medications

John J. Ratey, M.D. discusses ADD medications

This information is taken from an article by John J. Ratey, M.D. editing for use these pages by Steven Ledingham

Antidepressants

Research and clinical experience have shown that the antidepressants

Norpramin (desipramine)
Tofranil (impramine)

Effectively increase attentiveness and reduce distractibility in children and adults.

Tricyclic antidepressants exert their effect by acting upon norepinephrine and Dopamine, the two major neurotransmitters in the attention system. They block the re-uptake of norepinephrine and Dopamine into the presynaptic neuron and indirectly modify the rate of release, thus increase the activity of these two chemicals in the brain.

In our clinical experience, 40% or more of ADHD adults respond to between 5 mg/day and 40 mg/day of Norpramin. This dose range is considerable lower than that reported in current research reports (Biederman et al, 1985; Biederman, 1988).

We see the return to the use of low doses as a significant contribution to the practice of pharmacotherapy for ADHD because we have found the most dramatic responses at low dose levels.

Further, most of our patients report that the positive effect experienced at a very low dose range is often lost as the dose is increased.

We have found that

Norpramin

not only increases the ability to direct and maintain attention, but also can have a calming effect on the individual. It can decrease impulsive behavior, stop temper tantrums, regulate frequent mood shifts and increase reading and learning abilities. Norpramin also effectively treats the "mini panic state" to which so many individuals with ADHD are prone. This state begins as a startle response when the individual is flooded with stimulation, and develops into a full blown feeling of panic which predisposes the individual towards impulsive action, defense rumination or the repetition of trauma experiences.

Another antidepressant that is currently popular among clinicians treating adult ADHD is

Wellbutrin (burproprion)

which is a potent Dopamine re-uptake inhibitor. Research reports have attested to the moderate efficacy of this agent (Wender and Reimherr, 1990). Stimulants If response to antidepressants is not apparent or begins to wane within 4-6 weeks, we would try Phychostimulants such as

Ritalin (methylphenidate),
Dexedrine (amphetamine), and
Cylert (pemoline).

The calming effect of these agents in hyperactive children is paradoxical, but advances in the understanding of how these drugs work have provided insight into their clinical effect.

These drugs potently increase the concentration and activity of both Dopamine and norepinephrine, and thus possibly enhance activity and inhibition in the brain. According to some reports, Ritalin and Dexedrine increase attentiveness, reduce distractibility, enhance concentration, and decrease motor restlessness and hyperactivity in roughly 70% of adults with ADD (Barkely, 1977).

We would typically begin by starting Ritalin at 5 mg twice daily, then increase the dose upward, with most people ending at a dose between 30-40 mg/day. Many people find adequate calming and attention enhancing effects at lower doses (10-30 mg/day).

This response can be immediate, and often dramatic. If the individual does not respond to Ritalin we switch to Dexedrine. It is crucial to note that Ritalin and Dexedrine, while widely regarded as very similar drugs, are not. They have a different pharmacological profile, a different mechanism of action at the cellular level, and a not-so subtly different effect on patients.

The two drugs act upon separate neurotransmitter storage pools. For instance, Ritalin is a more potent re-uptake blocker of Dopamine, while Dexedrine may exert some of its effect through feedback inhibition (Zametkin et al, 1985).

We have found that when Dexedrine is successfully tried on people who have had an unsatisfactory trial of Ritalin, they report that the Dexedrine is a "softer drug." Some patients feel Dexedrine is enormously beneficial in alerting their brain to activity without causing them to feel somatically driven, as compared to Ritalin which sometimes makes patients feel like their body is in "overdrive."

One patient described Dexedrine as a "caffeine-less" Ritalin. Most clinicians, however, use Dexedrine as the second or third choice stimulant because of its reputation in the drug abusing community.

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