Drug Treatment: Stimulants vs. Stimulatory Antidepressants

Advantages and Disadvantages of stimulatory antidepressants including atomoxetine (Strattera^®), desipramine, and protriptyline) vs. stimulants (amphetamines and methylphenidate or Ritalin^®)

Advantages of Stimulants

• Effective in about 70% of children, teenagers and adults.

• With usual treatment doses, no significant adverse effects on the electrical conductivity of the heart.
• Amphetamines do not lower the seizure threshold.

Disadvantages of Stimulants

• Not effective in about 30% of children.
• More effective and better tolerated in teenagers and adults.
• Both the short-acting and the sustained-release formulations of stimulant medications, when wearing off, often cause a severe "drop-off," "letdown," or emotional and cognitive "crash."
• Except for the 9-12 hour-lasting preparations, stimulants usually need to be dosed more than once a day.
• Rarely help individuals fall asleep with less difficulty and may cause insomnia.
• Rarely make waking in the morning easier.
• Do not help young children who are awake but disorganized in the morning be more organized.
• Do not stop bedwetting, if the problem exists.
• May cause tics or worsen established tic behavior.
• Usually reduce appetite and eating.
• May stunt growth, at least temporarily, because of reduced eating.
• Have a potential for addiction and abuse.
• Ritalin does lower seizure threshold.
• Amphetamines are not recommended by the FDA for use in ADD/ADHD children under three years of age.
• Ritalin is not recommended by the FDA for use in children under six years of age.
  

Advantages of the stimulatory antidepressants (atomoxetine and desipramine and protriptyline)

• Effective in 80% of children, teenagers and adults.
• Only once-a-day dosing is needed.
• Effectively treats ADD/ADHD 24 hours a day.
• No "letdown" or "crash" at the end of the day.
• Not addicting. In fact, the stimulatory antidepressants are hard to abuse because excessive dosing causes undesirable, negative symptoms.
• Stop bedwetting, if present, in about 90% of those treated (this is certainly true for desipramine and may be true for Strattera).
• Do not cause tics; in fact, may stop tic behavior, if present.
• Help children, teenagers and adults fall asleep easily at night.
• Do not cause insomnia.
• Dramatically help children, teenagers and adults wake easily and be organized in the morning.
• Do not stunt growth.

Major disadvantages of the stimulatory antidepressant desipramine

• In many instances, the electrophysiology of the heart is mildly altered by desipramine and protriptyline; periodic ECG monitoring is indicated.
• The blood level of desipramine is not initially predictable when treatment is started. Accordingly, strict adherence to physician's dosing orders and timely follow up blood desipramine testing by the prescribing physician is appropriate and should be mandatory.
• The liver mechanism for metabolizing desipramine can be saturated and become inadequate over time, especially in children. This may occur quickly (the first week) although sometimes it happens slowly over the first two or three months. Monitoring of the blood desipramine level is valuable to ensure safety during the first three months after treatment is started.

Keep in mind that no one medication is ideally effective in all individuals. More detailed information on the treatment of ADD/ADHD can be found in my book, The ADD Brain.