Posts By :

neuralia_dEV

ADHD Medication (Stimulants and Non Stimulants)

ADHD Medication (Stimulants and Non Stimulants) 1748 879 Neuralia TMS

What causes ADHD?

Humans have forebrain which is involved in planning, concentration, impulse regulation and executive function. It aims to gives you top-down control of the more primitive/reptilian parts of the brain.
There is a narrow band where 2 important hormones called dopamine and noradrenaline at required to operate at the right level. Doing so will help manage the forebrain’s control of the midbrain and other more primitive regions.

In ADHD, it is believed that there is decreased levels of dopamine and noradrenaline in the prefrontal cortex circuits. All ADHD medication aim to increases the levels of the hormones.

There is a goldilocks zones where the increase in dopamine and noradrenaline will be “just right.” This is what we try to achieve when we titrate and adjust the dose of ADHD medication.

What should ADHD medication do?

By increasing the levels of dopamine and noradrenaline we should improve concentration, attention, impulse control, working memory and energy.

What are the 2 types of ADHD medication?
  • Stimulants (increases both dopamine and noradrenaline). On average these medications are effective for 80% of people.
  • Nonstimulants (increases noradrenaline). On average these medications are effective for 70% of people.
More about the Diagnosis and the Symptoms:

Download – ADHD-A-Guide-for-Adults-Diagnosed-with-ADHD
Download – ADHD-Behaviour-Symptom-Checklist

 
 

Stimulants:

The two main types of Stimulants are called Methylpenidate and Dexamphetamines. Usually we trial Vyanse (Lisdexamphetamine) first, as long acting stimulants are considered first line. Long acting stimulants assist a person with ADHD to focus and manage well throughout the day. They also have the benefit of requiring less frequency dosing, meaning you do not have to take medication with you when you are out and about. Usually this will be effective, however if it is not or is poorly tolerated, we may switch to standard Dexamphetamines.

Examples:

  • Amphetamine:
    • Vyvanse (Lisdexamphetamine).

Download – Vyanse CMI
Download – How to take Vyanse
Download – Things to know about Vyanse

  • Dexamphetamines:

Download – Dexamphetamine CMI

  • Methylphenidate:
    • Ritalin (Methylphenidate Immediate Release)

Download – Ritalin CMI

  • Ritalin LA (Methylphenidate Long Acting)
  • Concerta (Methylphenidate Slow Release)

Download – Concerta CMI

How do we dose stimulants?
  • Initially we will need to commence you on a low dose. The main reasons for this is to ensure your body gradually adjusts the medication and reduces your risk of serious side effects. You will be given a plan for how to increase the dose gradually when you receive your prescription. It can be tricky finding the correct dose for you. We may need to increase or decrease your dose several times before reaching your final regime.
What is the “goldilocks” dosing range for stimulants?
  • If your dose is too low:
    • You may find that your medication effects run out quickly than expected, resulting in in poor concentration, focus and impulse control. You may also experience increased distractibility and fatigue
  • If your dose is too high:
    • You may feeling irritable, highly energetic, wired, emotionally numb, rigid in your thoughts
  • If your dose is just right:
    • Focussed, Flexible, Clear in your thoughts.

Side effects:

Common side effects (>1%):
  • Nausea, diarrhoea, dry mouth, loss of appetite, weight loss, anxiety, irritability, insomnia, headache, dizziness, aggression, tachycardia, palpitations, changes in BP (usually increases in adults)
  • Decreased appetite and insomnia are generally temporary in nature and resolved after approximately a fortnight. If you experience these two particular side effects please attempt to persist for at least 1-2 weeks.
Serious side effects (<1%):

The risks of these side effects worsen if stimulants are taken in excess and at doses which are against the advice of your psychiatrist.

