Adult ADD

Chart Notes of Ernesto G.

Intake Note

Present Illness:
Ernesto G (not his real name) is  35 year old lawyer is a married father of three. He states that his life is great, his practice successful, marriage and children fine. Yet he is very unhappy. He works hard but has trouble concentrating. (Note: Difficulty concentrating is a common symptom of ADD but may also be caused by many other disorders that affect executive functions, including depression.)  The problem with concentration has been worse over the past five months. (Note: ADD most often is characterized by life-long symptoms. It is not yet clear whether this is so in his case.)

He gets no enjoyment from life, has decreased energy, and sleeps a lot, as many as 9 1/2 hours a night. He complains of a low sex drive, low self esteem, social withdrawal, and is somewhat sensitive to rejection. He occasionally has suicidal thoughts but no has plan to harm himself. (Note: These are all common symptoms of depression. His symptoms of sensitivity to rejection and increased need for sleep are common in the type of depression called “atypical depression.”)

Upon more detailed inquiry, the patient reported many executive function deficits: he procrastinates, has trouble with prioritization, needs to be isolated from external stimulation to read, and must do only one thing at a time or will become scattered. He says he functions well in court, when intense concentration is required.

He finds that he must be compulsive about finishing things, or he won’t get them done. (Note: this is not uncommon in adults with ADD who have worked out ways to over-compensate for their problem. On the other hand, it is not common in patients with depression.)  He has no problems with time management and is not late or forgetful about appointments. (Note: Problems with time management are frequently seen in adult ADD. However, few patients with ADD have all the usual symptoms of the disorder.)

He states that as a child he was hyperactive and an underachiever. During his adolescence, he took drugs recreationally and discovered that he felt normal only when he took “speed” (Dexedrine). (Note: These are important findings. A history of underachievement, especially during childhood, and responding well to psychoactive medications (like Dexedrine or Ritalin) are good indicators that ADD may be present. It is important to bear in mind, however, that many people without ADD also function better after taking psychoactive medications.)

Family history: Both Mr. G’s parents were depressed. A brother has been depressed on and off all his life.  None have a history of bipolar disorder. (Note: This is important information since bipolar disorder and ADD frequently occur together.)

Medical condition: Mr. G states that he has no medical problems and is not taking any medication. He had his last medical check up two years ago.

Psychotropic medications taken in the past: Zoloft 50 mg per day for depression about four years ago. He had a good response but it reduced his sexual function and feelings.

Psychiatric medications being taken at present: None

Diagnostic assessment: Depression, recurrent Rule out Attention Deficit Disorder (Note: It may turn out that if his depression clears up, his ADD symptoms may fade to an acceptable level.)

Prescription written: Wellbutrin 150 mg SR, gradually increasing to two per day. (Note: Wellbutrin was chosen because it is both a good anti-depressant and often helps with ADD.)

Plans and instructions: Patient told of usual effects of Wellbutrin and possible side effects. Patient given an information sheet on Wellbutrin and ADD.

Appointment for two weeks for follow up on effects of medication.

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Two weeks later
Medication taken during the past two weeks: Wellbutrin 150 mg SR twice a day for past ten days

Content of contact: Mr. G’s mood started to rise and his concentration improved within a few days of starting the Wellbutrin. He feels even better than before he got depressed. (Note: It is uncommon for antidepressant medication to work so quickly. It usually takes about a week for some effect to be seen and three weeks or so for patients to start feeling really better. This may be a placebo effect.)

He has some dry mouth. He wakes up at around 3:30 AM and stays up for about an hour.

Next appointment: Four weeks
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Two weeks later
Medication taken during the past two weeks: Wellbutrin 150 mg SR twice a day

Content of contact: Patient called, concerned about some tremor and agitation. (Note: These are occasional side effects of Wellbutrin.) Dose of Wellbutrin reduced to 100 mg SR twice a day.
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Two weeks later
Medication taken during the past two weeks: Wellbutrin 100 mg SR twice a day

Content of contact:  Mr. G notes that he is more irritable, having trouble sleeping. The Wellbutrin does enhance his concentration for five hours, but when it wears off he becomes more touchy and anxious. He always feels “a background noise”, is hypersensitive to sound. (Note: Wellbutrin sometimes seems to increase sensitivity to stimuli.)

He used Zoloft in the past. Despite the fact that it decreased his sexual drive, he would like to try it again.

He did not take the Wellbutrin today. I told him to stay off one more day then start the Zoloft.
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Two weeks later
Medication taken during the past two weeks: Zoloft 50 mg per day

Content of contact: Within a week of starting the Zoloft, he started obsessively worrying less, feeling less hopeless. Sex was great during a week-end vacation with his wife, however, since then, he noted some decrease in sexual drive but no difference in his feelings during sex.

His problems of concentration and focus have gotten worse since he stopped the Wellbutrin. He says that he would be interested in trying Ritalin but is a bit self critical for not being able to manage his symptoms without medication. Ritalin prescribed 10 mg per day.

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Two weeks later
Medication taken during the past two weeks: Zoloft 50 mg per day Ritalin 10 mg SR per day

Doing very well on the Zoloft/Ritalin combination. ADD symptoms have disappeared completely. Working effectively, good focus.

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Six weeks later
Medication taken during the past two weeks: Zoloft 50 mg per day Ritalin 10 mg SR per day

Content of contact: Ritalin has made a tremendous difference in his life. Focus, ability to study remarkably different.

However, he reports that over the past few days, his far off “constipated” (obsessional) look has returned. Some middle of the night and early morning awakening, a characteristic sleep pattern for him when he is getting depressed.

Zoloft increased to 100 mg per day and the Ritalin to 10 mg twice a day.
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Two months later
Medication taken during the past two weeks: Zoloft 100 mg per day Ritalin 20 mg SR per day

Content of contact: He is greatly improved on the higher doses of medication. His concentration is very much better, his moodiness is gone, he is better able to engage with people. Reading much more. Much more attentive to wife. No longer engages in obsessive thinking, no more days of rumination, worrying. Less compulsive about exercising.

The Ritalin SR works for about five hours. He notes no side effects, no change in weight or appetite.
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Fourteen months later
Medication taken during the past two weeks: Zoloft 125 mg per day Ritalin 20 mg SR per day

Content of contact: Generally doing very well.

About two months ago, he stopped taking the Ritalin when forgot to take it with him on a business trip abroad . A week later, he started having headaches not responsive to usual meds, flu like symptoms, was weak, tired, dizzy, had difficulty focusing, felt feverish though he had no fever. Within a day of restarting the Ritalin, the symptoms went away. This appears to be a withdrawal effect.

He noted how absent minded he was without the Ritalin, felt scatter-brained. This experience removed any doubt whether the medication was working or not. He has continued it to the present.