How To Take Ritalin Correctly
I've written three textbook chapters and a couple of articles on stimulants, and I may or may not have taken them at one time or another, so I'm an expert.
Because I work in a university hospital, and because I'm, well, different, I get approached by college or med students at least once a week for Ritalin or amphetamine prescriptions. Every one claims to have "ADD." (NB: I don't give them out.)
They want the Ritalin to help them study. I get it. I'm not advocating it, but if you are going to use Ritalin you should probably do it intelligently, to maximize the gains.
First, a disclaimer: you should only get Ritalin for indicated disorders by prescription from a physician. Ok? Because the doctor will rigorously apply artificial and unreliable diagnostic categories backed up by invalid and arbitrary screens and queries to make a diagnosis. So after this completely subjective and near useless evaluation is completed, your doctor should be able to exercise prudent clinical judgment to decide if Ritalin could be of benefit. In other words, he will ultimately decide based on little else but his own prejudices and/or consult the Magic 8 Ball. That'll be $250, please. Cash appreciated.
That said, the key to amphetamines and Ritalin is to stop thinking of them as stimulants, and to think of them as reinforcers.
Let's conceptualize how these drugs work. Imagine getting a brain scan while you are performing a task. The parts of your brain you are using for the task will light up, brighter than those you aren't using.
Now you drink coffee (1). The whole brain lights up brighter, proportionally.
Now you take amphetamines. The parts of your brain that you are using light up brighter, but the parts you aren't using go darker. Get it? Caffeine is a global brain stimulant, while amphetamines focus your attention, reducing distraction.
This is entirely selective and controlled by you. You have to decide what you want to focus your attention on. If it's reading, the reading parts of your brain will be brighter. But if you stop reading and decide to talk to your friend on the phone, you know, the hot one with the hotter roommate, then you'll be more focused on that (obviously). Attention is always decreased when it is split among several tasks. In other words, you can only concentrate on one thing at a time, even though it may feel like you are doing two things at once.
While amphetamines and Ritalin do stimulate you and keep you awake, using them to pull an all nighter completely subverts their awesome power. If you want a stimulant, drink coffee or Red Bull. Amphetamines should be saved for reinforcement.
You want to set up a study situation that as closely as possible resembles your testing context. Do you take tests in the middle of the night? Using multicolored highlighters? With The Daily Show on in the background and eating Doritos? Then you're a pig, and you deserve to fail. You're dead to me.
You should study in the morning, at a desk, under the same "fed" conditions as on test day. (So you would have eaten before taking the test, not snacking at the test.) Quiet room, no distractions. Remember, attention is decreased with multiple stimuli in normal conditions, but on amphetamines, this will be be greatly magnified. Studying while talking to your friend means your "talking to friend" parts of the brain are brighter while your ""studying" parts of the brain are darker. Same thing with listening to music and studying.
Take the amphetamine (takes about 30 minutes to "kick in.") Study, straight, with no distractions or interruptions, for about four hours. Quit. You're done. Amphetamines give you about 4 hours tops of great concentration. Go to lunch, the gym, watch a movie, etc.
The power of amphetamines is this: you take them again, in the same dose, 30 minutes before your test.
In a metaphoric sense, taking the amphetamines during the test, under the same circumstances as you had been previously studying, will "remind" the brain of that context. If you see a question that "resembles" something you studied, your mind will be primed to recall it better.
Remember I said you can only concentrate on one thing at a time, that attention decreases when it is split? The trick here is to make everything about studying into one large "thing."
Here's an example: if you listen to a symphony, you will hear music. Musicians, however, hear both the music and every single instrument. They can attend to each instrument individually and simultaneously hear how each instrument fits into the larger context. A non-musician can't do that. If he's concentrating on the oboe, he doesn't "hear" the violas.
Studying has to become a large symphony, everything doing its part correctly, expectedly. So on performance day (testing) you play the same symphony. You're not trying to concentrate on each part, if you've practiced enough it should be second nature. The amphetamine helps facilitate this.
Addicts can get physical feelings of withdrawal or "high" simply by being presented with the cues-- the environment-- of their drug use. And they key into these cues much faster than non-drug related cues. That's what you're looking for here. The amphetamine feeling "reminds" you of what you studied.
