Do stimulants cause depression?

[skunky386]

Does long-term stimulant use (ritalin, adderall, etc) have a propensity to cause depression? My thinking is that because stimulants tend to worsen anxiety, and GAD often leads to MDD, there may be a connection here. I've seen a number of patients who relay their history of depression to make me think this, though this is purely anecdotal. On the other hand there is evidence that stimulants can be effectively used as an adjunct to SSRI's for the treatment of MDD, though these studies don't chart outcomes for many months out. I've asked two of my attendings and they don't think there is a correlation between stimulant use and depression, though I'd like some input from everyone here.

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[nitemagi]

No.

Your error is the causative link between GAD to MDD. There is no such causative link. There may be a subtype of depression (anxious or irritable depression) or comorbid depression with anxiety, but neither are induced by stimulants.

 

[milesed]

It all depends on the patient. If in doubt of dx, treat mood and anxiety first and often the low concentration gets better as these sx do.

I've certainly had kids with no sx of anxiety or depression who only started to after use of stimulants. Just stop them and see if sxs improve. On the other hand, stimulants are occasionally used as add-on to antidepressants. I think Vyvanse just failed a clinical trial for this though.

 

[Shikima]

Question; anyone have experience with psychostimulants post-TBI (years later) to help with problems with concentration/focus?

 

[F0nzie]

Question; anyone have experience with psychostimulants post-TBI (years later) to help with problems with concentration/focus?

Nope. I have used guanfacine with success in 1 TBI patient. But if you do consider a stimulant consider low dose and watch for weird reactions.

 

[Shikima]

Nope. I have used guanfacine with success in 1 TBI patient. But if you do consider a stimulant consider low dose and watch for weird reactions.

Thanks. I did hit the hot sheets and there is a lot of data for using it early in the rehab process but not when it is 'years' down the road.

 

[whopper]

The problem with using almost any med with a TBI patient is the brain is very complicated and TBIs rarely are to the same exact area. So there's almost no point in doing a study on TBI patients cause a TBI in the right lateral frontal cortex vs the left makes a significant different. It's next to impossible to get a few dozen patients whose TBIs are essentially the same for study purposes.

Any meds used for TBI have to be done on a rationale that this is defacto unique case and that we're hoping for the best but we are not exactly doing FDA-approved treatment. You can give it a try, but if it doesn't work, by all means stop it and record it so the same trial isn't given again.

 

[whopper]

Stimulants could make one depressed in the sense that after the effect wears off, and the monoamines are depleted, there could be a "crash." So a typical presentation could be someone that was up literally for several days, now sleeping (to catch up on all the sleep they lost) but also feeling depressed during that time.

The person, however, should recover from the crash. Stimulants could also cause depression in the indirect sense that if one is abusing them they could become addicted and experience the fall from grace almost all addicts suffer that can greatly increase the odds of becoming depressed.

BTW, there is data showing that when stimulants are used for treatment-resistant depression or vegetative depression, it can be very beneficial but guidelines for duration of therapy are non-existent as far as I know.

Here's some data on long-term use of stimulants.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2670101/

 

[skunky386]

I've heard of some who recommend taking "stimulant holidays" every weekend to either help mitigate tolerance or for those who don't particularly like the effects of being on stimulants. What's your experience with patients been about taking such holidays? Do you find that the patients "crash" on the weekend?

I was working with a resident a few months ago and the child's mother wanted to see what the child was like off stimulants (after he had been on adderall XR 40mg/day for months). The resident recommended just taking a stimulant holiday over the weekend and using that as a baseline. This doesn't seem to me like the best gauge of baseline, as there is a good chance there will be a crash, though I'm still a medical student. If a patient did want to get back to baseline, how long would one recommend being off stimulants (days, a week, several weeks, a month?) I'm sure this would depend on dose, duration of treatment, coping skills, etc., but would anyone be able to give me some rough estimates from their experience?

 

[smalltownpsych]

The times I have seen stimulants cause a problem are when the patient has an anxiety disorder. It can increase agitation and appears to have less benefit for academic improvement. Any depressive symptoms that result appear to be more from frustration with not improving as opposed to a direct effect of the medication. I also haven't seen crashes from using prescription ADHD medications like you see with say crystal meth for instance. Probably because the dosages aren't even close and partly because of the route of administration being much slower in prescription medications.

 

[splik]

Question; anyone have experience with psychostimulants post-TBI (years later) to help with problems with concentration/focus?

yes i do all the time if they have frontal lobe pathology. i have had mixed results and never more than modest. have also had mixed results with amantadine. it's really trial and error with these patients, you never know how they are going to respond. i have only used methylphenidate, not other psychostimulants.

 

[xlithiumx]

yes i do all the time if they have frontal lobe pathology. i have had mixed results and never more than modest. have also had mixed results with amantadine. it's really trial and error with these patients, you never know how they are going to respond. i have only used methylphenidate, not other psychostimulants.

This. You must know your functional neuroanatomy. Stimulants simply turn up the volume of neural activity. They can absolutely make things worse in a pt with the wrong lesion, and can definitely make things better in a frontal deficit type of syndrome. Patients must know this going in to treatment and you need to be quite clear that an injured brain is yet again more unique than a non-injured brain (granting, if course, for the semantics freaks that there is no such thing as more or less unique). I have had quite good luck in treating a man with a frontal stroke with adderall. He found methylphenidate activating, but not helpful for concentration or mood. Adderall at a total daily dose of around 30mg has been both effective and tolerable for him.

