Updated: Sep 27, 2019
Today I'd like to share with you an interview I did with Dr. David Rosenthal, a psychiatrist here in Boulder, CO, who's an expert on ADHD. As someone with ADHD myself, I have found extremely effective ways of working with ADHD without medications. However, I understand that medications can be very helpful for many people, and as an ADD / ADHD coach, I sometimes refer my clients to Dr. Rosenthal as well. I love Dr. Rosenthal's approach because he's not "too fast on the trigger" when prescribing medications, and shares my view, that medications alone can't ever be the only solution. He's also always up to date with the most recent research, which I believe is an important responsibility of anyone who's in the medical and the mental health field.
Enjoy this conversation, and please leave a comment if you have any questions.
Sasha Raskin (ADD/ADHD Coach): Okay, so Dr. David Rosenthal, I think this interview would be possibly a good resource for people with ADHD and possibly also for mental health professionals who are not psychiatrist, to kind of get more idea about the different medications that are out there.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Certainly.
Sasha Raskin (ADD/ADHD Coach): And possibly even about current research. What has been working in the past, what seems to be working more recently based on current research, and also how do you decide to medicate or not medicated, are there other alternatives?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Sure.
Sasha Raskin (ADD/ADHD Coach): And also maybe kind of answer some concerns people usually have about side effects of medication.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Okay, certainly I can do that, yes.
Sasha Raskin (ADD/ADHD Coach): So maybe we can start with why did you choose to focus on ADHD as a psychiatrist?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Okay, well, actually it comes from many years of working at Kaiser in California. I was there for about nine and a half years until I would say until I burned out with 6,000 patients calling me their psychiatrist, which is an unbelievable number of people. And oftentimes I think people end up choosing their specialty not necessarily because they chose it themselves, but because somebody else chose you as the expert.
Sasha Raskin (ADD/ADHD Coach): So you're only chosen.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): So, what happened, well, the way I got chosen, let me put it that way, is I'm a child psychiatrist, I was at Kaiser all of those years. And part of being a child psychiatrist is to get huge number of referrals for ADHD assessments in kids. And so what happened is I just happened to be seen so many of those and having some good outcomes that I got to be well-known among my let's say adult psychiatry colleagues and as the guy who sees the ADHD kids. So it started out very much in the child psychiatry area.
And that eventually led to a colleague asking me to co-author a book with them, which eventually led to co-authoring three books on ADHD and lots of articles and lecturing on ADHD. So that's how I fell into becoming an expert on ADHD. And just the sheer patient volume I got tremendous experience with finding out what works and what doesn't work.
And now since that time, that was many years ago, since that time I've come to Boulder, Colorado and now I'm in a private practice. And still the majority of people I see are for ADHD assessments, but obviously I have branched out now and have seen a huge number of adults with ADHD in mountains, just children with ADHD. So that's how I fell into it. That was the first part of your question.
Sasha Raskin (ADD/ADHD Coach): Yeah. Do you have any personal connection to the meadow if you want to show?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Sure, I think that, and this is also common with people under a particular field, it's probably because I have ADHD myself even though ... and I always comment that my wife would like to see me medicated for ADHD. But I've always managed I think quite well without medication, which does bring us to an important other question you've asked, which is how do you decide who needs medication and who doesn't need medication?
Sasha Raskin (ADD/ADHD Coach): Yes.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Given that, and some of this again is my own personal opinion, if you ask different psychiatrists you'll get different opinions about what percentage of people really need to be medicated for ADHD. So here's my personal algorithm for deciding about medication - There is great concern in the country these days about whether ADHD is being over diagnosed and overmedicated, over treated. And I do think that I'm of the belief that a lot of ADHD is on a spectrum of anything from the person has severe pathology and dysfunction to those who certainly meet the criteria for ADHD, but are really very highly functional.
So the criteria I personally use and my own internal criteria, so here they are - So when I'm doing an assessment I try to get some sense as to what do I believe this person's innate ability actually is, whether that's their actual IQ, for instance, a lot of people have actually been tested that I see and I'm told their IQ is 130 or whatever those numbers may be. And sometimes they've had extensive testing.
Sasha Raskin (ADD/ADHD Coach): So that was an example of the screen kind of turned off and you are able to come back to that.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Come back to the original. I get distracted quite easily, but since I know the topic fairly well hopefully I'm able to quickly get back on track. So that's a good illustration of the ADD distractibility as immediately noticing the phone.
