Practices

The newer thinking about depression is less about topping up a missing chemical and more about connections that have thinned out being rebuilt. Recovery looks more like regrowth than refilling.

Long stretches of depression seem to leave parts of the brain less richly connected, and some treatments appear to work by helping those links form…

Before anyone concludes that nothing works, go back over the ordinary explanations: a dose that never went high enough, a trial that stopped after three weeks, doses missed on the hard days.

Treatment resistant has a technical meaning, which is that at least two proper trials at a proper dose and length have failed. A great deal of what…

When something has helped a little and then stalled, adding a different kind of help often does more than pushing harder on the first one.

That is the thinking behind adding a second medicine with a different action rather than only raising the dose of the first, and it is the same…

If sleep has gone since starting, look at what time the dose is being taken before deciding the medicine is the problem. A long acting dose swallowed at one in the afternoon is still working at bedtime.

Extended release preparations are built to cover eight to twelve hours from whenever they are taken, so a late start pushes the whole thing into the…

Count good days, not unbroken runs. Whatever yesterday was, brilliant or a write off, the only live question is what can be done with today.

Streaks make one slip cost everything, so the missed night turns into a missed week and then the whole effort gets quietly dropped. Aiming for more…

Debt, impulsive spending, an account that never quite recovers: this belongs in the conversation about attention rather than in a separate drawer marked shame.

People hide this part longer than anything else, which means it is usually the last thing to get any help. If you are the one struggling, saying it…

Where anxiety sits alongside the attention difficulty, a non-stimulant is sometimes the better first choice. Stimulants sharpen anxiety in some people, and that is a hard trade to live with.

The same holds when blood pressure rises on a stimulant that is otherwise working, since adding an alpha-2 agent can make it possible to keep the…

Doing badly on one long acting product does not mean the medicine inside it was wrong for you. The same molecule in a different capsule can behave differently enough to be worth trying before anyone gives up on it.

What gets described as the medicine not working is often the shape of the day being wrong: too slow to start, too abrupt at the end, strongest at the…

People usually stop for one of three reasons: the side effects are not worth it, the price is too high, or the dose was never raised far enough to do anything. The last one is the saddest, because it makes a workable medicine look useless.

If a trial ended with the words nothing happened, it is worth going back over what dose was actually reached and for how long it was held there. A…

Before anyone concludes that medication does not work for you, check what dose was actually reached. Doses in general practice often stay lower than a specialist would use, and a fair share of so called non responders respond once the dose goes up.

You are allowed to ask this, gently and without any accusation in it: what was the highest dose tried, and how long did it stay there? A trial that…

If one family of stimulant did nothing, or felt awful, that tells you very little about the other. Methylphenidate and amphetamine work in overlapping but different ways, and plenty of people who do badly on one do well on the other.

Stopping after a single class is one of the commonest routes to believing that nothing helps. Trying the second one is a normal next step rather than…

For someone who cannot swallow tablets, or whose mornings fall apart long before the tablet gets taken, patches exist that release medicine slowly through the skin over hours.

Going through the skin skips the first pass through the liver and smooths out the peak, which changes the timing and sometimes how well it is…

Much of the progress in these medicines over the past twenty years has been in how the drug is delivered rather than in new molecules. So if one version did not suit you, another form of the same drug can still be worth a try.

People often conclude that a whole class has failed them when what failed was one release pattern: too sharp, too short, too much at once. That is a…

Medication treats the attention difficulty. It does not teach reading, lift a depression, or repair a household that has been fighting for years.

Those things need treatment of their own, and they are often what the family actually came about. Treating the attention difficulty well can stop…

Smoking runs high in ADHD, and nicotine genuinely does something for attention. It helps to treat that as self-medication rather than as one more impulsive habit.

It changes what a conversation about stopping looks like. If a cigarette is doing a job, taking it away and leaving the job undone is a plan that…

When a medicine seems to be underperforming, look at what else is in the room before reaching for a higher dose. Anxiety, low mood and a wrecked sleep pattern can each blunt a good response or imitate a poor one.

Otherwise the dose climbs while the real driver goes untreated, and the side effects arrive without the benefit. Ask what a bad night actually looks…

If the first medicine disappoints, that is information about the first medicine. Plenty of people who get nothing from one class do well on another.

Methylphenidate and amphetamine are not the same drug at different strengths. They work by partly different routes, so a poor result on one says…

Most people who try do find something that helps, but often not the first thing they try. Not responding to one class of stimulant says surprisingly little about the other.

The high response figures you may have read come from people who worked through more than one option, not from one prescription going well. Response…

Unmanaged ADHD wrecks sleep, food and movement, and wrecked sleep, food and movement make the attention worse the next day. The loop feeds itself, which is also the hopeful part: a small repair anywhere in it pays back more than it should.

Short sleep hits the same front part of the brain that is already struggling, so a late night costs you more than it costs other people. Pick the one…

Missing a day is not the end of the programme. You missed a day. Tomorrow you carry on.

The dangerous part is not the missed session, it is the story that follows it, the one where you have blown it so you may as well stop altogether.…