William S.
Table of Contents of the Chart Notes of William S.
Intake Note: Five month history of depression and increased difficulty concentrating. Childhood history of some ADD symptoms, underachievement. Wellbutrin started.
Session Two: Depression and ADD responding well to Wellbutrin.
Telephone call: Side effects with Wellbutrin, dose reduced.
Session Three: More side effects. Wellbutrin stopped. Zoloft started.
Session Four: Depressive symptoms much better, but ADD symptoms worse. Vyvanse prescribed.
Session Five: Very good response to addition of Vyvanse. ADD symptoms virtually gone.
Session Six: Vyvanse having a dramatic effect on his life. Depression a bit worse over the past week. Dose of Zoloft and Vyvanse increased.
Session Seven: Excellent response to increase in dose of medications.
Session Twelve: After not taking Vyvanse for a week while on a business trip, ADD symptoms returned. Restarted Vyvanse and symptoms disappeared within a day. No current symptoms of ADD or depression. Feeling fine.
Intake Note
Present Illness: This 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 and anxiety.) The problem with concentration has been worse over the past five months. (Note: ADD most often is characterized by life-long symptoms that sometimes get worse when there is more demand or pressure on a person. It is not yet clear whether his symptoms are life-long.) 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 the type of depression called “atypical depression.” In the usual kind of depression, there is often difficulty sleeping and not so much sensitivity to rejection.)
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, that responds well to stimulant medications are good indicators that ADD may be present. It is important to bear in mind, however, that many people without ADD also function a little better after taking psychoactive medications.)
Family history: Both Mr. S’s parents were depressed. A brother has been depressed on and off all his life. None have a history of bipolar disorder.
Medical conditions: Mr. S 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
Patient’s self scoring of his symptoms
Key: 0 = none at all (no symptoms), the best, normal
10 = very severe discomfort or symptoms, the worst
Visit #
1
Depression
8
ADD symptoms
6
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. (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 in two weeks for follow up on effects of medication.
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Session Two
Date: Two weeks later
Medication taken during the past two weeks: Wellbutrin 150 mg SR daily for the past ten days
Content of contact: Mr. S’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. His response may be a placebo effect or it may reflect a rapid response of his atypical depression.)
He finds the medication acts quickly each time he takes it. (This rapid action is somewhat unusual for Wellbutrin.) Its effect peaks within five hours, then has a slow decline. He says that it feels like an antidepressant with a little kick to it. He reports that his wife sees him as coming back. He is not obsessing about what he needs to get done but doing it.
He has some dry mouth. He wakes up at around 3:30 AM and stays up for about an hour.
Patient’s self scoring of his symptoms
Key 0 = none at all (no symptoms), the best, normal
10 = very severe discomfort or symptoms, the worst
Visit #
1
2
Depression
8
6
ADD symptoms
6
2
Medications being taken: Wellbutrin 150 mg per day
Plans and instructions: Medications as above, periodic medication management sessions
Next appointment: Four weeks
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Telephone Call
Date: Two weeks later
Medication taken during the past two weeks: Wellbutrin 150 mg 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 a day.
Next appointment: Two weeks
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Session Three
Date: Two weeks later
Medication taken during the past two weeks: Wellbutrin 100 mg a day
Content of contact: W. 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. Wellbutrin usually has a smoother antidepressant effect – this five hour effect sounds more like one on his ADD rather than one on his depression.)
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.
Patient’s Self Scoring of Symptoms
Key 0 = none at all (no symptoms), the best, normal 10= very severe discomfort or symptoms, the worst
Visit #
1
2
3
Depression
8
6
6
ADD symptoms
6
2
1
Medications being taken: Wellbutrin 150 stopped. To start at Zoloft 50 mg per day
Plans and instructions: Medications as above, periodic medication management sessions
Next appointment: Two weeks
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Session Four
Date: 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 Vyvanse but is a bit self critical for not being able to manage his symptoms without medication. After further discussion, Vyvanse was prescribed starting at 30 mg per day with plans to increase it slowly until an optimal dose is found.
Patient’s Self Scoring of Symptoms
Key 0 = none at all (no symptoms), the best, normal
10 = very severe discomfort or symptoms, the worst
Session #
1
2
3
4
Depression
8
6
6
3
ADD symptoms
6
3
1
4
Medications being taken: Zoloft 50 mg per day Vyvanse 30 mg per day
Next appointment: Two weeks
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Session Five
Date: Two weeks later
Medication taken during the past two weeks: Zoloft 50 mg per day Vyvanse 30 mg per day
Content of contact: Doing very well on the Zoloft/Vyvanse combination. ADD symptoms have largely disappeared. Working effectively, pretty good focus.
Patient’s Self Scoring of Symptoms
Key 0 = none at all (no symptoms), the best, normal
10 = very severe discomfort or symptoms, the worst
Session #
1
2
3
4
5
Depression
8
6
6
3
2
ADD symptoms
6
3
1
4
1
Next appointment: Six weeks
Session Six
Date: Six weeks later
Medication taken during the past two weeks: Zoloft 50 mg per day Vyvanse 30 mg per day
Content of contact: Vyvanse has made a big difference in his life. Focus, ability to study remarkably different.
However, he reports that over the past few days, his far off “constipated” (preoccupied) 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 Vyvanse to 30 mg twice a day.
Patient’s Self Scoring of Symptoms
Key 0 = none at all (no symptoms), the best, normal 10 = very severe discomfort or symptoms, the worst
Session #
1
2
3
4
5
6
Depression
8
6
6
3
2
5
ADD symptoms
6
3
1
4
1
2
Next appointment: Two weeks
Session Seven
Date: Two months later
Medication taken during the past two weeks: Zoloft 100 mg per day, Vyvanse 30 mg x 2 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 Vyvanse works for about ten hours. He notes no side effects, no change in weight or appetite. I changed his dose of Vyvanse from 30 mg x 2 per day to 70 mg once per day. This cut his cost in half as pharmacies generally charge by the pill, not by the total dose.
Patient’s Self Scoring of Symptoms
Key 0 = none at all (no symptoms), the best, normal
10 = very severe discomfort or symptoms, the worst
Session #
1
2
3
4
5
6
7
Depression
8
6
6
3
2
5
2
ADD symptoms
6
3
1
4
1
2
2
Next appointment: Two weeks
Session Twelve
Date: Fourteen months later
Medication taken during the past two weeks: Zoloft 100 mg per day Vyvanse 70 mg per day
Content of contact: Generally doing very well.
About a month ago, he forgot to take the Vyvanse with him on a business trip abroad . Within a day he felt tired and had difficulty focusing. Upon his return, he restarted the Vyvanse, and his focus quickly returned. He noted how absent minded he was without the medication, felt scatter-brained. This removed any doubts in his mind whether he had ADD and whether the medication was working or not.
Patient’s Self Scoring of Symptoms
Key 0 = none at all (no symptoms), the best, normal
10 = very severe discomfort or symptoms, the worst
Session #
1
2
3
4
5
6
7
12
Depression
8
6
6
3
2
5
2
0
ADD symptoms
6
3
1
4
1
2
2
1
Next appointment: Three months