For example, what you don't want to do is NOT take amphetamines at testing if you had used them to study; or take them at testing if you didn't use them to study. Or change the dosage, or change anything else you eat. (2)
Similarly, you should only be taking one pill a day. Don't take amphetamines to study AND later to do other things (like go out at night.) You are destroying the context specific reinforcement. Additionally, tolerance to amphetamines happens pretty quickly-- if you take them every day, you're going to need higher doses as time goes on. Ideally, you'd use them only for the last stretch of time before the test. For example, maybe you'd take them only the last week or so before the test, when you are studying from back tests as opposed to a textbook. (See the context?) And you'd stop using them after the test, give yourself a break, etc.
As a public service announcement, don't worry too much about grades. This is America, not Germany, where success is determined by the solidity of your goal and the amount you are willing to work. I know you don't believe it now, but it's true. Go have a drink.
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and hey, what gives with the trilogy The Most Important Article on Psychiatry You Will Ever Read? It's funny, dammit, so digg it!
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1. What is the best and healthiest coffee to drink?
2. NB: diet and amphetamines are powerfully interactive. Acidic foods/beverages will rapidly accelarate the clearance of amphetamines. In other words, dexedrine + orange juice = a lot less dexedrine. (BTW, does anyone have any idea how to make footnotes with Moveable Type?)
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August 14, 2007 5:09 PM | Posted by : | Reply
You nailed the process of diagnosing ADD. Be still my heart!
August 14, 2007 7:30 PM | Posted by : | Reply
You are a god amongst mere mortals psychiatrists. This has quickly become one of my favorite blogs and I would like to thank you for your amazing talent, wit, and knowledge.
I'm sure you already know this but it is ridiculously easy to be diagnosed with ADD and be handed several months of Adderall after 5 minutes with a psychiatrist if you know what to say...do you ever see a change in the field of psychiatry in regards to the casual attitude many of your colleagues take to handing out pills?
Alone's response: this isn't meant as a joke: not while it costs $250.
August 14, 2007 9:40 PM | Posted by : | Reply
On footnotes...are you asking about making a link from the somewhere in the article to a particular footnote?
I don't know Moveable Type so I can't give any help there specifically, but I do know how to do it via html code. This Yahoo tutorial gives pretty good directions:
http://help.yahoo.com/help/ca/geo/ghtml/ghtml-14.html
I hope this helps!
Alone's response: What the hell is html?
August 15, 2007 1:00 AM | Posted by : | Reply
What the hell is html?
You're much better off not knowing. Seriously. It takes a lot of time and frustrating experience to understand the tool and learn to use it safely, and going through all that would distract you from doing what you want to (and we want you to) do, which is blog about drugs. Er, psychiatry. Blog about psychiatry.
Incidentally, the ads under the first couple of articles, which I didn't notice until I turned Adblock Plus off, aren't labeled as ads, either, though the formatting makes their advert nature more obvious than those ones in the sidebar. The under-article-ads also get cut off by the CSS-based formatting, but a) I might as well be speaking in tongues at this point, and b) nobody cares if they can't read your dumb ads.
August 15, 2007 6:31 AM | Posted by : | Reply
Alone's response: What the hell is html?
Er... html is the computer language web pages are made of.
Alone's response: computers? Is that on the internet?
August 15, 2007 12:39 PM | Posted by : | Reply
HTML could be another psych med, but apparently it's what your comment box says we can use "for style".
I think your blog should look the way it does, as a doc who appears to "get it" and appear human as in "sitting at the bar drunk". If I wanted to read intueri I'd go there.
cheers.
August 15, 2007 1:07 PM | Posted by : | Reply
As a current medical student, now I know how other baseball players feel about Barry Bonds.
August 15, 2007 3:36 PM | Posted by : | Reply
But there are some people who have legit ADHD, right? I mean, I'm a doctor and I know of a few in my own family! I agree that the diagnostic assessment for ADHD is ridiculous.
