05

Change Your Brain, Change Your Life
The Breakthrough Program for Conquering Anxiety, Depression,

Obsessiveness, Anger, and Impulsiveness
Daniel G Amen
Three Rivers Press
New York
Appendix
Medication Notes
1. Stimulants
In my opinion these are the first-line medications for treating ADD, especially ADHD
and ADD without hyperactivity, when ADD is the primary problem. They are also used to
treat narcolepsy, help in some postconcussive syndromes, and are used in resistant depression.
Our current understanding of these medications is that they increase dopamine output from
the basal ganglia and increase activity in the prefrontal cortex and temporal lobes.
- Contrary to popular belief, these are considered very safe medications when taken
as prescribed under a doctor's supervision.
- The PDR lists 60 milligrams as the top dosage for Ritalin and 40 milligrams as the
top dosage for Adderall, Dexedrine, and Desoxyn. Many clinicians, like myself, feel the range
of effectiveness may be much higher for some individuals.
- With Cylert it is very important to monitor liver function tests, as 2 to 3 percent of
people taking this medication may develop chemical hepatitis.
- Do not take stimulants with citrus juices (orange, grapefruit, lemon). They lessen the
effect.
- Decrease caffeine intake when taking a stimulant. Caffeine and these stimulants
together tend to overstimulate the nervous system.
- The common side effects of stimulants tend to be decreased appetite, sleep problems
(if taken too late in the day), and transient headaches or stomachaches.
Generic name
Brand Name
Milligrams a
day /
available
strengths
Times
a day
Notes
amphetamine salt
combination
Adderall
(sustainedrelease)
5-80 /
5, 10, 20, 30
1-2
my first stimulant of
choice for teens and
adults
methylphenidate
Ritalin
5-120 /
5, 10, 20
2-4
watch rebound when

wears off
methylphenidate
sustained-release
Ritalin-SR
10-120 /
20
1-2
may be erratic in
effect
dextroamphetamine
Dexedrine,
Dextrostat
5-90 /
5, (10
Dextrostat
only)
2-4
watch rebound when

wears off
dextroamphetamine
slow-release caps
Dexedrine
Spansules
(sustainedrelease)
5-80 /
5, 10, 15
1-2
methamphetamine
slow-release tabs
Desoxyn
Gradumets
(sustained
release)
5-80 /
5, 10, 15
1-2
pemoline
Cylert
18.75-112.5,
up to 150 for
adults /
18.75, 37.5,
75
1-2
routine liver screening

essential.
2. Tricyclic Antidepressants (TCAs) and Bupropion (Wellbutrin)

These medications are effective antidepressants. They tend to decrease overactive
limbic activity. These medications increase various neurotransmitters, including
norepinephrine (imipramine, desipramine, doxepin), dopamine (bupropion), serotonin
(clomipramine), or a combination of these (amitriptyline, nortriptyline). They tend to be more
stimulating than the others listed. Many of these are now considered second-line medications
for depression because they tend to have more side effects than the SSRIs (next section). Yet
some of them also have significant advantages. When depression is mixed with anxiety,
imipramine and desipramine may be a better choice. When depression is mixed with ADD,
desipramine, imipramine, bupropion, and venlafaxine (see next section) seem to be the most
effective. Bed-wetting and depression or anxiety may best respond to imipramine. A skilled
psychopharmacologist can help you sort through these medications.
Generic name
Brand
Name
Milligrams a
day /
available
strengths
Times
a day
Notes
desipramine
(TCA)
Norpramin
10-300 /
10, 25, 50,
75, 100, 150
1-2
stimulating; often helps

