Why aren't my stimulating meds stimulating me?
June 18, 2015 8:30 AM   Subscribe

You are not my psychiatrist! But maybe you have some idea about why this is happening. I've been diagnosed with dysthymia, major depression (in an episode now, triggered by trying to taper off of Cymbalta), and inattentive-type ADHD. I take a passel of stimulating psych meds but am still lethargic and, currently, pretty depressed, and my psychiatrists (two in the past year) don't know why.

I take Adderall XR; Cymbalta; Wellbutrin; and Abilify, with max doses of the Cymbalta and Wellbutrin. I should be jumping out of my skin, but I'm not. I also drink 2-3 cups of coffee a day. I tend to wake up during the night but fall back to sleep quickly. Lately (past 2-3 months) I've been sleeping 14 hours a day and can still nap during the day. I'm trying to get into a daily exercise program (though this has been hard!) and am contemplating cutting out sugar.

Blood tests for thyroid & iron have come back normal; I'm taking high-dose Vitamin D2 (50,000 IU/week for 6 weeks) to get my Vitamin D up, but even at times when my levels have been higher I've at least been dysthymic. FWIW we're going to try adding Prozac and then try tapering off of the Cymbalta again (I have a pretty bad side effect from the medication that impedes my quality of life). Next stop would be a different mood stabilizer, maybe Lamictal.

Is this a problem you've had? Is there some reason we're not thinking of that I am so tolerant of stimulants?
posted by knock my smock and i'll clean your clock to Health & Fitness (24 answers total) 7 users marked this as a favorite
I don't know anything about the pharmaceutical medication aspect, but:

If the coffee isn't doing anything for you anyway, cut it out and see what happens. And definitely also cut out the refined sugar. Pursuing a daily exercise program is a great idea, too!

And remember: action precedes motivation!
posted by aniola at 8:40 AM on June 18, 2015 [1 favorite]

Yeah, this is definitely a known thing for people with ADD. True ADD brains typically don't react to stimulants the same way as other people's brains do.

I'm on a somewhat similar med combo (Adderall, Wellbutrin, and Celexa) and have always been able to fall asleep on Adderall since literally the first day I began taking it, so it's not a tolerance that developed over time.

On the other hand, even a small amount of coffee makes me jittery and disrupts my sleep schedule.

In conclusion: ADD brains are weird and you can't assume that what works on non-ADD brains will work the same way on our brains.
posted by Jacqueline at 8:44 AM on June 18, 2015 [3 favorites]

If your psychiatrists are stumped you may want to see if you can find one that specializes in adult ADD instead of going to people who are just used to treating generic depression. Although I'm not sure if even an ADD specialist can do much more for you, given that this is just a known problem for ADD brains.

I had some improvement to my both my fatigue and ADD when I took a generic modafinil pill from India (Provigil is still under patent and considered "off label" for ADD in the US so wasn't affordable/available to me via regular prescription) but the mail order pharmacy I was using went out of business and I never got around to hunting down another reliable source.
posted by Jacqueline at 8:49 AM on June 18, 2015

Oh so another thing I've noticed with taking Adderall is that whatever I'm doing when it kicks in is what I'll keep doing for the next 4 hours. Before I figured this out, I assumed that taking Adderall first thing in the morning before I got out of bed would help me wake up but instead it just put me back to sleep for another 4+ hours.

So if you're currently doing something similar, stop taking your Adderall until you're already up and moving around in case the anti-task-switching action of the drug is actually just helping you sleep longer instead of helping you wake up.
posted by Jacqueline at 8:54 AM on June 18, 2015 [1 favorite]

If you get to a point where you really aren't being productive anyway, it might absolutely be time for a medication holiday from all the stimulants you are on - obviously you can't go off the anti-depressants in the same way, but it is very common to build up a tolerance to stimulants, and a short break can reset that tolerance.

Try absolutely no stimulants (coffee as well), for a week, or at least 3 days.
Even if you find that really hard, it might expose symptoms that the stimulants are masking, which might help identify the issue, longer term.

For myself, sleeping 16 hours a day, despite stimulants, was in response to allergies, so that's the drum I tend to bang on about. Try and limit your exposure to known or suspected allergens as much as possible, and if any suspected hayfever or contact allergens, shower before bed and have a clean sleeping space.
posted by Elysum at 8:56 AM on June 18, 2015 [1 favorite]

1) Are you sure your thyroid works normally? Because doctors aren't always caught up on the latest research, and the range of okay changes over time.