  • Psychosis
    • This includes paranoia, delusions, auditory or visual hallucination, disordered thoughts and behaviour
    • If you experience this symptom, please contact call 000 or present to your nearest emergency department
  • Mania
    • This includes risk-taking behaviour, grandiose thoughts, increased energy, pressured speech and decreased need for sleep
    • If you experience this symptom, please contact call 000 or present to your nearest emergency department.
  • Agitation/Aggression
    • If you experience this symptom, please contact your doctor as soon as possible and cease your stimulant medication.
  • Suicidal thoughts
    • If you experience this symptom, please contact call 000 or present to your nearest emergency department.
  • Liver dysfunction
  • Tics:
    • often tics may improve with medication. However occasionally they may worsen them.
Infrequent side effects (0.1–1%)
  • movement disorders, tics (but see Precautions above), rash, growth retardation
Rebound side effects:
  • When the effects of the stimulants begin to wear off, you may find that your pre-existing ADHD symptoms return more intense than before. To manage this side effects, we will need to adjust the dose and frequency of your medication.
Cardiac side effects:
  • Before commencing stimulants. a cardiac physical examination and ECG is required. The reason for this is because stimulants can cause increases in your heart rate and blood pressure. Rarely, you may also experience increased palpitations, rapid heart rate, dizziness, or syncope. If this is the case, please immediately cease your medication and see your doctor as soon as possible.
  • Stimulants are contraindicated with patients with a history of confirmed hypertension. If you have a history of occasional high blood pressure readings, your doctor may ask you to get weekly blood pressure readings from your local pharmacy or through a home-based automatic blood pressure monitor.
Foods and medication to avoid:
  • Caffeine: please avoid excessive consumption of caffeinated beverages. These may cause your heart rate, blood pressure and anxiety to increase.
  • Pseudoephedrine: please avoid cold and flu tablets that contain pseudoephedrine. These may cause your heart rate, blood pressure and anxiety to increase.
How long will I need take this medication?
  • It is likely you will need to take this medication long term (years). Often people will develop alternative skills to manage their attention deficit and impulsivity. In such case, we will be able to wean you off stimulants or consider alternative medication.
Are stimulants addictive?
  • If stimulants are taken in excess, then patients may become addicted. To ensure this does not occur, the WA Health government mandates annual urine drug screen. Stimulants are also a schedule 8 medication. This means they are highly regulated and there are many rules in places in relation to their prescription. For full details, please visit: https://ww2.health.wa.gov.au/Articles/S_T/Stimulant-medicines
Am I able to change to dose myself?
  • No, it is imperative that you do not change the dose without permission from your psychiatrist. There are a number of legal and safety reasons why this is the case. If evidence of this occurs, further prescribing will be ceased.
What happens if my script is lost or stolen?
    • Unfortunately if your script is lost or stolen, you will not be given a repeat script. You will also not able to have your next prescription early. Stimulants are highly regulated by the WA Health department and as such there are stringent rules in place. Please be very careful when handling your scripts. We recommend you keep all scripts on file with your local pharmacist

 
 

Non Stimulants

  • Non stimulants work by increasing the noradrenaline levels. They are usually better tolerated than stimulants, albeit with a slightly lower efficacy. Non stimulants are the recommended choice in patients with a history of addiction, poor response to stimulants or are highly anxious.

Examples:

1. Strattera (Atomoxetine)

Download – Stratera CMI

The most common side effects of Strattera in adults are:

      • Constipation.
      • Dry mouth.
      • Insomnia.
      • Sexual dysfunction
      • Urinary tract abnormalities (e.g., trouble passing urine, pain with urination).
      • Painful menstruation.
      • Hot flashes.

These side effects can be significant and may require stopping the medication.
However in most cases, these side effects are generally not severe. Only a very small percentage of patients needed to stop Strattera due to side effects experienced during clinical trials.

2. Guanfacine
3. Clonidine
4. Buproprion

 
 

ADHD WA coaching

ADHD WA coaching involves the teaching of psychological techniques to improves productivity, focus and reduce impulsivity.

