Hi All. I have a 16-year-old daughter that was diagnosed with severe anxiety and depression over the summer after completing a psych evaluation. Prior to the evaluation, she was convinced she had ADHD. She has had no behavioral issues or performance issues at school. In fact, she is an extremely high achiever taking several AP level courses. She is convinced that she works 10 times harder than her peers to maintain the grades that she achieves. A second evaluation conducted by a psychiatric nurse online this fall led to a diagnosis of ADHD. My daughter then started Adderall, but it did not help. It seemed that her anxiety and depression got worse, to the point where she was sleeping approximately one hour a night and forgetting to eat. In December she was switched from Adderall to Zoloft and we’ve seen a significant improvement. But she is convinced she still has ADHD and wants to resume medication for it. The psychiatric nurse is also recommending that she take Zoloft and Adderall together. I have read this can lead to things like serotonin syndrome. And I’m worried about adding Adderall back when I’m seeing her make so much progress on the Zoloft. I voiced my concerns to the psychiatric nurse, but she rushed me off the phone and I didn’t really feel heard. She sent me a link about medication which didn’t really help me. I truly want what’s best for my daughter, but I want to be careful with medication and make sure that we are an over medicating unnecessarily. Does anyone have experience with this? Have you given your teen both Zoloft and Adderall at the same time? How did it go? Thanks for any help you can offer.
Multiple Medications: Hi All. I have a... - CHADD's ADHD Pare...
Multiple Medications
While we do not have experience with those medications. Please consider Wellbutrin, which has really helped our son. It was recommended by his Child Psychiatrist due to the shortage of stimulants and it had replaced the stimulant. Good luck!
Has she ever been evaluated for learning disabilities? If she feels like she is working 10 times harder then others, sometimes it can be due to Dyslexia, Dysgraphia, Dyscalculia. Or it could be ADHD. Or it could be ADHD + learning disabilities.
My daughter tried taking Zoloft for her Anxiety, but it made her feel crappy. She is now taking Prozac for her Anxiety. She recently started on Focalin XR for her ADHD (after being off ADHD meds for over 1.5 years due to side effects and other medical issues).
I'm on 75mg zoloft, 70mg vyvanse, 10mg abilify, 15mg mirtazapine and not having any negative side effects. Also no signs of serotonin syndrome. I think it is good to listen to your daughter, ask her, what she wants to try.
This is not answering your specific question, but my DD 17 had several evaluations with none returning an ADHD diagnosis. I contcted a therapist who had been working with her over a period of time to express that I thought there was a piece missing in her diagnosis. Fortunately this therapist ahd a lot of experience with adult ADHD clients and shared that she had a suspiscion this might be the case with DD. Therapist administered a screener, to me, DD and herself. Yup, innatentive ADHD which was then confirmed by a Physcologist. Looking back at notes from school, there were definate signs - such as teachers noting she "doesn't pay attention, but seems to kno wthe material". She was also diagnosed as 2e, which helps her compensate. It's a big puzzle to get the correct diagnosis, so keep at it.
what is her diet like? Is she secretly starving herself? Could she have an eating disorder. At that age they can stop eating some things if they don’t like them much, and substitute with lots of junk food. She might not be getting enough vitamins and minerals, vegetables etc.
Thanks, she is a good eater except for when she was on the Adderall. She was forgetting to eat and had little appetite. Once she stopped the Adderall and started the Prozac, her appetite returned and she is eating healthy meals.
Ok good, it is good to keep an eye on it as at that age some with anxiety can develop anorexia so just make sure you see she is eating the food not pretending.
You can actually enter into chatgpt an estimate of what her daily meals are and ask it to tell you if their are any deficiencies it notices. It’s pretty cool. Prozac I think can make you crave carbs. My husband was on it and I couldn’t get him out of the pantry! He gained 10kg. If you can get her interested in gut health and eating a rainbow some kids can be quite interested.
Lack of eating may be due to Adderall effects.
1)Hyperfocus. People can get hyper focused on something and stimulants can either be the cause, or a contributor. Focussing on other things and not wanting to stop for food is not an unusual thing. As it takes focus, and progress that is happening away at that time.
2) Adderall is an appetite suppressant. Literally, amphetamine used to be sold as a weight loss drug specifically because of that.
