Can we talk about ADHD medications?
September 1, 2024 10:00 PM Subscribe
I have an ADHD diagnosis. I don't love Vyvanse. What other medications might be a good fit for me? I need to consider risk factors for glaucoma, schizophrenia, and mania.
You're not my doctor and I promise I won't take anything in this thread as medical advice! I just need a few sparks of interest to help me start researching.
45 year old woman. Demanding job. Young kids. Perimenopausal, having a period about every 3 months. I drink about 4 drinks a month, no recreational drugs, no other prescriptions. Generally healthy.
My main health concerns are:
Glaucoma - I have an elevated risk of angle-closure glaucoma due to narrow angles and very strong family history. Cataracts are also common in my relatives after age 60. My doctor said "we don't have data about ADHD drugs and glaucoma" but then I looked it up and, um, yes we do. So this degraded my trust in him and prompted me to ask this question, so I can go back with better suggestions. Are there any ADHD drugs that don't dilate your pupils? That would probably be a great start.
Schizophrenia - I have a full-blood sibling with pretty severe schizophrenia (seemed to be triggered by heavy adolescent drug use). I have never had any symptoms of it, and I know I'm not really in the risk profile at this point, but I mention it because it's something I think about when considering medication.
Possible warning signs for Mania / Bipolar - Never bad enough to be diagnosed or cause problems, but some diagnosed friends say they see manic tendencies in me. I agree that I veer towards mania when my life is overstimulating (prolonged high energy, low sleep, racing thoughts, talking a lot, irritable, over-productive). And I occasionally have bouts of situational depression brought on by major life stuff like bereavement. Luckily no harmful stuff like overspending or risk-taking. I value the periods of heightened energy, so I don't want to risk tipping over the edge into something detrimental. Overall my mental health is pretty stable.
My main ADHD symptoms are: extreme procrastination, complete lack of motivation to start unappealing tasks, forgetting to do things I don't care about, being late all the time, zoning out when auditory processing is needed, being indecisive and distractible, and frequent analysis paralysis where all tasks seem equally important and overwhelming, which makes it hard to prioritize and start.
I tried Vyvanse for a few months, experimenting with dosage per my doctor's advice. At 20mg I felt nothing. 40mg felt the best. At 50mg I felt a bit jittery and pressured. I didn't take it every day - although recently a friend said it works better if you do (is that true?) It lasts for 14 hours which is excellent for me. I didn't have any negative side effects and slept fine on it. But sadly I don't experience the level of mental clarity a lot of people like about Vyvanse - it boosts my focus by only about 25%, which isn't enough. It also makes me extremely prone to undesired and uncontrollable bouts of hyper-focus, which is a huge problem.
So I'd like to try a different drug - hopefully something that works better for focus, and also feels safer for my glaucoma risk.
Given these details, what else should I look into?
You're not my doctor and I promise I won't take anything in this thread as medical advice! I just need a few sparks of interest to help me start researching.
45 year old woman. Demanding job. Young kids. Perimenopausal, having a period about every 3 months. I drink about 4 drinks a month, no recreational drugs, no other prescriptions. Generally healthy.
My main health concerns are:
Glaucoma - I have an elevated risk of angle-closure glaucoma due to narrow angles and very strong family history. Cataracts are also common in my relatives after age 60. My doctor said "we don't have data about ADHD drugs and glaucoma" but then I looked it up and, um, yes we do. So this degraded my trust in him and prompted me to ask this question, so I can go back with better suggestions. Are there any ADHD drugs that don't dilate your pupils? That would probably be a great start.
Schizophrenia - I have a full-blood sibling with pretty severe schizophrenia (seemed to be triggered by heavy adolescent drug use). I have never had any symptoms of it, and I know I'm not really in the risk profile at this point, but I mention it because it's something I think about when considering medication.
Possible warning signs for Mania / Bipolar - Never bad enough to be diagnosed or cause problems, but some diagnosed friends say they see manic tendencies in me. I agree that I veer towards mania when my life is overstimulating (prolonged high energy, low sleep, racing thoughts, talking a lot, irritable, over-productive). And I occasionally have bouts of situational depression brought on by major life stuff like bereavement. Luckily no harmful stuff like overspending or risk-taking. I value the periods of heightened energy, so I don't want to risk tipping over the edge into something detrimental. Overall my mental health is pretty stable.
My main ADHD symptoms are: extreme procrastination, complete lack of motivation to start unappealing tasks, forgetting to do things I don't care about, being late all the time, zoning out when auditory processing is needed, being indecisive and distractible, and frequent analysis paralysis where all tasks seem equally important and overwhelming, which makes it hard to prioritize and start.
