Question on stimulants

[cbrons]

For drugs like Vyvanse, dextroamphetamine, etc. what is responsible for causing the low energy/depressed mood crash later in the day?

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[VA Hopeful Dr]

For drugs like Vyvanse, dextroamphetamine, etc. what is responsible for causing the low energy/depressed mood crash later in the day?

The same thing that causes a crash in people who do meth...

 

[milesed]

It's a bit of "what goes up, must come down" IMO. The med has raised levels of neurotransmitters for 8-12 hours, then wears off leaving the neurons in a state of re-uptake and repackaging them.

 

[FlowRate]

I'd imagine it also depends on the indication. If used for SWSD, Anhedonic Depression, etc., then it may just be return to baseline symptoms.

 

[jettavr6]

For drugs like Vyvanse, dextroamphetamine, etc. what is responsible for causing the low energy/depressed mood crash later in the day?

Agree with what everyone has written above. But if prescribed appropriately for ADD, the depressed mood shouldn't be present. The low energy crash occurs in some patients, but seems to be less so with Vyvanse.

 

[DD214_DOC]

Agree with what everyone has written above. But if prescribed appropriately for ADD, the depressed mood shouldn't be present. The low energy crash occurs in some patients, but seems to be less so with Vyvanse.

Incorrect. The withdrawal effects can include somnolence, irritability, hyperphagia, and dysphoria. It can happen with any of them.

 

[thoffen]

I agree. Withdrawal effects are physiologic and don't depend on underlying pathology.

 

[jettavr6]

Incorrect. The withdrawal effects can include somnolence, irritability, hyperphagia, and dysphoria. It can happen with any of them.

I have more patients complain of these symptoms from caffeine withdrawal than from stimulants. Sure, one can't argue with physiology, but it is rare that anyone suddenly becomes "depressed vs. low energy" at 6PM. If any patient reported symptoms of classic depression after the drug wore off, I would question whether the stimulants were appropriate for the patient.

 

[jettavr6]

Withdrawal effects are physiologic and don't depend on underlying pathology.

So the two have no correlation? Patient with existing depression undergoing withdrawal from any medication/drug vs. patient with no history of depression undergoing withdrawal from any medication/drug. Which patient would you worry about more?

 

[thoffen]

So the two have no correlation? Patient with existing depression undergoing withdrawal from any medication/drug vs. patient with no history of depression undergoing withdrawal from any medication/drug. Which patient would you worry about more?

Stimulant withdrawal is still a physiologic phenomenon and occurs independent of any mental health diagnosis. It's the reason why seroquel has street value.

I would accept it as plausible that different illnesses would modulate likeliness of withdrawal and/or severity of withdrawal. But only on principle. I would need to see some actual data on this and not anecdotal evidence.

That still does not address your question, though. Obviously my concerns are going to be different for each patient. That's not because I suspect a different physiologic process is going on, but more because if significant withdrawal is experienced it is going to have significantly different impact on one patient vs another (e.g. suicidal patient with comorbid substance abuse and baseline high degree of somatization vs. ADHD adult with no comorbidity, good support network, and good coping mechanisms).

 

[DD214_DOC]

I have more patients complain of these symptoms from caffeine withdrawal than from stimulants. Sure, one can't argue with physiology, but it is rare that anyone suddenly becomes "depressed vs. low energy" at 6PM. If any patient reported symptoms of classic depression after the drug wore off, I would question whether the stimulants were appropriate for the patient.

Well, ok, but this is a pretty easy thing to figure out. Withdrawal dysphoria typically resolves after a few hours or less. Also, it's important to assess if they experienced such symptoms prior to use of stimulants or if it occurs during prolonged periods of not taking the stimulant.

Assuming that a common and expected withdrawal effect from a medication is indicative of an incorrect diagnosis is completely wrong. It's not difficult to differentiate this from actual depression.

