The Rochester Center Study on Stimulants and Chronic Fatigue
When he returned to his hometown to practice psychiatry after completing his residency training, Dr. Y was greeted with a large caseload. His colleagues learned that the young doctor was interested in treating patients who had not fared well with their current treatments. Dr. Y also expressed an interest in adult ADHD, a niche that was basically unfilled. Referrals were directed in, and the psychiatrist scrambled to find his stride. He was clear what to do for patients with anxiety, depression, and ADHD but was less sure how to approach patients who were concerned about their generalized fatigue and chronic pain.
In his psychiatric residency training, scant attention was given to patients with fatigue and chronic pain. He was taught the standard medical workup for fatigue but noticed in nearly all of these patients that the usual suspects (thyroid abnormalities, anemia, or underlying cancer) did not explain the fatigue. While the doctor was struggling to develop a meaningful intervention for his chronically fatigued patients, his other patients—notably, those with adult ADHD—were flourishing. Dr. Y noticed that some of his ADHD patients also complained of chronic pain and fatigue, and he observed that treatment with standard ADHD medications, specifically stimulant medications, significantly relieved their fatigue symptoms. On these medications, patients reported more energy and less pain; their need to visit the chiropractor or physical therapist diminished; and most importantly, they were able to back off their opiate pain medications. In case after case, Dr. Y made this same observation, and he became eager to share these findings with other colleagues.
As you may have guessed, I am the “Dr. Y” in the opening anecdote, and since this book has many stories about people, I indulged in writing one about myself. For many years, I discussed my observations about chronic fatigue in informal discussions with fellow doctors and published several case studies for wider distribution. I soon realized that for any new idea to gain traction, it must be scientifically proven. A formal clinical study is the best way to confirm or refute a new treatment. Meaningful studies are double blind and placebo-controlled and are structured so that patients with CFS are randomly assigned into one of two groups. One group receives the active agent, and the other group receives a sugar pill. Neither group knows which group they are assigned to because they receive identical-looking capsules. My hypothesis was that in a study population of CFS, patients given the long-acting stimulant medication LDX (Vyvanse) would have greater improvement in cognition, fatigue, and pain complaints compared to subjects given placebo.
Of course, when a clinical study is performed, one can never be certain of the outcome. Science and medicine are full of stories in which ideas were dismissed after negative results from a double-blind, placebo-controlled study. In this case, I only wanted to know the truth—I had no vested interest in proving the hypothesis, I owned none of the rights to the medications, and I had nothing to gain from a positive study. What truly motivated me was advancing a treatment option for people with chronic fatigue and related conditions.
In this chapter, I will describe the Rochester Center Study (RCS), comparing LDX to placebo in patients with chronic fatigue who are experiencing executive function deficits. Spoiler alert: the study revealed that LDX did improve cognitive function and other symptoms commonly known as brain fog. When compared to placebo, LDX also improved symptoms of pain, anxiety, and fatigue. The implication of the study for CFS and many of the medical and psychiatric conditions associated with CFS are discussed. The chapter concludes with a case study of Abby, a patient who waited years to get diagnosed with CFS but who greatly benefited from LDX.
Background of the Rochester Center Study on Chronic Fatigue
I have spent the past 25 years as medical director of the Rochester Center for Behavioral Management (RCBM) in Rochester Hills, Michigan. RCBM is an outpatient psychiatric clinic staffed with psychiatrists, psychologists, psychiatric nurse practitioners, physician assistants, mental health counselors, and social workers. We are a team of 60 professionals with a single mission of tending to the mental health needs of our patients. Working parallel to RCBM is the Clinical Trials Group (CTG) of Southeastern Michigan, where I serve as chief medical officer. For over 20 years, CTG has participated in clinical trial research; in this capacity, we are approached to conduct national clinical trials of a new medication or of an existing medication that needs to undergo further testing. I have been the principal investigator in more than 90 clinical trials. CTG has studied scores of different medications, ranging from antidepressants to antipsychotics to psychostimulants. We have studied numerous clinical conditions, including eating disorders, treatment-resistant depression, bipolar disorder, and movement disorders. Many of the medications now approved by the FDA and widely prescribed were at one point studied at CTG. Not everything we studied has gone on to be a successful medication. More than once, I received urgent calls instructing me to immediately suspend an ongoing clinical trial because an early analysis of the data found the medication unsafe or ineffective. In clinical research, there are good days and bad days.
