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ADHD Meds are Predictable: Use The Therapeutic Window For Best Results
Tune in to CorePsych Radio Thursday 4PM EDT and download the Program Outline here.
If you simply pay attention to these basic details the possibility of the biggest two problems with ADHD medications are almost naturally corrected – no more frustration, no more fear of adverse effects. This program is a summary of several articles already published at EzineArticles on the Therapeutic Window
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I Overview: Sides, Top, Bottom: The big picture.
7 Tips To Recognize The Window at the Outset
1. The Sides: The Entire Problem with Stimulant Meds can be summarized in two ways- Too Much, or Not Enough – the Therapeutic Window is the correct dosage, not too much, not too little, lasting exactly the right duration through the day. Stimulant meds don’t last all day, thus the problem with timing. Everybody is built different metabolically, thus the problems with dosage.
2. The Therapeutic Window is specific for each individual adult or child
3. Stay away from the Top of the Window:
4. Watch for the Bottom of the Therapeutic Window: 5. Watch for the Sides to find the DOE, Duration of Effectiveness: Each stimulant medication lasts only a specific duration. If you are under that expected duration and the sides do not cover it properly as noted in the “Sides” article, you are underdosed. If you go past that expected DOE, you are on too much.
6. Drug Interactions do occur and may cause unpredictable diminishing. – More here on 2D6, an important metabolic pathway.
7. Denial of the Importance of The Window: If you don’t think about it, if you don’t know it’s there, you simply cannot target it. If you don’t target the ‘Window’ you are either shooting geese at night, or simply throwing cans of paint at the barn door.
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II The Insufficient Bottom:
Often ADD/ADHD medications aren’t targeted, or dialed carefully in, for the Entire Day, but rather set for an inadequate objective to just “get through work or school.” This problem has been with us since much before the 1960s – is Paleolithic – and simply does not address the ‘bewitching hours’ of 4-8 PM.
7 Tips to Find and Correct Insufficient Dosage
1. Look for that longer objective: It may sound simple, but with the new drugs we can significantly change our PM objectives. The new drugs such as Vyvanse and Daytrana will last 13-14 hrs easily, but just take some time to ask the questions carefully and then adjust the dosage.
2. DOE, ‘Duration of Effectiveness,’ evaluation must come up at every medication check. If your doctor doesn’t ask about it, you must think about it anyway to encourage the discussion.
3. Know The Characteristic Subsets of the PM Drop: – Each medication reviewed in detail for DOE and characteristic drop in PM.
4. How Vyvanse covers 12-14 hr: Increase it carefully with 10 mg increase in the AM will add about 2-4 hrs on the PM bewitching hours.
5. How Daytrana can cover 12- 14 hr: I like both of these medications because compliance goes up with less afternoon dosing, and there is no need to remember that PM dose.
6. Other Meds: Adderall XR, Concerta, Focalin XR, Metadate CR Durations:
7. Teach the children at the outset: It is harder for them to know what to look for setting these PM treatment objectives. Spending just a little time at the front end will help them feel like part of the team.
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III The Toxic Top
Simply stated: The Top is too much, the Bottom is too little.
7 Tips to Find and Correct The Toxic Top
1. The Reasonable Objective – No side effects
2. Recognize Too Much
3. Toxicity Timing: All Day Problems – Toxicity may appear as absolute: All day buzzing.
4. Toxicity Timing: On and Off Problems -Toxicity may appear as cyclical, mercurial — off and on — with hyperfocus and subsequent inability to focus.
5. “Drugged” Is Too Much: Simply feels like you are toxic; it’s just too much. You shouldn’t feel stoned or drugged.
6. More Symptoms at the Top: Confusion, disorientation, cognitive stress, anxiety, are all increased, while self-expression diminishes.
7. Different Stimulant, Different Tops: Stimulants Adjusted Incorrectly: If you feel these kind of symptoms for the first couple of days after starting a new med, usually no problem. ____________________________________________________________________
III The Understandable Sides
The 7 Tips For The Sides of The Therapeutic Window
1. The Sides of the Window Are Based Upon Time: The Expected DOE – Duration of Effectiveness
2. Know the Medication DOE Expectations from the Outset:
3. Measure Precisely the Time DOE At Every Meeting: Easy questions: “When did you take it and when does it stop working?”
