Adult ADHD Treatment
October 22, 2013 3:03 PM   Subscribe

So, after long suspecting that I had some kind of medical condition that was keeping me from being as awesome as possible, I went to a psychiatrist today and was diagnosed with ADHD. But the treatment he prescribed is a bit odd.

I've had a lifetime of classic ADHD symptoms - I was the kid either blurting out answers in class or waving my hand around frantically to be acknowledged, the kid who always forgot his pen or lunch, the kid who never did homework. Despite this I managed to do OK in school and decently enough in college.

But it's carried over into my adult life as well - I fit every single symptom under "inattentive type" here to a T. And it's beginning to actively disrupt my life - I was recently passed over for a promotion at work over forgetfulness and disorganization, my apartment is a disgusting mess, and my graduate schoolwork is becoming overwhelming.

I told this to the doctor and he agreed that it sounded like I had ADHD. I was expecting a prescription for some kind of stimulant and CBT (which seems to be standard), but instead he put me on Lamictal and Invega, a mood stabilizer and antipsychotic (?), respectively. He said that he wanted to narrow the range of my moods before he tried stimulants, saying that if I were to take Ritalin, Adderall, etc, that I might end up in the hospital with mania.

Does this make sense to anyone else? It didn't to me, but I didn't really have the wherewithal to say anything. The guy has gotten really bad reviews on some doctor websites and the experience was less-than-overwhelming, from a professional perspective (he was 15 minutes late, spent most of the visit futzing around with his computer trying to enter my information in, and the conversation was not at all in-depth).

What do you think?
posted by downing street memo to Health & Fitness (38 answers total) 8 users marked this as a favorite
 
Sounds like he's not sure if you've got ADHD or bipolar disorder.
posted by elsietheeel at 3:07 PM on October 22, 2013 [4 favorites]


Unless there's some reason it's really prohibitive, I'd be getting a second opinion.

Those drugs are serious business. And as someone who had been on and off a wide variety of antidepressants over two decades, I can say that chopping and changing psychiatric meds is not a simple thing. (Withdrawals, side effects, tapering-off periods, etc.)

I'd rather be sure before I started a treatment protocol, if I were you.
posted by Salamander at 3:15 PM on October 22, 2013 [6 favorites]


Don't fill the prescription. Seek a second opinion.
posted by jbenben at 3:15 PM on October 22, 2013 [6 favorites]


+1 second opinion.
posted by rabbitrabbit at 3:16 PM on October 22, 2013


Unless there were serious clues pointing to bipolar disorder, this seems way excessive.
posted by Oktober at 3:20 PM on October 22, 2013


Yup, yup, second opinion. This sounds like my favorite "Dr. Crackhead" who took my symptoms of mild depression and decided I was bipolar. Three years lost to HORRENDOUSLY terribly side-effects from heavy medications that just made me feel horrible all the time, I found a doctor who wasn't so heavy-handed with immediate medications for a thirty-minute diagnosis, and I was free from Dr. Crackhead's clutches.

I'm not saying your doctor has anything but your best interests at heart, but it's always worthwhile to question medical decisions that don't make sense to you.
posted by xingcat at 3:22 PM on October 22, 2013 [4 favorites]


It's always wise to pursue a second opinion and as the parent and wife of two people with severe ADHD, the appointment and course of treatment you describe seem lacking to me.

I am not a doctor, let alone an expert in ADHD, but the simple fact that you have doubts/feel uncomfortable with your experience makes me even more sure that you should seek a second opinion.
posted by cooker girl at 3:25 PM on October 22, 2013 [1 favorite]


Second opinion time. Invega is a new antipsychotic and I'm seeing it being prescribed a lot...which is fine if you're psychotic. If you aren't, there's no reason to start out with it (although some people with bipolar respond well to a small dose of antipsychotic along with their mood stabilizer, that's generally not the first thing you try).

Lamictal has been around for a while and has several different uses. I can't say for certain it is the right drug for you...it's usually not used to treat a simple condition of ADD/ADHD. However, it is used in mood disorders. It sounds like your doctor isn't sure if there's a mood disorder going on or not, which is why I'd get a second opinion. I'd get the doctor's note from this visit to take to your next visit just in case.

