So quick disclaimer, both my wife and I are on the Autism spectrum, we both figured this out far too late in our 20s and have been working to re-frame our mindsets about it to understand ourselves better.
Recently, she reached out to a Psychiatrist for adhd and PMDD symptoms and was immediately clocked as ASD and prescribed zoloft to help long term with PMDD syndromes.
The first night was absolute hell of mood swings and discomfort so I was looking more into SSRIs, previously all I knew is you cant just stop taking them and they make certain people's dicks stop working.
Strolling into the zoloft subreddit is an absolutely crazy experience, half the posters are like "i'm going insane is this normal?" and they receive responses like "yeah just wait 12 weeks of these symptoms and maybe you'll be cool". The other half of the posts are people post 12 weeks being like "this shit cool", but there's a weird confirmation bias where the people who got off of it are not lurking in the zoloft subreddit. Every once and a while you'll see someone necro-bump a year old post about someone giving it time and they'll be like "oh yeah sorry for the late reply, the drug was incredibly bad for me and I had to get off of it".
My wife was experiencing this out-of-character rage at certain things, but also felt a weird control over said rage and began looking into posts about that and apparently its common? Weird rage too, like being frustrated with fellow ASD people. I started connecting the dots and thinking about people in my life who were on these and holy shit, they're absolute seething assholes to us, is this why? What is this drug???
And this doesn't even touch getting off the drug, apparently the withdrawal is absolutely demonic for many many days. Then you have serotonin syndrome, the endless list of side effects that you have no idea if you'll experience or not because doctors don't give a shit and blood panels for drug reactions are too expensive to bother with.
All this stuff basically points to "neurodivergent people are being tortured with the promise of a semblance of normalcy in order to cope with our capitalist world, and all the "normalcy" is, is the ability to control your emotions externally despite them being wildly out of control internally".
Rip me apart for this all you want but i'm leaning towards crank status being anti-anti-depressants. All this to say I'm prescribed stimulants and i'm grateful I can just take days off or just not take them when I'm happy to be my autistic-adhd self.(I know not all people can do this with ADHD, my heart goes out to them, but it's more an issue with existing at baseline rather than going off wrecking havoc)
psyilocibin therapy needs to become more widespread because SSRIs are far more terrifying than seeing god and your subconscious.
Speaking from anecdotal reports from autistic people, SSRIs generally don't seem to go over well with autistic people.
If your partner is autistic and suspects that they're ADHD as well that's not uncommon, with the estimated rates of ADHD occurring in autistic folks being at around 20-40%.
If your partner is ADHD or suspects being ADHD then PMDD is extremely common as dopamine drops due to hormone changes around menstruation.
Without writing a whole piece on something when I don't have the spoons for it, serotonin can compete in the brain with dopamine and SSRIs can reduce dopamine transmission.
If we go by a hypothesis that your partner is correct about PMDD and ADHD, what we should expect to see from an SSRI would be an aggravation of their PMDD and a deterioration of their mental health overall, all things being equal.
If your partner is looking for a better alternative in the antidepressant class, venlafaxine is likely the best bet as it is an SNRI with dopaminergic effects at higher dosages. Venlafaxine can be combined relatively safely with mirtazapine, which is unusual for antidepressants, and this may boost the effects on the PMDD symptoms or other symptoms - this combination is well known as a potent treatment for depression that is not responding well to other antidepressants.
Bupropion is the other candidate to consider as it has a desirable effect on both norepinephrine and dopamine for an ADHDer although the evidence for it treating PMDD shows that it is less effective than venlafaxine.
If we're throwing shit at the wall to see what sticks, agomelatine is an antidepressant that is unique in that it's the only one that has been shown to have a side effect profile lesser than placebo and it doesn't cause withdrawals so it's possible to stop it without tapering down. There's little to no evidence establishing it as a suitable treatment for PMDD but I figured that it was worth an honourable mention given the concerns that you have identified.
But with all this said, it takes a psychiatrist to really understand these things and it requires good knowledge of the case history of the patient to be able to determine what would really work best, and even then it's still a bit of a guessing game as neurochemistry is very complex and it's more of an art than a science to figure out what would work for any given person for reasons I won't bother going into here.
Honestly though, if your partner is an ADHDer or suspects that they have ADHD then really their best bet is stimulants because antidepressants rarely manage to treat ADHD symptoms by themselves.
I would urge caution about jumping to conclusions about psychiatric meds - the nervous system is both extremely complicated and also kind of simple in the sense that it relies on a few key things in order to achieve a lot (well, basically everything...) which means that tweaking the levels of one thing in the nervous system often has major flow-on effects for other parts of the system, like it or not. Add to that the fact that meds like antidepressants almost always have a really broad effect across the brain, not to mention across a lot of different neurotransmitters as well, and it starts getting really, really complicated.