4. The First Side Objective – AM Onset: All meds should be working in 30-45 min after taking the medication.
5. Regulating the AM Onset: Protein Breakfast is Essential
6. The Second Side Objective – The PM Release - When They Stop Working:
7. The Mystery Objective: The PM Release with Vyvanse
See ya there!
cp
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- Evaluation of Vyvanse for ADHD Treatment (adhd-treatment-options.blogspot.com)
- What side effects does Adderall have? (cnn.com)
- Daytrana Absorption and Metabolism Patterns Compared to Ritalin and Concerta (adhd-treatment-options.blogspot.com)
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Make sure you take a look at these pages!
ADHD Medication Rules Purchase
“Rules” Affiliate Link
Neuroscience Details
Link to this page
{ 6 comments… read them below or add one }
Long post here, but I think you might find it interesting.
I would have loved to have heard all you said today on CPradio, but I was distracted…
What little I heard (MES had tech probs until 4:30 and then cut you off mid-sentence at 5 pm) was interesting and relevant. Gonna watch Eastwood specially tonight. Was it High Plains Drifter?
Just like you said “suicidal thoughts” should trump “distracted at school” it seems that depression should be treated before ADD (and sleep problems–restless legs/Mirapex–before anything else.)
When my depression–really, irritability and cynicism–colors my responses, the people around me dismiss my words as “bad attitude.” Consequently, my cognitive abilities are ignored and my relationships don’t get past first impressions. Of course, I’ve been unemployed for 13 years, since I left the military.
You’re right about military structure. As an enlisted man, being told what to do and when to do it, I performed really well: lots of promotions and medals. As an officer at remote locations, I was on my own. I was often praised for outstanding performance under pressure, but often chewed out for being unreliable.
It was quite normal for me to stand in front of a general officer while he says, “Listen carefully, this is vitally important…” and then hear him say, “… so those are your orders. We’re counting on you!” Umm. Oops. Huh?
Although I’m really a fine upstanding law-abiding good citizen, I’ve faced the barrel of a gun several times in my life and even been read my Miranda rights a couple times as a result of my impulsive actions. (I once told my troops to burglarize a top-secret vault because we couldn’t find the keys to the radio codes. In hindsight, I suppose I should have gone through channels, instead.)
Prior to the service, I got plenty of structure from the counselors during two years at the Ozanam Home for Boys and from the nuns at Bishop Hogan High School. (I ran away from home at 14, and now I know I was quite fortunate to have been jumped by an off-duty plain-clothes cop. If I had had time to pull my pistol, my last structured environment would have been a pine box.)
Now that I’m diagnosed (I recognized myself while watching my little boy), my wife and I accept the fact that, if I set out to do something simple, even important, I’ll totally forget it within seconds, and get caught up in something else. I often have no idea if I’ve paid the bills, and my kids have become accustomed to being forgotten at the bus stop.
Today, I really hoped to listen to your show, but instead, I got up for a cup of coffee, forgot to put the water in the pot, did a yard chore, and finally realized your show was half over. So it goes.
My big question: Instead of stimulants, couldn’t Effexor address both the cynicism/irritability and the inattentive ADD? (I’m wary of stimulants only because, after 2 years of Ritalin, I noticed my resting heart-rate was over 100.) Is this the “burn out” part of the Therapeutic Window you referred to?
Should irritability really be called depression? I’m not overly sad, I’m just easily pissed. The sadness and lethargy components of my depression are easily explained by the isolation of long-term unemployment. I’m really quite lucky that my wife can put up with all this.
You mentioned metabolism: I have irritable bowel syndrome. I’ve been a gaseous guy all my life. A standard meal goes from front to back in 19 hours, but long ago I learned never to drink coffee with filet mignon: as soon as steak and coffee mix, my butt explodes within seconds! (Always happy to share.)
Still, I love protein, ever since a dietician said my magnificent omentum is due to my body not handling carbs well. At 5’8” I’m a good looking guy, except my beer gut and consequent 194#) gives me a BMI of 29! (I’ve got Lipitor, aspirin and Lofibra on-board, to prevent me from following my multiply-infarcted father into the dementia clinic.)
Been googling in vain for the Kelsey scale you mentioned. Is there a better name for it? Which Kelsey?