 

[jettavr6]

Assuming that a common and expected withdrawal effect from a medication is indicative of an incorrect diagnosis is completely wrong. It's not difficult to differentiate this from actual depression.

If a patient is experiencing the symptoms you described above as a 6PM "crash vs. depression," and was bothered by it, I would question whether the medication was appropriate for the patient. Using your own words, it would be "completely incorrect" and potentially dangerous not to do so. What if something else is going on?

It is exceedingly rare for any of my patients taking stimulants to present with dysphoria, irritability, and/or hyperphagia after the effect of the medication wears off later in the day (6PM crash). We do see these withdrawal symptoms upon tapering or abrupt cessation of treatment, but onset tends to occur after 24 hours.

Now, reading into this, we may actually actually agree more than disagree. Tough to work in absolutes in this field. Cheers!

 

[smalltownpsych]

If a patient is experiencing the symptoms you described above as a 6PM "crash vs. depression," and was bothered by it, I would question whether the medication was appropriate for the patient. Using your own words, it would be "completely incorrect" and potentially dangerous not to do so. What if something else is going on?

It is exceedingly rare for any of my patients taking stimulants to present with dysphoria, irritability, and/or hyperphagia after the effect of the medication wears off later in the day (6PM crash). We do see these withdrawal symptoms upon tapering or abrupt cessation of treatment, but onset tends to occur after 24 hours.

Now, reading into this, we may actually actually agree more than disagree. Tough to work in absolutes in this field. Cheers!

Some people are more sensitive or attuned to their internal state than others. I had a patient yesterday who told me the exact same thing occurs with their stimulant medication. I am not sure what you are saying but the concern I would have is what happens when we start treating side effects of one medication with another medication. Such as adding an SSRI to the stimulant because of the patient's sensitivity to a physiological side effect. It also brings to mind how much patients differ in their descriptors and expressions of internal states and how cautious we need to be in the interpretation of that.

 

[Psych Doc 28]

Okay. TALK TO YOUR PATIENTS. Like really really talk to them. A crash of any stimulant SUCKS. It's like a caffeine crash but a lot worse. You feel a little like death, your body aches, your head hurts, you can't eat but your mega hungry because you haven't been able to eat, you can't really move, your heart feels funny, the room spins. It isn't a pleasant experience and it usually lasts 45 minutes to 2 hours. Sometimes you need to sleep it off. If all is right it should happen around bed time so you really shouldn't "feel the crash" you'll be asleep, but if your meds are off and you get a crash mid-day you are toast. And the whole it goes out of your system in 8-12 hours is not true. AT ALL. Ask your patients coming off stimulants how much their life sucks for days after stopping. Really. Tapper people TAPPER DOWN. Cold turkey stimulant stopping is just cruel and naive. Again you want to know about meds? Get on boards that really talk about these meds. Facebook has tons of Bipolar, ADD/ADHD/PTSD/Depression, ect groups talking about meds and their affects and what they're really like. Learn really what meds are like not from a book.

 

[Ceke2002]

Okay. TALK TO YOUR PATIENTS. Like really really talk to them. A crash of any stimulant SUCKS. It's like a caffeine crash but a lot worse. You feel a little like death, your body aches, your head hurts, you can't eat but your mega hungry because you haven't been able to eat, you can't really move, your heart feels funny, the room spins. It isn't a pleasant experience and it usually lasts 45 minutes to 2 hours. Sometimes you need to sleep it off. If all is right it should happen around bed time so you really shouldn't "feel the crash" you'll be asleep, but if your meds are off and you get a crash mid-day you are toast. And the whole it goes out of your system in 8-12 hours is not true. AT ALL. Ask your patients coming off stimulants how much their life sucks for days after stopping. Really. Tapper people TAPPER DOWN. Cold turkey stimulant stopping is just cruel and naive. Again you want to know about meds? Get on boards that really talk about these meds. Facebook has tons of Bipolar, ADD/ADHD/PTSD/Depression, ect groups talking about meds and their affects and what they're really like. Learn really what meds are like not from a book.

