View Full Version : Doctor Credentials/Strategy?


adhbee
03-12-17, 01:37 PM
Hello everyone. I'm curious what the general consensus is for doctor credentials and ADHD. Do you see a psychiatrist or a different type of doctor? What is their strategy?

Backstory: I've been visiting therapists on and off (currently on) for a few years for anxiety. I was referred late last year to the office of a licenced psychiatrist for ADHD diagnosis and treatment. I haven't actually seen this psychiatrist, and instead have been seeing one of their Certified Physician Assistants. The office gave me a fairly extensive self-assessment for anxiety, depression, and adhd. Besides the obvious anxiety, I scored in "range" for ADHD (not severe but affected).

I do like and feel comfortable with this doctor so far. He's taking a very careful approach, in part due a bad reaction I'd had to low dose sertraline (Zoloft) that was prescribed by my GP. However, after reading about others ADHD'ers experiences, I'm not sure if his approach is standard or not.

Most people seem to be titrated up to a 20mg dose when they try Adderall, but I was switched from Adderall to Ritalin after a two week test at 10mg. Maybe these medications tend to hit small people harder (I'm 5'2, 104lb), but all these medications save the SSRI have had pretty mild effects so far. Enough that I'm concerned as to whether I'm going to find something that's truly effective.

I'm writing a log this time so that I can better discuss how the Ritalin is working at my appointment in a week's time.

Postulate
03-12-17, 02:26 PM
Body mass is not a factor in dosing Adderall. What was the bad reaction you had to Zoloft? And what's wrong with your doctor testing several medications on you to see which works best?

Lunacie
03-12-17, 02:28 PM
Hello everyone. I'm curious what the general consensus is for doctor credentials and ADHD. Do you see a psychiatrist or a different type of doctor? What is their strategy?

Backstory: I've been visiting therapists on and off (currently on) for a few years for anxiety. I was referred late last year to the office of a licenced psychiatrist for ADHD diagnosis and treatment. I haven't actually seen this psychiatrist, and instead have been seeing one of their Certified Physician Assistants. The office gave me a fairly extensive self-assessment for anxiety, depression, and adhd. Besides the obvious anxiety, I scored in "range" for ADHD (not severe but affected).

I do like and feel comfortable with this doctor so far. He's taking a very careful approach, in part due a bad reaction I'd had to low dose sertraline (Zoloft) that was prescribed by my GP. However, after reading about others ADHD'ers experiences, I'm not sure if his approach is standard or not.

Most people seem to be titrated up to a 20mg dose when they try Adderall, but I was switched from Adderall to Ritalin after a two week test at 10mg. Maybe these medications tend to hit small people harder (I'm 5'2, 104lb), but all these medications save the SSRI have had pretty mild effects so far. Enough that I'm concerned as to whether I'm going to find something that's truly effective.

I'm writing a log this time so that I can better discuss how the Ritalin is working at my appointment in a week's time.

The thing with ADHD is that it may not be severe when there isn't a lot of
stress going on and when the person has a good support system and coping
skills. But then something changes ... our coping skills don't work in the new
situation, we lose our support person, there is a lot of stress ... and the adhd
impairment is now severe. Just be aware that can change over time.

Yeah, most think a psychiatrist is the best way to go, especially one that
specializes in ADHD. I didn't realize there are PAs for this branch of medicine,
but over the years I've actually been happier with a PA in most cases than a
medical doctor.

If the benefits of a low dose of Adderall outweighed the unwanted side effects,
then I'm suprised the PA didn't try increasing the dose to see what happened.
But maybe she just wants to compare how Adderall and Ritalin work for you.
They work quite differently and some people do better on one than the other.
You might want to do the comparison trial for a couple of weeks and then give
the PA your feedback on which works best with fewest side effects.

adhbee
03-12-17, 02:47 PM
Body mass is not a factor in dosing Adderall. What was the bad reaction you had to Zoloft? And what's wrong with your doctor testing several medications on you to see which works best?