Which is a good reminder. It is after 8PM and I should probably have breakfast now. Have my own hyperfocus issues LOL. Not quite as bad as it sounds as my schedule is rotated forward from the average person. So this is more like a late lunch as far as time comparison goes.
My 16-year old daughter is also a high achiever taking AP classes and in several clubs, worked a part-time job. She was diagnosed with ADHD when she was 7 but we never medicated her as she was getting A’s at school. We finally realized due to her advocating for herself that she was depressed and had a lot of anxiety due to “just holding it together and getting by” for so long. She was started on Prozac by a psychiatrist but gained a lot of weight and seemed more impulsive. She switched to Wellbutrin and at 300mg after three months she is thriving and does seem a bit more focused. Wellbutrin may help with depression AND ADHD.
thank you for sharing! You should setup an appt with the doc instead of talking with the nurse about medication changes. Maybe write an email to get articles but be prepared to talk concise with the doc. Maybe ask for a neuro psychological examination. I wouldn’t go back on adderall if it did that. I wouldn’t ask to try a non stimulant. Stimulants are known to raise anxieties. They made mine worse, and I love the effects of my stratera.
Also, if she’s stressed in ap classes, go to less rigorous ones. I’m a teacher. I’ve been told by college people that good grades in regular classes are better than ok grades in ap classes.
Thank you so much. This is great advice.
A few things to unpack here:
1) someone can excel academically and have adhd. Often it comes at the expense of our mental health, as it did for me. Unlike your daughter, it didn't really hit me until my university years.
2) I can't tell you how frustrating it is to see other people doing things seemingly without effort that is like pulling teeth for me. Especially when I was frequently being told I was falling short of my potential (despite doing well academically) and being told I just needed to try harder when I put in immense effort every day.
3) with respect to adhd, we better understand now that it can present differently in girls than in boys. Instead of thinking about the stereotypes, look up "executive function" and see if your daughter struggles in those areas. You mentioned her doing well academically, but you didn't mention if she has friends, has been bullied, has emotional disregulation, or if her personal relationships seem particularly challenging.
4) more than one med is not the end of the world. I'm on two meds and have been for years with no issues that couldn't be resolved. The key is keeping an eye on things and addressing them early if they develop. Ultimately it will come down to what your daughter finds most effective at getting her life back on track. As someone else mentioned, welbutrin can be a good choice because it is an antidepressant that can also be used for ADHD. That being said, don't get rid of a med that works for something that might be better.
5) it is very much possible for your daughter to have a mood disorder and adhd. Comorbid mood disorders are quite common both due to our leaky dopamine bucket and the high levels of stress we experience trying to conform to a world not designed for us.
6) neither you nor your daughter should anchor yourselves to a particular diagnosis. Even for professionals with years of experience, differentiating between conditions with a very similar symptom profile can be challenging. As scary as the label is, consider the possibility of bipolar disorder. This often gets overlooked because hypomania can look like adhd, and some docs only see patients during their depressive cycle because you don't seek out a doctor when you feel awesome.
7) you can't see the mental effort your daughter puts in, so when she says she works 10x as hard, believe her. Adhd is a disorder of doing, not of knowing. You have no idea how frustrating it is to know exactly how to do something and be unable to make yourself do it. Or maybe you do (see my next point)
8) Look into getting assessed yourself. Often one or both parents have adhd when their kid has it. Not knowing you, it's possible that you could be downplaying her symptoms because you've lived with them all your life, so you just think your experiences are normal. I still fight against self-judgment over things that are adhd because I just thought everybody dealt with what I do and they just worked harder or were more disciplined.
I hope this was helpful. None of the above is a reflection on you. You are right to be concerned about making sure she has the right diagnosis and treatment, and I'm glad you decided to post here.
"A second evaluation conducted by a psychiatric nurse online this fall led to a diagnosis of ADHD" I'm not a doctor, but I would throw that diagnosis out.
To diagnose someone, you have to first rule out anything else that can cause the same or similar symptoms. There are over 2 dozen disorders that can present with same or similar symptoms to ADHD. Of course, Depression and Anxiety are both on that list.
So, she can not likely be diagnosed with ADHD properly without first managing depression and anxiety, which may be the cause of the ADHD like symptoms.