Sasha Raskin (ADD/ADHD Coach): And the ability to refocus.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And to refocus, which is again to the point about I'm not sure that I need medication, even though I have a whole range of ADHD symptoms. All right, so my own internal criteria, number one is so when I look at what I perceive as the person's innate ability level. And then I look at, all right, now compared to their ability level what is their current performance level, and is there a major discrepancy between their current performance and their innate ability level? And if that discrepancy between the two seems to be very small, then I'm not sure that they need to be treated with ADHD medication.
The other thing I'm certainly going to look at there is whether how much other ... well, I'll just go to the second criteria as it relates to what I was about to say. So the second criteria I use is that you there's a big discrepancy between their innate ability and their performance, what kinds of secondary complications is this person developing as a result of that discrepancy?
And I'll tell you what those are, so for an example, I mean, if you look at starting with childhood and it does differ ... the course differs whether you're talking about the average male or the average female. And these are just statistical differences. You can certainly see females who have a more of a male pattern and males who have more of a female pattern. But we know that statistically ...
Sasha Raskin (ADD/ADHD Coach): But just to clarify you're talking about biological sex assigned at birth, not necessarily about gender.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And that's true. I'm not talking about gender. So we know that statistically biologically speaking more males tend to have hyperactive-impulsive ADHD and more females tend to have an inattentive subtype of ADHD with less hyperactivity and sometimes less impulsivity. We see plenty of females who have impulsivity problems. So obviously that's just a statistical thing.
So what I'm about to say when I talk about hyperactive-impulsive ADHD, if a girl is super hyperactive and impulsive then this is going to apply to them as well when I talk about the course for hyperactive-impulsive ADHD. It is just that statistically it tends to be more males biologically and statistically more females tend to get diagnosed with inattentive ADD.
But anyway the natural course of hyperactive-impulsive ADHD is that these typically are kids who are in trouble at early ages. And again, females happen to be hyperactive-impulsive, they're often in trouble at early ages as well. Now what I mean by being in trouble is meaning because they're hyperactive, because they're impulsive they're often being reprimanded, whether it's by their parents before they even reach school or now when they're in school they're not sitting still, they're not listening to directions, they're blurting out answers to questions before waiting their turn. So that's what I mean by being in trouble.
So I think innately I have belief that kids fundamentally want to please the adults in their lives, whether it's their teachers or their parents. And obviously there are many complications when there's dysfunction within the family. But most kids start off wanting to be well-behaved and to please, but what happens so often that I see time and time again in hyperactive-impulsive kids with ADHD is that at some point they get frustrated, they're always in trouble, it doesn't seem to matter how hard they try they can't seem to meet the expectations of the adults around them.
And then the next thing that we start to see, and I don't know if you wanted me to go into the whole comorbidity about ADHD which is where I'm headed.
Sasha Raskin (ADD/ADHD Coach): Yeah. I think before you go there, you're talking about also how the system affects ADHD as well, right? Kind of this circle of, "Well, if I can't sit still or if I interrupt people while they speak, my parents have the tendency to try and do their best to control that which makes me more frustrated," and then the comorbidity.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): More frustrated. And now the comorbidities or co-existing problems start to develop. Dramatically we use the word comorbidity but it's not a very pleasant term, so co-existing problems might be a better term than the term comorbidity.
So the first co-existing problem that we start to see with ADHD when the frustration level gets high enough is oppositional defiant disorder or oppositional defiant traits. So that's when the child starts to get defiant, you tell them to do A and they do B, they go out of their way to do B. They're angry, argumentative, defiant, frustrated, irritable.
We call that a diagnosis oppositional defiant disorder, but I have a lot of problems with that as a diagnosis because ...
Sasha Raskin (ADD/ADHD Coach): What is the main problem as you see?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Well, because I think it's just a set of symptoms that reflect the level of frustration that the child is feeling. I don't like labeling it as a disorder. And in fact, what we typically see is that if you find a solution and you reduce the frustration that the child is experiencing, it tends to go away.
Sasha Raskin (ADD/ADHD Coach): And the solution can be behavioral, emotional.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Absolutely, behavioral, emotional.