At RCBM, we treat patients ranging from ages 4 to 100. At CTG, we have studied preschool tic disorder, eating disorders in adolescents, and late-life dementia. Still, not all research questions are of equal interest. A respected pathologist once confided to a group of medical students, “You will find over time that each of you has your favorite disease.” This is a complicated statement to unravel because, as doctors, we must be the enemy of all disease. In medical school and training, we all learn about the entire spectrum of human illness, but in practicality, we can only become experts in a few.
Early in my career, I observed the link between treatment with stimulants and CFS, but it was a decade or so later, after I had additional clinical research experience, that I felt ready to organize a clinical trial to explore whether this observation held up under closer scrutiny. The burning question I needed to resolve was this: Do psychostimulants improve cognition in patients with CFS? And if so, what other aspects of CFS do they improve? Most importantly, are they safe to use in this population?
Undertaking the Project
Many elements are necessary to conduct a research study, and trials involving human subjects are complicated and expensive to pull off. All clinical trials require a protocol, which are the rules governing each step of a trial. This protocol went through many revisions and was reviewed by many experts; a statistician determined that if our single site could obtain data on 26 subjects, the study would have enough statistical power to draw meaningful conclusions.
The next challenge was to obtain approval from an Institutional Review Board (IRB). Decades ago, research on human subjects was performed without close oversight, and this led to unethical conditions that were unfair to study participants. Contemporary standards demand that study participants be fully aware of the process and give their informed consent. We approached the Western Institutional Review Board, an established IRB, to review our proposal. They scrutinized our protocol, made some changes, and ultimately approved our study design. CTG took all measures to ensure that our research protocol was carefully executed and ensured the safety of our subjects.
We also needed to find a sponsor to fund the study and supply the study drug. I was interested in studying LDX, which is a prodrug compound developed by Shire Pharmaceutical, allowing for a long-acting effect over time. At the time, LDX was newly approved for ADHD. Shire offered support for investigator-initiated studies and agreed to supply us with the LDX capsule and look-alike placebo capsules. The company had no say in the protocol or in the interpretation of the data. (Read Chapter 6 for an overview of LDX and other stimulants.)
It might sound like a conflict of interest for Shire to fund a study of their own medication, but this is the way research on new medications is performed in this country. Very few medication trials are sponsored by the government, universities, or another neutral party. Until a better system emerges, the veracity of the study data depends on the integrity of the researchers. Indeed, Shire took a hands-off approach to the project and in no way tried to influence me or the outcome of the study.
Off-Label Prescribing
Off-label prescribing refers to ordering a medication for a patient which has not been specifically designated for a disease or disorder based on recommendations from the Food and Drug Administration (FDA). The practice is common, and doctors often order medications off-label based on their experience and knowledge that these medications may help. Sometimes doctors discover that a medication works well for a condition, and then the FDA later approves it for that condition. For example, duloxetine (Cymbalta) was approved by the FDA in 2004 for depression, but it became apparent that certain types of back pain responded to duloxetine. Subsequent clinical studies verified this, and in 2010, this drug was approved for the treatment of musculoskeletal pain, osteoarthritis, and low back pain.1 Prior to this label update, all duloxetine prescriptions for back pain were off-label. One of the most commonly prescribed medication for insomnia, trazodone does not have an FDA indication. Lisinopril has an FDA indication for hypertension but is also commonly used off-label for coronary artery disease.2
This does not mean that every off-label use of a drug will be approved by the FDA. Early studies help develop the agenda for further research. Good ideas take root if they are rational and are proven by independent clinicians. New medical practices should be adopted after sober analysis; an FDA indication should only be granted after intense scrutiny.