I realize I’m taking your time. But still, I’d be grateful for your considered opinion, as you seem to be the smartest guy on the subject. I hope you found this life story interesting. I do, every day.
Hey Mike,
Great comments, almost a post in itself.
1. Clint Eastwood: Yes, The Stranger in High Plains Drifter
2. Kelsey: He was Jeff Kelsey MD, PhD in Atlanta, formerly with Emory, died about 4 years ago now, and that reference may have never been published as he became sick, and died of Leukemia. He was a good friend of mine on the teaching/speaking circuit for Wyeth with Effexor. Did a study, and he was a perfectionist comparing the HAM-D to the scale of 1-10, and found highly correlated [statistically significant] the remission of =/< 7 on the HAM-D with 7 or more on his 1-10 scale. Use it all the time… comes closer to actual testing.
3. I don’t use Effexor for ADHD tho there may be one or two papers that have seen some significance – I just don’t. I treat the ADHD unto itself and that plan works well over 95% of the time.
4. Stimulants do the trick best, and if you can take an AMP, then you are a candidate for Vyvanse, started slowly regardless of any previous AMP dose.
Got a kick out of your writing about your mil experience… almost like I was there with you.
Thanks for your great comments – give the stims a try with Effexor if you have comorbid depression, depending on what your doc says.
cp
Hi Dr. Parker, since i’m not sure the best way to reach you these days (there are SO many choices – twitter, fb, feedblitz, corepsycblog, myexpert, etc!) – i’ll post here too. I was very excited to hear your therapeutic window program today, but what ran was half (starting at 4:30pm est) of your previous depression program! Everything ok?
Jackie,
Program on Therapeutic Window was recorded as i was flying to Indiana on Thurs – heard about this problem Fri when I checked my email, left a VM at the station, and will post you back on what happened when we correct the situation. Thanks for trying!
cp
Thanks for your helpful posts.
I’m a 53-yro ADDer diagnosed only after 20 years of military service. (Boy! When you can’t pay attention to even the most important military orders, it’s a real career killer.)
Now, after 13 years of Zoloft and a few tries with Adderal (sometimes made me hyperactive), Ritalin (elevated my heart rate after 2 years), Wellbutrin (instant skin itch on the first day), Strattera (no effect whatsoever) and Effexor (nice antidepressant), I’ve settled on some facts about timing. I get angry at my kids far too easily during the first hour after taking a Zoloft. Now, my best results with mood control are to take 100mg Zoloft at bedtime, then 3×37.5mg Effexor mid-morning.
Just today I discovered the invention of SNRIs for ADD, so I’m hoping to increase my Effexor dose to see what happens to my ADD symptoms.
Any thoughts?
Mike-
Yeah, if you had it bad in the military you were either in some very unstructured assignments – or… I don’t need to tell you. Most often the military and structure helps with the ADHD.
On the meds: My take on SNRI queston: I don’t mix apples and oranges: for ADHD they are ‘helpful,’ but not as consistently corrective as stims. I love Effexor and Pristiq, both SNRIs, but use them for the affect [anger, depression, anxiety] not the cognition, and they may very well help with the anger you describe. I use the Kelsey scale for anger/depression and rate the problems from 1 being the very worst to 10 perfect – you want to be at a 7 or more. Using that simple scale can take much of the guess work out of titration for affect with antidepressants.
For the Adderall and Ritalin probs: Burn out is usually diet, and especially protein/diet related. If they are not dialed in correctly they will cause side effects – thus this radio program and this detailed post. Everyone should be using this Therapeutic Window concept with every med check. Too much Adderall = out the top. Insufficient = out the bottom. If no breakfast with protein the likelihood of toxic like med problems is high – 70-80%.
Stay tuned here for all the material coming soon on ‘neurotransmitter precursors’ and their important relevance in med management. At CorePsych we measure these specifically and augment with specific amino acid precursors for the burnout, and for proper balance on the front end, if indicated.
Finally, it does sound like you have some chronic metabolic issues, and since we are here on line I won’t ask you how many times a day you go #2, – but if your transit time is either too long or too short – I can pretty well guarantee long term problems with psych meds, all/any of them.
Try correcting these items, and do carefully review the Therapeutic Window topics, something just wasn’t right with the stim meds – and the reason was biologic, i just don’t have enough additional info to suggest other specifics.
Hang in there,
cp