Don't start any meds without a second opinion.
posted by MultiFaceted at 3:28 PM on October 22, 2013


RUN.

If you have a job and are basically a functioning member of society (even if you're not "as awesome as possible" in your opinion) antipsychotics are NOT worth the horrific side effects.
posted by horizons at 3:29 PM on October 22, 2013 [6 favorites]


Get a second opinion before you do anything.

Methylphenidate-type stimulants such as Ritalin, Adderall, and friends, are short-acting. They will go right through your system with no lasting effects. You can take one on Thursday [1], not bother on Friday, try half a one on Saturday, and on Sunday decide you don't like them and leave them in the drawer until you change your mind. This isn't the case with very many drugs. At all. It doesn't mean you should be cavalier about taking them, but the point is that there's not a lot of commitment with the common or garden ADHD drugs.

Most other drugs involve a lot of commitment. Heck, I had to stay on antidepressants for four months after I felt better. I don't know anything about Lamictal, Invega, or other antipsychotics, but I'm given to understand that this kind of drug is long-acting and that once you start, you're in it for the long haul. Those drugs may also have lasting effects, quite unlike Ritalin et al. which is here today and gone tomorrow.

tl;dr Do not fuck around with any psychiatric meds, especially not those which may be long-acting and have lasting effects. This is your BRAIN we're talking about. If you doubt your diagnosis, get a second opinion and don't fill any prescription until then.



[1] Assuming your prescription tells you to take a whole one at a time, and not half of one.
posted by tel3path at 3:30 PM on October 22, 2013 [2 favorites]


If he was just hesitant to start you on a stimulant, he could have started with Wellbutrin or Strattera. I would go try another doctor. If he thinks you might also be bipolar, he should not be hiding this from you. But ordinary people do not go manic off of stimulants, so it does sound distinctly like he's made another diagnosis and he's prescribing for that, not for the ADD.

It is not at all common, but there are some doctors out there who have a distinct habit of prescribing whatever the new hotness that the pharmaceutical rep is pushing is. This could also be a bit of that, with a side of the rep, under the guise of "education", making some fuss about how there are lots of people with ADD who are actually bipolar or something. They get pushy and sometimes more, and most doctors ignore it but a few don't. The troubling part is that he would do this without starting off with "and also some of these symptoms are consistent with bipolar disorder" or something.
posted by Sequence at 3:41 PM on October 22, 2013 [4 favorites]


And I'll tell you another thing, which is too often forgotten. Years ago I read Temple Grandin and she said that, in order to justify the side effects and general health costs that you get from taking psych meds, that the results had better be FANTASTIC.

If you are not saying WOW, this is the best medicine EVER, and I am OVERJOYED at the difference it's making... it's not worth it.
posted by tel3path at 3:44 PM on October 22, 2013 [7 favorites]


Ha ha NO.

A psychiatrist looking to start you on a new anti-psychotic for ADHD (they can have BAD BAD side effects and should be prescribed sparingly) is basically just sleepwalking through his job, prescribing whatever the pharma companies are pushing.

ADHD and bipolar can be hard to pick apart, but that means you take more time and actually bother to do it, not throw a hardcore med at it.

Just really not good. NO. Please see someone else.
posted by the young rope-rider at 3:49 PM on October 22, 2013 [3 favorites]


If he is not telling you he suspects bipolar type 2 then in my opinion he should not be prescribing those drugs. BP2 is not the easiest thing in the world at all to diagnose, but you don't play medicine roulette to do it, and if he does suspect it and is not telling you I wouldn't go back to him period.


