Are you manic right now?

I recently had a patient who was diagnosed with pneumonia. We had been treating with antibiotics, as well as some temporary puffers, for symptom relief. Unfortunately the puffers did not suffice, and the antibiotics had not acted quickly enough. One evening, after he finished dinner, this gentleman began experiencing shortness of breath. He was concerned, and called an ambulance, who took him to the hospital.

On arrival to the emergency room he was offloaded from the ambulance and given some oxygen, which helped him immensely. His breathing actually settled relatively quickly and he was able to breath without the oxygen mask. The emergency room physician (ERP) took this opportunity to get a more wholesome history from him.

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“Do you smoke?”

“Not for the last few years.”

“Do you take any medications?”

“Just the puffers and antibiotic my doctor had prescribed.”

“Very good. Do you have any medical illnesses?”

The patient paused for a moment to think. He had been through this rodeo before, for other medical problems. He was wondering whether or not to mention to the doctor a previous diagnosis of bipolar disorder.

In the past, he had told physicians and paramedics about this diagnosis to underwhelming results. Instantly, the affect of the providers would change. Suddenly, his credibility was drawn into question. Where before he was allowed to speak and describe his story without interruptions, he was now met with requests to, “slow down.” The questions like, “are you feeling like yourself right now?” seemed to bother him the most.

This ERP on this particular day however seemed professional enough, and the patient wanted to be as transparent and honest as possible, so that his medical care could be the most informed it could be.

“I’ve been diagnosed with bipolar disorder, though I’m not on any medications, and I don’t know that I agree with the diagnosis.”

The silence was deafening, although it only lasted a second. The physician quickly regained her composure and started down another line of questioning.

“Have you used any drugs recently?”

“No.”

“Do you smoke?”

“I already told you I didn’t.”

“Are you manic right now?”

He tried his best not to role his eyes.

“I feel perfectly fine, I’m sleeping eight hours a night.”

“Are you having thoughts of violence or suicide?”

He looked at her sternly and decided not to answer this question – he was here, after all, for pneumonia. No razor blades had been held at any wrist.

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The conversation continued and eventually the physician left to order some investigations. Various nurses were in and out of his hospital room, all of whom seemed to suddenly have a lot less to say.

The patients condition improved, and he was eventually discharged on a low dose steroid for a few days to aid in his recovery.

“I don’t think I’ll take this tonight but I’ll take it in the morning.”

It was the ERP’s turn to role her eyes. The patient felt obligated to explain himself.

“If I do have bipolar disorder, the absolute last thing I want to do is take a steroid tonight, be awake the whole night, and have an episode.”

“Alright, see ya,” the doctor said as she left the room.

Now I had heard this story from the patient second hand of course, and I’m sure the dialogue wasn’t exactly as I have described above. But there are some things that are certainly true. This man was extremely aware of the prejudice he received, by virtue of the (unconfirmed) diagnosis he carries, and suffered because of it. He felt insulted, degraded, and less than human.

Great way to make people want to seek treatment for mental illness, eh?

There were a few things that bothered me about the story, the least of which was this physician’s skill in assessing mental illness. For the record, you could ask a naked man screaming about Jesus on top of a Walmart, who hasn’t slept in eight days, “are you manic right now?” and I would be shocked if they said yes. To those of us in the field, we recognize the mental status exam and the whole picture as key instruments leading to diagnosis. Personally, I don’t see the utility in asking seemingly well and euthymic (normal emotion) people what they think of their mental status, irrespective of their diagnoses, when they are seeking help for an unrelated medical problem.

Bipolar people get pneumonia too, y’know.

The physician’s apparent novice skill in this field isn’t why I chose to write this post – it’s the prejudice that came attached. Because this man had a diagnosis of mental illness in the past, and one of the “scarier” ones, his credibility was immediately drawn into question. Are you sure you didn’t accidentally take a bunch of cocaine before you arrived here? Are you positive you don’t want to blow your brains out after you leave here?

That’s not to say that this information doesn’t matter, because it does. On a professional level, whenever I assess someone with mental illness that may put them at risk, I’m always on the look out for any red flags or warning signs.

I’m also sure to treat the patients like humans.

Medicolegally, I understand the need. “Oh Doctor, you didn’t ask about suicide when you assessed Mr. so and so five months ago? And why is that? He did have bipolar disorder, after all.” And Im not saying theese questions shouldn’t be asked. How you go about it however, is another story.

Do any of you have real life examples or prejudice inflicted upon you, or a friend as a result of mental illness? Without going into too much personal detail, share below!