I tried Vyvanse for a few months, experimenting with dosage per my doctor's advice. At 20mg I felt nothing. 40mg felt the best. At 50mg I felt a bit jittery and pressured. I didn't take it every day - although recently a friend said it works better if you do (is that true?) It lasts for 14 hours which is excellent for me. I didn't have any negative side effects and slept fine on it. But sadly I don't experience the level of mental clarity a lot of people like about Vyvanse - it boosts my focus by only about 25%, which isn't enough. It also makes me extremely prone to undesired and uncontrollable bouts of hyper-focus, which is a huge problem.
So I'd like to try a different drug - hopefully something that works better for focus, and also feels safer for my glaucoma risk.
Given these details, what else should I look into?
Unfortunately, ADHD medications more or less fall into two categories: stuff that doesn't really work, and stimulants. And among the stimulants, amphetamines (e.g. vyvanse) tend to be almost universally seen as the most effective, with phenidates (e.g. ritalin) being more hit-or-miss -- but also still stimulants, and thus prone to all the same problems. While there are variations to be had, e.g. 100%-dex-amphetamine (vyvanse, dexedrine) vs 75%-dex (adderall), or racemic methylphenidate (ritalin) vs dexmethylphenidate (focalin), and some people prefer one over the others, the differences are pretty small.
So, in short, if vyvanse wasn't "focusing enough", it's highly unlikely anything else will be. There are some gentler alternatives, e.g. bupropion has some mild benefit with some people, as does modafinil -- but they're still both stimulants, and weaker than vyvanse at that. I would not recommend them given your description of your experience.
Given your description of your symptoms, it sounds like stimulants are effectively serving as adrenaline to kick you into gear and help (chemically) pressure you to "do things you don't want to do" (e.g. unpleasant tasks). This is... well, unfortunately a very normal way stimulants are used, and undoubtedly part of how they "treat" ADHD (speaking from experience). But as you can tell, it's kind of a band-aid; given your troubles with using stimulants, you might find non-pharmaceutical approaches to be useful. For example, it's a bit out of the scope of this post, but a few years ago I got great mileage out of a regular meditation practice, which more or less helped me deal (to an extent) with all the symptoms you described even after I went off adderall.
Another option could be to try combining pharmaceutical and non-pharmaceutical interventions, but given your glaucoma concerns, ruling out stimulants doesn't exactly leave many (pharmaceutical) options.
although recently a friend said it works better if you do (is that true?)
Untrue, to the point of perhaps even being the opposite; all stimulants generate tolerance fairly rapidly, so some people report they work better when you don't use them all the time. It is certainly okay to use them every day though, for some definition of okay at the very least. I did so for half a decade and I don't think they completely ruined my brain, at least.
posted by etealuear_crushue at 12:26 AM on September 2 [6 favorites]
So, in short, if vyvanse wasn't "focusing enough", it's highly unlikely anything else will be. There are some gentler alternatives, e.g. bupropion has some mild benefit with some people, as does modafinil -- but they're still both stimulants, and weaker than vyvanse at that. I would not recommend them given your description of your experience.
Given your description of your symptoms, it sounds like stimulants are effectively serving as adrenaline to kick you into gear and help (chemically) pressure you to "do things you don't want to do" (e.g. unpleasant tasks). This is... well, unfortunately a very normal way stimulants are used, and undoubtedly part of how they "treat" ADHD (speaking from experience). But as you can tell, it's kind of a band-aid; given your troubles with using stimulants, you might find non-pharmaceutical approaches to be useful. For example, it's a bit out of the scope of this post, but a few years ago I got great mileage out of a regular meditation practice, which more or less helped me deal (to an extent) with all the symptoms you described even after I went off adderall.
Another option could be to try combining pharmaceutical and non-pharmaceutical interventions, but given your glaucoma concerns, ruling out stimulants doesn't exactly leave many (pharmaceutical) options.
although recently a friend said it works better if you do (is that true?)
Untrue, to the point of perhaps even being the opposite; all stimulants generate tolerance fairly rapidly, so some people report they work better when you don't use them all the time. It is certainly okay to use them every day though, for some definition of okay at the very least. I did so for half a decade and I don't think they completely ruined my brain, at least.
posted by etealuear_crushue at 12:26 AM on September 2 [6 favorites]
Also worth noting, and this is quite oversimplified, but one common way ADHD medications are compared is effectively the ratio of their dopamine vs norepinephrine effect ratio. Dopamine governs the brain's reward loop and "making it feel good/rewarding to do and think things", while the norepinephrine governs the adrenaline, the (physical and mental) energy, the pressure, so to speak.