Second opinion. And don't tell the other doc what the first doc prescribed, is my suggestion.
posted by St. Alia of the Bunnies at 4:01 PM on October 22, 2013 [1 favorite]


I should add, he explicitly said that I don't have bipolar or any sort of schizoaffective disorder. Thanks for the answers so far.
posted by downing street memo at 4:02 PM on October 22, 2013


Nthing second opinion, if possible. Having been on several antipsychotics and mood stabilizers before being diagnosed ADHD with depression and anxiety, I will tell you right now that they did NOTHING for me. Made me foggier and fatter. Didn't even help the depression or anxiety. If he didn't want to start with stimulants, it should have been Wellbuttrin or Strattera. Or even an SSRI. If you aren't obviously psychotic, an AP is never a first line choice. Especially not a brand new one without anecdotal off-label use. If you don't have bipolar or epilepsy, Lamictal is a very expensive sugar pill.

Don't take those pills, especially, on preview, as he said that you didn't have anything that they're actually used for! Find a doctor you trust and feel more comfortable with, who uses actual proven approaches to brain things, not whatever the drug rep is pushing this week or he heard about from some random oddball journal article.
posted by monopas at 4:07 PM on October 22, 2013 [1 favorite]


PS, Invega is the new, expensive version of now generic Risperdal. Also not given for ADHD. Sometimes, but not often, given for bipolar or as an addition to SSRIs for treatment resistant depression.

The possible and probable side effects from these meds would probably make you feel worse, and harder for a better doc to diagnose. They did for me.
posted by monopas at 4:14 PM on October 22, 2013 [1 favorite]


In addition to a second opinion, you also might want to consult a malpractice lawyer. This guy sounds dangerously incompetent.
posted by oceanjesse at 4:24 PM on October 22, 2013 [3 favorites]


"I should add, he explicitly said that I don't have bipolar or any sort of schizoaffective disorder. Thanks for the answers so far."

Wait, what?
I'd assume he was lying, and trying to treat you for the Bipolar/schizoaffective order he thinks you have, without you wigging out, because that is still less bad than how completely freaking incompetent he would have to be to be prescribing those meds for you if you DON'T have something like that.
No family history of mania or anything?!?


So yeah, what Sequence said. There are alternatives to traditional stimulants that make these drugs way, way, way down the list of even off-label uses.
o_O?
posted by Elysum at 4:58 PM on October 22, 2013


When I was diagnosed, it was by a psychiatrist that my GP referred me to. I didn't really like his style, so I had him send his diagnosis to my GP, who prescribed me ritalin, and I've been working with her ever since.

So you can go back to your regular doctor, or go to another psych - you don't have to stick with this guy. I'd look around and find someone who specializes in ADHD and gets good reviews.
posted by lunasol at 5:15 PM on October 22, 2013


OK, so the consensus is, "terrible treatment plan". I'm thinking of just writing to him and saying - look, I've read some stuff about these antipsychotics, and they look like bad news, can I just try a low dose of Ritalin etc., instead?

I really have no doubts about the diagnosis itself, just the medication - but I don't know if asking something like that will make me look like a fiend or something.
posted by downing street memo at 5:19 PM on October 22, 2013


I'm so sorry. I know it must have taken a great deal of effort to decide to make the appointment, pick the doctor, schedule the appointment and read about these medications. But no, they're not appropriate 1st attempts at treating ADHD without any indication of other psychiatric issues.

You need to ask friends to recommend another psychiatrist. Or if you post your location here, you might get some suggestions.
posted by barnone at 5:24 PM on October 22, 2013


I do not believe that people can be diagnosed through AskMe. I am skeptical of answering psych/med questions here, and of many of the answers that routinely get trotted out.

I think antipsychotics are largely bad medicine, and I think doctors who prescribe them for non-psychotic symptoms (or, at the very least, non-life threatening symptoms) are pretty much bad doctors.

I am a clinical social worker who diagnoses and treats mental disorders, and who regularly works with doctors who prescribe psychotropic medications.

Get a second opinion.
posted by OmieWise at 5:48 PM on October 22, 2013 [11 favorites]


Just adding to the chorus of people who would seriously recommend a second opinion because the prescription of two heavy hitting drugs (Lamictal requires regular blood monitoring I think) including an anti-psychotic (the Invega) for an ADHD diagnosis sounds really really incredibly wrong.

Although you can feasibly go back to the doctor and just ask for the "right" medication (especially given the effort it probably took to find this MD), I feel like that would be a disservice to yourself.

