Last week, a client, with whom I have been meeting for the past couple of months, came in and asked me if I thought they were depressed. Before I answered, I asked them why they were asking. They told me that their mother noticed some things about their behaviour and had asked them if they were feeling depressed.
For context, this client had been diagnosed relatively recently with our old friend, adhd, and was, after meeting with some resistance from their doctor, now on a therapeutic dose of a first line stimulant medication. That context is important, because what they were experiencing is something with which I have become very familiar. That something I, many years ago, gave the name "a time of sadness." And I realized that I had not done any writing about it, and so... I'm here to remedy that oversight.
This is a phenomena that goes back to the very first client I had with adhd, prior to to my own diagnosis and treatment. The cadence was approximately the same as with this recent client: two to three months after commencement of stimulant therapy. In the first instance, I remember being concerned. My client reported to me, after a very positive response to their medication, that they felt that is was no longer working. Even worse, they worried, was this sadness that they were experiencing three months into stimulant therapy a serious side effect? And, they wondered, should they stop taking their medication?
With that client from all those years past, they and I proceeded slowly and cautiously. They continued taking their medication and the sadness they were experiencing stopped. But why the sadness? Why after two to three months would a person experience this "time of sadness" when diagnosis and treatment was so obviously appropriate and effective?
What I came to realize over time is that this phenomenon is, in fact, related to medication. But this is not something that would be appropriate to refer to as a "side effect" or even what I would call a first order effect of the medication. By "first order effect," I mean that it is not a direct effect of the medication's understood mechanism of action.
For instance—the understood mechanism of action for stimulant medication is, roughly speaking, that they work primarily by increasing dopamine and norepinephrine availability in the prefrontal cortex and striatum. The two available stimulants, amphetamine and methylphenidate, do this in different ways, but the effect is largely the same.
The understood mechanism of action of these medications and their accepted effects are, as their classification suggests, to stimulate, to energize, to help produce focus and concentration. Sadness and stimulation do not, on first blush, feel at all related. So... what gives?
The first thing to say is that the medications we classify as stimulants do not simply produce physical stimulation. That claim is easily demonstrated if you know a person with adhd who takes the right stimulant medication at the right dose, because you will observe that person become the opposite of what we think as "stimulated." Those of us who have adhd and take stimulant medication will regularly feel a greater sense of calm and more emotionally regulated after taking our stimulant medication. How can something that stimulates produce calm?
This question is part of my larger investigation into this phenomena we call adhd actually is, and I'd like to keep this post short, but... for the time being, let me address it in the following way: what if the thing—or one of the things—in us that is stimulated by taking these medications is our ability to be better boundaried in the most global meaning of that world. I have referred to this in past posts in the context of loudness. What if, by taking these medications, the world becomes quieter: the auditory world, the emotional world, the existential world, the cognitive world, the memorial world (i.e. our past), and the futural world? What would happen if stimulant medication helped to turn down the volume on all of these ways the world can be loud?
This brings us back to this idea of "a time of sadness," because it is this decrease in volume that has the potential to produce sadness. Again... this might seem counterintuitive or strange to link a stimulant medication that helps to turn down the volume on the many ways in which we relate to our world which then... produces sadness? Yup.
Why? Well... for many of us with adhd, our lives are characterized by hanging on for dear life. I know that sounds a bit dramatic, but... it's so. Many folks with adhd move from one dramatic situation to the next. That is so, because it does not matter from where stimulation comes, and whether it comes from a stimulant in pill form or stimulation in the form of personal drama, or the feeling of victimhood, or getting in bar fights, or bungee jumping... stimulation is stimulation.
And though stimulation is stimulation, the dramatic forms that I mentioned above produce a lot of consequences. For instance, if you derive your stimulation through bar fights, then you spend a lot of time in fights, convalescing from fights, dealing with the police and courts, etc. These dramatic forms of stimulation are... well... dramatic. But when a person with adhd starts taking medication, there is no longer the need to resort to these other sources of stimulation. Moreover, when people start taking these medication, as noted above, the world gets quieter. And the thing all of this produces is clarity, and sometime... clarity can produce sadness.
Clarity can produced sadness, because after two or three months of taking a therapeutic dose of a stimulant, the world is quieter and, to be a bit reductive about it, people are getting less trouble—trouble here simply means all of the stimulation seeking activities mentioned above. And for many people, that creates a scenario that is novel—namely, the first time in a person's adult life when reflection and contemplation are possible.
And sometimes, reflection and contemplation are directed back to one's very life.
And sometimes, that creates an internal environment in which people, for the first sustained time in their adult lives, might ask certain questions, such as:
- am I in the right job or career?
- am I spending my time in a meaningful way?
- am I with the right person?
And sometimes, the answers to those questions produce sadness.
It is important to say that this phenomenon that I have named "a time of sadness" is not pathological. This is not an illness or a disease state. It is not a side effect of the medication. It is the state we arrive at when we have the space and wherewithal to take a deep breath and look around and ask questions.
A time of sadness is not pleasant, but it is a necessary, because without experiencing that sadness, it is impossible to know where you are. Sadness, in this sense, is a kind of a wayfinding method towards finding where your there ultimately is.
