Psychiatric medications are like any other medication: they must always be adjusted correctly to correctly. The size and weight of the patient no longer matter. Today, medication adjustments have to do with this little-known mental biomarker: the therapeutic window. We used to think that weight and body size were the two most important variables in understanding proper dosing. Today those somatic parameters are old news. What matters a lot in 2008: metabolic ratehow medicines burn and whether they burn correctly.

It sounds complicated at first, but in the end it’s really easy and the benefits are clearly measurable. We are now taking the medication understanding of using somatic surface appearance as predictors, to the molecular and cellular level: metabolism, metabolic rate, is the key predictor to open that challenging door and properly adjust stimulant medications to treat ADD/ADHD challenges. If the drugs are adjusted correctly, the patient lives just inside that Therapeutic Window: they do not come out above, nor do they collide below. They float right inside that all-important window like this: Bottom line: the top is too much, the bottom is too little.

General description: After acknowledging these Fundamental Lessons from the Window, the patient becomes an essential partner in the complicated process of medication dosage adjustment. Without this essential information, medication adjustment becomes a roll of the dice, reactions frequently occurring because “How are you feeling?” it’s nothing more than a small, often macro, imprecise measure of subtle microprocesses of each person’s metabolic activity: their burn rate. And the good news in this regard: The Therapeutic Window is actually not difficult to find or measure, it just takes a little longer. Here are seven simple tips for recognizing the top of the therapeutic window:

1. The Reasonable Goal – No Side Effects: If the medication is Just fine in dosage and duration, you’ll feel like you’re just floating through that effective window opening, smoothly and with little or no “side effects.”
2. Acknowledging too much: If the drug is too, too high in dosage, you’ll have signs of toxicity and you’ll hit the top of that window – hit your head against the top of that window.
3. Toxicity time: all day Issues – Toxicity can seem absolute: All day buzzing and not being able to think, just going out the window, feeling high, or so full of thoughts that you can’t do anything.
4. Toxicity time: on and off problems -Toxicity can appear as cyclical, mercurial, from time to time, with hyperfocus and later disability to focus. This is the most frequently missed side effect at the top, and most important clinically, because it encourages regular and predictable negative medical consequences. Most of the time with amphetamine products like Adderall IR, Adderall XR, Vyvanse, and Dexedrine, a person at the top of the window will have periods of hyperfocus that come on later in the morning, then fluctuations later in the day in the noon time range. It seems that the medicines are almost working and often confused with the bottom of the window – not enough. Adjusting upwards without acknowledging this essential top-of-the-window issue can become catastrophic, because becoming toxic and completely out of control is very likely. An easy mistake: interpreting only the part of the cycle on the unfocused side as insufficient medication, which is why you need to step back and review the entire day.
5. “Drugged” is too much: It just feels like you’re toxic, it’s too much. You shouldn’t feel high or high.
6. More symptoms at the top: Confusion, disorientation, cognitive stress, anxiety increase, while self-expression decreases.
7. Different stimulant, different tops: Incorrectly adjusted stimulants: You may feel moody and depressed all day, and relieved at night, as they have a shorter half-life with an expected duration of less than 12-14 hours. If you feel better when they are no longer in your system, this is a great clue. [Big drops in the PM are also associated with comorbid depression – more later.] With amphetamine too high stimulants, you may feel buzzed, uncomfortably intense, overly attentive, with angry and often sad mood swings. With the methylphenidate [‘Ritalin-like’] products may feel more “high and out” if the drugs fit past the top of the window.

If you feel these types of symptoms for the first few days after starting a new medicine, it’s usually not a problem. If symptoms continue, urgency is required, and adjustment is most likely necessary, see your doctor, and feel free to share this article with your medical professional and friends.

This is the first article in a series on dosing stimulant medications for ADD/ADHD. I’ll be back with tips on the “bottom of the window,” “duration of efficacy,” and other important Therapeutic Window tips for medication management. We strongly support your medical team and hope this helps with your progress.