ADD in adults, not
currently used in children
imipramine
(TCA)
Tofranil
10-300 /
10, 25, 50,
75, 100, 150
1-2
also used for anxiety, panic

disorder, bed-wetting
bupropion
Wellbutrin
50-450 /
75, 100 250,
500
1-3
never > 150 mg a dose; do

not use if prone to seizures
bupropion
sustainedrelease
Wellbutrin
SR
150-450 /
50, 100, 150
1-3
never > 150 mg a dose; do

not use if prone to seizures
amitriptyline
(TCA)
Elavil
10-300 /
10, 25, 50,
75, 100, 150
1-2
often used to help with

sleep problems, headaches,
fibromyalgia, and pain
syndromes
nortriptyline
(TCA)
Pamelor
10-150 / 10,
25, 50, 75
1-2

sleep problems, headaches,
fibromyalgia, and pain
syndromes
doxepin (TCA)
Sinequan
10-300 / 10,
25, 50, 75,
100, 150
1-2

sleep problems
also used for OCD.

10-200 for a 1-2
child, 10-300
for an adult /
25, 50, 75
- These medications need to be monitored more closely than stimulants, especially
their effect on hear function.
clomipramine
(TCA)
Anafranil
- Many adults respond to very low doses of these medications for ADD symptoms.
This is important because the low doses often produce far fewer side effects than the higher
"antidepressant" doses.
- Unlike stimulants, these may take several weeks to a month to become effective.
- When Wellbutrin was first released in the USA, a number of people developed
seizures while taking it. It was pulled from the market in the early 1980s. The manufacturer
3
figured out the dosage pattern was wrong, and the FDA allowed it to release it with a
different dosage regimen. Do not take more than 150 milligrams at a time.
- These medications are usually not first-line treatments for ADD. I use these
medications to treat depression, anxiety disorders, bed-wetting, and the limbic subtype of
ADD, often in conjunction with one of the stimulants.
3. Antiobsessive or "Antistuck" Medications
Generic name
Brand
Name
Milligrams a
day /
available
strengths
Times
a day
Notes
fluoxetine
(SSRI)
Prozac
10-80 /
10, 20
long acting; do not use if

temporal lobe symptoms
are present
clomipramine
(TCA & SSRI)
Anafranil
10-200 in
children, 10300 in adults
/ 25, 50, 75
1-2
tends to have more side

effects, so not used as a
first-line drug
sertraline
(SSRI)
Zoloft
25-200 /
25, 50, 100
often my first choice of

these meds
paroxetine
(SSRI)
Paxil
10-60 /
10, 20, 30,
40
fluvoxamine
(SSRI)
Luvox
25-200 /
50, 100
venflaxine
Effexor
37.5-300 /
18.75, 25,
37.5, 50, 75,
100
2-3
best of these meds for

ADD symptoms
mirtazapine
Remeron
15-60 /
15, 30
smaller doses cause

drowsiness
nefazodone
Serzone
100-600 mg
2
good for depression and
/ 50, 100,
anxiety.
150, 200,
250
These medications increase the availability of serotonin in the brain, and they are often
helpful to calm down cingulate hyperactivity. They are typically marketed as antidepressants.
They also tend to calm down limbic hyperactivity. Except for Effexor, these medications are
not first-line treatments for ADD and, in fact, they may make ADD worse. These serotoninenhancing medications are also used to treat eating disorders, obsessive-compulsive disorder,
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oppositional defiant disorder, PMS (over-focused type), excessive worrying, temper problems
associated with things not going a person's way, and other cingulate problems listed in this
book.
5. Blood Pressure Medications
- Contrary to the negative media attention, Prozac is generally a very safe medication.
In our experience, however, people who have temporal lobe problems may experience an
intensification of angry and aggressive feelings on Prozac or other serotonin-enhancing
medications. Therefore, we are careful to screen for these before placing someone on these
medications. If you have side effects on any medication, it is important to contact your doctor
and discuss them.
- Unlike stimulants, these may take several weeks to several months in order to be
effective and even three to four months to become optimally effective.
- The most common side effect of these medications is sexual dysfunction. Sometimes
adding gingko biloba or bupropion counteracts these problems.
4. Anticonvulsant or Antiseizure Medications
Generic name
Brand
Name
Milligrams a
day /
available
strengths
Times
a day
Notes
carbamazepine
Tegretol
100-200 /
100, 200
essential to monitor white