      • Grace Da Camara (teens and adults)
      • Dr Andrew Sheridan (teens and adults)
      • Karen Breeze (parents and adults)

Email: hello@adhdwa.org, or phone 6457 7544
 
 

Other resources:

Websites:

SolvingProcrastination.com – excellent list of strategies if you are finding yourself constantly procrastinating
http://www.adhdwa.org
http://add.org
http://adhdandyou.com/
http://adhdtogether.com/

Books:

ADHD Answer Book by Susan Ashley
ADHD Handbook by Munden and Arcelus

Support groups:
ADHD WA – Facebook group

Antidepressant Medication

Antidepressant Medication 2560 1557 Neuralia TMS

TSSRIs (Selective Seritonin Reuptake Inhibitors):

  • Citalopram
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Paroxetine (Paxil, Pexeva)
  • Sertraline (Zoloft)

SNRIs (Serotonin and norepinephrine reuptake inhibitors):

  • Venlafaxine (Effexor).
  • Duloxetine (Cymbalta).
  • Desvenlafaxine (Pristiq)

NaSSA (Noradrenergic and specific serotonergic antidepressants):

  • Mirtazapine

Tricyclic Antidepressants:

  • Amitriptyline (Elavil),
  • Clomipramine (Anafranil),
  • Doxepin (Sinequan),
  • Imipramine (Tofranil),
  • Desipramine (Norpramin),
  • Nortriptyline (Pamelor)

Newer Antidepressants:

  • Vortioxetine
  • Agomelatine

What are the side effects of SSRIs and SNRIs?

Common (>1%):
  • nausea, diarrhoea, agitation, insomnia, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety, sexual dysfunction
  • SNRIs are more likely to cause withdrawal symptoms if tablets or missed or dose is reduced rapidly. They are also more likely to cause increased anxiety, heart rate or blood pressure.
Infrequent (0.1–1%):
  • extrapyramidal reactions (including tardive dyskinesia and dystonia), sedation, confusion, palpitations, tachycardia, hypotension, hyponatraemia (usually occurs early in treatment, may be asymptomatic, and is part of SIADH), abnormal platelet aggregation/haemorrhagic complications (eg bruising, nose bleeds, GI, vaginal or intracerebral bleeding), mydriasis
Rare (<0.1%):
    Elevated liver enzymes, hepatitis, hepatic failure, hyperprolactinaemia, eg galactorrhoea, blood dyscrasias, akathisia, paraesthesia, taste disturbance, acute angle-closure crisis (especially with paroxetine)
Serious side effects:
  • Serotonin syndrome
    • Very rarely patients may experience excessive increases of serotonin. This will generally only be found in patients taking other medication that increases serotonin level. Your doctor will ask about your other medication and take steps to avoid this condition from occurring.
    • Serotonin syndrome symptoms include high body temperature, sweating, shivering, clumsiness, tremors, and confusion
  • Suicidal ideations:
    • Rarely patients may experience increased suicidal ideations in the first few weeks of commencing an antidepressant or increasing the dose.
    • If you experience this symptom, please contact call 000 or present to your nearest emergency department.
  • Mania:
  • This includes risk-taking behaviour, grandiose thoughts, increased energy, pressured speech and decreased need for sleep

    If you experience this symptom, please contact call 000 or present to your nearest emergency department.

How long will I need to take antidepressants for?

The recommendation is that antidepressants are taken for at least 9-12 months after your first depressive episodes. If you have had 2 depressive episodes, we recommend that you take antidepressants for at least 2 years.

What happens if you miss a dose of antidepressant?

If you miss a dose of your antidepressant or stop your medication suddenly you may experience discontinuation symptoms (anxiety, insomnia, nausea, fatigues, irritability, flu-like symptoms). This is caused by your body adjusting to a lowered dose or serotonin and/or noradrenaline. As such, it is essential to take your antidepressant every day. If you forget, please set up a system to help your remember (Eg. reminders on your phones, alarms, sticky notes on your mirror, placing your medication next to your toothbrush)

What are the symptoms of Depression?

What are the symptoms of Depression? 1480 987 Neuralia TMS

Sadness and Depresssion exists on a continuum. We all have low days. That is normal. However, we believe clinical depression occurs when these low days become persistent and patient’s experience additonal affective, biological and cognitive symptoms. When this occurs, we suspect changes in a one’s seritonin, dopamine and noradrehnaline levels.