Dr. Travis Barron is a resident physician in Toronto, Canada.

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The four kinds of OCD – Intrusive thought predominant

From Part 1:

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Part 2

Part 3

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Intrusive thought predominant

“Hi Doctor, we have a consult for you,”

“Go ahead.”

“He is a 18 year old male with daily, intense suicidal ideation. We’ve placed him on a form 1 and he’s in the emergency waiting for you.”

***

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Early on in my career as a psychiatry resident, I met a young man, just graduated from high school at one of the hospitals I was working in. I was working in the Psychiatric Emergency Service (PES) at the time, and had been asked to see the man by an Emergency Medicine colleague.

As these things go, you don’t always get the most information. Really all I knew about this person was that he was eighteen, was going to university for engineering, and had daily, intense suicidal thoughts.

As I walked down the hallway to meet him, I considered a differential in my head. Could it be depression? Psychosis? Had a manic depressive fallen into my lap? Or a personality disorder, perhaps?

***

“Hi, my name is Dr. Barron, I’m one of the psychiatry residents.”

“Hi I’m Sam, nice to meet you.”

“Nice to meet you as well. My emergency medicine colleague asked me to speak with you, is that OK?”

“Yes of course.”

“Let’s start with your understanding of why you are here in hospital.”

***

We began speaking, and very quickly it became apparent that Sam was not depressed. He wasn’t psychotic. He definitely wan’t manic. I couldn’t even get a whiff of a personality disorder off of him. What the hell was going on?

I didn’t know it yet, but what I was seeing was a common manifestation of OCD, called intrusive thoughts. These thoughts are intense, and are very bothersome to the person. Some classic examples include:

  • Suicidal thoughts (killing yourself)
  • Violent thoughts (killing a random person or a family member)
  • Sexual thoughts (homosexual behaviours if you are heterosexual, heterosexual behaviours if you are homosexual, or pedophilia)
  • Blasphemous thoughts (against your own religion*)

An important point here is that blasphemous thoughts typically only occur when someone cares about being blasphemous i.e. it would not be considered a blasphemous thought to pee on a church if you didn’t care about peeing on churches.

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So wait. Suicidal thoughts can be intrusive? How is that different that a regular suicidal thought? Well, in intrusive thought predominant OCD, the thoughts are egodystonic, meaning they are in direct conflict with that persons values. In other words, a person with intrusive thought predominant OCD does not want to kill themselves, hurt someone, abuse a child, or disrespect a religion. In fact, they are often extremely disturbed by these thoughts.

Another important point to remember is that all forms of OCD have some level of intrusive thought based symptoms, however, the intrusive thoughts are not the predominant feature.

  • In contamination based OCD, intrusive thoughts of contamination cause extremely debilitating compulsions, focused around cleanliness, which tend to be the primary feature.
  • In doubt based OCD, compulsory checking tends to be the predominant feature.
  • In numeracy/symmetry based OCD, extreme cognitive rigidity and intolerance, as well as compulsions, tend to be the predominant feature.

***

“So doctor, what do you think is wrong with me?”

“Well, this sounds like OCD, a treatable illness. This doesn’t mean you have to kill yourself, or hurt anyone. These thoughts you are having don’t represent anything about who you are, or anything bad about you. In fact, the fact you’re so bothered by them shows how much you value human life. We’re going to help you.”

***

These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Of depression

Sitting in the doctor’s office, I hear the words. They leave her mouth like an anvil and slam upon the floor, the noise made by each previous contact making the next syllable more impossible to hear.

“You have depression.”

I leave my body and float out of the chair. I’m outside the hospital, gazing down on all that was. I’m flying further, and further, overcoming the very curvature of the world, and then I see it. My future, everything that will become of me, and all that was, laid before my very eyes.

My first sense is loss. Loss of mystery, of individuality, and most importantly, of choice.

My head is spinning. I’m falling, crashing through the sky. I miss the chair and my body and drown below into the depths of hell. I’m confronted by all that has ever scared me, a violent torture to my all-seeing soul.

I’m fired, divorced, my family has shunned me. Strangers spit on me, I’m left to rot. Slowly I decay into nothingness until the coolest realization, as I’m forced to linger while all I once loved is forgotten to me.

My heart skips a beat and I’m back in the chair. The doctor is still talking, I realize to myself. I haven’t heard a damn thing she’s said to me in the last five minutes. I hope it wasn’t important.

“The important thing is that there is hope, treatment, and I am going to help you.”

