Expert: Dr Billy Levin - 3/27/2008

Question
QUESTION: I was recently diagnosed with Adult ADD and BipolarII. Previously my internist prescribed me Zoloft and Strattera, but I decided I should see a doctor of Psychiatry to make sure my medications are right for me.

I am now taking Aderall 40mg,Zoloft 50 mg, Strattera 80mg. Depakote 600mg at night, Klonopin 1mg at night.

My next Psychiatrist appointment is a few weeks away and he is very hard to get in touch with. I know that he plans to take me off either Stratter or Zoloft. I would rather get off of Strattera since it is more expensive and makes me nauseated. Which medication Zoloft or Strattera will benifit my current medication cocktail and diagnoses of ADD and Bipolar II?


Thanks, I really appreciate any advice!

ANSWER: I cannot advise you as I have not assessed your needs. However it is cetainly possible to make comments of a general nature. It is most unusual to need so mamy different medications. Moreover you are taking a stimulant (Addrall 40mg ) for ADD but there is NO suggestion of what time you take it or if the dose is optimaL. Rating scales like the Conners rating scale are essential to optimise the dose. Only an optimal dose covering the full day works! Adderal fades after about 4 hours so it cannot cover your full day! If your Addreall was at an optimal level and covered the 12 hours usually needed it might not be neccessary to use Strettera.
    Depression may be a complication of ineffective treatment of ADD and Zoloft may be a good choice. What time of day are you taking it? Are you being monotored with rating scales (Hamilton rating scale for depression) and is your dose of Zoloft being adjusted to optimal levels?
    As Addrall and Zoloft stimulate the brain which is necessary for ADD, Klonopin sedates the brain which is counter productive.
    Depokate may or may not be indicated depending on how effective the Zoloft and Adderall works.  
    Without effective monitoring, using rating scales on a regular monthly basis, the treatmednt is not much more than a guessing game. How can a doctor be difficult to get in touch with. He has to be available at any time!

---------- FOLLOW-UP ----------

QUESTION: Dr. Levin, I take twenty mg. Adderall in the am and 20 mg around noon. I was already on the Straterra from my internist so I think the Psychiatrist did not want to change everything at once. As for the Klononpin, I have a very hard time getting to sleep and that is why he gave me that.

More advice please.

Answer
With no disrespect intended, nothing could be worse in my opinion, than giving a sedative to an ADD patient who need a`stimulant to succeed. Insomnia `is a very frequent complication of the medical treatment or  depression. But there are alternative medications that are not going to reduce `the effect of the stimulants while assisting the insomnia.. Another concern is sedatives may become addictive.