The zoloft completely took away my ability to sleep (insomnia), my anxiety amplified to the point of constant panic attacks, and I was having palpitations. I wound up going to UC a few days after I stopped taking it. :( Not sure if it was this bad, but the doctor was worried about serotonin syndrome. Thankfully the benzo I was prescribed took the edge off and I started to recover after that.

adhbee
03-12-17, 03:23 PM
Oh, missed your question about the meds, sorry about that. Nothing wrong with testing different medications, I guess I just had high expectations for adderall based on what I'd read.


The thing with ADHD is that it may not be severe when there isn't a lot of
stress going on and when the person has a good support system and coping
skills. But then something changes ... our coping skills don't work in the new
situation, we lose our support person, there is a lot of stress ... and the adhd
impairment is now severe. Just be aware that can change over time.

Yeah, most think a psychiatrist is the best way to go, especially one that
specializes in ADHD. I didn't realize there are PAs for this branch of medicine,
but over the years I've actually been happier with a PA in most cases than a
medical doctor.

If the benefits of a low dose of Adderall outweighed the unwanted side effects,
then I'm suprised the PA didn't try increasing the dose to see what happened.
But maybe she just wants to compare how Adderall and Ritalin work for you.
They work quite differently and some people do better on one than the other.
You might want to do the comparison trial for a couple of weeks and then give
the PA your feedback on which works best with fewest side effects.

That's good to know. I'm in somewhat of the perfect storm of stress right now (had to quit job in late 2016 and struggling to find a new one, family in another country, no friends, but do have my spouse).

As far as meds go, that could be the case. We aren't actually 100% that the adderall was ineffective (I had a really weird week of things that may or may not have been affected by meds), but we can compare what it does with what the ritalin does.

Postulate
03-12-17, 03:38 PM
The zoloft completely took away my ability to sleep (insomnia), my anxiety amplified to the point of constant panic attacks, and I was having palpitations. I wound up going to UC a few days after I stopped taking it. :( Not sure if it was this bad, but the doctor was worried about serotonin syndrome. Thankfully the benzo I was prescribed took the edge off and I started to recover after that.

Did the doctor notice high body temperature? If you entered SS only by taking Zoloft, it's highly unusual. I've never heard of anything like this. Normally, a person enters serotonin syndrome after taking an SSRI, a MAOI and doing some amphetamine abuse on the side.

Has the doctor ever investigated why you entered SS only by taking Zoloft? Because it's highly unusual and may be indicative of other things. It matches with the medication sensitivity you're describing...requires more testing! Look into it please. If your doctors can't provide you with an answer I suggest getting examined by a University doctor with a PhD who is teaching classes and doing research in a University, and specializes in neuro-chemistry. You may have a rare condition that very few doctors heard of.

adhbee
03-12-17, 04:50 PM
Did the doctor notice high body temperature? If you entered SS only by taking Zoloft, it's highly unusual. I've never heard of anything like this. Normally, a person enters serotonin syndrome after taking an SSRI, a MAOI and doing some amphetamine abuse on the side.

Has the doctor ever investigated why you entered SS only by taking Zoloft? Because it's highly unusual and may be indicative of other things. It matches with the medication sensitivity you're describing...requires more testing! Look into it please. If your doctors can't provide you with an answer I suggest getting examined by a University doctor with a PhD who is teaching classes and doing research in a University, and specializes in neuro-chemistry. You may have a rare condition that very few doctors heard of.

Fortunately my temp was normal, it was mostly abnormal blood pressure/pulse. So it may have just been my heightened anxiety rather than SS. It wasn't investigated (I was actually perscribed lexapro after instead, but didn't try any out of concern).

Cyllya
03-12-17, 08:02 PM
I got my diagnosis and initial treatment from my primary care provider, who is a DO (similar to MD). Most of my follow-up visits for modifying my meds or getting meds have been with nurse practitioners (FNP and ANP) in the same practice. Since my ADHD treatment hasn't worked as well as I'd like, I decided to see a psychiatrist (MD). Although he does seem more knowledgeable about ADHD meds, he hasn't actually been more helpful.