Alone's response: what's "legit?" As defined by "could benefit from ritalin" a lot of people have ADHD. As defined by the DSM, less people have it, but it carries no useful treatment implications (i.e. doesn't mean ADHD patients would respond better to ritalin than people who don't "have" ADHD. If you think of ritalin less as a treatment, and more as a performance enhancing drug, my meaning becomes clearer. Some people will get more out of it than others. But does that make it a treatment? Or: how is it different than steroids for baseball players?
August 16, 2007 8:28 AM | Posted by : | Reply
Last Psychiatrist refers to 'context dependent' learning.
Decades ago, when I was an undergraduate, the texts we were given referred to this same thing as 'state-dependent' learning.
So if anyone wants to search the med psych databases, search both 'context*dependent' and 'state*dependent'
Hmm. It almost seems to me that anyone who is well organized enough to follow LP's detailed and precise recommendations would, if that person did *NOT* have ADD, do pretty well without taking the Ritalin.
Question too is, if we have legions of people, with and without ADD, who are using Ritalin to function in school and at work, what will this do to their sense of personal agency/internal locus of control?
Its nice to get all A's and make Phi Beta Kappa, but what does it do to self concept, if deep down, you fear that you needed medication to do it?
Its one thing to have a very clear DX of ADD--I know people for whom the right drug was sanity saving. Ditto for something like diabetes or bipolar or schizophrenia--those require medical follow up.
But..I know a family where the parents are in conflict and covering it up, and dont know how to provide structure for the children. The younger boy has a prescription for an ADD drug.
Maybe he has ADD. But no one is addresssing family context. The household is so noisy and chaotic that even a non ADD kid would have difficulty learning to pay focused attention.
And the culture is getting more and more supportive of multi-tasking and split attention. This too may be causing more and more people to think they need medication who do not have the actual neurological configuaration for ADD.
Every time they invent a new gadget such as an IPOD or a Blackberry or a Bluetooth, that may generate more scrips for Big Pharma
Alone's response: my feeling is that ADD is an environmental phenomenon. The internet encourages it, actually refines it. So the ADD isn't the relevant issue in this post. I'm emphasizing how a ritalin acts as a reinforcer-- this would occur in pretty much anybody, at the right dose, ADD or not. The reinforcer itself isn't doing anything in itself-- the ritalin doesn't improve your memory-- but it does make the whole context that much more... interesting and reliveable. And yes-- state dependent.
August 17, 2007 12:01 AM | Posted by : | Reply
I've taken Dexedrine ever day for nearly ten years. During that time i've had to increase the dose due to tolerance maybe once. I've found that while the physical effects wane in time, at the correct dose the cognitive effects are there to stay.
Do keep in mind that severe ADD can be just as disabling as bipolar. It's not just that it's unsafe for me to operate a motor vehicle and I occasionally forget to wash the conditioner out of my hair before getting out of the shower. I impulsively do things that are dangerous and socially unacceptable. I really think it's more accurate to think of ADD as an executive functioning disorder than anything else. Impulse control is at the heart of it. Procrastinating, switching tasks, and getting stuck on a task once it's started are huge problems. I'll stay up all night working on something pointless just because I get sucked in and stuck on it. The attentional problems stem from the fact that I tend to impulsively think about all kinds of random crap when I'm trying to focus on just one thing.
August 18, 2007 4:24 PM | Posted by : | Reply
I don't want to sound maudlin and whine here, but usage of amphetamines gave me Chronic Motor Tic Disorder 15 years ago. Side-effects are no laughing matter. My experience is not typical, but then side-effects are a problem for a small percentage of the population - though I suspect Big Pharma downplays the numbers. At any rate, for myself and others
amphetamines are dangerous.
I understand your academic interest in helping people use amphetamines with efficacy, but don't you think you should have taken some space to warn people of the hazardous and potential side-effects? Just because your summary of the assessment process was spot on (Darkly humorous, but spot on) doesn't mean that academic amphetamine usage is therefore hazard-free. My life is irrecoverably impacted by vocal, facial, and various physical tics. I'd hate to see others suffer the same.
I expect a cheeky response from you because that's the nature of this blog, and I won't be offended. I'd rather take my chances and voice my concern than be silent and safe from reprisal.
