In my practice, I’m amazed about how many people come to me and have taken some test online and have self-diagnosed themselves with ADHD or ADD and want me to give them stimulants. It happens every week. I also don’t know how many times I’ve had to tell these same people that stimulants may not be the answer to their problems and can even make their mental health symptoms worse! Let me give you a case in point of when stimulants may have done more harm than good.
Larry, (not his real name) is a 53 year old male who reports that he has taken Adderall or the equivalent for 30 years. He reports it makes him organized. It makes him be able to focus and concentrate and complete tasks. I take careful note but also observe that this same guy is very rigid, angry and irritable during our visit. He has a history of attempted suicide and has been hospitalized several times. He also tries to hide the fact that he lived in a reclusive situation away from civilization for years and has been unable to work for authority figures. He also reports he is estranged from friends and family.
Yes, it is true that stimulants help many people with focus and concentration. It is also the fact that ADHD is not the only condition that makes a person disorganized, unfocused and unable to complete tasks. For instance the guy above ended up being diagnosed with Schizophrenia. Other conditions like Bipolar Disorder, Depression, anxiety disorders and Thyroid Disorders can look like ADHD. Giving the above patient stimulants can bring out his rigidness, his anger and irritability and even psychotic symptoms. If one has tendencies toward obsessive compulsive disorder it would be especially important to avoid taking stimulants. Stimulants can make the OCD worse. A better way to go might be to effectively treat the OCD symptoms and the patient may find that their ADHD like symptoms greatly improve.
Sadly, years of stimulant misuse for the above patient made him so rigid in his expectations that he was psychologically unable to consider other possibilities for his problems. This is why it is so important that when suffering from ADHD like symptoms that a specialist who works regularly with the various mental illnesses be called upon to do the initial evaluation. It can potentially prevent years of problems and help a person become quickly more functional to reach his goals. I wish this guy could have been spared all the pain he went through! Can you imagine the implications for posterity and other family members?
In my practice I often see patients self referred or sent in by their general practitioner who tell me that he or she has Major Depressive Disorder. Problem is, medications and therapy have had little success so my expert advice is needed.
When evaluating a patient it is crucial not to miss the diagnosis of bipolar depression. A recent article in a Chilean medical journal (Rev Med Chili 2010 Jun) identifies suggestions of how a proper diagnosis can be achieved. This information resonates with my practical experience seeing patients through the years.
First it is important to use standardized diagnostic criteria such as the DSM-IV or ICD 10 manuals. Second it is important to check whether certain clinical features are present. These features tend to be less known to the general practitioner and population. These criteria include whether there are previous episodes of mood elevation. Mood elevation can include times when mood is either positively elevated as in euphoria or high energy that is distinct from other times, or it can be negatively elevated. An example of the latter would be “road rage”. One is driving and the person in front of him lingers a little too long at the stop sign and the drivers gets unusually angry and wants to punch the guy out. We all have heard of that happening.
Another lesser known criteria is current or past episodes of psychotic depression which are episodes of depression that are so severe and debilitating that a person has great difficulty getting out of bed in the morning and functioning.
Recurrent depressive disorder before the age of 25 and a strong family history of mood disorder and suicide are other red flags for Bipolar Disorder.
Finally there are the signs related to past antidepressant usage that can be valuable information in proper diagnosis. If a patient has had a lack of response or “wearing off” to well conducted antidepressant treatment, or an unusually fast response to antidepressants with features of elation these are all red flags of Bipolar Disorder.
Finally, it is important that the proper professionals are utilized in making the diagnosis. While it can be a starting place, it can not be adequately done by self-diagnoses through the internet!
When I see patients in my office I would say that 75% have as a major complaint of insomnia or having difficulty going to sleep and/or staying asleep. Many times the problem has been going on for years. How does one know who to see about their insomnia? The general practitioner? The Sleep Specialist? The Mental Health Specialist?
Questions to ask yourself: How long have you had this problem? If it’s only been a few days or weeks then I would say it would be ok to see your general practitioner or mental health practitioner. Both have the knowledge to help you get to sleep. If you say all your life or since I put on a lot of weight, that is work for the specialist. There could be a mental health disorder or a physical structural disorder that is causing a disorder called “Sleep Apnea.” This is a condition where a person stops breathing in the middle of the night sometimes thousands of times resulting in a restless or inadequate sleep. A major symptom of this is if a person snores loudly and a sleep partner observes the person actually stopping breathing for seconds at a time. Another major symptom is extreme fatigue during the day.
In the mental health category, if a person has been experiencing anxiety or depression and he/she is having trouble sleeping then a mental health evaluation may be appropriate.
Major Depression, General Anxiety Disorder, PTSD and Bipolar Disorder are all conditions that interfere with sleep. These are treated in different ways. In my practice I teach my patients “Sleep Hygiene.” This is a program to help the body cue itself that it is time for sleep. We often lose that cue with bad habits and lack of routine over time.
What kind of medications are the best for insomnia? I always start with the mildest remedies that are not addictive. Melatonin and antihistamines top my list. Second tier would include medications in the antidepressant class such as Trazadone. One does not
have to be depressed to use Trazadone. It is very effective. Third tier would be other antidepressants and mood stabilizers according to what are the diagnoses. I totally avoid the Benzodiazepine class. Benzodiazepines are only meant for the occasional sleep problem. If one has issues with addictions of any kind, or has it in their family, then I would recommend avoiding this class altogether. The problem is Benzos can cause addictions but also can cause Depression when used long-term.