Vyvanse is among the heaviest on the dopamine side of things, from what I recall. So it's probably more prone to hyperfocus, comparatively, while being less pressuring. So its possible you might find one of the alternatives to have a slightly different ratio of hyperfocus to pressure.
Of course, being all stimulants, all of these will probably have the same glaucoma concern. (disclaimer: I don't know anything about whether the glaucoma interaction is a serious enough risk to worry about or not, so don't take my word to mean anything; I'm just taking your word on it).
posted by etealuear_crushue at 12:38 AM on September 2 [2 favorites]
Vyvanse is among the heaviest on the dopamine side of things, from what I recall. So it's probably more prone to hyperfocus, comparatively, while being less pressuring. So its possible you might find one of the alternatives to have a slightly different ratio of hyperfocus to pressure.
Of course, being all stimulants, all of these will probably have the same glaucoma concern. (disclaimer: I don't know anything about whether the glaucoma interaction is a serious enough risk to worry about or not, so don't take my word to mean anything; I'm just taking your word on it).
posted by etealuear_crushue at 12:38 AM on September 2 [2 favorites]
On the question of taking medicine daily or not, I take it daily because I need to focus everyday. I have not “built up a tolerance” over the couple of years that I have been taking it.
It doesn’t “cure” my focus challenges, but it does make a 50%+ difference.
Another extended release medication is Concerta, but it looks like your concerns with glaucoma would still apply to it.
posted by bruinfan at 4:47 AM on September 2 [4 favorites]
It doesn’t “cure” my focus challenges, but it does make a 50%+ difference.
Another extended release medication is Concerta, but it looks like your concerns with glaucoma would still apply to it.
posted by bruinfan at 4:47 AM on September 2 [4 favorites]
> although recently a friend said it works better if you do (is that true?)
>Untrue, to the point of perhaps even being the opposite
My understanding of this is that daily use means your body builds up a resistance to the drugs, so they're having less effect on your body. At the same time, this can diminish unpleasant jitters etc and give one a more "smoothed out" and predictable daily experience. I have never taken my drug (the lowest dose Concerta comes in for adults) regularly, mainly when I need to do my quarterly taxes or some other horrible bureaucratic task I want to avoid. It helps me a LOT with the decision paralysis/prioritization issues you describe, but has never helped me at all with constant lateness. I don't have auditory space out struggles.
I can't really weigh in on how anything interacts with your other concerns, besides mania. I have a similar hypo-mania experience to what you describe and I don't feel that taking the meds triggers me. Being on it feels similar to being hypomanic, but the feeling goes away when the drugs wear off, 4-6 hours for me. I dont know if I've ever taken the drugs while hypomanic, I don't see it being necessary for me to use them then because I am generally very productive in hypomania.
posted by Summers at 5:05 AM on September 2
>Untrue, to the point of perhaps even being the opposite
My understanding of this is that daily use means your body builds up a resistance to the drugs, so they're having less effect on your body. At the same time, this can diminish unpleasant jitters etc and give one a more "smoothed out" and predictable daily experience. I have never taken my drug (the lowest dose Concerta comes in for adults) regularly, mainly when I need to do my quarterly taxes or some other horrible bureaucratic task I want to avoid. It helps me a LOT with the decision paralysis/prioritization issues you describe, but has never helped me at all with constant lateness. I don't have auditory space out struggles.
I can't really weigh in on how anything interacts with your other concerns, besides mania. I have a similar hypo-mania experience to what you describe and I don't feel that taking the meds triggers me. Being on it feels similar to being hypomanic, but the feeling goes away when the drugs wear off, 4-6 hours for me. I dont know if I've ever taken the drugs while hypomanic, I don't see it being necessary for me to use them then because I am generally very productive in hypomania.
posted by Summers at 5:05 AM on September 2
I take my ADHD medication daily. I find that taking it daily minimizes the jittery over-caffeinated side effects, and it makes me much more functional. (I take 60 mg of Vyvanse.)
For what it's worth, the abstract of this article found amphetamines and strattera increase risk of angle closure glaucoma while methylphenidate increased risk of open angle glaucoma.
IANAD/IANYD, but if you are specifically concerned about the ACG, maybe methylphenidate class of meds is worth trying (concerta, focalin, ritalin... I've always stuck with the amphetamines).
But also, the medications alone aren't always enough. You have to really work on coming up with systems and everything else.
