Vyvanse was helping depression . . . now . . . aggravating mania?

James writes in to say . . .

I started having panic attacks and was very unsociable and kept to myself,all this started about 10 years ago. The doctors diagnosed me as bipolor,i’ve been on every med available for bipolar with no positive results. Last december my doc decided to try me on 20 mg 1 a day generic adderral. It turned my life around i was talking to people i had avoided for years and started back doing normal activities instead of cutting myself off from the rest of the world i also was not as angry as before. To start with one a day is all i could handle, it gave me more than enough energy. Now in august i am taking 4 a day and i feel almost like i did before i started taking them. I have severe headaches and mood swings,i also become very angry easily. My doc switched me to vyvanse, i am scared i will fall back in the rut i was in for all those years. Will vyvanse be as good as adderral, and how long should i take it before i notice a change? I wonder if i quit adderral for a couple of months and then start it again , will it give me the affect it originally did? My behavior is affecting my whole life. Is there any advice or anything encouraging?

James, I’m going to start with the assumption that your diagnosis of Bipolar disorder is accurate.  With that assumption in place, the medication used for Bipolar are quite varied so that it is a leap to say that you have tried “every med available” but I will even accept that as fact.  A question that is not answered is if you tried COMBINATIONS of medications.  For example, combinations of antidepressants, or antidepressants with Lamictal can be quite powerful.  It is also not unusual for patients to benefit from combinations when use of single agents is not helpful.  But let’s assume that combinations were tried but were not successful.  Use of a stimulant medication is a bit unorthodox . . . and brilliant!  Hats off to your shrink!

In cases of Unipolar Depression that is unresponsive to medication, there are a variety of augmenting strategies that can be used.  One of them is to use stimulant medication such as Ritalin or Dexedrine.  Adderall, of course, is a dexedrine-based medication.  Using stimulant medication in Bipolar patients can be tricky.  The risk of precipitating mood instability, irritability, or frank mania is uncomfortably high.  I can suppose that, at first, it was able to bump you out of your depression for a while . . . and then you became tolerant to it . . . and it was increased . . . and you became tolerant . . . etc until now you are on 80 mg daily (a whopping dose) and not getting benefit.  Is switching to Vyvanse any better?  Hhhhhhmmmmm . . . hard to say.  It is not a big difference.  Adderall is a combination of two amphetamine salts and two dexedrine salts.  Vyvanse is also a dextroamphetameine product. Not a lot of difference.  Might make a difference . . . but . . . maybe not.  Won’t know till you try.  

My preference would be to put a mood stabilizer on board (whichever one you tolerated best) and then challenge you with a stimulant.  This could be either with a dexedrine product like Vyvanse, or with a ritalin product (such as Ritalin LA or Concerta).  The hope is that the stimulant medication would provide the same mood boost with the mood stabilizer providing for stability and act as a buffer for the irritability.  One of the tricks we use with ADHD kids who develop tolerance is to switch between a Ritalin product and a Dexedrine product.  For some reason, this can work with some kids.  Will it help with you??? Maybe.  Certainly seems worth a shot.

Good luck and keep plugging away.  If your doc gets stumped, arrange for a second opinion.  There are always new options and combinations to consider as well as life-style changes and therapies that can be helpful.

–Dan Hartman, MD

4 comments to Vyvanse was helping depression . . . now . . . aggravating mania?