In an era where doctors are moving away from using opioid medications, the search for safer agents to treat conditions involving chronic pain and fatigue need to be vigorously pursued. For the sake of our CFS patients, I am hopeful that over time, LDX (Vyvanse) will be subjected to multicenter, double-blind trials seeking to confirm or disavow the safety and efficacy of this new approach.
Notes
1.Katrina Woznicki, “FDA Approves Cymbalta for Chronic Musculoskeletal Pain,” WedMD, November 5, 2010, https://www.webmd.com/pain-management/news/20101105/fda-approves-cymbalta-for-chronic-musculoskeletal-pain (accessed July 11, 2019).
2.Susan Ipaktchian, “14 Drugs Identified as Most Urgently Needing Study for Off-Label Use,” Stanford University News Center, November 24, 2008, https://med.stanford.edu/news/all-news/2008/11/14-drugs-identified-as-most-urgently-needing-study-for-off-label-use-stanford-professor-says.html (accessed August 6, 2019).
Study Details
To enroll for the study, we reached out to both our existing clinical patients and the general public. We publicized the study through local newspaper and web advertising and benefited from referrals from two local hospitals. The recruitment efforts worked, and we received a flurry of phone calls of willing participants. The next phase was selecting the appropriate participants.
Our study was limited to adults diagnosed with CFS between 18 and 60 years old. To be eligible for the study, patients were screened for CFS. As many people with CFS have other psychiatric conditions, we did not exclude potential subjects if they also had anxiety, depression, or ADHD. Many patients with CFS report difficulties in their ability to organize and in overall working memory, and we were especially interested to see if LDX helped these cognitive conditions. Subjects who did not have moderate-to-severe impairment at baseline were excluded from the study. Anyone with untreated hypertension, thyroid disease, or other medical problems for whom a stimulant would be a bad idea were excluded. No one who had previously taken LDX for any reason could participate.
The participants who qualified for our study ranged from ages 21 to 59. All of the subjects were female except for one. Early in the process, two groups were randomly assigned: one group to the active agent (LDX) and the other group to placebo. It turned out that 15 individuals joined the LDX group and 11 entered the placebo group. Unfortunately, four participants who had been preassigned to the placebo group did not enter the study because they ended up not qualifying. In retrospect, we should not have preassigned participants before they were randomized. However, although this was a technical mistake, I do not believe it changed the outcome of the study in a meaningful way.
The study was designed to last six weeks, and measurements on various scales were made at predetermined intervals. The LDX group was started at a dosage of 30 mg per day. If this dosage was tolerated, then after one week, it was increased to 50 mg per day. If that mid-range dosage was also well tolerated, then we administered the highest dosage of 70 mg per day. Equivalent modifications were made in the placebo group as well. The active drug and the placebo looked the same, so participants did not have a visual cue regarding whether they were receiving the LDX or the placebo.
At the beginning of a formal study, the protocol identifies one primary and several secondary outcome measures. The Behavior Rating Inventory of Executive Function-Adult (BRIEF-A) is an instrument that tests executive functioning (EF) skills, and it also nicely reflects changes over a short period. For this reason, it was a good instrument to assess the primary outcome measure we were looking for, which was cognitive changes in CFS. The secondary outcome measures were included to assess the levels of fatigue and pain in the subjects. Here we used the Fatigue Severity Scale (FSS), the McGill Pain Questionnaire (MPQ), and the Fibromyalgia Impact Questionnaire (FIQ). Other secondary outcome measures included the ADHD-Rating Scale (ADHD-RS) and the Hamilton Anxiety Rating Scale (HAM-A). Finally, we employed the Clinical Global Impression-Improvement Scale (CGI-S) to assess changes in overall functioning. These rating scales were administered at the beginning and end of the trial. Safety is the paramount concern of every human trial; we assessed both blood pressure and pulse throughout the study.1
A Dive into Executive Functioning
CFS patients report that they have trouble with planning and organization. They also describe impaired concentration as well as difficulties starting and completing tasks and shifting to new tasks. Rapid mood swings can interfere with their daily functioning. This “emotional lability” represents the tendency to overreact to everyday stress or to experience heightened irritability. These functions contribute to EF, and these deficits are associated with the concept of brain fog, which is covered in Chapter 9.