 

[Indodo]

What kind of stimulants?
Like serotonin, norepinephrine and dopamine?

 

[smalltownpsych]

What kind of stimulants?
Like serotonin, norepinephrine and dopamine?

Those would be more aptly described as neurotransmitters, whereas stimulants are a class of medications (or street drugs) that might affect the presence and availability of those neurotransmitters in the synapse. The definition of a stimulant is a drug that increases CNS arousal. Were you making a joke? Cause I must have missed it.

 

[Ceke2002]

The times I have seen stimulants cause a problem are when the patient has an anxiety disorder. It can increase agitation and appears to have less benefit for academic improvement. Any depressive symptoms that result appear to be more from frustration with not improving as opposed to a direct effect of the medication. I also haven't seen crashes from using prescription ADHD medications like you see with say crystal meth for instance. Probably because the dosages aren't even close and partly because of the route of administration being much slower in prescription medications.

This is purely anecdotal of course, but from personal experience I did used to take brief 'medication holidays' (usually 2-3 days every few weeks or so) when I was being legitimately prescribed therapeutic amounts of Dextroamphetamine to treat ADD symptoms, and not once did I experience anything even remotely akin to 'crashing'. In comparison, when I was abusing crystal methamphetamine I'd typically be injecting the drug several times a day for anywhere from 4-5 days straight and the 2-3 days I wasn't using I'd crash hard - irritability, depressed mood, hypersomnia, anhedonia, lack of motivation, etc. From the outside looking in I probably would have appeared to have had many of the 'hallmark' traits of a depressive episode.

 

[smalltownpsych]

This is purely anecdotal of course, but from personal experience I did used to take brief 'medication holidays' (usually 2-3 days every few weeks or so) when I was being legitimately prescribed therapeutic amounts of Dextroamphetamine to treat ADD symptoms, and not once did I experience anything even remotely akin to 'crashing'. In comparison, when I was abusing crystal methamphetamine I'd typically be injecting the drug several times a day for anywhere from 4-5 days straight and the 2-3 days I wasn't using I'd crash hard - irritability, depressed mood, hypersomnia, anhedonia, lack of motivation, etc. From the outside looking in I probably would have appeared to have had many of the 'hallmark' traits of a depressive episode.

That's pretty consistent with what I have seen in my experience. Very big difference between taking a substance in an abusive way and taking it as prescribed. There are always some effects of discontinuing the medications, but from all reports it seems that the prescription stimulants are some of the easier medications to stop.

 

[Indodo]

Those would be more aptly described as neurotransmitters, whereas stimulants are a class of medications (or street drugs) that might affect the presence and availability of those neurotransmitters in the synapse. The definition of a stimulant is a drug that increases CNS arousal. Were you making a joke? Cause I must have missed it.

Stimulants don't have to be medications or street drugs.
Serotonin, NE and dopamine (or histamine) do cause CNS arousal and ARE stimulants. Your definition is a little too narrow.
It was a joke in a way and yes, I think you missed it.

 

[whopper]

. it's really trial and error with these patients, you never know how they are going to respond. i have only used methylphenidate, not other psychostimulants.

Yes. I worked in a forensic and long-term unit for a few years. In that setting I had the time and partnership with a psychologist to give adequate medication trials along with psychological testing. While it is trial and error after several months you might actually get some of these TBI patients on a medication regimen that actually tremendously helps them.

Then you can sit back, feel like you've done a good job and wait for the outpatient doctor to foul it up and change the regimen again. Some of them having the logic to the effect of, "I stopped his Lamictal 400 mg Q daily and changed it to Zyprexa because Zyprexa is my favorite medication." (Insert image of me smashing my head against the wall repeatedly).

Whenever I had a TBI patient that tremendously improved only after several medication trials were done, I wrote up a history of which meds were used with which effects and gave it to the next provider. It did reduce the amount of idiotic medication changes with the future providers but it still happened with some of them.

Great to see the next patient switched to Zyprexa yet again despite that I told the next doctor that Zyprexa was already tried with no benefit at the maximum dosage for 2 weeks, and then being told again it's because "It's my favorite medication."

 

[smalltownpsych]

Yes. I worked in a forensic and long-term unit for a few years. In that setting I had the time and partnership with a psychologist to give adequate medication trials along with psychological testing. While it is trial and error after several months you might actually get some of these TBI patients on a medication regimen that actually tremendously helps them.

Then you can sit back, feel like you've done a good job and wait for the outpatient doctor to foul it up and change the regimen again. Some of them having the logic to the effect of, "I stopped his Lamictal 400 mg Q daily and changed it to Zyprexa because Zyprexa is my favorite medication." (Insert image of me smashing my head against the wall repeatedly).

Whenever I had a TBI patient that tremendously improved only after several medication trials were done, I wrote up a history of which meds were used with which effects and gave it to the next provider. It did reduce the amount of idiotic medication changes with the future providers but it still happened with some of them.

Great to see the next patient switched to Zyprexa yet again despite that I told the next doctor that Zyprexa was already tried with no benefit at the maximum dosage for 2 weeks, and then being told again it's because "It's my favorite medication."

Just helping you out with the graphic.

 

[spemat31]

it's quite possible that your obsessive drive and focus is in that one spot of your life making you depressed.