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Thursday, December 5, 2013
Attention Deficit Hyperactivity Disorder
How much Adderall is too much?
Within the last year I started seeing a psychologist and psychiatrist for depression and anxiety that wasn`t being properly addressed by my primary care physician. After a few sessions with the psychiatrist, he prescribed 40mg of Adderall a day (1 20mg pill twice daily) along with 40mg of Prozac. After a few months, I felt the Prozac wasn`t helping, so he prescribed the generic form of Celexa 40mg a day. At our last session, I explained to my psychiatrist that I was still experiencing anxiety throughout the day and evening. Based on what I told him, he thinks my anxiety is being caused by the wearing off of the Adderall so he increased my dose to 20mg three times a day. Since I started this regimen, my anxiety has decreased. The only times I feel anxious are when I`m at work and I can hear other people talking, laughing, etc around me. I work in an office building in a cubicle. I tend to get tense, anxious and irritable when this occurs. Granted, it hasn`t happened much since the Adderall was increased, but it does occur. I have noticed that when there is a lot of activity or noise around me, I can feel my anxiety increase. The only way I can describe it is that I feel over-stimulated, almost as if I`m at a three-ring circus and can`t figure out what I should be focusing on. Is it possible that my Adderall dose is too high? Is 60mg of Adderall a day considered a large dose?
60 mg/day of Adderall is a large dose but not outside the commonly used range for an adult. The important issue is individual dose optimization. Because of individual metabolism differences, the optimal dose varies from one person to another manyfold. One person's optimal dose might be as low as 10 mg or even rarely as low as 5 mg and another's over 60 mg. That is why it should be carefully adjusted individually, considering benefit and side effects. For this reason, the drug is supplied commercially in a wide range of sizes. One size does not fit all. For more details about dose ranges of the various ADHD drugs, see the tables in "A Family's Guide to ADHD" from Handbooks in Health Care, http://www.hhcbooks.com/, (215) 860-9600. Anyone who is not satisfied with the results of their current dose should discuss it with the prescriber, who might adjust the dose up or down or try a different drug.
There are 4 main FDA-approved molecules for ADHD: methylphenidate (Concerta, Ritalin, Focalin, Metadate, Methylin; Daytrana); amphetamine (Adderall, Dexedrine, Vyvanse); atomoxetine (Strattera); and guanfacine (Intuniv), each with slightly different profile of benefit and side effects. They are available in different dosage strengths and formulations for quicker or slower action and different duration of effect. Often one works better than another for a given patient, and it may be worth trying more than one to find the best for an individual.
Incidentally, those Prozac and Celexa doses are also towards the high end of the usual range but within common usage.
Most psychoactive medications depend on the brain's ability to make neurotransmitters, which depends on the availability of dietary amino acids, vitamins, minerals, and other substrate and cofactors for the enzymes to work on. Therefore, a balanced diet with the 4 essential food groups is important for optimal benefit of the medication.
L Eugene Arnold, MD, MEd
Professor Emeritus of Psychiatry
College of Medicine
The Ohio State University