Study Findings
The RCS showed that the group receiving LDX demonstrated significant improvement in executive skills compared to the group treated with placebo. The improvements in total EF as measured by the BRIEF-A in the LDX group were impressive; for example, at the end of the study, the placebo group improved 3.36 points, but the LDX group improved 21.38 points from their baseline score. This improvement is considered statistically significant, meaning that the change could not be considered accidental and was almost certainly associated with the use of LDX.
In looking at individual components of the BRIEF-A scale, some of the improvements were dramatic. For example, in the placebo group, the ability to plan and organize from the start of the study to the end improved by less than a point (0.64 points); however, the average score of the LDX group improved by 23 points. Furthermore, the working memory of the placebo group improved by 1.09 points. This improvement was minuscule compared to the memory improvement noted by the LDX group (21.46 points). Without exception, in this study, executive function scores significantly improved in the LDX group.
Considering Fatigue Changes
The unremitting exhaustion stemming from CFS concerns CFS patients as much as their cognitive complaints. To assess this symptom, we used the FSS. The FSS is a 9-item scale that assesses the impact fatigue has on the individual’s motivation, exercise, and other physical and routine responsibilities. The FSS also quantifies self-image and the effect fatigue has on family relationships. Each item can be scored 1 to 7, with higher scores equating to more severe complaints.
As was seen with the EF scales, major improvements in fatigue were observed following the administration of LDX. Over the course of the trial, the baseline to endpoint improvement in fatigue was 5.08 points for the placebo group, but it was a hefty 20.92-point improvement for the LDX group. This level of improvement was robust and meaningful to the subjects with CFS.
Evaluating Pain in CFS
A subgroup, not all patients with CFS, complains of generalized pain. This is a low-level, chronic discomfort distinct from the sharp pain one might expect after surgery or a physical injury. Often the pain is musculoskeletal and takes the form of persistent achiness and tenderness. The pain might migrate throughout the body but is most often in the neck, jaw, and joints. Most characteristic of this type of pain is that doctors cannot seem to find an anatomical explanation. X-ray images or CT scans of the areas of concern do not reveal significant abnormalities. Sometimes the patient is told she has mild arthritis, inflammation, or a bit of bone degeneration, but the pain usually does not retreat with time and does not respond to anti-inflammatory medications.
The RCS used two scales to capture pain symptoms. The MPQ is a validated scale that takes about five minutes to complete. Subject responses, on a scale of 0–3, describe the presence and intensity of many different pain complaints. Among other descriptions, they can report throbbing, shooting, stabbing, exhausting, aching, or gnawing pain. Pain complaints can be summarized using adjectives such as, none, discomforting, horrible, or excruciating.
The second pain inventory used was the FIQ, which was developed at the Oregon Health and Science University in the 1990s and has since been revised. The FIQ surveys functional impact and allows the patient to gauge, in light of their discomfort, their ability to participate in daily activities, including shopping, preparing meals, and doing yard work. The questionnaire is very sensitive to change, so it is a useful instrument to use in short-term medication study. The FIQ was validated in fibromyalgia patients, but because a similar instrument did not exist for CFS, it was used as a secondary outcome measure in the RCS.