Douglas Cootey
☆ The Splintered Mind
Alone's response:No, you are right about the toxic effects of amphetamines, and perhaps I should have emphasized them. The perspective of this post was that since people are going to take them anyway-- I doubt anyone is seriously considering amphetamines based on the ravings of a rum soaked pirate-- that they should take them to maximize the reward/risk ratio. Additionally, you will notice the potentially sneaky way I influenced the use of the meds, by suggesting that you only take one pill (and not TID dosing), etc. But you're right, I should have done more warning. I'll just add here that this blog isn't HIPAA compliant, either.
August 20, 2007 9:01 PM | Posted by : | Reply
" based on the ravings of a rum soaked pirate", God don't tell me you wear eyeliner and talk science.
August 21, 2007 4:53 PM | Posted by : | Reply
What if you want to be perpetually in the zone? Will Wellbutrin do the trick? I can get that from my GP for a $10 copay.
August 23, 2007 9:55 AM | Posted by : | Reply
If LP is a guy (LP definitely writes like a guy), its pretty unlikely he wears eyeliner, unless he's a pirate who operates from the Johnny Depp archetype.
August 23, 2007 7:32 PM | Posted by : | Reply
Or is in a band, or just plain hot.
Alone's response: hey, I resemble that remark!
August 26, 2007 3:20 PM | Posted by : | Reply
No, Welbutrin won't help you stay "in the zone." It's good for reducing depression, and it's good for libido (that's not something your doctor is likely to tell you), which in turn is probably also reducing depression, but better sex probably won't help you focus on schoolwork or anything else unrelated to sex or your partner(s).
September 24, 2007 9:01 PM | Posted by : | Reply
Just wanted to say:
1)This site is wonderful, and
2)How would this relate to the military use of amphetamines? I've read a personal account of special forces in Laos using them just before conducting an elaborate nighttime raid on the Ho Chi Minh Trail. The author said it was to keep the team alert during the overnight, but it seems they could have improved their performance if they had used amphetamines during their practice runs for the raid. Should I alert the Green Berets?
Alone's response: depends on what the point of the amphetamines was. If you were looking simlpy to stay awake, you wouldn't want too much prior exposure (because of tolerance.) If the goal was better performance in a task, then yes, you'd want to practice on the Ritalin. As an aside, amphetamines are still used but Provigil is getting much more play-- and Provigil would not have this task-specific enhancing effect. It only keeps you awake.
September 25, 2007 6:57 PM | Posted by : | Reply
Hmmm, does this mean I should be doing more than watching The Price Is Right after my morning dose of dexedrine? On the bright side I now know a crappy cereal dispenser is $40...
If amphetamines, essentially, amplify the areas of the brain that are focusing in on one specific task while quieting down everything else, would it vary in effectiveness if you were already pretty alert as opposed to being zombie-like?
Also, my doc gives me the dexedrine to work in conjunction with zoloft. I never quite grasped why. He told me, but it didn't register. Any idea?
October 13, 2007 1:50 AM | Posted by : | Reply
Hi, I have a question. I have ADHD, or as they would call it out of the types, the "Ring of Fire". And I was wondering, I wanted to ask for Adderall, because honestly, this is affecting my life in more ways than one. And I wanted to know what procedure you had to go through to be prescribed Adderall? Like can I just ask for it and they do a lil test and that's it? I doubt it's that simple but oh do I hope lol. Or do they go through a more complex procedure? And also, does free Medical insurance cover Adderall expenses? If not how much would it normally cost? Please I need answers people! lol
Thank you so much :)
Alone's response: getting a script for Adderall is, unfortunately or fortunately, a relatively trivial exercise: you go to a doctor, you cite some ADHD symptoms, mention you've failed other meds but did well on Adderall and have no hx/fam hx of drug abuse, and boom. There's no test. Insurance covers it, mostly, though you can take dexedrine (d-amphetamine) which is essentially half of the ingredients in Adderall (IMO, the relevant one) and is generic.
But Amen's "ring of fire" subtype includes, essentially, a hostility component. Angry/aggressive/impatient/insensitive etc. Without debating whether these formally belong in ADHD, BAD, or anything else, you should try to understand _why_ you have this hostility. In other words, don't simply attribute it to an organic cause, or link it to ADHD-- find out why you are angry, _exactly._ It might not even be a psychodynamic reason, it could be as "simple" as too much coffee.