Depression and Anxiety can cause ADHD like symptoms. ADHD, can cause Anxiety and Depression. Have to sort out if they are comorbid (occurring together) or if one is presenting like the other, or being caused by the other. Someone who is really good with experience may be able to sort things out, but don't count on a quick solution. It's a process. Plus, there may be other factors, like I saw another response mention, that are not ADHD either.
Who did the psych evaluation over the summer and what did it entail? Why are you consulting an online nurse? Was the psych evaluation not implemented by a psychiatrist? If done by a psychologist, ask if there is someone they can refer you to for proper treatment. When a therapist rushies you along or makes you feel like they are not helping, and you are not being heard, it is time to find one that actually helps. Which may be just answering questions and helping you and your daughter to understand things better.
Are you pursuing non-medication based therapy too? Proper therapy is about more than just drugs. Especially when Anxiety and Depression are involved. She needs the proper tools to manage those things and reduce negative thought patterns that may be contributing, or be the actual problem.
To give you an idea of a proper diagnostic process. For me, I had done neurological testing, took a sleep aid for a while to rule out sleep disorders (always had issues with sleep), hearing test, eyesight test, physical exam with blood tests to rule out a number of other factors. 3 visits for psych testing with a psychologist trained in psych test evaluations. And several appointments with my psychiatrist going over life long histories, symptoms, etc. Then I was diagnosed with ADHD. Because they ruled everything else out as part of the "differential" diagnosis.
All that and they missed sluggish cognitive tempo (SCT, officially cognitive disengagement syndrome (CDS) as of 2022) that is not in the DSM guide yet due to not enough research being done yet on it. And mild narcolepsy which was dismissed due to not having most of the symptoms that are typically listed. But, many years later (18.5), actually looking at the diagnostic criteria instead, fit the diagnostic criteria like a glove. But narcolepsy is still tentative as I have not had the chance to do the proper sleep testing for it. SCT is officially comorbid diagnostic (and such a relieve as all my "other" symptoms were basically ignored since therapists didn't know what it was. (Really, since ADHD meds also helped with those symptoms they left it at that. But it was those other symptoms that drove my dosage escalation issues due to not being the optimal solution for comorbidity). Uhg, it's a process.
Your daughter may want Adderall since it will allow her to focus better and longer making homework easier. Even if it doesn't help her depression and anxiety. Same reason college kids have been found in a high percentage to pursue it even without any disorders. Cognitive enhancement, being able to study harder longer has advantages. Just because it gives a boost, does not mean someone has ADHD. If she does go the amphetamine route (that's what Adderall is), go with Vyvanse. Less side effects, longer lasting, less chance to build tolerance. Would suggest concerta (basically extended release Ritalin) as it has less potential long term issues as amphetamine based meds. And can always switch to amphetamine later if need be. But, if a tolerance is built to amphetamine. Once you get to a mid level dose, other things may no longer be therapeutic as amphetamine is stronger than other ADHD meds. Leaving nothing to switch too. (Which is how I got stuck with Adderall and couldn't get off it. Most people are stable at a reasonable dose. But, like you said, it wasn't really doing much for her over all so why go down that road if you don't have to.)
Overall, multiple medications can often be more beneficial than mono-therapy. The key is titration. Some meds will have crossover effects and enhance each other which requires a lower dose of both. Titrating up from a low dose to find the optimal dose of both is not a bad thing. Like I said, I am not a doctor, have no professional credentials. Serotonin syndrome is something to keep an eye out for, as are any adverse reactions. But I would guess not too big of a risk. Depression is often associated with serotonin dysregulation, being too low or signalling being not strong enough. Zoloft works on Serotonin primarily I think? Amphetamine only has a weak effect on serotonin. I think Zoloft has a weak effect on dopamine while amphetamine is strong. So, they may enhance each other. But, that is if she really needs vyvanse.
**Really need to go to a proper in person therapist that your daughter can get the full benefits of both medication and non-medication therapy and work on her anxiety and depression issues properly.