Holy mother of lulz we're not talking about Heroin or Benzos here. Sure what goes up must come down, but you're being a tad hyperbolic with your 'OMG its torture, it's kinda like death, seriously if you crash at lunchtime you're totally screwed' spiel. If you've got a patient begging you to increase doses or prescribe other substances of abuse on top of that, when it's not medically indicated at all, then chances are you've got yourself a drug seeker.

 

[Ceke2002]

Some people are more sensitive or attuned to their internal state than others. I had a patient yesterday who told me the exact same thing occurs with their stimulant medication. I am not sure what you are saying but the concern I would have is what happens when we start treating side effects of one medication with another medication. Such as adding an SSRI to the stimulant because of the patient's sensitivity to a physiological side effect. It also brings to mind how much patients differ in their descriptors and expressions of internal states and how cautious we need to be in the interpretation of that.

I'm in the middle of cooking tea, but I just read this and had to say I totally agree with what you've said. I'll write more later, but yes, definite agreement here. 👍

 

[smalltownpsych]

Holy mother of lulz we're not talking about Heroin or Benzos here. Sure what goes up must come down, but you're being a tad hyperbolic with your 'OMG its torture, it's kinda like death, seriously if you crash at lunchtime you're totally screwed' spiel. If you've got a patient begging you to increase doses or prescribe other substances of abuse on top of that, when it's not medically indicated at all, then chances are you've got yourself a drug seeker.

Hehe. I don't know sometimes I get sleepy after lunch too. Actually, that post does point to something related to the being more sensitive to effects of drugs and that is difficulty with distress tolerance. Also coming into play is suggestibility and self-soothing. Medications are a relatively small part of helping patients with most mental illnesses that tends to be over emphasized on many fronts. If I had a dollar for every patient who responds to a bad day with "I think I need my meds adjusted".

 

[Ceke2002]

Hehe. I don't know sometimes I get sleepy after lunch too. Actually, that post does point to something related to the being more sensitive to effects of drugs and that is difficulty with distress tolerance. Also coming into play is suggestibility and self-soothing. Medications are a relatively small part of helping patients with most mental illnesses that tends to be over emphasized on many fronts. If I had a dollar for every patient who responds to a bad day with "I think I need my meds adjusted".

Things like not adding more drugs to counteract the side effects of what amounts to a low distress tolerance is definitely what I was agreeing with what you wrote before (by the way I'm currently sharing a lovely bottle of Stonyfell Shiraz with my husband so excuse the grammatical errors and potential for sudden tangentials). But also if the concern was with teasing out potential co-morbid depression from a simply physiological response to medication then I'd think that's where clinical skills in interviewing would come into play, especially if you've got someone who is more in tune because what they might express or be experiencing as 'depression' may not actually be the case at all. I would imagine, and I could be way off base with any or all of this, but I would imagine someone who is more attuned might be more likely to describe their experiences in terms of feeling 'depressed' or couching it in the language of depression. I can see then how there might be a temptation to jump to the idea of 'well maybe there's something more going on here', but the thing is, and obviously this is coming from direct personal experience, the 'crash' (whether it be physiological or otherwise) from stimulants feels absolutely nothing like an experience of true clinical depression. But if you don't know the right questions to ask, at the right time, for the right patient, and you don't know how to properly interpret that patient's responses then that's when I can see things getting messy when one medication gets piled on top of the other when it's not actually needed.

