It's not just about the receptors . . . Sometimes it's just about common sense

Dell writes in with an issue . . . but I think the real issue is deeper than the chemistry . . . 

I’ve just been prescribed Vyvanse for refractory Clinical Depression. I was hospitalized twice decades ago then was started on a regimen of dexedrine which I never abused. It got me through graduate sschool. After about seven years I was taken off it. since then I have had several severe depressions as I am now. I have been prescribed every possible antidepressant; the SSRIs make me somnolent, only Wellbutrin improves my mood somewhat, but the inability to focus is making me even more despairing.
After such successful experience with dexedrine, I am very angry at shrinks/psychopharmacologists who have denied me the one drug that has kept me from diving off the Brooklyn Bridge. I hope Vyvanse works

In all the training we receive as psychiatrists . . . four years of college . . . four years of medical school . . . four years of post-graduate training . . . we never get a course in common sense.  What a shame.  In the theoretical world, you should not be prescribed a stimulant medication for depression.  Whatever improvements you would experience would be considered a “drug-induced high” and not a recovery from depression.  And while true for all stimulants, for some reason, dexedrine has been singled out as the “badder” of the two stimulants.  For all practical purposes, there is nothing better or safer about Ritalin, but conventional wisdom is conventional wisdom.  Once upon a time, the prescribing of dexedrine and dexedrine based products was frowned upon greatly.  This is at least in part because it did become a big drug of abuse in the 60’s and 70’s.  With modern psychopharmacology in its infancy, there was no advocacy to have dexedrine available.  

The left-over from this is that most docs have the sneaking suspicion that people like you are just getting high and, therefore, prescribing it for you would be promoting your addiction.  That is why you have a hard time getting it from a doc.

But, back to that missing course on common sense . . . If the typical stuff ain’t working . . . be innovative.  And TAKE A HISTORY!!!  If a patient has significant improvement on an unusual regimen of medicine, I guess that is the regimen that works.  We can get lost in second-guessing ourselves about the clinical picture and the medications that we use.  But, where the rubber hit the road, what works is what works.  Its NEVER about fitting the patient into the text book.  

I’m glad you finally found a doc who is willing to be practical with you.  Communication with the doc is important and you must always always always be honest with him/her about your use of the medicine.  

–Dan Hartman, MD

2 comments to It's not just about the receptors . . . Sometimes it's just about common sense

  • Barbara

    Dr. Hartman,
    Thanks for your response regarding Vyvanse for treatment-refractory depression. I have also been on most of the SSRIs, SNRIs and Wellbutrin with little success. My psych treats alot of adult ADD pts. and is very familiar w/the stimulants. Tried me on adjunctive Provigil, then dexedrine, and I am now much better on Vyvanse. I am also on Pristiq.
    When I researched the stimulants/amphetamines, some are referred to “dopamine reuptake inhibitors.” Also, my understanding is that Wellbutrin also increases dopamine and norepinephrine. Being that the person asking the question had some response to Wellbutrin and a good response to dex and Vyvanse, would it not follow that she and I are “dopamine responders”? Do you feel that DA is being overlooked in treating depression? Also, if that is POSSIBLY true, why do the SS/SNRIs take several weeks to work and the “DRIs” act so quickly?
    I could ask so many more questions, but will leave it at that.


  • Barbara– Good questions and comments. I DO think that some patients have a version of depression that requires intervention at the dopamine receptors to get better. Or, it may be that all patients with depression have some sort of dopamine dysregulation but are ‘well connected’ enough that intervention at the serotonin system effects the dopamine system enough that they get better. Who knows. It is mostly speculation. In my experience, people don’t respond to wellbutrin any faster than they do to SSRIs or SNRIs. Some respond quickly. Others take more time. I will qualify that by saying that adding wellbutrin in to an existing SSRI treatment can provide very quick response and improvement in mood.