The symptoms of depression can be divided into the following three categories:

1. Affective symptoms:: decreased mood, hopelessness, worthlessness, guilt

2. Biological symptoms: early morning wakening, decrease appetite, psychomotor slowing ie. monotonous/slow/delayed/decreased amount speech & decreased facial expressions OR psychomotor agitation ie. hand wringing.

3. Cognitive symptoms: decreased concentration, decreased memory, daily tasks take longer than normal, decreased self esteem, self harm or suicidal thoughts)

At times one’s thoughts can become extremely dark. When this occurs. occasionally one’s mind can start playing tricks on them and psychotic symptoms develop (delusions and hallucinations). Delusions are fixed, false beliefs out of keeping with a patient’s culture. Hallucinations occur when one experiences a perception eg. voice or image, in the absence of an actual environmental stimuli.

Treatment for depression span three major categories.

Medication

Talking Therapy

Neurostimulation eg. TMS.

The Science of TMS

The Science of TMS 900 807.2553 Neuralia TMS

TMS uses an alternating current passed through a metal coil placed against the scalp to generate rapidly alternating magnetic fields.

This passes through the skull nearly unimpeded and induce electric currents that depolarize neurons in a focal area of the surface cortex

The magnetic field generated by TMS is comparable to that of a standard magnetic resonance imaging (MRI) device (approximately 1.5 to 3 Tesla); however, the TMS field is very focal (beneath the coil).

TMS stimulates regions of the brain that are underactive in patients with depression, anxiety disorder and chronic pain. Specifically the Dorsolateral Prefrontal Cortex with respect to depression and anxiety.

During TMS treatment, magnetic s fields timulate neural activity in the underactive areas. When this is done tens of thousands of times over a course of 4-6 weeks, lasting changes in brain circuity occur.

The exact mechanisms of action for TMS is unknown. One hypothesis is that stimulation of discrete cortical regions alters pathologic activity within a network of grey matter brain regions that are involved in mood regulation and connected to the targeted cortical sites. To find out more, please visit About TMS.

Both ECT and TMS have been shown to increased monoamine activity (seritonin in particular) and assist in the normalisation of the Hypothalamic pituitary axis.

The effect on TMS varies based on a number of factors. These include whether a high frequency of magnetic stimulation is used. When this occurs the targeted neurons are stimulated. We generally used high frequency stimulation when target the left prefrontal cortex in the treatment for Depression.

In contrast low frequency stimulation appears to inhibit cortical activity (and is usually directed at the right prefrontal cortex). Inhibitory stimulation to the Right DLFPC is an alternative treatment used in depression. This can be useful in patients who are at a high risk of seizure (Eg. depending on their medication). Inhibitory stimulations greatly reduce any risk of seizure.

In a systematic review by Noda et al, the review examined 66 studies in depressed patients who were treated with TMS targeting the dorsal lateral prefrontal cortex and found that high frequency TMS generally increased regional cerebral blood flow and that low frequency TMS generally decreased regional cerebral blood flow

The intensity of the treatment is the other main parameter we can change to ensure efficiacy.

If you would like to know how your GP or psychiatrist could refer you for TMS please visit our Referrals page.

If you are psychiatrist or pain specialist looking to introduce TMS into your clinic please visit our Partnering With Us page

Neuralia TMS are the Transcranial Magnetic Stimulation (TMS) specialists in Perth, WA. TMS is non-invasive treatment for depression and several other conditions.

Phone: 6230 3996
Email: info@NeuraliaTMS.com.au
Fax: 6230 2231
Healthlink ID: neuralia
Medrefer: Dr Shanek Wick

Find Us

Palmyra
Melville House,
Suite 12, 25 Foss Street
Palmyra WA 6157

​West Leederville
2/160A Cambridge Street,
West Leederville, WA 6007

Albany
2 Pioneer Road
Albany WA 6330

Join Us

Subscribe to our newsletter here and stay in the loop.

Visit our TMS Education portal for regular discussions on Mental health, Psychology, Neurostimulation and the latest innovative technologies in Psychiatry.