2) How are your vitamin B levels?

3) Antidepressants can make you super sleepy, unfortunately, and being tired feels kinda like depression, at least to me.
posted by LoonyLovegood at 9:02 AM on June 18, 2015

Have you checked with a regular doctor?
posted by amtho at 9:04 AM on June 18, 2015

Have you asked why you're on D2 and not D3?
posted by discopolo at 9:04 AM on June 18, 2015

Also don't stop taking anything without consulting your doctor.
posted by discopolo at 9:06 AM on June 18, 2015 [1 favorite]

Response by poster: Have you checked with a regular doctor?

Yep, that's where I had all the blood work done.

Also don't stop taking anything without consulting your doctor.

Don't worry, not my first time at the rodeo! I won't!

D2 tends to be what gets prescribed for major deficiencies. Usually I take D3 (and will as soon as the 6 week high-dose period is over).
posted by knock my smock and i'll clean your clock at 9:44 AM on June 18, 2015

Have you ever had a sleep study done? It sounds like you could have a sleep disorder, which could be impacting your depression and causing your ADD meds not to work.
posted by emilynoa at 10:03 AM on June 18, 2015 [4 favorites]

Have you tried lowering your dosages? or changing the time of day you take them? I know that sounds odd, but sometimes the max levels can have the opposite affect on some brains. Stimulants do weird things to my brain, for example, I have to take my thyroid meds (which are supposed to be stimulating) at night because they wipe me out. And I can drink coffee all day and not feel a thing, energy wise. But if I drink one cup of coffee in the morning, I'm not tired all day like I was when I was drinking a pot of coffee throughout the day. I'd talk to your doctor about maybe going down on your dosage rather than up.
posted by patheral at 10:16 AM on June 18, 2015 [1 favorite]

When I was massively oversleeping and feeling fatigued all the time, my doctor put me on Synthroid, even though my thyroid labs were normal. It worked well. We've had to bump up the dosage a few times, but my labs are still in normal range and I feel much better.

I don't have ADD -- I'm just bipolar and tough to treat.
posted by sock puppet du jour at 10:42 AM on June 18, 2015

I'd like to add a data point.

You say you've recently started sleeping more. Has that happened to coincide with your Abilify use? I ask because I took Abilify for a hot minute a few years ago, and it turns out that Abilify makes me crazy tired. Crazy tired. Like, "have to drink eight cups of coffee in the morning to do anything" tired. I have a friend who has had a similar experience with it, and an internet search will show you that we are not the only two people on the planet with that reaction.

So while I'm sure it isn't "the answer", I wanted to say that Abilify may be hurting you rather than helping, and you may want to see if messing with your dosage (or temporarily getting off it) changes your sleepiness any.
posted by Poppa Bear at 10:43 AM on June 18, 2015 [1 favorite]

Abilify. Notorious for knocking people out.
posted by internet fraud detective squad, station number 9 at 11:08 AM on June 18, 2015

Wellbutrin also sometimes makes people sleepy. Might want to take it at night.
posted by internet fraud detective squad, station number 9 at 11:09 AM on June 18, 2015

Just a few of my personal data points.

1. When I start feeling that way on Adderall, like it just isn't doing anything and I'm in a fog, I plan a weekend when I don't have to be on point for anything and I just don't take it for a few days. Its up-regulating, it resets you're response. It helps me and my doctor suggested it. Check it out with your doctor.

2. Wellbutrin makes me a zombie. I took it (while I was also on Adderall) for "I can't get off the couch" type depression and it just made me feel ok with not getting off the couch. I would explore getting off that and see if that helps.
posted by stormygrey at 12:25 PM on June 18, 2015

Response by poster: The Wellbutrin, fwiw, is probably not the central problem: I've been on it for something like 7 years. If anything, it probably isn't working much anymore.
posted by knock my smock and i'll clean your clock at 4:52 PM on June 18, 2015

Then it's the abilify. The atypical antipsychotics are all like this.
posted by internet fraud detective squad, station number 9 at 5:12 PM on June 18, 2015

Have you always taken the brand-name versions of Wellbutrin and Cymbalta? Because there have been recalls for generic versions of both drugs.

Presumably, the manufacturers fixed their quality issues, and the FDA is making sure it won't happen again.

Then again, there are currently generic ADHD drugs being sold, even though the FDA has found them to be not functionally equivalent.
posted by invisible ink at 8:51 PM on June 18, 2015 [1 favorite]

Have you ever had a sleep study done? It sounds like you could have a sleep disorder, which could be impacting your depression and causing your ADD meds not to work.