blood cell count and blood
levels
valproic acid
Depakene
125-3.000 /
250
1-2
monitor liver function and

blood levels
divalproex
Depakote
125-3.000 /
125, 250,
500
1-2
monitor liver function and

blood levels
gabapentin
Neurontin
100-4.000 /
100, 300,
400
1-2
tends to have the smallest

number of side effects
lamotrigine
Lamictal
25-500 /
25, 100, 150,
200
1-2
start slow, watch for rash
phenytoin
Dilantin
30-300 /
30, 100
1-2
monitor blood levels.
These medications are used to treat temporal lobe dysfunction, seizures, aggression,
emotional instability, headaches, resistant depression, and bipolar disorder. They are often
very effective in resistant psychiatric conditions where all else has failed.
5. Blood Pressure Medications
The following blood pressure medications have been used to help with tic disorders,
hyperactivity, aggressiveness, and impulsivity. They are not usually helpful with the
attentional symptoms, and they are often mixed with a stimulant medication when ADD is
present.
Generic name
Brand
Name
Milligrams a
day /
available
strengths
Times
a day
Notes
clonidine
Catapres
0.05-0.6 /
0.1, 0.2, 0.3
tabs and
patches
1-2
watch rebound hypertension

and sedation
guanfacine
Tenex
1-3 / 1.2
propranolol
Inderal
10-600 / 10, 2-3

helpful with hand tremors
20, 40, 60,
as well.
80
- Clonidine and guanfacine are also used as primary treatments for tic disorders such
as Tourette's syndrome.
- When I use clonidine in addition to a stimulant medication, I order a screening EKG.
There have been several reports that this combination may cause problems, even though I
have found it to be effective and safe.
- These medications are also used to treat insomnia, which is very common in ADD.
6. Combination Medications
People can have more than one problem or more than one brain system involved in
their symptoms. Sometimes one medication seems to be able to treat a number of problems,
as mentioned above, and sometimes a combination of medications is needed to obtain full
therapeutic benefit.
Here are four common combinations of medications I use in my practice.
- A stimulant plus an antiobsessive antidepressant (such as Adderall plus Effexor) for
patients with ADD plus depression, obsessiveness, or severe oppositional behavior. In my
clinical experience I have seen many people who are children or grandchildren of alcoholics
benefit from this combination. Frequently, this population presents with cingulate (overfocus
symptoms) and prefrontal cortex problems (attentional symptoms).
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- An anticonvulsant plus an antiobsessive antidepressant (such as Depakote plus

Zoloft) for patients with temper problems and excessive worrying or depression.
- A blood pressure medication, plus a stimulant and an antiobsessive antidepressant
(such as Catapres, Adderall, plus Effexor) for patients with Tourette's syndrome, ADD, and
OCD.
- A tricyclic antidepressant plus a blood pressure medication (such as Tofranil plus
Inderal) for patients with depression, anxiety, and hand tremors in social situations.

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Change Your Brain, Change Your Life

The Breakthrough Program for Conquering Anxiety, Depression,

watch rebound when

watch rebound when

routine liver screening

2. Tricyclic Antidepressants (TCAs) and Bupropion (Wellbutrin)

stimulating; often helps

also used for anxiety, panic

never > 150 mg a dose; do

never > 150 mg a dose; do

often used to help with

often used to help with

often used to help with

also used for OCD.

long acting; do not use if

tends to have more side

often my first choice of

best of these meds for

smaller doses cause

essential to monitor white

monitor liver function and

monitor liver function and

tends to have the smallest

start slow, watch for rash

monitor blood levels.

watch rebound hypertension

10-600 / 10, 2-3

- An anticonvulsant plus an antiobsessive antidepressant (such as Depakote plus

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