I stumble home from the office, dreading the moment I finally stop. When my footsteps no longer crowd my ears, I’m left with my thoughts. Depression. What does this mean?

It takes a while, but my life takes a surprising fork as I journey on the path to recovery. I actually get better. I’m working again, and somehow, my relationships are more fulfilling. It’s a Saturday, and I want to go to the park. Why? Just because. It’s a refreshing release, to finally do something because. 

On Monday, I’m back in her office. She’s asking me questions and I can’t stop thinking about this chair.

“How are you feeling?”

I speak for a while and we exchange pleasantries. She’s happy to hear I’m doing well. In a way, it feels surreal. The doctor catches my smile and asks me what’s up, and I give a small chuckle.

“Last time I was here, I thought I was drowning.”

Editor’s note: The above is a fictional piece I wrote, as inspired by a recent conversation I had with a patient regarding the meaning of a diagnosis. They had felt a diagnosis made a lot of assumptions about them, and what their future looked like. They were glad to be proven wrong.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The pills aren’t working

“I’m never trying this again, it was awful. I thought you said this thing was supposed to make me feel better?”

“I’m sorry that happened to you. As we discussed, some side effects like nausea and headache are quite common when you start–“

“Start?! I took this thing for four whole days, doctor. I need a different pill. Will my depression and anxiety every go away?”

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Medication selection can be a painful time for patients. As with our diagnoses, often times there is trial and error in selecting the right medication that works for you. When it gets to the fourth, fifth, and sixth medications in some cases, it can be demoralizing, not only to the struggling person, but to their doctor. The fact is the science isn’t the most clear to the researchers in the laboratory, let alone a doctor in the office, and for that reason arriving at a suitable psychiatric treatment regimen can take some time.

Don’t despair – the medications work! Not only often, but usually. I see and help people recover every single day in my office, and it can be refreshing. However, that’s not always the case. Sometimes, struggling lasts a little longer than we would like it to. Sometimes, people lose faith in the system and look elsewhere for help. These cases can be tough; but there’s an upside! In my opinion, the majority of these treatment failures are actually preventable. So what am I talking about?

There are many reasons a particular medication regimen does not work. First and foremost, the most common reason I see, as described in the example above, is a misunderstanding of the expectations of an antidepressant or anti-anxiety medication.

Anti-depressants take time to work.

The textbooks would tell you that you need six weeks at a suitable dose to have a full effect. What does this mean? Here’s an example;

Week 1 – Sertraline (Zoloft) 25mg, oral, daily
Week 2 – Sertraline 50mg, oral, daily
Week 3 – Sertraline 75mg oral, daily
Week 4 – Sertraline 100mg, oral, daily


Week 9 – Sertraline 100mg, oral, daily
FULL EFFECT
Week 10 and onwards – Sertraline 100mg, oral, daily

The dose this person required was 100mg, and not until 100mg was achieved for six weeks do we see full effect.

What if 100mg isn’t enough? Well, a further increase may be required. The maximum recommended dose of sertraline is 200mg. You and your doctor may ultimately try a 100mg dose for a few weeks, decide it is sub therapeutic, and titrate further. Yes, this means we can be talking week 15, 16 in some case. But remember – this is for full effect. In reality, a skilled clinician and a patient can often tell after the first four weeks of a treatment whether there may be a significant benefit from a particular medication. That’s what the doctor’s are for!

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Side effects are expected and will happen.

And they aren’t permanent. Like anything, your body takes time to adjust to anti-depressants and anti-anxiety medications. In fact, the presence of side effects shows that the medications are getting to the brain and having some kind of effect! It’s important to appreciate that this is a normal part of the journey, not only with starting, but with significant dose increases.

Side effects suck and the last thing your doctor wants to do is make you feel worse – like all things in mental health, trust me, it’s an investment! Side effects like nausea and headache and anxiety tend to go away after the first half week-full week of therapy (yes, anti-depressants and anti-anxiety medications can cause transient anxiety – it’s your brain adjusting to the changes). Doctor’s are also all about safety, and don’t worry, the side effects are reversible with dose decrease.

What is considered a true treatment failure?

Part of my job when you come see me for a mental health problem is to take a detailed medication history; people have often tried multiple medications over time, and if something hasn’t worked in the past, it’s unlikely to help in the future. But what constitutes “doesn’t work?”

Not the above example. For a course of an SSRI to be considered a treatment failure, you need to have completed at least six weeks on an appropriate dose of that medication. A rough estimate of an “appropriate dose” is half the maximum dose.