Sasha Raskin (ADD/ADHD Coach): And parents coaching as well.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Parent coaching, absolutely. I mean, a big thing is that these kids lose their self-esteem if you don't do anything. And so intervening early and even aggressively is really important. Sometimes we say from a parenting standpoint these kids are so challenging that when I'm trying to teach parents about parenting skills I often use the expression that it's not good enough to just have good parenting skills, you have to be able to write the book on parenting, because these kids find loopholes. Everything you try to do works for a little while and then they find a way around your wonderful solution for a particular behavior problem.
So parents have to really know good parenting skills, behavioral management skills, to be able to stay on topic. Totally, because they're extremely challenging, as opposed let's say to the inattentive ADD kids who are often very compliant and not causing behavioral problems. That is a different person.
Sasha Raskin (ADD/ADHD Coach): And then it can be undiagnosed, right? Because I have read some books that actually talk about the fact ... well, the researchers think that it's actually might be undiagnosed, and specifically with inattentive ADHD that seems to be no behavioral problems and they experience it internal.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Internal, right. And so I'm starting to say they have very different courses, so the hyper ... I agree, the hyperactive-impulsive kids come to somebody's attention very early, and the inattentive kids, statistically more females, often don't show up until high school or junior high or high school or even college. Because they've been quietly falling behind and not working up to their potential.
Sasha Raskin (ADD/ADHD Coach): And there are more requirements as they're progressing greater.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Right. So maybe I'll just briefly summarize the comorbidity problem or co-existing disorders, and then we'll move on to the stimulants in the interest of time. So briefly the hyperactive kids, impulsive kids, start off with oppositional defiant behaviors. If it continues and gets worse and there's still no intervention, they often end up with conduct disorders, meaning more serious behavioral problems, stealing, lying, dishonest behaviors, and delinquent behaviors when they hit the teenage years, they're very high risk for substance abuse and on and on. And it can get progressively worse. The females, and sometimes depression and anxiety but less commonly more the conduct, we call them as externalizing behaviors instead of internalizing, which I'm going to turn to the inattentive type.
So the inattentive type as we just said is more commonly diagnosed at a much later age. It gets missed very often. But when we start to really manifest itself as you were saying, when the academic challenges get greater and greater, particularly in highly intelligent kids - They manage to perform at a very high level because if you actually look at their ability to focus they have terrible inability to focus on things they're bored with, but ...
Sasha Raskin (ADD/ADHD Coach): As segue way that was my experience in high school, I became very good in memorizing to compensate the fact that I could not focus. I did not remember what the teacher was talking about and I have ADHD as well.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): So that's a great example. So they managed to skate by on their intelligence for years, until the academic load gets so extreme that they can no longer get by just on being smart.
Sasha Raskin (ADD/ADHD Coach): Yes.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Because at some point you actually have to study, most people have to start at some place.
Sasha Raskin (ADD/ADHD Coach): And independently the parents are not required as ... well, at least as society views it to help their kids with homework and so on.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Right. Well, in our society particularly because we're very ... we stress the need, well, we do have a need for kids to learn to be independent and so we call it separation individuation. So, because they're struggling with that as teenagers as a normal developmental phase in our society, then they get very upset and angry when parents hover and try to help them with their homework and want to help them succeed, they get more defiant because they want to do it on their own.
Now there are societies in the world where there is no separation individuation phase, you grow up, you live with your parents until you die or until they die. And there's no need for separating. Well, then it's not ... we don't have that same developmental phase, it doesn't create the same degree of problem. If we have time I can certainly talk about those societies. I did a research study in Bali, Indonesia.
Sasha Raskin (ADD/ADHD Coach): Yeah, that's the concho annamund is very important.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Yeah.
Sasha Raskin (ADD/ADHD Coach): Maybe we can another ...
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Yeah, we can do another one, we can do another. So here we have a strong need for separation individuation which creates a lot of conflict with parents. Well, anyway, so quickly the female, it is not always female, but the inattentive course then is it's often discovered much later and it's often by the time it's discovered they're often ... it's often at that point there's often tremendous anxiety or depression, comorbidly or co-existing with the ADD by that time, because the frustration level rises and rises and manifests itself in those forms, in depression and anxiety much more commonly.
Okay, so going back to my original criteria for using medications. So one is, is there a big discrepancy between innate ability and low performance? And secondarily is that discrepancy causing these secondary problems? And if those secondary problems are great and there's a big discrepancy, then absolutely we should intervene with medication.