Once we analyzed the LDX study, it was clear that subjects taking the active agent experienced more pain relief than those on placebo. The mean MPQ went down 10.38 points for those treated with LDX compared to a mean decline of 2.45 points in the placebo group. The FIQ also detected a decrease in pain impact in the actively treated group’s mean decline (20.90 points) vs. mean decline in the placebo group (8.83 points).
Anxiety Improvements
The product warning for every stimulant medication includes the potential for increased anxiety. For this reason, the RCS tracked the HAM-A throughout this LDX study. The 14-item scale is widely used in psychiatric medication trials, as it carefully tracks anxiety-related symptoms.
Two findings are notable here: First, the patient population recruited into the study met the criteria for CFS. It was interesting that when we started the study, both the LDX and placebo groups had rather high levels of anxiety. This reflects the extent to which generalized anxiety is characteristic of CFS. Second, over the course of this six-week study, the group treated with LDX had a mean decline in the HAS scores of 11.31 points compared to the placebo-treated group, who experienced a mean decline of 6.18 points. Not only did LDX not worsen anxiety, but the reverse was true. The RCS data showed a trend (not full statistical significance) of an improvement in their baseline high level of anxiety.
The final secondary outcome measure was the Clinical Global Improvement Scale-Severity of Illness (CGI-S). This scale allows the investigator to rate the severity of a subject’s illness on a 7-point continuum. A score of 1 indicates “normal, not ill at all,” a score of 4 means “moderately ill,” and a score of 7 represents “among the most extremely ill patients.”
At the beginning of the study, the mean CGI-S score was 5.1 for the LDX group and 5.4 for the placebo-treated group. At the end of the study, the group treated with LDX improved by 1.92 points compared to a mean decline of .92 points in the placebo group. This was a statistically significant decline and part of the larger trend showing decreased severity of symptoms in the LDX group.
Looking at Side Effects
Researchers refer to undesirable responses to a medication as adverse events, though most people use the term side effects. Because the RCS was double blind, neither the study team nor the study subjects knew who was assigned to the active treatment arm vs. the placebo arm. The protocol demanded that all subjects be asked at every visit how they were tolerating treatment. The most common side effects were headaches, dry mouth, and insomnia. The RCS found that 15 percent of the LDX subjects had headaches, compared to 8 percent of the subjects in the placebo group. In addition, about 8 percent of the LDX group experienced insomnia and dry mouth, whereas no one in the placebo group had these two complaints.2 (I talk more about the insomnia side effect in Chapter 6.) It was noted that none of these side effects interfered with the subject’s ability to stay in the study. No life-threatening adverse events occurred.
As mentioned above, the overall effect of LDX in this study showed anxiety reduction, but it is noteworthy that two of the LDX subjects discontinued the study because of increased anxiety. Both subjects improved rapidly once they stopped LDX. The message of the RCS regarding anxiety is that LDX can increase anxiety in select subjects but decreases this symptom in many others.
Safety: Blood Pressure and Pulse Changes
Many clinicians predict that a person’s blood pressure and pulse would significantly rise while taking a stimulant drug, but interestingly, RCS found only a minor change in vital signs. As a reminder, blood pressure is measured in millimeters of mercury; a pressure reading of 118/70 means the systolic pressure (SBP) is 118 and the diastolic pressure (DBP) is 70.
In our study, the placebo group started with a mean SBP of 119.5, and it slightly increased to 121.3 by the end of the study. By chance, the LDX group had a baseline mean SBP of 124.10, but at the end of the study, it dropped to 119.75, a slight decrease.
The DBP of the placebo group was an average of 78.15 at the onset of the study, and it was 79.20 at the conclusion of the study, a nonmeaningful change. For the LDX group, the average DBP was 78.60 at the start of the study, and it slightly increased to 81.05 by the end of the study.
