush, just feeling calm and clear. Which is less a recommendation for Claritin specifically than to say it has opened my mind to someday trying a stimulant again, under good supervision: apparently the difference between different types of meds in the same family can be night and day.
posted by Merricat Blackwood at 7:42 AM on January 26, 2021 [5 favorites]

whether, if I can get my doctor to just let me try something without sending my parents a questionnaire about what I was like as a kid

This really depends on your doctor and the laws and standard practice in your area, but it's definitely worth asking. I was able to get a prescription for Vyvanse just by having a 5-minute conversation with my doctor where I explained my ADHD-like symptoms. No official diagnosis process (unless I want to pursue it).

Non-stimulant meds have (supposedly) less potential for abuse, so your doctor might be more willing to let you try Strattera than one of the stimulant meds.

I will say that the way Vyvanse affects me is similar to super-strong coffee. For me, that's a good thing, but if you don't handle caffeine well then I think your instinct to start with the non-stimulant meds is a good one. That said, there's no harm in trying a stimulant med if it's more accessible to you for whatever reason. You can always stop after a week if it's affecting you badly. Depending on your relationship with your doctor, they might be able to advise you about this as well if you explain your reaction to caffeine.
posted by mekily at 7:45 AM on January 26, 2021 [3 favorites]

I was prescribed Adderall then I wanted to switch to Vyvanse after about a 5 minute conversation, no real testing required.

One thing I learned was that I self medicated heavily with caffeine because stimulants calmed my brain down. It's fairly common among ADHD people. Just try the non-stimulants if you think the stimulants might have a bad effect. The way you describe it sounds like your anxiety is leading you to a real spiral of thoughts whenever caffeine/stimulants enter the equation.
posted by OnTheLastCastle at 8:04 AM on January 26, 2021 [1 favorite]

I am on the same journey as you right now--late ADHD "diagnosis" (I have not done neurological testing, but my prescriber (psychiatrist) and two therapists have strongly agreed that it's indicated and we're proceeding that way). Stimulants make me feel "overcaffeinated" and jumpy. Add to this, I'm pretty sure a large percentage of my anxiety has developed over my life as a coping strategy for my inattentiveness--I am constantly scanning the environment for whatever it is I'm forgetting or neglecting.

My psychiatrist has basically said that the neuro testing for an official diagnosis is not necessary. My insurance wouldn't pay for it, we're pretty sure that this is what I have, and we try meds periodically. My job situation for the past few years has been such that I haven't needed the kind of sustained focus that I used to fail at in old jobs, so I've set aside the search for meds for a while. But covid-brain is real and I've been having trouble keeping on top of any line of thought lately, so we're just starting to pursue this again. I'll be watching for other answers, and I'll let you know if I have some kind of breakthrough!
posted by gideonfrog at 8:06 AM on January 26, 2021 [5 favorites]

So I’ve taken Strattera for years and I love it. But even in its generic form it’s incredibly expensive, like in the hundreds of dollars a month tier. So I would expect that barring a major drug interaction (I.e. you’re already on Effexor, for example) the insurance company will probably want you to try other things first.
posted by chesty_a_arthur at 8:19 AM on January 26, 2021 [1 favorite]

I'm also late diagnosed, and prior to pursuing ADHD treatment I was diagnosed with anxiety anytime I tried to talk to a provider about my mental health. Strattera did not work well for me, and had bad side effects, but it might be worth trying first for you! I'm still ironing out what stimulant meds work best for me, but it seems that some of them reduce my anxiety by like, 95% because they make me so functional that I am no longer constantly ruminating over what could go wrong, be forgotten, ect and instead I just engage with what I am doing. Some (ritalin, mostly) make me very anxious and jittery. I think you likely need to have a few months marked as 'use self as guinea pig to identify the right meds' on your calendar and make sure you have good support during that period.
posted by nevernines at 8:23 AM on January 26, 2021 [1 favorite]

In my state, as far as I remember from what the diagnosing psychiatrist told me (it's possible I misremember or things have changed-this was 15 years ago), you have to go through a bunch of tests to be able to get the stimulant meds. So, when he diagnosed me with ADHD (inattentive) after a 15-minute conversation/questions session, he put me straight onto Strattera.