The important part of psychiatric treatment is the communication and trust built between the doctor and the patient. A diagnosis should not just feel like the result of a completed checklist or computer input. At best, diagnostic conversation about symptoms, medical/family history and current life situation presented by the patient could help to anticipate possible problems with treatment before they happen. At worst, the doctor should sound reasonably more competent than a crowd of people on AskMe. Sounds like you got neither. Hope you have a better experience the next time around.
posted by warm_planet at 5:57 PM on October 22, 2013 [1 favorite]


Run as fast as you can. This sounds like my old pdoc who eventually had me on 600mg of Seroquel for anxiety.

Lamictal is not a drug to fuck with. When I started taking it, I had to increase my dose in very small increments and watch for a serious rash.

Definitely get a second opinion, because this sounds batshit.
posted by sperose at 6:08 PM on October 22, 2013


Yeah, my "Maybe I have ADHD" after getting sub-par reviews at work process sounds a lot like yours, but I went to an ADHD specialist for diagnosis/treatment and had a VERY different experience. She started me with dexedrine (dextroamphetamine), which she described as the most basic drug out there for treating my symptoms - but also one with a very short life-span - and asked me to come back after one week to describe how I reacted so she could help me determine what treatment would work best. We tried a couple of things over the course of a month before I found a stimulant med that seemed to offer the best focus while minimizing side-effects, and then I switched to quarterly appointments for CBT-based therapy. When my insurance changed and the drug we'd settled on (Vyvanse) became too expensive, she switched me to generic Ritalin.
posted by croutonsupafreak at 6:16 PM on October 22, 2013


If I were in your position, I'd get a second opinion with another doctor, rather than write this guy a note or otherwise try to change his mind. He's already not very engaged with you, and prescribing meds that are ill-advised given what he's shared with you about his diagnosis. Writing a note, or confronting him in person, isn't likely to get you a good result. Get a second opinion.

(which is basically what warm_planet said, but I'm saying it too.)
posted by davejay at 6:18 PM on October 22, 2013 [2 favorites]


Yeah, you really don't want a doctor who prescribes weird things you don't think you need without providing sufficient explanation and then is subsequently talked into giving you a different thing instead because you ask him for it. You want a doctor who evaluates your symptoms and decides on a course of action that makes sense from the get-go. Drop this guy and go to someone else.
posted by something something at 6:34 PM on October 22, 2013


Whoa! Second opinion time.

Glad you're listening, even if we don't have medical degrees, based on what I know of Lamictal--because I take it for Bipolar--I would RUN if someone told me to take it when I didn't have a diagnosis of either Bipolar or epilepsy.
posted by BlueHorse at 7:49 PM on October 22, 2013


Lamictal does not need blood monitoring. You might be thinking of lithium, warm_planet.

That having been said, yes, you have to be careful taking lamictal at the start because of the small but significant risk of the deadly rash. And I know of no reason to take it if you are not either bipolar or epileptic.

Second opinion!
posted by St. Alia of the Bunnies at 8:00 PM on October 22, 2013


Yep, thinking about the rash-monitoring for Lamictal instead of blood monitoring, thanks St. Alia. I think the "monitoring" part of it stuck out in my memory as making it especially problematic as used in questionable treatment.
posted by warm_planet at 8:19 PM on October 22, 2013


downing street memo: "I should add, he explicitly said that I don't have bipolar or any sort of schizoaffective disorder. Thanks for the answers so far."

Run. Cancel any follow-up appointments. Find a new doc. This guy is either lying about his intended diagnosis or he's not paying attention to which patient is in front of him or something.

downing street memo: "OK, so the consensus is, "terrible treatment plan". I'm thinking of just writing to him and saying - look, I've read some stuff about these antipsychotics, and they look like bad news, can I just try a low dose of Ritalin etc., instead? "

No, do not negotiate or give him an opportunity to play the "I'm the doctor and you're just a person who reads too much internet" card. He's not your supervisor. He gave you a consultation and was paid for it. You owe him nothing, morally, professionally, or otherwise. Go find another doc who shows up on time and listens to you and works with you on a reasonable treatment plan.
posted by desuetude at 8:57 PM on October 22, 2013 [7 favorites]


And it's beginning to actively disrupt my life - I was recently passed over for a promotion at work over forgetfulness and disorganization, my apartment is a disgusting mess, and my graduate schoolwork is becoming overwhelming.