And in terms of the hypomania, I have no idea if this is accurate, but I feel like untreated ADHD can sometimes manifest (for me) in that sort of hypomanic type of way. When I get really wired, get really into something - but maybe this depends on having hyperactive/impulsive type of ADHD.
posted by litera scripta manet at 6:08 AM on September 2 [1 favorite]
For what it's worth, the abstract of this article found amphetamines and strattera increase risk of angle closure glaucoma while methylphenidate increased risk of open angle glaucoma.
IANAD/IANYD, but if you are specifically concerned about the ACG, maybe methylphenidate class of meds is worth trying (concerta, focalin, ritalin... I've always stuck with the amphetamines).
But also, the medications alone aren't always enough. You have to really work on coming up with systems and everything else.
And in terms of the hypomania, I have no idea if this is accurate, but I feel like untreated ADHD can sometimes manifest (for me) in that sort of hypomanic type of way. When I get really wired, get really into something - but maybe this depends on having hyperactive/impulsive type of ADHD.
posted by litera scripta manet at 6:08 AM on September 2 [1 favorite]
I had a bad time on Vyvanse (awful side effects, including the undesired hyperfocus you described) and am having a pretty decent time on Concerta (no side effects and better focus). My understanding is that reactions to stimulants are extremely idiosyncratic.
posted by toastedcheese at 6:24 AM on September 2 [3 favorites]
posted by toastedcheese at 6:24 AM on September 2 [3 favorites]
Diet. Diet is huge with Vyvanse.
I would wake up with no breakfast, drink coffee all morning, then eat a big lunch, and wonder why my afternoon was full of jitters and panic attacks. It wasn’t until a friend of mine tipped me off that I should eat a breakfast, especially with protein.
My—massively oversimplified, possibly wrong—understanding of way it works is your body metabolizes the Vyvance into the active ingredient, and food is a central key to all of that.
posted by jonnay at 6:38 AM on September 2 [3 favorites]
I would wake up with no breakfast, drink coffee all morning, then eat a big lunch, and wonder why my afternoon was full of jitters and panic attacks. It wasn’t until a friend of mine tipped me off that I should eat a breakfast, especially with protein.
My—massively oversimplified, possibly wrong—understanding of way it works is your body metabolizes the Vyvance into the active ingredient, and food is a central key to all of that.
posted by jonnay at 6:38 AM on September 2 [3 favorites]
I have a similar ADHD presentation to you, and I have found Strattera (one of the non-stimulant meds) to give me some relief.
It doesn’t take instantly the way Vyvanse does, so at first it can feel like it’s not working — but after about two days of taking it I can feel a distinct difference. I take it on and off due to the side effects, and currently I am not taking it, but may start again soon.
Here is an Ask thread with some posts about experiences with Strattera which was helpful to me.
posted by mekily at 7:23 AM on September 2 [1 favorite]
It doesn’t take instantly the way Vyvanse does, so at first it can feel like it’s not working — but after about two days of taking it I can feel a distinct difference. I take it on and off due to the side effects, and currently I am not taking it, but may start again soon.
Here is an Ask thread with some posts about experiences with Strattera which was helpful to me.
posted by mekily at 7:23 AM on September 2 [1 favorite]
You haven't mentioned bupropion (Wellbutrin); it didn't help me, but some others described positive experiences when I asked about it.
posted by paduasoy at 7:38 AM on September 2
posted by paduasoy at 7:38 AM on September 2
I had a shit time on Vyvanse and Concerta works wonders for me, so definitely different drugs work differently for different people. Concerta does potentially raise blood pressure, though not for everyone (it doesn't for me), so it is worth a try if you keep an eye on your blood pressure and other side effects.
My doctor was great at trying a week by week titration of the ADHD drugs to see what worked and at what levels. As adults, we can generally tell pretty quickly whether something is making a difference for us, so it's worth giving some others a try to see what sticks.
posted by urbanlenny at 8:21 AM on September 2 [1 favorite]
My doctor was great at trying a week by week titration of the ADHD drugs to see what worked and at what levels. As adults, we can generally tell pretty quickly whether something is making a difference for us, so it's worth giving some others a try to see what sticks.
posted by urbanlenny at 8:21 AM on September 2 [1 favorite]
Concerta (methylphenidate) is what works for me, 27 mg extended release with a separate prescription for 5 mg instant release if I feel like I need it (I usually don't.)
posted by emelenjr at 10:24 AM on September 2
posted by emelenjr at 10:24 AM on September 2
I was getting jitters and having difficulty sleeping on stimulants. Strattera alone was not super helpful, but it seems like Strattera + a very small dose of stimulant is giving me the good effects without the troublesome side effects.
posted by BrashTech at 4:31 PM on September 2 [1 favorite]
posted by BrashTech at 4:31 PM on September 2 [1 favorite]
Just went off Wellbutrin, (couldn't handle the insomnia and the massive return of my essential tremor), and just got a script for Strattera. We shall see how that goes.