I've had a reasonably good experience with it, as it tamps down my mental flightiness enough to get way more done than I could do previous to taking it, with minor side effects. It doesn't solve all my problems, however, as part of not getting things done is anxiety and avoidance of difficult tasks, but at least if I manage to get myself onto them, they get done.
posted by telophase at 8:27 AM on January 26, 2021 [1 favorite]

For what it's worth, I and a lot of people I know find that the anxious-making effects of stimulant meds are much stronger if you mix them with caffeine.

I know you say you barely drink caffeine now, but did you drink more of it back in grad school? If yes, you might find stimulants easier to handle now that you've nearly quit.
posted by nebulawindphone at 8:39 AM on January 26, 2021

Response by poster: Thanks everyone.

I've heard the stuff about how stimulants help some people with ADD calm down, which is actually the one reason I wonder if it's not my actual mental problem, because I gather lots of those people are also the ones who constantly drink coffee, which would kill me. (I have always been so envious of those people who are made functional by coffee and wondered what that feels like.)

nebulawindphone, no, I have avoided caffeine for the most part since I was about 25 and figured out it messed with me. Grad school was a couple of years later.
posted by less of course at 8:58 AM on January 26, 2021

I find that a small amount of caffeine is very good at focusing me (like, one diet coke). Any more than that and I'm a jittering mess. I worry a lot about caffeine addiction, especially reducing its efficacy, so I save that and basically only drink soda on the days when I need to bring my A game. I suspect that I just can't get low enough doses of regular stimulants--though we tried doses below the suggested levels.
posted by gideonfrog at 9:19 AM on January 26, 2021

For me, stimulant based ADHD medication has been life changing. But your access to it depends a lot on where you are and your doctors and specialists. I live in a country where even almost-impossible-to-abuse Vyvanse is stigmatized: I can only get refills a couple of days before I run out, if I lose any I can't get replacements until my next refill, and if any are stolen I'm supposed to report it as dealing in it has similar legal penalties to methamphetamine.

It took me a while for it to become useful. The first couple of weeks were a bit scary: speedy, babbling and jaw-clenching. But after that I learned to feel for its calming effects. A sample course might only give you the initial effects, which may not calm your anxiety.
posted by scruss at 9:24 AM on January 26, 2021

Response by poster: I guess partly what I'm asking is: is there any reason NOT to try the nonstimulant ones? Is there any disadvantage to them? (Or maybe I mean "it"--I've only seen reference to Strattera for adults.)
posted by less of course at 9:26 AM on January 26, 2021

Some people find Strattera works less well. At least a few people find it works better. Psych meds are infuriating. But since the drill is "try one, see if it works, if not then iterate" anyway, you might as well start with the one whose side effects you think you'll find most tolerable.
posted by nebulawindphone at 9:28 AM on January 26, 2021 [2 favorites]

I think the main reason not to try the non-stimulant meds is that they are second-line drugs for ADHD because a smaller percent of people respond to them. My psychiatrist let me try Straterra for 3 months because I really wanted to (it sounds like a dream to have mitigated ADHD symptoms 100% of the time, not just for the 8 hours after taking a stimulant) but she was clear that she thought it was unlikely to be effective for me.

Edit: Wellbutrin is the other non-stimulant second line ADHD med I know of. I’m on it as an antidepressant but I think it is not recommended for people with anxiety. Works fine for me though.
posted by nevernines at 9:38 AM on January 26, 2021

After trying one of the first-line ADHD stimulant meds and finding it pretty unpleasant my experience with Strattera has been overall positive. One thing to keep in mind about Strattera is the long ramp-up time to get to the final stabilized dosage. Unlike the traditional stimulants where effects can be seen (and wear off) same-day, it may take several weeks to titrate up with Strattera. It's also very expensive (even as generic) and sometimes hard to source—on the plus side it's not a controlled substance so there is less hassle around Rx renewals and refills.
posted by 4rtemis at 9:47 AM on January 26, 2021