Sasha Raskin (ADD/ADHD Coach): And do you see the same criteria for children and adults? It just manifests.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Yeah, I use the same. Yes, I use the same criteria for children and adults in terms of when to intervene with medication. And then you ask the question about, well, when do you use stimulants versus non-stimulants? If you want me to go ahead and answer that.
Sasha Raskin (ADD/ADHD Coach): Yeah, and maybe a sentence about what stimulants are and what are non-stimulants.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Okay, so stimulants, I mean, looking chemically in the brain, stimulants are anything that increase norepinephrine and dopamine, two very important neurotransmitters of brain chemicals. And we know that low levels of norepinephrine and dopamine are associated with problems with inattention and focusing. And so stimulants work by essentially they don't give you more norepinephrine and dopamine, but if you have low levels of norepinephrine and dopamine in the brain these drugs work by making better use of what little you have so that it's like giving you more, so that you improve ... to be technical for a second, you improve the neuronal transmission or neurotransmission in those parts of the brain that are not firing well, or some people say it's like, I don't know, putting gas in your car or there all kinds of different ...
Sasha Raskin (ADD/ADHD Coach): That's a good analogy.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Different analogies to make your car, or in this case your brain, run more normally. So ideally when a stimulant works they can help tremendously with attention and focusing and staying on task. And ideally with a minimal number of side effects so that you just feel normal.
One of the big fears that parents or adults who tries stimulants for the first time, one of the things they often fear is, is this going to change my personality in some adverse way? I don't know if I want it if it's going to change my personality. So what my answer to that is if it's changing your personality - you're probably on too much medication. In fact, we commonly hear about kids who look like they're zombies. Well, you're overmedicated if your kid is a zombie.
The goal is strictly to help with focusing and attention and staying on task, without changing the person's fundamental personality. If it's changing personality, that's an adverse side effect.
So stimulants can be phenomenally helpful with attention and focusing. What I unfortunately often find is that stimulants where they are disappointing, well, the first thing is that they tend to last for a specific number of hours, and this by the way caffeine is a stimulant that most of us are familiar with, we have a few different classes of stimulants - caffeine happens to be one of the classes of stimulants. But since we know caffeine we can relate to this, that it can help you focus and stay on task, but that it wears off after a certain number of hours.
And one of the problems with stimulants is that if they're in your system too late into the evening many people will not be able to go to sleep if a stimulant is in their system. Now we do have a minority of people with ADHD who actually sleep beautifully on stimulants, but the majority of people find they are stimulating and they will keep them awake at night.
Sasha Raskin (ADD/ADHD Coach): Many of my coaching clients with ADHD they tend to forget to take them early morning, and then they take them at evening, and then they ...
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And then they can't sleep, yeah, right.
Sasha Raskin (ADD/ADHD Coach): And then they need to wake up early.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And then they have to wake up early. Of course, we have another problem, a separate problem, with people who tend to be sits in the hyperactive-impulsive group, that people are hyperactive also by the way they tend to have a very hyperactive brain, not just their bodies, especially when they hit adulthood. Sometimes the physical external symptoms are bouncing off the walls are long gone by the time they reach adulthood. But really what's happened people say, "Oh, hyperactivity goes away when you reach adulthood." Well, physically it may go away, but it doesn't go away internally.
Sasha Raskin (ADD/ADHD Coach): That's interesting.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Because those same people who were hyperactive children now find that as adults their mind is working, working, working. And if you ask those people, "All right, on a scale of one to ten, how much does your brain feel like it's a TV remote control that's switching channels constantly?" Those same people who are hyperactive children are now saying, "Oh, my God, my brain is all over the place."
Sasha Raskin (ADD/ADHD Coach): So the popular question now, you're driven, do you feel like you're driven by a motor, it's not just are you pacing in your room all the time of fidgeting, is are you constantly thinking about subjects and feels like you're thinking so fast you can't relax.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Right. So going back to sleep, most of these people, if not all of these people as adults, some of them have learned good coping mechanisms, but as adults virtually all of them have difficulty quieting their brain to go to sleep at night. When they're younger they have trouble quieting their body maybe and their brain to go to sleep at night, but as adults oftentimes, again, they're not just physically hyperactive, they have hyperactive brains.