***

The moral of the story? The medications work, they take time, and they can be a nuisance. Careful time, understanding, and collaboration with your physician is the best way to work through a mental health disturbance. With patience, I promise we’ll help you.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Numeracy and Symmetry

From Part 1:

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Part 2

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Numeracy and Symmetry

Have you ever seen a kid walking in the mall (sorry Gen Z), jumping from small blue tile to small blue tile?

“Avoid the lava!”

“Watch out for the monsters!”

This is a completely normal behaviour, and many children, including myself, dabble a little in the lava-tile game.

But imagine if to you, it meant a little more. Imagine that your found yourself unable to walk on white tiles, because of a crippling sense of anxiety that if you did, something bad would happen. You would probably know this doesn’t make much sense, which only adds to the madness.

It wouldn’t be easy going to the mall.

This type of behaviour, in it’s extreme form, falls under the umbrella of a symmetry/numeracy based obsession. In this type of OCD, the obsessional thought is usually something along the lines of, “if this isn’t this way, than something bad will happen.” There may or may not be a specific type of “bad”-consequence perceived. Some examples;

***

An eight year old boy goes through the home and makes sure every single TV and computer has the volume set on an even number. His father has the TV on 15 one day, and the child gets very upset and throws a temper tantrum when his father doesn’t let him change it. The next day, his mother asks him what happened. The boy responds, “if the numbers are odd numbers, I’ll die.”

A twenty four year old woman is late for work every day. She’s eventually fired from her job, and ends up in a doctor’s office while she is off of work. “I think I need help doctor.” “OK. You’re in the right place. What do you think is going on?” “Every time I look in a mirror, I can’t leave until I catch my nose at the perfect angle, perfectly symmetric. I don’t know why, I just can’t. Some days it takes up eight or more hours.”

A fifteen year old is teased at school for his quirky behaviour. He doesn’t tell his parents why, and they only know that he is being bullied. One day, when dad is picking the boy up from school, dad notices the boy jumping from dark tile to dark tile on the sidewalk. “What was that about?” dad asks when the boy gets in the car. The boy blushes and says, “can we just go?”

***

These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The four kinds of OCD – Doubt

From Part 1:

Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.

Doubt

Sometimes, OCD can be obvious. Other times, it is more nuanced. This is the case with obsessional doubt, one of the most common, but under-recognized, subtypes of OCD.

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So what makes doubt obsessional? To understand that, we need to remember what makes an obsession an obsession. An obsessional thought is unwanted, and comes about seemingly out of our control. This is called an intrusive thought. Obsessional thoughts occur over and over again, and won’t go away. Importantly, obsessional thoughts consume a significant amount of time, and result in a functional impact. Remember, if it’s not causing you problems, it’s not a disease!

Taken all together, obsessional doubt occurs when someone repeatedly doubts they have remembered something. Obsessional doubt is also often coupled with compulsions, to relieve the anxiety associated with the doubt. Compulsions in doubt-based OCD tend to complement the doubt, and therefore the compulsions tend to be reassurance-based. Now I know this sounds underwhelming, but trust me, it can be debilitating. The following are some examples of people I have met (with their stories altered, of course) with obsessional doubt.

***

Richard was a 27 year old man living in Toronto. He was getting ready to go out on a date one evening and found himself very anxious. He was getting ready to head out, and had the sense he had forgotten to turn off the stove. He checked the stove and realized it was off. He did this two hundred and twenty two times, for good luck. Before he knew it, he had missed his date.

Dema was a 29 year old female admitted to an inpatient psychiatric ward for severe OCD. During rounds one morning, the word “complete,” was mentioned. Dema fixated on the word and became unable to answer any other questions. She repeatedly asked I repeat the word, “complete,” so that she could ensure she had heard me pronounce it correctly.

Mohammad was a 17 year old young man. He presented to my office one day complaining of difficulties studying. He found himself unable to move beyond the first few pages of his notes, as he felt he had to perfectly memorize everything if he were to succeed. He reflected on a similar incident a year prior, where he developed a fear he would forget his memories with a family member. He would repeatedly look at pictures of the memories he had, to ensure they were real memories. This would take hours a day.

***

These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it, and the remainder of the, “four kinds,” series.

Dr. Travis Barron is a resident physician in Toronto, Canada.

What makes something addictive? Are ADHD drugs addictive? What about sugar?

“I’m going to head to Tim Horton’s for a coffee.”

“Sure, no problem.”

