Back to methylphenidate

I can’t remember the last time I was unable to fall asleep. I mean I’ve lost sleep on several days in the last month or two, but on all occasions it’s been after I’d gotten woken up in the middle of my sleep. Today is different – it’s nearly 1 am, and I’ve been in bed for two hours tossing and turning, and completely unable to fall asleep.

I think I left it until it was a bit too late today to restart my methylphenidate, after a three year gap. The dosage is half of what I was used to in 2012-13 and 2015-16. Just 5 milligrams to be taken twice a day. This convinced me that it would be okay to take it in the afternoon. Big mistake. I’ve been completely unable to switch off this evening.

The good thing is that this afternoon ever since I took the tablet I’ve had the kind of hyperfocus I hadn’t been able to achieve for I don’t know how long. I continue to get distracted, but it’s easier to get back to where I was. The big change is that I no longer feel the constant need for stimulation. The need to “feel accelerated”, as I call it, which would result in my opening dozens of tabs on my browser and checking websites one by one without any need to do so. Sometimes it would end in the rabbithole of playing online chess, and wasting hours at a time.

I’ve written about ADHD before on this blog, and elsewhere. I’ve written it as a condition where you’re unable to hold attention on what you are doing, and getting distracted easily. In the past I’d come off medication because I missed being distracted – in my methylphenidated state, I have missed the ability to think laterally which I’m so capable of in my “ground state”.

Thinking about it, though, it’s not distraction or the lack of it that’s the problem with ADHD. It’s the constant need for “stimulus”. It’s the constant need to “keep doing something” that makes me fidgety. It’s possibly the same feeling that made me run out of class when I was in kindergarten and do somersaults. The same feeling that would make me open my computer and open a dozen chat windows upon coming home from work a decade ago. Well the latter had its good parts – a lot of the time, one of those dozen chat windows would involve the person who I later married.

It’s funny how I got here today, in this methylphenidated state. As you might know, I’ve been living in London for nearly two years now. And the medical system here is government-run.

In October 2017, when I was in the middle of my last (and largely unsuccessful) full time job, I felt the need to get back on to ADHD medication. I got an appointment with, and met my general practitioner in November 2017. He asked me to share with him my diagnosis of ADHD from back home. In December 2017 I was back in India, and I got back my medical records, and shared a copy with him in January 2018.

In February 2018 I got a call to set up an appointment with the mental health practice. It was at a clinic some distance away from home, and I met the psychiatrist in March 2018. I was administered the usual ADHD questionnaire and told that I would be contacted by the “national ADHD centre” in a “couple of months”.

It was finally in January of 2019 that I heard back about this. It was my GP once again, saying my prescription for methylphenidate was ready, and I should start taking it asap. The next day I got a call asking me to meet the psychiatrist again, in the faraway mental health clinic. And today I started taking the medication. And I’ve been so unable to switch off that I’m unable to sleep!

PS: I’m publishing this a day late. I wrote this last night but couldn’t publish it since daughter started crying and I had to rush back to bed. Hopefully I’ll be able to sleep well tonight

Discrete and continuous diseases

Some three years or so back I got diagnosed with ADHD, and put on a course of Methylphenidate. The drug worked, made me feel significantly better and more productive, and I was happy that a problem that should have been diagnosed at least a decade earlier had finally been diagnosed.

Yet, there were people telling me that there was nothing particularly wrong with me, and how everyone goes through what are the common symptoms of ADHD. It is a fact that if you go through the ADHD questionnaire (not linking to it here), there is a high probability of error of commission. If you believer you have it, you can will yourself into answering such that the test indicates that you have it.

Combine this with the claim that there is heavy error of commission in terms of diagnosis and drugging (claims are that some 10% of American kids are on Methylphenidate) and it can spook you, and question if your diagnosis is correct. It doesn’t help matters that there is no objective diagnostic test to detect ADHD.

And then your read articles such as this one, which talks about ADHD in kids in Mumbai. And this spooks you out from the other direction. Looking at some of the cases mentioned here, you realise yours is nowhere as bad, and you start wondering if you suffer from the same condition as some of the people mentioned in the piece.

The thing with a condition such as ADHD is that it is a “continuous” disease, in that it occurs in different people to varying degrees. So if you ask a question like “does this person have ADHD” it is very hard to give a straightforward binary answer, because by some definitions, “everyone has ADHD” and by some others, where you compare people to the likes of the girl mentioned in the Mid-day piece (linked above), practically no one has ADHD.

Treatment also differs accordingly. Back when I was taking the medication, I used to take about 10mg of Methylphenidate per day. A friend, who is also on Methylphenidate and of a comparable dosage, informs me that there are people who are on the same drug at a dosage that is several orders of magnitude higher. In that sense, the medical profession has figured out the continuous nature of the problem and learnt to treat it accordingly (a “bug”, however, is that it is hard to determine optimal dosage first up, and it is done through a trial and error process).

The problem is that we are used to binary classification of conditions – you either have a cold or you don’t. You have a fever or you don’t (though arguably once you have a fever, you can have a fever to different degrees). You have typhoid or you don’t. And so forth.

So coming from this binary prior of classifying diseases, continuous diseases such as ADHD are hard to fathom for some people. And that leads to claims of both over and under medication, and it makes clinical research also pretty hard.

Do I have ADHD? Again it’s hard to give a binary answer to that. It depends on where you want to draw the line.

Depression and Stimulus

Ok so this post has nothing to do with macroeconomics, though it borrows its concepts from there. As the more perceptive of you might have figured out by now (ha, i love that line!) I was diagnosed with clinical depression about a year back. Actually that was the second time I had been diagnosed with that diagnosis, the first being a full six months earlier, when I had suddenly stopped medication after I had lost trust in that psychiatrist.