As for the pulse, the placebo group started out with an average pulse of 81.55 beats per minute, but it dropped to 77.55 by the end of the study. In contrast, the average pulse of the LDX group increased from 73.60 at the baseline to 81.05 by the end of the study. Thus, the actively treated CFS group did have an average increase in pulse rate; the clinical significance of this change is unknown. This finding is consistent with other LDX studies and is reassuring news to prescribers and patients, defeating the contention that stimulant medications are uniformly associated with deleterious changes to vital signs.
Limitations of the RCS Study
The RCS is one of several studies that have found that stimulants improve the plight of patients with CFS. Similar to its predecessors, the RCS has some inherent limitations. It was conducted at a single site; the ideal data should be gathered at multiple independent centers. The number of subjects studied was small, and some technical mistakes regarding randomization were eventually recognized. As a result, more participants received active agent than placebo. Although women are more likely to have CFS than men, the RCS had a disproportionate number of women. Finally, RCBM is an established ADHD center, and it is possible that this introduced a selection bias, resulting in a higher number of ADHD patients recruited into the CFS study.
The Way Forward
Despite these concerns, the positive findings of the RCS open the doors of imagination. From the study, we glean that global CFS symptoms respond favorably to LDX. There are four specific findings: Compared to placebo, LDX improved cognitive deficits in subjects with CFS. CFS subjects treated with LDX reported less fatigue. Most surprising was the noted decline in the physical pain experience by the CFS subjects. Finally, subjects with CFS treated with LDX reported less generalized anxiety.
The RCS forces a rethinking of the properties and proper uses of stimulant medication. Most fundamentally, the RCS reveals that LDX provided relief to subjects with CFS who were experiencing cognitive deficits. This is an important finding; very few medications available in the marketplace sharpen cognitive skills. As many individuals with CFS are diagnosed with other cognitive complaints ranging from brain fog to post-concussive syndrome to early dementia (discussed further in Chapter 9), this finding has potentially extensive implications.
In the RCS, LDX-treated subjects with CFS experienced improvement in the core symptom of fatigue. This might be the most predictable finding—it is well-known that stimulants augment energy. Earlier studies (to be described in Chapter 6) have reported similar findings with CFS.
Taken together, these studies offer a data-confirmed finding that LDX, and probably other molecules similar to LDX, have strong anti-fatigue properties. I assert that the symptom of fatigue is highly prevalent, quite debilitating, and underappreciated as a source of human distress. Often, fatigue patients are misdiagnosed as having anxiety or depression and as a result are treated with inappropriate medications. In the future, I hope the diagnosis of CFS is considered more routinely. Medications such as LDX should occupy a prominent role as a treatment option for these patients.
An understanding of the way LDX helps ADHD patients may explain why the medication worked to decrease pain scores. In ADHD patients, LDX enhances concentration by decreasing distractibility. A classic example is that with treatment, ADHD patients are better able to stay focused on tasks that require sustained attention, such as reading. Treated patients will often report that they no longer need to reread a simple paragraph, and they are less distracted while performing mundane tasks such as unloading the dishwasher. The same model applies to pain in the distinctively different CFS patient. As LDX increases attentional focus and decreases distractibility, CFS patients are better able to filter out irritating muscle and joint pain. I believe it is this mechanism, played out in the cortical dopamine circuits, that accounts for the reduction in the FIQ and MPI scales. In this era, when American medicine is moving away from long-standing opioid use, LDX might emerge as an alternative for chronic pain relief.
The RCS also documents a reduction in overall anxiety. This contradicts the general belief that stimulants increase generalized anxiety, but it is consistent with what many LDX-treated patients have described to me over the years. The biochemical mechanism probably involves LDX effects on the basal ganglia and the prefrontal cortex via dopaminergic properties, but this model will need further refinement. For now, I can say confidently that treated patients report they can focus more easily and are less distracted by worrisome thoughts. For this reason, they feel less anxious and overwhelmed.