You walk to Tim’s and you begin to realize you’re hungry. It’s 11:45 AM and lunch is only fifteen minutes away. You’ve brought your lunch to work today as well so you should be good.

Just a coffee, you say to yourself.

“Hi, welcome to Tim Horton’s! May I take your order?”

“Hi, yes I’ll have a large coffee with milk, a vanilla dip doughnut, and a pack of those doughnut sticks you have.”

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What is it that makes fried, sugared dough addictive? Or deep-fried potatoes? Or sour patch kids? Or anything, for that matter?

In our brains, there exists something called the nucleus accumbens. This part of the brain is known as the reward centre. What does this mean? Every time you do something that feels good, this centre “pings,” and makes you feel good. Why does this part of the brain exist? Well, it’s actually essential to our survival! Things like eating, drinking water, and having sex, are vital biological functions for our species. Without them, we would not survive. Very few of us, however, are thinking about, “I need to survive and propagate my genes,” as we eat and have sex. No, most of us do these things because they feel good. That’s where the nucleus accumbens comes in. It pings and rewards us with a shot of dopamine, the brain’s “happiness chemical,” when you do something that’s good, biologically. It’s a built-in incentive system to ensure we are doing, and feel good about doing, those functions essential for species survival.

This system, however, is imperfect, and it is prone to being hijacked. The nucleus accumbens is where many substances of abuse act, including cocaine, crystal meth, and any number of drugs. This is why many people with drug addiction become very skinny, and can waste away. The drugs hijack the system, and reward you more than food. Drugs steadily train the brain that the best rewards come from the drugs, and not food or water or sex. A great example of how strong the craving for drugs can be is a study that examined rats, who had electrodes placed in their brain at the site of the nucleus accumbens. The rats were given the ability to hit a button in their cages, which would activate the electrode, stimulate the nucleus, and cause a reward. The rats eventually choose to die while hitting the button, and totally neglect vital functions such as eating and drinking.

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But what is it that makes a substance addictive? Sugary foods can be addictive and cause cravings, for example, while carrots almost certainly do not. Cocaine and crystal meth are extraordinarily addictive drugs, while ritaline and vyvanse, medications for ADHD which act similarly, are not. What is responsible for this difference?

We think we know!

The nucleus accumbens appears to be sensitive the the size of a potential reward. Finding a penny on the ground, for example, makes us feel a lot less better than finding a one hundred dollar bill. Biologically, this discrimination has allowed the brain to prioritize eating high caloric foods, over low caloric foods, although both may taste good. (This function would have evolved prior to the food-availability we experience today in the Western world – the drive to eat higher calorie foods is a clear disadvantage to many of us nowadays.) The same principle applies today, which is why sugary, fatty foods are so addictive. The sugar and the fat, the nutrients essential to life which are activating the nucleus accumbens in the first place, are higher in doughnuts than they are broccoli, and therefore we crave doughnuts. This is actually a great example of how the advantage of a particular behaviour, and whether it is a mental illness, depends entirely on context. A drive to eat high caloric foods would have previously been evolutionary essential – now it causes heart disease.

So what’s the deal with drugs?

Well, the same principle applies. The strength of a stimulus is directly proportional to how addictive the substance is. So what affects the strength? Food that are higher in sugar and fat cause a higher level of nucleus stimulation, therefore we crave food that are slowly killing us. This is also true for drugs of abuse; crystal meth is several orders of magnitude stronger than cocaine, and meth is a hell of a lot more addictive. But there’s more! The speed of the stimulus also matters!

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When a sugar/fat/drug reward is given to us suddenly, the nucleus reacts more strongly to it, and we get a higher reward. This also reinforces the strength of an addiction. This has implications for food, which is why a banana and a candy with the exact same amount of sugar make us feel differently. The candy which instantly digests and gives us a sudden jolt of sugar, is highly addictive. The banana, which takes time to digest and releases the same amount of sugar, just over time, is not addictive!

This principle also applies for drugs, and gets to the root of why ADHD medications are not addictive – usually. The medications used for ADHD tend to digest very slowly, and although they act on the brain in the exact same way as cocaine and crystal meth, are not addictive. This is because that, relative to drugs of abuse, the medications are released very slowly.

The exception can be if you use ADHD medications in ways they are not meant to be – such as snorting or injecting (neither of these are safe methods to use). By snorting/injecting, instead of digesting you get around the bodies need to digest, and you can get a sudden jolt of dopamine, which would potentially contribute to an addiction.

Dr. Travis Barron is a resident physician in Toronto, Canada.