For over a year now, I have been on anti-depressants. It started with 37.5 mg per day of Venlafaxine (brand name Veniz), which got slowly bumped up until at 187.5 mg per day I started going crazy and having crazy mood swings and had to be scaled back to 150 mg. I was at that level for over six months when I realized that I had plateaued – that there was no real improvement in my mental situation thanks to continuous intake of the drug and perhaps I should consider getting off.

I proposed this idea to the psychiatrist when I met her last month and amazingly she agreed without any hesitation and quickly drew up a plan on how I need to get off the drug (you need to decrease dosage slowly else you’ll have withdrawal symptoms which are pretty bad). I found it a little disconcerting that she so readily agreed to take me off the drug, given that she had herself not given any indication of wanting to take me off the drug. I was disconcerted that I had been taking the drug for much longer than necessary, perhaps.

The doctor, however, paired the paring of my anti-depressant with doubling the dosage of the stimulant that I have been taking for my ADHD for the last six months. As it happened, though, I went through a major bout of NED that evening, and didn’t muster the enthu to go to the one pharmacy that legally sells Methylphenidate (the ADHD drug, ¬†supposed to have similar chemical composition as cocaine) in Bangalore. That I managed to function pretty well the following one week, including the three days spent at my client’s office, meant that I probably didn’t need teh ADHD drug also. So as I write this I’m off all mind-altering substances (apart from my several-times-a-day doses of caffeine and occasional ingestion of ethanol).

Recently I met a friend who told me that I had been too generous in my praise of psychiatric drugs in my blog, and that I hadn’t taken into consideration their various side effects and addictive symptoms. I’ve heard this from other people also – that I probably wasn’t doing the right thing by taking anti-depressants. So do I now regret taking them, given that I’ve chosen to go off them? Probably not.

This is where the analogy of economic depression and clinical depression comes in. In an economic depression, there is a halt in economic activity thanks to which there isn’t much circulation of money. When people start earning less, they start spending less, which further depresses their income and the whole economy goes into a tailspin. Going by Keynes’s theory, letting the economy slowly repair itself would take an extraordinarily long time (in the course of which we will all be dead, as the joke goes), so it is recommended that the government steps in and spends heavily in order to “stimulate” the economy and break the vicious circle it was getting itself into.

When you suffer from clinical depression, there is a shortage of flow of this chemical compound called Seretonin in your brain. Thanks to that, your mental energy is at a much lower level and you get tired and stressed out easily. Moreover, depression also leads to a significant drop in your confidence levels. You start believing that you are useless and not capable of anything. But then, your lowered mental energy levels mean that it is tough for you to be good at work, and do things that are likely to give your confidence a boost. And this in turn leads to further lowering of confidence and there is no way out for you to break out of this vicious circle.

A number of people believe that depression can be conquered with “willpower”, but this is applicable only if you’ve recognized it in its early stages. In most cases though, you realize it only when it’s deep into the vicious circle, and your “willpower”, much like “normal economics” during an economic depression, will take way too long to break you out of the vicious circle, and by then half your productive life will be gone.

Hence, to draw the Keynesian analogy, you need a stimulus. You need some sort of an artificial stimulus that breaks you out of your vicious cycle of low self-esteem and low performance. Sometimes, there can be a fortuitous life event which by matter of chance gives you a sudden sense of achievement and helps you break out of the cycle (for example, I was quite depressed (most likely clinically) through most of my life at IIT, but success in CAT proved to be a good stimulant in helping me break out of that cycle). But then, most of the time, life is structured such that there are few opportunities for such positive black swans, especially when you are older and especially when your mental energy levels are in general quite low.

Under these circumstances, I believe, there is no way out but chemical stimulants to help you get out of your depressive state. Clinical researchers and psychiatrists over the years have found the answer to be this molecule called “SSRI” which slows down the rate of seretonin uptake into the brain, with the result that there is greater flow of seretonin in your nervous system (continuing our economic analogy this is like the government cutting taxes as a form of stimulus). Greater seretonin in the system means greater mental energy, and sometimes the difference in energy levels is itself enough to push up your self-esteem levels, and the new energy levels means you have given yourself a chance to perform, and the cycle breaks.

Keynes said, as part of his theory, that it is important that a stimulus is short and targeted, and that in good times a government needs to be fiscally conservative so that, if not anything else, it has the necessary firepower to deliver a stimulus when necessary. Similarly, it is important that you don’t get yourself addicted on these anti-depressants and that you don’t become immune to them. Which is why psychiatrists typically wean you off your anti-depressants six months to a year after you started on it. By then, they expect, and in my case it did, that the stimulus would have been delivered.

Pot and cocaine

Methylphenidate, the drug I take to contain my ADHD, is supposed to be similar to cocaine. Overdosing on Methylphenidate, I’m told, produces the same effects on the mind that snorting cocaine would, because of which it is a tightly controlled drug. It is available only in two pharmacies in Bangalore, and they stamp your prescription with a “drugs issued” stamp before giving you the drugs.

Extrapolating, and referring to the model in my post on pot and ADHD, snorting cocaine increases the probability that two consecutive thoughts are connected, and that there is more coherence in your thought. However, going back to the same post, which was written in a pot-induced state of mind, pot actually pushes you in the other direction, and makes your thoughts less connected.

So essentially, pot and cocaine are extremely dissimilar drugs in the sense that they act in opposite directions! One increases the connectedness in your train of thought, while the other decreases it!

I’ve never imbibed cocaine, so this is not first-hand info, but I’ve noticed that alcohol when taken in heavy doses (which I never reach since I’m the designated driver most of the time) acts in the same direction of cocaine/methylphenidate – it increases the coherence in your thoughts. Now you know why junkies in your college would claim that the kind of “high” that pot gives is very different from the kind of high that alcohol gives.