Good luck!
posted by Windopaene at 6:51 PM on September 2
Good luck!
posted by Windopaene at 6:51 PM on September 2
Hi, I am also 45 and have been medicated for ADHD for nearly 30 years now (with a couple breaks in between that were pretty disastrous). I've taken both methylphenidate and adderall over the years and am currently prescribed 40 mg daily of extended release MPD (aptensio or metadate, depending on availability). YMMV, of course, but I found that the adderall was more consistent & more physically stimulating while also being less effective from a cognitive standpoint. I switched to methylphenidate again just about six months ago because of this. It's a lot better for working memory and executive functioning, and just feels "gentler". No jitters even if I drink coffee. My point being that even among stimulants, you can have different responses based on your individual body/brain chemistry.
posted by aecorwin at 1:32 PM on September 3
posted by aecorwin at 1:32 PM on September 3
Wellbutrin gives me panic attacks. I tried Strattera and Vyvanse and neither one did anything helpful. I take generic Adderall, an extended release one in the morning and a short acting one in the early afternoon that gets me through the mid-afternoon slump. I tried various doses and combinations and this works for me. I also take an anti-depressant (Cymbalta).
I also have weekly therapy with a therapist who also has ADHD, although she is unmedicated. Mostly, I have had to learn to make to-do lists in the smallest subtasks imaginable to get through day and set an alarm to stop work every 45 minutes to break my hyperfocus and stand up for a few minutes. I was diagnosed very late in life (at 58); apparently, many women find their ADHD gets worse after menopause.
posted by ceejaytee at 1:32 PM on September 3
I also have weekly therapy with a therapist who also has ADHD, although she is unmedicated. Mostly, I have had to learn to make to-do lists in the smallest subtasks imaginable to get through day and set an alarm to stop work every 45 minutes to break my hyperfocus and stand up for a few minutes. I was diagnosed very late in life (at 58); apparently, many women find their ADHD gets worse after menopause.
posted by ceejaytee at 1:32 PM on September 3
I don't have the answer for you, but I have some resources.
Dr. Dodson on ADHD medication management -- this was super useful for me.
Discussion of autism and ADHD medication strategies - discusses combo therapy, which can be useful for folks for whom just stimulants alone aren't cutting it.
I personally am on guanfacine ER with a low dose of Vyvanse. The Vyvanse really helps me focus, and the guanfacine gets rid of the anxiety and stress the Vyvanse was causing.
I hope you find the right medication combination for you!
Also I'll say that misdiagnosis of bipolar for ADHD is not uncommon, especially in women (not sure of your gender). I don't know you and I'm not a provider; you may have bipolar traits, or those traits may specifically be manifestations of ADHD (or in some folks, a combo of ADHD and trauma), with zero bipolar.
Excessive talkativeness, lots of energy (hyperactivity), hyperfocusing on things you're super interested in while neglecting other life activities and obligations, sleep disturbances -- those are all 100% common ADHD symptoms and traits! So it's definitely worth digging into that and disambiguating whether you need to be genuinely concerned about bipolar or not.
posted by cnidaria at 9:43 PM on September 3
Dr. Dodson on ADHD medication management -- this was super useful for me.
Discussion of autism and ADHD medication strategies - discusses combo therapy, which can be useful for folks for whom just stimulants alone aren't cutting it.
I personally am on guanfacine ER with a low dose of Vyvanse. The Vyvanse really helps me focus, and the guanfacine gets rid of the anxiety and stress the Vyvanse was causing.
I hope you find the right medication combination for you!
Also I'll say that misdiagnosis of bipolar for ADHD is not uncommon, especially in women (not sure of your gender). I don't know you and I'm not a provider; you may have bipolar traits, or those traits may specifically be manifestations of ADHD (or in some folks, a combo of ADHD and trauma), with zero bipolar.
Excessive talkativeness, lots of energy (hyperactivity), hyperfocusing on things you're super interested in while neglecting other life activities and obligations, sleep disturbances -- those are all 100% common ADHD symptoms and traits! So it's definitely worth digging into that and disambiguating whether you need to be genuinely concerned about bipolar or not.
posted by cnidaria at 9:43 PM on September 3
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