Brief Answer:
Please see details below

Detailed Answer:
Hi XXXXXXX

I went through your query in detail and can understand your concern regarding your medications.

You have been diagnosed with major depressive disorder and attention deficit hyperactivity disorder (ADHD). i would have liked to know what symptoms did you have and since how long.

Depression is a disorder which manifests as low mood, decreased body energy, anxiety, sleep ad appetite disturbances. In addition, it also causes attention and concentration difficulties. ADHD can also manifest with attention and concentration difficulties. But to diagnose ADHD in children , it is important that a person has been suffering with ADHD even in childhood and the symptoms of inattention has persisted.

You have also been prescribed atomoxetine as well as modafinil. Modafinil is prescribed for excessive sleepiness in depression or to improve concentration and attention. Both being prescribed together means that either one of it (in your case Modafinil) is not working alone effectively. In any case, even the dose of modafinil could be increased (maximum recommended dose is 200 mg/day) before adding another drug for similar complaints.

I would also want to know how much depnoc (dotheipin) is ale to improve your depressive symptoms. In case you have shown response, but some symptoms are still persisting, increasing the dose of dotheipin could also help in improving the attention and concentration difficulties. Alternatively, if you are not finding any response in depressive symptoms with dotheipin, another anti-depressant like venlafaxine or sertraline could be tried.

In addition you are also taking 2 mg clonazepam per day. Clonazepam is a sedative which can also cause attention deficits. So, the dose of clonazepam can also be reviewed and modified as per requirement.

You can discuss the above options with your psychiatrist. In case of any further queries, please feel free to ask.

Wishing you speedy recovery. Best wishes.

Dr. Sunil Gupta

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Brief Answer:
Please see details below

Detailed Answer:
Dear XXXXXXX

Thanks for following up and filling in the details that I had asked for.

From the details that you have provides, you seem to be suffering from anxiety disorder which is leading to your being anxious, tensed, restless and worrisome. In addition you just also may have some degree of attention deficit disorder. Both anxiety and attention deficit disorder can co-exist.

Adderall is a mixed salt of amphetamine and definitely has a better effect on attention deficit compared to atomoxetine or modafinil. Another option is methyl-phenidate which is commonly used for attention deficit disorder.

Since you are away from home, I would suggest that you decide about change in medications only when you are back home under supervision of a psychiatrist.

Had I been your psychiatrist, I would had offered you treatment with medication as well as cognitive behavior therapy. The medications would include a change of dotheipin to either venlafaxine or sertraline. Escitalopram (Nexito) was seemingly not effective as mentioned by you earlier. Dotheipin could be gradually tapered (25 mg every week). Clonazepam would also be tapered but in a more gradual way, not more than 0.25 mg at a time as it may cause sudden increase in anxiety. If you are also having sleep disturbance , low dose of clonazepam can be continued at night time till your anxiety symptoms subside. Methyl-phenidate or amphetamine salts could be added for attention deficit and other two medications, modafinil and atomoxetine could be tapered and stopped.

In addition to medications, i would also advise sessions for cognitive behavior therapy. It would include once or twice weekly sessions focusing on learning relaxation, behavioral methods to improve concentration and ways to help change the way your thought pattern is (like worries, which is causing the anxiety symptoms). You might need anything from 12 to 20 sessions and will need you to be motivated and dedicated for it.

I do hope the above information was helpful. In case of any further query, please do ask. I will be glad to offer possible help.

Best wishes,

Dr. Sunil Gupta

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Brief Answer:
CBT will be very helpful.

Detailed Answer:
Dear XXXXXXX

Thanks for following up.

From what you have mentioned, it seems that you are sometimes impulsive which makes you take decisions without putting much thought into it. Impulsivity is one of the features of ADHD as well. So it can very well stem out of it.

Regarding atomoxetine, its response usually start showing response within 1-2 weeks and has significant response i around 4 weeks. You are already on 50 mg on atomoxetine. The recommended dose range of atomoxetine in adults is 40 to 100 mg. So, in your case the dose may be increased and response to it then assessed.

I firmly believe that cognitive behavior therapy will be very helpful in your case, both for anxiety as well as attention difficulties. But do remember that it is no magic wand and you will have to put in due effort as advised by your therapist. As mentioned earlier, it will require your motivation as well as dedication. Regarding finding a therapist in XXXXXXX you can contact a psychiatrist in XXXXXXX who can either offer cognitive therapy himself or will guide you to a psychologist or the same. There are multiple mental health clinics in XXXXXXX all of which offer psychotherapies. You psychiatrist there could guide you regarding the same. Another option is the Institute of Mental Health, which is a government institute and can offer you help. If you would had been in XXXXXXX I would have advised NIMHANS as the center for the same.

Hope the above information was helpful. In case of any further queries, please feel free to ask. In case you don't have any more queries, you can close the discussion and rate the answer.

Best wishes,

Dr. Sunil Gupta

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Brief Answer:
Please see details below.

Detailed Answer:
Dear XXXXXXX

Thanks for following up. It does happen that when you are anxious and preoccupied with certain thoughts, it becomes difficult to sleep.

Since you are already on Aplaz (clonazepam) taking it 1 mg twice a day, you can start taking 2 mg together at night which may help in inducing better sleep. The half life of clonazepam is long enough to take care of the anxiety throughout the day.

Alternatively, another medicine like zolpidem can be added to your prescription for a short period of time. It can be initially taken at a dose of 5 mg/day.

Another alternative can be to change clonazepam over to some other benzodiazpeine like nitrazepam (10 mg can be initiated) or flurazepam (at 15-30 mg at bed time) which can be more effective for inducing sleep. Remember, the above medications including zolpidem are prescription drugs and not over the counter medications.

In the end, I would like to stress that the best way is to treat the primary cause of the insomnia. That will automatically take care of the sleep.

Hope, I was able to answer your query. In case of any future queries you can ask me directly on the following link:
http://doctor.healthcaremagic.com/doctors/dr-sunil-gupta/67657

I will glad to help you at any time ahead. Please rate the answer if you decide to close the discussion.

Best wishes.

Dr. Sunil Gupta

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