I've heard anecdotes of people dealing with doctors--even psychiatrists--who have inadequate knowledge of ADHD in adults, so I recommend mostly ignoring the credentials and focusing on how well their treatment is working for you.

So, if I understand right
--You previously had horrible results from sertraline (which is an SSRI but also a very weak dopamine-reuptake inhibitor) and the PA is aware
--You were taking 10mg/day of Adderall for two weeks with only "mild" effects (good and bad?)
--The PA switched you to 10mg/day of Ritalin.

While switching to a higher dose of Adderall might have been the more common choice, switching to Ritalin doesn't seem too weird or unreasonable. It's possible he's thinking that a higher dose of Adderall could be dangerous in your situation, or maybe he just thought since Adderall had so little effect, Ritalin seemed like a higher chance of being helpful than a higher Adderall dose.

The manufacturer recommended starting dose for adults starting Adderall is 20mg/day, and I think it's 18-20mg/day for Ritalin/Concerta also. However, for a small group of people, that dose seems too high to start with. I started on 5mg Adderall XR, and it worked great for months before I built up tolerance and had to increase the dose.

Are you taking instant release pills? I think the statistical trend is for Concerta and Adderall XR to be more effective than their instant-release equivalents, but Ritalin LA is not so good (http://journals.sagepub.com/doi/abs/10.1177/0009922815611647?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed). (Despite the title of that paper, the difference isn't generic-versus-brand but rather the type of release mechanism used by the sustained release pill.)

aeon
03-12-17, 08:32 PM
I've only ever seen my primary care physician for my ADHD (and everything else) because he has a specialty in ADHD, among other things, so he is a one stop shop.


Cheers,
Ian

Lunacie
03-12-17, 08:42 PM
I've only ever seen my primary care physician for my ADHD (and everything else) because he has a specialty in ADHD, among other things, so he is a one stop shop.


Cheers,
Ian

Too bad there aren't more like him around.

Little Missy
03-12-17, 08:50 PM
I have one too and have had him for over 30 years. We even kind of grew up together, but I have had my share of many interesting ones along the way. :eek:

aeon
03-12-17, 08:57 PM
Too bad there aren't more like him around.

Agreed, given he also diagnosed my adhd when I was 41.

And to think, I picked him out simply because he went to the Pritzker School of Medicine.


Cheers,
Ian

adhbee
03-12-17, 11:39 PM
I got my diagnosis and initial treatment from my primary care provider, who is a DO (similar to MD). Most of my follow-up visits for modifying my meds or getting meds have been with nurse practitioners (FNP and ANP) in the same practice. Since my ADHD treatment hasn't worked as well as I'd like, I decided to see a psychiatrist (MD). Although he does seem more knowledgeable about ADHD meds, he hasn't actually been more helpful.

I've heard anecdotes of people dealing with doctors--even psychiatrists--who have inadequate knowledge of ADHD in adults, so I recommend mostly ignoring the credentials and focusing on how well their treatment is working for you.

So, if I understand right
--You previously had horrible results from sertraline (which is an SSRI but also a very weak dopamine-reuptake inhibitor) and the PA is aware
--You were taking 10mg/day of Adderall for two weeks with only "mild" effects (good and bad?)
--The PA switched you to 10mg/day of Ritalin.

While switching to a higher dose of Adderall might have been the more common choice, switching to Ritalin doesn't seem too weird or unreasonable. It's possible he's thinking that a higher dose of Adderall could be dangerous in your situation, or maybe he just thought since Adderall had so little effect, Ritalin seemed like a higher chance of being helpful than a higher Adderall dose.

The manufacturer recommended starting dose for adults starting Adderall is 20mg/day, and I think it's 18-20mg/day for Ritalin/Concerta also. However, for a small group of people, that dose seems too high to start with. I started on 5mg Adderall XR, and it worked great for months before I built up tolerance and had to increase the dose.