I tried Strattera as a kid and had an allergic reaction to it. I don't recall if it helped my anxiety or not. I recently tried a stimulant prescribed to me that I avoided trying for a long time due to my anxiety issues, and the effect of the stimulant actually helped my anxiety. Wellbutrin has been slightly helpful for ADHD related challenges. I am in process to hopefully get back on stimulants. YMMV.
posted by crunchy potato at 10:18 AM on January 26, 2021

Addendum. I self medicate with caffeine (600-800 mg) and cardio pending a trial of actual medication. The caffeine might make my anxiety worse. I'm aware that people say that. But I don't have palpitations or any other concerning side effects from it.
posted by crunchy potato at 10:21 AM on January 26, 2021

I take Strattera and it's helping. For some reason I tend to have strong reactions to stimulants like coffee and also new pharmaceuticals, so my doctor started me out at 40mg (which is, like, small child dose). After a few months I inches up to 60, which is where I am at now. The first few days I tried Strattera and the first few days of the uptick, I felt like I was vibrating. It reminded me of how I felt in an anxiety spiral so I was glad to be taking it slow.

I'd say that Strattera is helpful, sort if. I've missed a day or two on occasion and I can tell the difference. I know that stimulants would be even more helpful but I don't know if they make a dose small enough to not resemble an anxiety attack in me. So for now I'm glad there is a non-stimulant option.
posted by Gray Duck at 10:23 AM on January 26, 2021 [1 favorite]

I was diagnosed in my late 40s. I have always had a low tolerance for caffeine, more than one cup makes me bad-buzzy. I also have anxiety. Adderall and Ritalin are the only 2 ADHD meds I have tried and the effect is nothing like caffeine for me. I started with the minimum dose & worked my way up gradually, like over 4 months. When the dose was too high I knew right away and just went back & stayed on the previous dose.

Meds were not what I imagined they'd be. I am lucky I had minimal side effects and having a quieter brain is remarkable. The quiet really paved the way for me to be able to work on my anxiety and depression & to improve significantly. I still have anxiety frequently but not at all like I used to. I can practice mindfulness now which would have been impossible for me before meds.

I encourage you try first-line meds. You can always stop & try something else.

Good luck to you!
posted by i_mean_come_on_now at 10:28 AM on January 26, 2021 [3 favorites]

I was diagnosed with ADHD as a child, and spent the next 20 years going on and off of stimulant medication. My experience is that it would work for a short period of time, calming my mind and allowing me to focus. But, after a three week "honeymoon" period, it would start to show its negative effects. Either I would experience lethargy, or a constant heart-racing general anxiety until I stopped taking the medicine. Sometimes adjustments to dosage would help, but only briefly. I eventually gave up.

A few years later, I started a morning mindfulness meditation routine. I've made much more progress in the last three years with this routine than I had in 20 years with medication, and the baseline level of anxiety I used to have sans medication is effectively gone. It's also led me to eliminate a lot of substance usage from my life, including caffeine, which was a trigger for my anxiety and irritability.

I don't want to sound like I think medication is a bad idea for anyone or that meditation is a cure-all for mental conditions--there's enough success stories and medical evidence out there to put medication on anyone's list of remedies to try. It simply wasn't right for me. If you feel like you're not making progress with medication, I would encourage trying meditation.
posted by TrialByMedia at 11:28 AM on January 26, 2021 [1 favorite]

FWIW coffee and prescriptions affect me totally differently. One cup of coffee does nothing, no quiet brain, no focus help; but two cups or Rx + one cup make me feel awful for several hours. Right Rx and dosage = no jitters and a quieted, calmer brain.