As far as combined medication therapy, I take Armodafinil, Adderall, Strattera, Guanfacine, and Caffeine. And add or substitute in some Modafinil from time to time. So, I can be on up to 6 drugs at a time. Which specifically for me and all my own factors. Is far more therapeutic than Adderall alone. And less side effects. And my blood pressure is fine. 120/80 exactly at last doctors visit. But again, that is me, my tolerance and titration after many years. I know caffeine is not prescription, but therapist knows I titrated caffeine pills and contributes to my therapeutic effect. And blood pressure etc. was monitored along the way. Point being, you can get into trouble combining medications, but for some people, they get the most benefit from the right combination.
Last thing, I am not saying your daughter does not have ADHD, no way for me to know. Just saying there is a proper process and self diagnosing is not it. Sooooo often people misdiagnose themselves as ADHD. There is a common joke among psych majors, The first year they self diagnose with everything in the book. Because anyone can look at symptoms and recall times they presented with them. Understanding the difference between a common symptom and a clinical one, and the concept of a differential diagnosis is what is usually missed. Your daughter's case is not so cut and dried and really needs the proper attention, diagnostic process, and therapy.
Sorry for the blabbering post. Long story which I will skip for now.
What dose of Adderall did your daughter start on? It is very common for someone to be started on too high of a dose to begin with. Sleeping an hour a night sounds like she was on maybe triple the dose she should be. That is a good way to cause tolerance and start building toward long term side effects. Can even be damaging to pathways like the NMDA/glutamate pathways that are more sensitive to over excitement. Plus acute tolerance becomes regular tolerance if the medication does not give sufficient time between doses to be off of it and allow downregulated receptors to upregulate. After a while, the body will just permanently remove them if constantly suppressed. Making the tolerance a long term thing.
Plus, amphetamine can cause high levels of ACTH and Cortisol, stress hormones. A good way to make depression and anxiety worse I would would assume.
I am someone who was not stable on a low or even medium dose of Adderall. The list of side effects from high cortisol, is also a list of side effects I have long term from Adderall (plus a bunch of others). Not to scare anyone off Adderall. It can be very effective. But your daughter was not off to a healthy start with it. I always advocate amphetamine based meds after trying others first. Why go to the one with the highest potential for long term side effects, and has cross tolerance on higher doses that negate being able to switch to another medication? And always go Vyvanse first if going the amphetamine route. Less side effects, resists tolerance more, longer lasting.
Has anyone checked your daughters cortisol levels? Cortisol is a stress hormone. To the best of my knowledge, a significant correlation with anxiety. Cortisol should be naturally highest in the morning and decrease during the day. Blood tests usually have a 9 am and and a 4 pm range as cortisol should drop during the day. Anxiety can increase cortisol, which exacerbates anxiety. Don't really know, maybe high cortisol can cause anxiety? All that stuff is well outside my knowledge base. But may be worth talking to a therapist or primary doctor about it. I do know that on Adderall, at 2:45pm, my ACTH and cortisol was over double the 4pm range. And the prescriber documentation for Adderall says that cortisol would be highest in the evening. So, I may not have even been at a high point yet. I didn't have anxiety issues myself though.
If an online nurse or other doctors snickers at Adderall and cortisol, send them this link and quote. It is a link to the FDA official Adderall prescriber documentation that they likely never read. (again, can't say amphetamine based meds are not a good end option for your daughter, it may very well be. In my unprofessional, having no relevant credentials, random disgruntled guy on the internet opinion, amphetamine would not be off the table, just not any of the first options to try).
“Amphetamines can cause a significant elevation in plasma corticosteroid levels. This increase is greatest in the evening.”
dailymed.nlm.nih.gov/dailym...
Strattera is sometimes prescribed to people with ADHD who have also had a history of Depression. As it has been found to help depression. Which was my first medication for exactly that reason. Although I had not been clinically depressed in over 6 years by then. Having had that prior history was one of the factors in going with Strattera first. (worked well, other factors I have that lead to dosage escalation with any medication for the most part). Unlike amphetamine (Adderall, Vyvanse, Dexedrine, zenzedi, desoxyn, etc.) and methylphenidate (Ritalin, concerta, focalin, etc.) based meds, it is technically a non stimulant and 24 hour medication. Does not wear off toward the end of the day. Someone like your daughter who may be studying at all times of the day, may need the therapeutic effect in the evening too. Trying to get amphetamine or methylphenidate to work from morning through the evening is not healthy for most (not all) people. I put the link with drug design and acute tolerance in my other response.
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