Came in to second this. I take meds for depression and for ADHD. I get no stimulating effect from methylphenidate or caffeine either. But I do have whats called Central sleep apnea where I stop breathing for extended periods, perhaps for 30 seconds 15 times an hour.

Getting this addressed improved my mood remarkably, increased my motivation, and allowed me to wake up rested (no more craving naps in the middle of the day). This was only caught via a sleep study (where they wire you up and check things like leg movement, REM sleep cycles, etc).

I am not discounting that one of your meds is causing your exhaustion, but addressing apnea (if you have it) is a really important aspect of getting depression under control. My psychiatrist was the one who suggested I look into it after having trouble finding meds that worked.
posted by qwip at 2:28 AM on June 19, 2015

You are on an antipsychotic, so it's not remotely surprising that you are lethargic. Sleepiness is a very, very common side effect of antipsychotics, to the extent that they're frequently prescribed as a sedative. I don't know why you've been given to understand that Abilify is 'stimulating' other than the fact that it's been marketed as causing somewhat less sleepiness than other antipsychotics. Even if you buy that, 'somewhat less' is still 'a lot'. Oh, and I guess it causes akathisia in many, many people, but I don't think akathisia can fairly be described as being 'stimulated' Having a sleep study to solve the 'mystery' of sleeping 14 hours a day on an antipsychotic would be really bizarre; it might find some incidental sleep issue, as those are rather common, but it would involve an odd blindness to the reality of the situation.

I'd get serious about that switch to Lamictal, and then if that didn't help I'd have a serious talk with my psychiatrist about whether mood stabilisers were the right thing for me. You don't seem to have bipolar, so there are lots of other options. If they are sure it's the right thing, ask about lithium, which still may make you sleepy but may not.
posted by Acheman at 2:39 AM on June 19, 2015 [2 favorites]

Methylphenidate doesn't work for me (although we may experiment further if atomoxetine doesn't work out). I have PTSD. I score very, very low on anxiety scales, which the scales themselves point out can mean a suppression of anxiety symptoms. MPH at too low a dose had no particular effect, and in larger doses tipped me straight into a low-level triggered state. At one particular formulation and dose I felt exactly as I had felt during some of the worst periods of life with my abusive partner, who I left some years ago - I hadn't felt those feelings for a long time.

Basically I felt tired, and useless, and too traumatised to be on edge. My system has a very good "stay the fuck calm" response to intense stress, but it involves brain fog, a lot of sleep, loss of autonomy and self-worth, physical fatigue, no energy and low tolerance for physical exertion. It takes me longer to recover from exercise and my mood is seriously low, worse under real stress (exercise beyond my capacity and stressful events/encounters). Oh, and I had mild tremor of course.

My prescriber measured my pulse and blood pressure and said, yep, definitely this is central nervous system activation stuff, this really isn't working for you and let's try something else.

Coming off MPH was bliss. I felt more normal straight away. I had an advantage in that it was very clearly a medication induced episode and very short. But I'm sharing this story because I think that yes, this is part of ADHD variation in brains, but it's also a way that some people - a lot of people - react to episodic or ongoing stress and trauma. With dysthymia, that's what you have day to day in your life.

Good luck. There will be a treatment regime that works for you (and me!)
posted by lokta at 5:00 AM on June 19, 2015

It sounds like a most of the things you described are all contributing to the lethargy, so I'm not too sure why everybody is pinning the blame on Abilify. Yes, Abilify does give a population of patients somnolence, but it does have stimulating properties for another population. I'm on Vyvanse, Abilify, and Lamictal, and I include myself in the latter.
I had Chronic Fatigue Syndrome a long while back and what really helped was the switch to Vyvanse, so that might be something to look into. In terms of medication, it could just be a matter of your medication "schedule." Personally, I'd take the Cymbalta and Abilify at night and the Wellbutrin and Adderall in the morning.

Issues that could be present are: Three of your medications have dopaminergic properties, potentially reducing some of the "stimulating" properties of any given one. Your sleep schedule seems pretty screwed up and finding a stable sleep schedule will likely give you more energy, as will diet and exercise (I can't emphasize those three things enough.)

But also, it could simply be the depression in particular giving you this predicament. Once your mood becomes stabilized, you might see yourself pepping up without caffeine and stimulants.

Good luck!
posted by omgkinky at 7:59 PM on June 19, 2015

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