Considering the Case of Abby
Abby is 56 years old and has been married to her husband, Logan, for 25 years. She was referred to my office for ongoing treatment of anxiety and depression. Abby related that since the onset of menopause six years earlier, she felt drained all the time, as if her “mind was somehow trapped in mud.” Abby felt achy and bloated much of the time. She slept poorly at night and often felt restless during the day. Of concern to Logan was that Abby was increasingly unreliable; she was late for appointments, forgot to pay bills, and got stranded on the interstate after failing to fill the car with gas.
A paralegal, Abby had received several warning notices about her declining performance, and she was apprehensive that she would soon be fired from her job. Fueling her despair was Abby’s persistent worry that her symptoms stemmed from an undiagnosed medical condition or even a latent cancer. Her trusted family doctor examined her carefully and referred her to specialists. Abby’s gynecologic checkups and mammograms were normal, as was a colonoscopy. Her blood tests revealed a normal thyroid level and complete blood count. After an extensive workup, Abby’s doctor told her, “You have no clear medical illness and do not show evidence of cancer. I cannot find an explanation for your fatigue.”
Abby started to cry when she learned of her nondiagnosis; she had desperately wanted to find an explanation. Sensing that Abby was still in distress, her doctor referred her for psychiatric evaluation, having little else to offer.
Abby greeted me with the following: “My doctor thinks I am crazy, so she sent me to you. You will probably agree. I don’t think anyone knows what wrong with me. Is there any hope for me at all?” I listened and then carefully documented Abby’s history.
•Age 16: Diagnosed with mild depression and prescribed with the antidepressant desipramine, which she recalled helped her. Treatment ended about a year later, uneventfully.
•Age 20: Left college after her third semester. Was placed on academic leave and told she had ADD and possibly a learning disorder. No treatment was pursued.
•Age 25: Broke her leg while ice skating and was grounded from active sports for several months. She put on weight during the injury and has gained an average of a pound per year since then.
•Age 32: Now with two small children, Abby became a full-time homemaker. Her weight escalated during her pregnancies, and she struggled to maintain a basic exercise schedule.
•Age 49: Her mother died, and her primary care doctor prescribed a three-month course of fluoxetine (Prozac) during her grieving stage. Abby did not request refills after the prescription ended.
•Age 50: Began experiencing lethargy, lack of initiative, and an overall lassitude. Failed trials of the antidepressant Lexapro and Effexor resulted in referral to my clinic.
After reviewing her comprehensive medical workup and psychological testing, I diagnosed Abby with CFS. I explained that her history was consistent with CFS and encouraged her to try a small dose of Vyvanse. Abby was ambivalent about my diagnosis and expressed fear that she might develop a dependency on the medication. I reassured her that the risks were minimal, and she consented to proceed.
Within about a week of treatment with Vyvanse, Abby called my office to ask if the medication was also an antidepressant. Told it was not, she seemed surprised, because her long-standing feelings of depression and fatigue were essentially gone. Her performance improved at work, and her supervisor observed that Abby must have gotten her pep back, because she was doing so much better. Abby began going out with old friends she had not seen for years, to their mutual pleasure. She no longer needed to nap during the day, and her neck pain diminished to the extent that she was not taking ibuprofen. Instead of needing massages, she was working out in the gym three days per week and had lost 12 pounds. Three months into treatment, Logan came into our office to thank us for “giving me my wife back.” He said he didn’t know what happened to her or why it had happened, but that Abby was her old self again, and he was extremely relieved and happy.
This chapter concentrated on the RCS and the use of LDX in treating patients with CFS. The next chapter will explore all the stimulants that may be helpful to individuals with CFS, both long-acting and short-acting drugs. In addition, I will also discuss modafinil, a drug that promotes wakefulness and that been found helpful with chronic fatigue.
Notes
1.Joel L. Young, “Use of Lisdexamfetamine Dimesylate in Treatment of Executive Functioning Deficits and Chronic Fatigue Syndrome: A Double Blind, Placebo-Controlled Study,” Psychiatry Research 207 (2013): 127–133.
2.Ibid.