The weird thing about all this is that they land so differently and you won’t know what drugs and dosages will work for you until you actually try them out. So who knows, stimulants may end up actually working well for you even though coffee doesn’t.
posted by squasher at 1:05 PM on January 26, 2021 [1 favorite]

(I didn't read all the other comments -- sorry!) I too am late diagnosed, was good in school, etc. etc. I had been treated (for a long while) for depression and anxiety prior to my ADHD diagnosis. So, when I started trialing meds, I was already adequately treated for those issues, and was taking bupropion (depression) and sertraline (anxiety). I did not experience any increased anxiety with any of the stimulants I've trialed (various formulations and dosages of Ritalin, Adderall, and Vyvanse). I did have other side effects (headaches, irritability, and currently reflux) but anxiety was never an issue. Additionally, my p-doc said that bupropion acts synergistically with the stimulant meds, so we decreased my dosage on that.

As a side note, since my diagnosis I've started reading and researching all things ADHD. I listened to a lecture by a well known psychiatrist about fine tuning dosages, and was struck by something he said: the (according to him, established) way to find proper stimulant dosage is to start very low, and continue increasing until you experience negative side effects. Then, you step back to the previous dose increment. He said many people end up under-medicating their symptoms because they stop as soon as they experience any amount of relief. He also said that another test to see if a dosage is appropriate is to take a nap while medicated. A proper dosage shouldn't leave you feeling wired to the point that you couldn't fall asleep.
posted by bluloo at 1:47 PM on January 26, 2021 [2 favorites]

For whatever it's worth, coffee/caffeine do almost nothing for me. Adderall did sometimes make me feel a bit jittery, but I take Vyvanse now, and it actually helps keep me calm. This is very much YMMV.
posted by litera scripta manet at 1:53 PM on January 26, 2021

There are more nonstimulant ADHD meds out there than Strattera.

I just got diagnosed and can't take stimulants until my hypertension is under better control, and I was prescribed guanfacine, an alpha agonist that's also prescribed to treat hypertension. It's also sometimes (more rarely) prescribed for anxiety. I just started taking it literally yesterday, so no indication yet how it works for me.

The article I linked mentions a few more, including the antidepressant Wellbutrin.

With the right doctor you may be able to get a prescription for one of these or a different anxiety-treating medication without a psychiatrist referral. If you're stuck with Kaiser this may be harder than it should be, because they are very committed to their protocols, but it's worth trying.

Also, in case you are able to go outside Kaiser's system, I will share that the forms my psychiatrist had me fill out included a self-assessment for my childhood years -- no awkward parental encounter required.
posted by rhiannonstone at 10:21 PM on January 26, 2021

Have you need tested for anxiety? I'm on an anti-anxiety med (and drink a lot of coffee) which is helpful for a lot of my symptoms. I went through the ADHD testing but! failed to qualify because I am too fucking-functional and thus do not qualify by the VERY outdated and stringent requirements my system uses. So I am the "99% sure you have ADHD and your psych says well yes, but you're doing fine without medication" warning - do not underplay from politeness how much it impacts on your life if you get an old school doctor.
posted by dorothyisunderwood at 11:52 PM on January 26, 2021 [1 favorite]

Adderall was like a miracle for me. I felt like a functioning human being for the first time. But it didn’t last. After a few months and some dosage fiddling, I was left with all side effect and no beneficial effect.

If your doctor is willing to work with you, and to jump through whatever hoops your insurance company holds up, that’s really all you need. It can’t hurt to talk to them.
posted by The Underpants Monster at 4:32 AM on January 27, 2021 [1 favorite]

One note about Strattera - it is not an immediate action medication the way stimulants are. You should take it for a few days to see the full effect.

If Strattera doesn't do it for you, you could also try Modafinil. It is related to stimulants, but does not tend to cause the jitters / anxiety the way classic stimulants do.

Good luck!
posted by Winnie the Proust at 5:19 AM on January 27, 2021

Speaking more generally to ADHD: it's a rule-out diagnosis, in the sense that a lot of factors/illnesses can mimic its symptoms, and those would ideally be ruled out first. To that effect, consider doing a bloodwork panel if you haven't done that in a while/ever. There are some physiological systems (e.g. endocrinal) where when they go out of whack, can produce changes in your anxiety/mood, which could in turn affect your ability to concentrate and plan. It's not a necessity to do this, but might be something worth looking into just to cover that base.
posted by obliterati at 9:51 AM on January 27, 2021 [1 favorite]