Sasha Raskin (ADD/ADHD Coach): So I'm sure when people hear stimulants the assumption is, well, my mind is already overly active, it would just ...
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Make me worse.
Sasha Raskin (ADD/ADHD Coach): Yeah.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And if you overdose them, they either become zombie-like, well, I can define that in a minute. Or they're more hyperactive, and you're correct.
Sasha Raskin (ADD/ADHD Coach): Yes.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): But at smaller doses what we want to see is that actually you see potentially a calming effect. But again, the reason they work so well they work for attention and focusing, so instead of having either ten thoughts going at once or ... because some people say, "My brain is like a TV with all the channels going at once."
Sasha Raskin (ADD/ADHD Coach): That's a good analogy.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): But more commonly they say, "My brain is like a TV remote control that's switching channels constantly."
Sasha Raskin (ADD/ADHD Coach): Yeah, I was doing that a lot as a child. I could sit for two hours and switch channels all the time.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And switch channels all the time. All right, so you were very much like that. So if you sleep well now then I would argue that the only reason you sleep well now if you're not taking herbs or medications, and oftentimes we can fix this with simple herbal approaches without using a heavy duty medication at bedtime, this is very responsive to herbal interventions. Ideally though the things that work the best with no medication or no herbs would be meditation or some mindfulness, some kind of practice, a progressive relaxation process. Or there are a number of techniques you can learn to quiet your brain.
Now many people without doing anything have learned something, they've discovered on their own, that helps them quiet their brain to go to sleep. But it's definitely a problem.
Sasha Raskin (ADD/ADHD Coach): Yeah, and it's so good to hear from a psychiatrist just saying that it's not just medication that can help - Meditation can help.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And meditation could be enormously helpful for ADHD in general, a whole variety of ADHD symptoms. The problem we run into with the ADHD population is it's more difficult than in the average person getting them to learn to meditate.
Sasha Raskin (ADD/ADHD Coach): Yeah.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): It's absolutely effective if you can get them to do that.
Sasha Raskin (ADD/ADHD Coach): Yeah. And what I tend to use is neuro feedback device that luckily today are very affordable, like the (Muse?) headband, a little shout out to this company. And you can find that ...
Dr. David Rosenthal (ADD/ADHD Psychiatrist): You've told me about this. It sounds like it's really effective.
Sasha Raskin (ADD/ADHD Coach): Yeah. You can find links to that on my website. And what they do, they just basically train you in the real time. So once you get some basic meditation instructions, a simple one would be just counting your breaths, kind of focusing on what happens to your stomach when you breathe in and breathe out, and just count in breath one, out breath one, do the same thing till seven, seven, seven, and then start again.
And that way you're focusing on something that constantly repeats itself. So what the (Muse?) headband does, it's an EEG device, it measures your brainwaves, those brain waves tell the app how activated your brain is. And in your headphones you will be able to hear when your mind is activated you will hear thunderstorms or heavy winds. And the more you can quiet down, basically bring your focus back to the anchor which in this example is your breathing, the mode, the weather sounds calm down. So this is incredible in terms of ... You actually get real-time feedback instead of thinking, "Well, I'm a bad meditator. I don't know if I'm doing it right," and all of that.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Right.
Sasha Raskin (ADD/ADHD Coach): And it also gamifies this whole thing. I don't know if that's your experience, but people with ADHD love video games.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Absolutely. And that's why, and you're much more of an expert in this field than I am, but all of the different apps that have come out, many of them are based on that idea that people with ADHD tend to love video games.
Sasha Raskin (ADD/ADHD Coach): Gamify the whole process, numbers, points.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And I can't even ... I thought I can't even keep up with the number of apps out there available. But yes, you don't ... This isn't a problem that typically needs heavy duty medication. In fact, actually when I find that statistically speaking people with ADHD are at higher risk than in the general population for a variety of sleep disorders like sleep apnea or restless leg syndrome, as that would actually be much more common in the ADHD population. So sometimes we need to do a good assessment to figure out what's going on.
But typically, so as I was starting to say, almost everybody with hyperactive ADHD has this problem with quieting their brain. But the typical pattern is that once they get to sleep they sleep very well. So any pattern that's different from that, like I wake up constantly in the middle of the night - it needs a further assessment because it's not the typical pattern, the typical ADHD pattern. So you have to look a little deeper if they have a different pattern.