  • Sounds like you have exactly the same problem I did. I was misdiagnosed almost 10 years ago with Bipolar depression. It was completely debilitating but I had extremely adverse reactions to anything they pu tme on whether it was Epilepsy meds, Lithium, anti-depressants. None of it worked. I was off medication for about 3 years and still having a lot of the same difficulties as before (almost exactly the same ones you described). I was having a lopt of trouble sticking to a schedule at work and to avoid being fired, investigated whether I might have ADHD. It came back as a loud and resounding yes. I was given IVA (Integrated Visual-Auditory) response test and all results said I had Extremely severe deficits across the board. Hada similar magic wand effect with teh adderall. Around 40 mg though, I plateaud on the IVA tests and they were still showing what would be a mild deficit for someone with an average IQ, but given my extremely high IQ they translated to moderate to severe deficits. I hesitantly tried the Vyvanse. My Psychologist was very resistant to it as the 2 ppatients she had supervised on it complained of lethargy and reduced effectiveness (even though their scores improved). I have now been on 50 mg of Vyvanse for 2 months and it is amazing. The rebound headaches I got on the adderall have all but disappeared (they are only there when I don’t drink enough water or eat enough protein in a day), I used to get 9 hours of “on” time with the Adderall and now I get about 15-16 hours on the Vyvanse. Emotionally, the roller coaster has become a train ride through the foothills. I am an extremely emotional person. I have had to accept that. With personal awareness I am able to take the final edge off the moodiness and my husband and I have new communication techniques that give me permission to be emotional while also giving him tools to let me know when he thinks the reaction is inappropriate. Vyvanse was the answer for me and like I said. The Bipolar was what they thought I had. ADHD and Bipolar disorder apparently have a 100% overlap of symptoms and are commonly misdiagnosed.

  • NOTE . . . ADHD and Bipolar Disorder do NOT . . . repeat DO NOT . . . have 100 % overlap in symptoms. There are vague similarities that a good psychiatrist can tease out in most cases.

    Just my opinion . . .

    DH MD

  • alb202

    Lady K – the first five sentences of your comment could have been written by me. I was diagnosed Bipolar in 1996 and took many combinations of mood stabilizers, anti-anxiety meds and antidepressants until 2001. Nothing worked. The funny thing is, I never exhibited signs of full blown mania so they said my racing thoughts and irritability were forms of hypomania. huh? (In retrospect they seem more like ADHD symptoms) I completely gave up meds in 2001 and started using fish oil and eating a better diet. My 8 year old was diagnosed ADHD inattentive type last year and recently I allowed his doc to start him on 20mg of Vyvanse. He has gone from struggling to get B’s to making straight A’s. The transformation has been amazing. I think there is a significant overlap in the symptoms of Bipolar and ADHD – my experience with 5 different docs hasn’t been that they can “tease it out.” It seems to me that they are trying to squeeze my symptoms to fit the initial diagnosis instead of bothering to probe deeper. I’ve decided to schedule and appointment to see if I might just be dealing with ADHD all these years. In my son’s intial assessment, his doc told me that many people (in his opinion) were incorrectly diagnosed Bipolar in the timeframe I received my diagnosis.

  • Justin

    This article has caught my interest. In my teen years (now in early twenties) i used to have some issues with anger and frustration, there was more to it but my rents only saw that as the issue. What im seeing now the problem was they had always scolded me for poor grades, lack of follow through on chores/homework and i didnt know why/ didnt mean to do these things so would get very angry because i had no way out of the trouble. They sent me to a psychiatrist who used me as his personal guinea pig. I was on EVERYTHING Zoloft Prozac Seroquel Cymbalta Risperdal Celexa and about 4 others with real weird names. They wouldnt work, not to mention would cause disfunctions in the “lower” zone.. and the only answer was to stack something on or try another in the same class. This caused so much pain in my life (thinking your the crazy kid in your school even though you feel your not). One time a friend was over and saw the meds, and told everyone in school : (. I have now come to the point of realization that many of the symptoms were adhd! I suggest anyone interested read driven to distraction to help identify if they could be suffering. Unfortunatly i did not realize that adhd could affect you in so many ways, always thought it just made you dumb(it doesnt). Currently seeing a therapist who is diagnosing me with adhd-pi. I hate psychiatrists for this reason and i strongly agree they try to “fit” symptoms into a diagnosis to make things easier. Parents be warned! My parents say taking me to a psych was the worst mistake they ever made. I would hate for anyone to have to suffer this!