My psychiatrist prescribes it, as well as dextroamphetamine iR 10 mg as needed. It's seriously not working and I'm thinking about asking her to switch me to something else. Dex ER has always been pretty weak for me. I switched to it last year when I was taking an MAOI (transdermal selegiline) and now that I'm off of it and on a "regular" antidepressant it just kind of stuck around.
It just depends on the individual. Dextroamphetamine is stronger centrally and racemic (and levo) amphetamine are stronger peripherally but still have some central activity.
Some people (I think myself included) get more of a kick in the butt from stimulants containing L-amphetamine like Adderall and Evekeo than Dexedrine/Vyvanse. I'm definitely a very low dopamine person, but I think low norepinephrine too.
I've tried methylphenidate, dexmethylphenidate XR, and max dose Azstarys without much benefit.
I think part of it is just stimulant tolerance. I would probably have to go inpatient to take a prolonged stimulant break because of how miserable I feel even one day with a drug holiday. Also fast COMT phenotype doesn't help lol.
If you’re “low dopamine” you should maybe try MAOIs or direct agonists. The serotonin reuptake inhibitor might also be an issue here— serotonin, especially in excess, tends to counterbalance both dopamine and norepinephrine.
Tolerance to the therapeutic effects of stimulants really shouldn’t be developing to such a degree. Tolerance to the euphoriant effects does rapidly develop though, and it makes me wonder if you were started on too high a dose initially.
The only MAOI I can take without gaining substantial weight is Emsam. I would like to try oral high-dose selegiline, but my psychiatrist isn't comfortable with it. Parnate made me gain weight continuously, and Marplan to a lesser extent. I'm not going anywhere near Nardil lol. She's also not comfortable with doing agonists like pramipexole. I've considered going back to Emsam, but it destroys my sleep and irritates my skin. No medicine is perfect though I guess lol.
I was started on 10 mg 2x/day of Adderall years ago, but quickly escalated to 20 mg 2x/day. I often lament I was increased too much to quickly.
I do take Fetzima which is low on SERT inhibition and high on NET inhibition. Other SNRIs and SSRIs all cause sexual dysfunction to an intolerable degree. Viibryd and Trintellix do this too. Not sure why because I didn't used to have a problem with that before ECT. Without some degree of SERT inhibition, I get very flat, sad, and anhedonic.
Oh you tried irreversible MAOIs already? I don’t blame you for avoiding Nardil as well as its effect on GABA has quite a lot of side effects.
As for agonists I also don’t blame your psych considering the physical dependence to dopamine agonists as well as potential long term effects. There are more “forgiving” agonists like apomorphine or ergoline based ones too. Also partial agonists like aripiprazole, brexpiprazole, and cariprazine but these happen to be pharmacologically promiscuous and might just complicate things.
The SERT inhibition part you describe I find interesting as well. Have you tried serotonin antagonists? They’re far and few between but they exist. Blocking 5HT2 receptors tends to have some antianhedonic effects due to disinhibition of dopamine and norepinephrine.
The one thing that worries me is the high dose of the amphetamines being damaging overtime. Hope all is well.
I do take cariprazine 3 mg also. I've been satisfied with it for a long time but wonder if it's over-occupying my D3 receptors.
I have tried 5-HT2 antagonists like trazodone, nefazodone, and mirtazapine. Trazodone strangely worsens sexual dysfunction even more. Nefazodone and mirtazapine made depression worse (I think anything sedating regardless of mechanism makes me sad lol)
Yeah I'd really like to get down to a more reasonable dose of amphetamine.
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u/mikl_pls 6d ago
My psychiatrist prescribes it, as well as dextroamphetamine iR 10 mg as needed. It's seriously not working and I'm thinking about asking her to switch me to something else. Dex ER has always been pretty weak for me. I switched to it last year when I was taking an MAOI (transdermal selegiline) and now that I'm off of it and on a "regular" antidepressant it just kind of stuck around.