Sasha Raskin (ADD/ADHD Coach): Yeah, and what about non-stimulants? If stimulants work so well, why would you need a different type of medication?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Okay, so here's where they don't do well, and occasionally they do, but for the most part while stimulants I said are amazing for attention and focusing and staying on task - they often are disappointing when it comes to their ability to treat hyperactive symptoms and impulsive symptoms. Sometimes they work well. All the studies on stimulants show that they can help with impulse control and hyperactivity, but I often find them very disappointing if that really needs to be the focus of treatment.
So it is common in hyperactive-impulsive kids to either use ... So if attention and focusing are not the main problem, and hyperactivity and impulsivity are the major problem, then a non-stimulant may make a lot more sense. If you have both symptoms, both sets of symptoms, again, hyperactivity impulsivity and inattention, that you may end up being on a stimulant plus a non-medication.
Now the most benign of those medications that I've become very fond of is it is a product called Vayarin, there's a new one called Vayarin plus. And Vayarin is really I'll just describe it briefly in the interest of time, and we can do other podcasts like this to go into much more detail, this is a little more of an overview today. So just quickly mentioning the main ones, so Vayarin is really an omega-3 fatty acid product which primarily which for example omega-3 fatty acids most people think of fish oil or krill oil are very high in omega-3s. Omega-3s are incredibly important to the brain, we know from a variety of studies that people with ADHD tend to be much lower in omega-3 levels than in people who don't have ADHD, so it's especially critical for the brains of people with ADHD to find a way to get omega-3s into their brains.
The problem with fish oil is that it's a huge molecule, so even when you take very large doses of fish oil which you should still do, but it's very hard to get it to cross into the brain, it's something caused the blood-brain barrier. And these are very big molecules that have a hard time getting in. So this product is really designed specifically for those with ADHD.
The molecule, it comes from krill oil, which is a little more ... which crosses that blood-brain barrier more readily. But this is in the form ... it's designed to be in the form that our brains evolved ... the molecule that our brains evolved with, this is that molecule precisely. So in fact, while I usually start by writing a prescription for it, the FDA has ruled that a prescription is no longer required as long as you are getting it from ... as long as you've seen a healthcare professional. The reason they still want a prescription to be written the first time is so that the education piece will be there, so that the patients understand how it works, why it works, and how much to take and so forth.
But anyway, unfortunately all omega-3 products while I think this is the best one on the market, they typically can take six, eight or twelve ... all the way up to twelve weeks to be effective, because it takes a long time to saturate the brain with these, whereas stimulants work the first day you're on the right dosage, you get what you get that day. That's really the beauty of the stimulants.
Briefly the other non-stimulants that we use a lot of, they're either forms ... actually two of them are forms of blood pressure medicines, fortunately they're not very good blood pressure medicines which makes them perfect for psychiatric use because we're not trying to lower people's blood pressure. Unfortunately some people have very low blood pressure, so it could be a side effect of the medicine, so we don't want to lower their blood pressure too much, in which case they might get lightheaded when they stand up.
But two very popular drug, so Clonidine is one of them, and there's a time release form of Clonidine called Kapvay. The short acting Clonidine, it is a little too short acting and it's frustrating giving anybody, not just with with ADHD or without ADHD, having to take something three times a day is not likely to work. It's very hard to remember anything three times a day.
And then the other one is the molecule called Guanfacine, the most popular form of that, and I do use a lot of this one is called Intuniv. And now there is generic Intuniv. The older form that's not as smooth of a time release is called Tenex, but Intuniv, I use a lot of Intuniv. And it's really good for just as the Vayarin or Vayarin plus for adults, is really good for impulse control and fidgeting, but takes a long time to work. Intuniv can work much faster and treats the same kinds of symptoms.
But the downside is that it does affect blood pressure and it can be very sedating, whereas the Vayarin is sedation. So if you have the luxury of waiting, Vayarin is certainly a much better choice. And it actually works two-thirds of the time. And I would say Intuniv does not work as frequently as that.
Sasha Raskin (ADD/ADHD Coach): And a month and a half it's not so ... such a long time for people who live with ADHD.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Well, usually if you're dealing with [unclear/cross talking 33:26]. So it is the most natural way to do this. And then the third medication I'll mention is Strattera. Strattera can also treat the same symptoms. By the way the Vayarin plus, there's just an adult study that came out showing that even though it's a non-stimulant, it can help some with attention and focusing, not nearly to the degree that a stimulant helps. So again, all the non-stimulants are not nearly as effective as stimulants for attention and focusing, but they do a better job than stimulants targeting these other hyperactive and impulsive symptoms, and emotional, I want to mention emotional dysregulation.