Okay, I think that's my rambling quota for the month. 😎

 

[smalltownpsych]

Things like not adding more drugs to counteract the side effects of what amounts to a low distress tolerance is definitely what I was agreeing with what you wrote before (by the way I'm currently sharing a lovely bottle of Stonyfell Shiraz with my husband so excuse the grammatical errors and potential for sudden tangentials). But also if the concern was with teasing out potential co-morbid depression from a simply physiological response to medication then I'd think that's where clinical skills in interviewing would come into play, especially if you've got someone who is more in tune because what they might express or be experiencing as 'depression' may not actually be the case at all. I would imagine, and I could be way off base with any or all of this, but I would imagine someone who is more attuned might be more likely to describe their experiences in terms of feeling 'depressed' or couching it in the language of depression. I can see then how there might be a temptation to jump to the idea of 'well maybe there's something more going on here', but the thing is, and obviously this is coming from direct personal experience, the 'crash' (whether it be physiological or otherwise) from stimulants feels absolutely nothing like an experience of true clinical depression. But if you don't know the right questions to ask, at the right time, for the right patient, and you don't know how to properly interpret that patient's responses then that's when I can see things getting messy when one medication gets piled on top of the other when it's not actually needed.

Okay, I think that's my rambling quota for the month. 😎

A bit rambling, but yes, it is important to tease out what the patient means with their description. That is where focusing on the diagnostic criteria can be helpful and especially the more physiological signs. On a related note, just had a good discussion with our NP about diagnostic differential for anxiety which can cause paranoid thought processes vs paranoia which can cause anxiety. Extreme anxiety can look an awful lot like milder paranoid delusions and vice versa. Don't know what this has to do with stimulant crash, but I do like to take tangents that I find interesting.

 

[DD214_DOC]

Okay. TALK TO YOUR PATIENTS. Like really really talk to them. A crash of any stimulant SUCKS. It's like a caffeine crash but a lot worse. You feel a little like death, your body aches, your head hurts, you can't eat but your mega hungry because you haven't been able to eat, you can't really move, your heart feels funny, the room spins. It isn't a pleasant experience and it usually lasts 45 minutes to 2 hours. Sometimes you need to sleep it off. If all is right it should happen around bed time so you really shouldn't "feel the crash" you'll be asleep, but if your meds are off and you get a crash mid-day you are toast. And the whole it goes out of your system in 8-12 hours is not true. AT ALL. Ask your patients coming off stimulants how much their life sucks for days after stopping. Really. Tapper people TAPPER DOWN. Cold turkey stimulant stopping is just cruel and naive. Again you want to know about meds? Get on boards that really talk about these meds. Facebook has tons of Bipolar, ADD/ADHD/PTSD/Depression, ect groups talking about meds and their affects and what they're really like. Learn really what meds are like not from a book.

It's useful. I never discount a reported side effect, simply because we don't know everything. If you start a med, a new symptom/effect develops, and then goes away when you stop the med, then most likely it was caused by the med. This isn't rocket science. I've seen meds do some whacky things, especially stimulants. Had a kid on concerta get diagnosed as autistic due to restricted behaviors, lack of socialization, poor frustration tolerance. I stopped his meds for a bit because parents reported he wasn't like that before the meds. Guess what? All that stuff went away.

Also don't forget the stimulants are sympathomimetics. Know your autonomics and you can deduce most other side effects. Dexedrine can cause urinary retention, for example. Stop memorizing and start understanding and thinking about things. It's not that hard.

 

[Par4thecourse]

A slow release stimulant might help. Ritalin is known for being more jagged when wearing off than Dexedrine.

Non-stimulant meds may be an option.

 

[tr]

This is the right idea but - apropos of the other thread on the utility of neuroscience for psychiatry - betrays a slight confusion about how neurotransmitters work.

(Edit, sorry, quote didn't make it in, meant to quote milesed's post at the top)

The brain isn't a chemical soup where you have more or less of a given ingredient to make a change.

Stimulants dump a neuron's whole payload of catecholamines into the synaptic cleft at once. (So talking about 'levels' doesn't make so much sense -you're depleting the neurotransmitters from inside the vesicles and increasing their concentrations in the cleft).

After the catecholamines in the cleft have been cleared, the presynaptic cell is still depleted and can't maintain its previous baseline level of catecholamine release until it has time to regenerate the vesicle contents. That's the crash.