ADHD doesn't get worse as you get older.

Giving the doctor the benefit of doubt, maybe it's possible that the ADHD diagnosis is a stretch so as to avoid diagnosing you with something more stigmatizing. Regardless, google searching seems to indicate those drugs aren't unheard of in treating ADHD.

But the advice remains the same. Find another doctor and tell your story to them.
posted by gjc at 10:54 PM on October 22, 2013


Yes, Lamictal, a.k.a. lamotrigine (for epilepsy in my case) gave me Stevens-Johnson Syndrome. It is quite rare as a side effect, but obviously very serious. (I was lucky and only in the hospital for 5 days and out of work for a month.) Best to avoid it if possible.

I agree with everyone here. 2nd opinion.
posted by miss tea at 5:26 AM on October 23, 2013


I'm thinking of just writing to him and saying - look, I've read some stuff about these antipsychotics, and they look like bad news, can I just try a low dose of Ritalin etc., instead?

Your problem is not that you've been prescribed dangerous drugs of dubious benefit. Your problem is that you're working with the kind of nuff-nuff who would prescribe dangerous drugs of dubious benefit.

Go find a less dangerous doctor of less dubious benefit.
posted by flabdablet at 7:15 AM on October 23, 2013 [2 favorites]


gjc: "ADHD doesn't get worse as you get older.

Giving the doctor the benefit of doubt, maybe it's possible that the ADHD diagnosis is a stretch so as to avoid diagnosing you with something more stigmatizing. Regardless, google searching seems to indicate those drugs aren't unheard of in treating ADHD.
"

I don't think that downing street memo was saying that his ADHD is getting worse as he got older -- just that his situation and responsibilities have shifted and the coping mechanisms that allowed him to muddle through school are no longer adequate.

Off-label use of Lamictal isn't unheard in treating ADHD. But Invega??
posted by desuetude at 9:50 AM on October 23, 2013 [3 favorites]


I visited a psychiatrist recently because I have been having a hard time with depression, not managing my temper well, and not able to do much work for about year now due to being so distracted. He said it's possible that I have ADHD or bi-polar but I didn't have all the symptoms of either. He did not want to prescribe Ritalin because there are some pretty severe side effects, nor an SSRI because he said that their success rate is very, very low in the long-term. He prescribed lamotrigine and I have been taking it for about three weeks now. Can't say I feel any different, but I haven't been quite as moody. Good thing is I haven't felt any side effects -- no rash or feeling weird, great sex drive) but I'm on a pretty low dose so far (you bring it up over about one month). I am hoping to improve as the dose goes up, but can't say much about it for now.
posted by waving at 10:01 AM on October 23, 2013


Seconding desuetude. It's about coping mechanisms - the coping mechanisms I had for getting through high school living at home and undergrad at a small residential college were suddenly completely inadequate my first year of grad school when I was in my own apartment, living completely alone for the first time, dealing with cooking all of my own meals, needing to pay multiple bills per month, etc. It's not a matter of the issues getting worse per se, but the consequences of forgetting small things over and over become more serious, and as an adult you have fewer people looking out for you on a day-to-day basis who might push you to remember stuff, leave the house, and do other important human activities.

Back on topic, both of these drugs are really serious in terms of side-effects. I'm not a doctor so I have no idea if there is some justification that your doctor has in mind, but I can tell you that in every single experience I've had with a new psychiatrist, the focus has ALWAYS been on easing into treatment with lowest-possible-side-effects drugs at low doses, and then ramping up from there should the drugs not be helpful. I think you're right to feel uneasy about this, and I would definitely go to a second doctor if I were in your shoes.
posted by augustimagination at 10:03 AM on October 23, 2013 [1 favorite]


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