And I'm starting to say the third one is Strattera. Emotional dysregulation is something that very often goes with ... in addition to hyperactivity and impulsivity, it very much goes with those kids or adults who have ADHD. And I will define it as the quickness to anger, the irritability, the moodiness, the low frustration tolerance that tends to come with many of these people with ADHD. Those are the symptoms it actually treats the best.
Now Vayarin plus in the new study also found that it improved executive dysfunction, and those are things like time management, organization, impulse, also impulse control, transitioning like when you need to turn off the computer because you've got five other things that need to be done and they're not getting done, or initiating homework, initiating activity. So those are more executive.
Anyway, the executive functioning traditionally we've had a hard time finding any medication that targets that, the Vayarin plus does to some degree. The other one that does, and hasn't been studied for this, but we think that it helps a bit with executive function is this other one called Strattera.
Now Strattera is a little frustrating, because statistically it only works about a third as often as a stimulant does. Usually a stimulant you can get most people to respond to a stimulant.
Sasha Raskin (ADD/ADHD Coach): And stimulants are ... the common ones are?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): So the common stimulants on the market - Adderall is the most common. But just to throw out a few names, so all the Ritalin-based products which is chemically is known as Methylphenidate products, Amphetamines or Adderall, Dexedrine, Vyvanse, a newer one called Dyanavel XR which is a liquid time release. And then in the Ritalin class Methylphenidate being the simplest generic, there's time release Methylphenidate, Concerta, [unclear 36:05], or other time release Ritalin-based products. Ritalin actually is the brand name for Methylphenidate. So again, Ritalin is Methylphenidate and Amphetamine, not Methamphetamine. Amphetamines are Dexedrine, Adderall, Vyvanse, Dyanavel.
Sasha Raskin (ADD/ADHD Coach): Great.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And then the Strattera, and also one more comment about Strattera, it's a difficult medicine to use because it's very tricky to figure out the right dosage. Now maybe next time we can talk much more about the common fears and concerns that parents have or people have about stimulants, their abuse, the appropriate use, how long you take them, what kinds of side effects do you need to watch out for, are they safe with long-term usage, all those things are things we probably address in the next session.
Sasha Raskin (ADD/ADHD Coach): Perfect. And you're about to go to a bike ride.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Even though it's hot I'm about to ...
Sasha Raskin (ADD/ADHD Coach): Yeah, and people with ADHD and bikes tend to go along very well.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And I would say that one of the reasons maybe I don't need medication is because exercise is a phenomenally helpful coping strategy for me personally, for mood, for focusing. So it's my main coping device.
Sasha Raskin (ADD/ADHD Coach): Perfect. Thank you so much.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Thank you. Thanks for listening.
Sasha Raskin, MA, is an international #1 bestselling co-author , the founder and CEO of Go New , a transformational education program, a life, and business coach and a psychotherapist in Boulder, CO. He is working on a P.h.D in Counseling Education and Supervision and is an adjunct faculty at the Contemplative Counseling master’s program at Naropa University, from which he also graduated. Sasha has been in the mental health field for more than 10 years, worked with youth at risk, recovery, mental health hospitals, and coached individuals, couples, families, startups, and groups. He has created mindfulness stress reduction and music therapy programs within different organizations. Whether it’s in person or via phone/video calls, Sasha uses cutting-edge, research-based techniques to help his clients around the world to thrive.
As a coach Sasha Raskin provides individual and group coaching in Boulder, Colorado, and worldwide via video and phone calls, drawing from over ten years of experience. His services include: life coaching, business coaching, career coaching, ADD / ADHD coaching, leadership coaching, and executive coaching. Schedule your free 20-minute coaching phone consultation with Sasha Raskin
As a counselor in Boulder, CO, Sasha provides individual counseling in Boulder, CO , family therapy in Boulder, CO, and couples therapy in Boulder, CO, marriage counseling in Boulder, Colorado, and couples intensives / couples retreats, drawing from over ten years of clinical experience. Schedule your free 20-minute psychotherapy phone consultation with Sasha Raskin