Here's my point, and its the same as the argument against SSRIs. Even if the med helps, unless there is learning going on as well, then you set yourself up for disaster, because you have not learned to cope with the emotions.
October 26, 2007 11:01 AM | Posted by : | Reply
Here's my Ritalin question:
I am on prozac & buspar for depression & anxiety and my doc prescribed Ritalin for lack of libido, to be taken daily. But I keep hearing all these awful things about Ritalin. Will I become a horrible junkie? What can I expect when I start taking it? Will I crash in between doses? Also, how easy is it to take for a few months and then ween myself off of (with doctor's help?) Thanks.
NG
Alone's reponse: I can't answer any of these questions, not least because there are lawyers afoot :-) But I can say that, in general, the effects of Ritalin get weaker over time, but at least not stronger over time (vs. say, Prozac over the first two months.) Addiction is fairly uncommon, as defined as a desire to do more and more with less and less efficacy. And, most people I recommend it to (i.e. people I actually think will benefit) I recommend as prn. But the internet is full of information...
January 17, 2008 10:48 AM | Posted by : | Reply
Hello,
I've been seeing a Psychiatrist for depression over the last 4 months or so and she has recently diagnosed me as having ADD. I'd been using Vicodin at night (partly pain management .... partly not) and told her that it tended to "perk me up" a little and clear my head, which she thought was counter to what most people might experience. Also when I drink any more then a small cup of coffee I get sleepy. This also runs counter to the "norm" (I guess). So based an a few more questions, a couple of questionairs, and notes from previous meetings, I am now taking Amphetamine Salts twice a day. I admit that it does appear to quiet the stampede and allow me to focus more efficiently on a single thing, but if it does that for everybody, how do I know that I've really got this thing? If I read some of the symptoms of Adult ADD I think - oh yeah, that's me alright. But couldn't almost everybody say that when looking at lists like this ......
Procrastination
disorganization
inability to prioritize
Zoning out
etc.
I mean, don't we all experience this at various times? The answer would be yes of course, but it all depends on excessive tendencies. So my question would be - if you're experiencing (and analyzing) your own symptoms through the lens of your own perspective, how do you know if it's out of whack - what yardstick do you use? It's tricky.
PT
February 12, 2008 7:00 AM | Posted by : | Reply
How to take caffeine properly:
http://scienceblogs.com/developingintelligence/2008/02/optimally_wired_a_caffeine_use.php
April 11, 2008 11:08 PM | Posted by : | Reply
Interesting article! I found it while googling "how to take Ritalin". My psychiatrist recently prescribed the long acting formula. I guess everyone experiences different effects from it. I endured strange headaches and the feeling of hot spears being punched through my orbitals.
GOOD GOLLY MISS MOLLY! After enduring all that for a good 5 or 6 hours, I can't imagine why anyone would willingly take the stuff if they didn't have a debilitating condition. I was just wondering what kind of effect it had on those individuals that take it recreationally.
April 11, 2008 11:09 PM | Posted by : | Reply
Interesting article! I found it while googling "how to take Ritalin". My psychiatrist recently prescribed the long acting formula. I guess everyone experiences different effects from it. I endured strange headaches and the feeling of hot spears being punched through my orbitals.
GOOD GOLLY MISS MOLLY! After enduring all that for a good 5 or 6 hours, I can't imagine why anyone would willingly take the stuff if they didn't have a debilitating condition. I was just wondering what kind of effect it had on those individuals that take it recreationally.
April 23, 2008 1:53 AM | Posted by : | Reply
Hi Sir!!!
A Wonderful Blog you have rite here!!!Its contented and compiled nice with a great deal of knowledge while congradulating on your successful work...i would like to ask you on the dosage of Ritalin per day if you are planing to study for a quite a long period when the exams are around 3 weeks ahead!!should i take 10mg per day? or could you please tell me a correct dosage to study more effectivly and for longer hours...Thanks Alot
Really learnt a great deal from your Blog!!!
Regards!!!
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