Are you taking instant release pills? I think the statistical trend is for Concerta and Adderall XR to be more effective than their instant-release equivalents, but Ritalin LA is not so good (http://journals.sagepub.com/doi/abs/10.1177/0009922815611647?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed). (Despite the title of that paper, the difference isn't generic-versus-brand but rather the type of release mechanism used by the sustained release pill.)

Thanks for sharing your story! I didn't realize that primary care providers could diagnose ADHD. In my case, all my non-general concerns have had me referred to specialists. From what I've read, though, it doesn't seem that the practice I visit specializes in ADHD.

Your understanding is pretty much spot on. I guess it's better to be cautious.. It only took 25mg of sertraline (half the starting dose) to turn me into a crazy person.

I'm pretty sure the methylphenidate I take is instant release.. Ritalin seems to have clearer effects than Adderall in that I get a caffeine-like temp energy boost. Focus still somewhat eludes me. I'm surprised that the official Ritalin LA brand would be less effective than something like Concerta, but I doubt I'll be taking it specifically as I've only been prescribed generics (which is another question mark in and of itself for me).

sarahsweets
03-13-17, 03:58 AM
I think its best to try and see a psych who deals with adhd, simply because they can rule out other mental health issues and because they tend to have more experience with the type of meds to treat adhd, HOWEVER, its so hard to get in to see one, or find a good one in a lot of cases so seeing your primary or PA or NP is not bad either.

Swissy
03-13-17, 06:25 AM
I see a neurologist. I chose him because a friend referred him. When I called to make my first appointment, I made sure he had experience evaluating adults for ADD as my primary care physician suggested I might have it. He wanted to have me try vyvanse but my insurance wouldn't cover it. I asked for something more affordable and was given adderall IR, which works well for me. I am sensitive to meds, too, so I had to reduce my 10mg pill in half to start. After a few months I moved up to the full 10mg dose twice/ day. I was given the green light to go higher but I chose to stay at the current dose for a few reasons and am doing well for the most part, with a few slips here and there. Good luck.

Postulate
03-13-17, 10:20 AM
Fortunately my temp was normal, it was mostly abnormal blood pressure/pulse. So it may have just been my heightened anxiety rather than SS. It wasn't investigated (I was actually perscribed lexapro after instead, but didn't try any out of concern).

You can ask your doctor if it's wise to add Intuniv in combination with Adderall. Intuniv will lower blood pressure and treat ADHD.

ToneTone
03-14-17, 03:45 PM
So here's the thing: if you really want good treatment, it definitely helps to ask all the questions you want to ask.

I go to a nurse practitioner and I'm quite happy with her. I previously had three psychiatrists. What I really like about the nurse practitioner is that she is really thorough about adjusting the dosages (she would definitely tinker with dosages of one med before going to the next). And she listens deeply to my reports about the effects of the meds.

Now, I imagine that a physician assistant follows the practice and steps of the psychiatrist they work with. And perhaps this psychiatrist has had better experience with Ritalin than with Adderall. In any case, you should definitely feel OK about asking about going back to Adderall at a different dosage.

When I have suppressed skeptical questions, I have later found out (most of the time) that the provider had a pretty good for reason for why they prescribed what they did. So now, I ask the questions right away. If the answers are not persuasive to you, that's a sign to go to a different provider.

Don't let the appearance of being mean or cold (to the PA) get in the way of asking to see the psychiatrist if you think your treatment would be better. Your job is to advocate aggressively and to advocate selfishly for yourself. You harm no one by being selfish in this way.

Indeed the psychiatrist most likely assumes that people who don't complain about the PA are happy with the PA. The psychiatrist's practice is most likely set up on the assumption that people will advocate aggressively on their own behalf. If you have questions about the PA, then totally go for asking to see the psychiatrist.

Good luck.

Tone

dvdnvwls
03-14-17, 04:01 PM
If you aren't being selfish while at the doctor, you are mucking up the whole process. They need your selfish opinions in order to treat you properly. They think if you're fine, you would have stayed home, so if you show up and then you're fine, it's very confusing for them.