Throw into the mix the fact that an individual might have an abnormal amount of receptors or transporters in any particular part of the brain and this may cause a "deficit", not in the neurotransmitter itself but a sort of shortfall compared to "demand", and thus treating this shortfall usually entails broad spectrum treatment which can increase the neurotransmitters elsewhere in the brain which can easily cause side effects worse than what the particular medication is treating.
It's just really, really complicated. Add into that that one person's depression might be due to low serotonin, another's might be due to low norepinephrine, another's might be due to low dopamine... or likely some combination of these and the complexity gets kinda staggering to try and wrap your head around.
If you've ever played one of those puzzle games where flicking one switch turns other ones on/off and you have to make a path or turn all of one row to a particular setting, that's what psychiatric meds are like - you often don't get a grasp of how one change affects the rest of the system and it often takes a few tries until you even understand what you're dealing with and to develop a good plan for how to proceed.
I guess I'm trying to say that antidepressants have a long list of side effects because they typically affect a lot of systems, especially in the brain, and typically a lot of different chemicals in the brain in different ways. It's easy to get spooked by this or to become very cynical about it (believe me, I understand this very well personally) but I'd try to withhold from making snap judgements.
There's hardly a medication out there that doesn't have horror stories attached to it but then again the same could easily be said for all sorts of common foods that we eat - caffeine can trigger mania in some people with bipolar, gluten can make someone so sick that they're incapacitated for days, there's a particular amino acid that can cause brain damage for people with a certain condition meaning that they have to carefully restrict their protein intake, salt could be enough to cause a particular person to have a heart attack, heck in situations of heart failure your fluid ntake is restricted...
If we went by horror stories caused by the effects of dietary intake then we would be avoiding salt, sugar, wheat, protein, dairy, water, carbohydrates, fats... it's hard to imagine a single thing that would be considered safe.
I told my wife that I was going to "post a rant on the bear site so the true materialists come out of the wood work to explain things to me" and this is basically what I was anticipating. Thank you for being a valuable member of this community.
The doc was actually a NP and wanted to see if the zoloft would help the PMDD but doubted she had ADHD, just that she was on the ASD spectrum. The NP was extremely sweet and understanding about the ASD apparently, I really hope she knows what she's doing with this stuff, the thing about SSRIs with autistic people you mentioned is concerning.
Thanks, that's a big compliment.
I think the general awareness of ADHD is abysmally low and, not to shit on any particular doctor (let alone a specialist 😬) but if I encounter someone who is AFAB and late-diagnosed/undiagnosed autistic then that's gonna raise a hell of a lot of flags for needing to investigate before you'd be able to either rule an ADHD diagnosis in or out.
Women are much more likely to go undiagnosed for ADHD. Whether it's due to socialisation or it's a distinct behavioural difference or something in between, ADHD women tend to fly under the radar.
Adult ADHDers, especially the undiagnosed and late-diagnosed, also fly under the radar because they are much less likely to exhibit the hyperactivity and the outward signs of impulsivity that are easy to catch for the purposes of diagnosis, not to mention that they tend to have developed all sorts of coping strategies to conceal and compensate for ADHD throughout their lives.
ADHD in autism was, until recently, not even "permitted" to be diagnosed formally and there's a desperate need for better research and education amongst healthcare providers on this. The combination of autism and ADHD is, imo, unlike either autism or ADHD by itself and when co-occuring it's not nearly as simple as just the combination of the two.
But the combination of all three of these factors together in one person?
Yeah, I'm not sure even the foremost experts in ADHD would be able to identify ADHD in a case like that on the first session...
Idk. I'm not a doctor and I'm not an expert or anything like that but I would encourage your wife to do a screening test outside of the NP's direction or to get her to come up with a list of symptoms that she's identified that seem to map onto ADHD to take to the NP so she can make a case for herself. Otherwise it might require seeing a different doc because, unfortunately, some of them are just a bit outdated or they have preconceptions about these things.
Anyway, I hope my input has been helpful and hit me up anytime if you ever need my input in future. Good luck with it!
I have ADHD myself and a sibling on the ASD spectrum, so likely on it a bit mysel, (by what my psychiatrist has told me). I wanted to briefly add my experience to what the wonderful commenter that you replied to.
First, there are some genetic medicine blood tests that can be helpful in predicting how one will react to psychoactive drugs. My wife had such screening after bad reactions to several medications. Basically, there are known variants of the genes involved in the structures of neurons and there is a large amount of data that has been correlated to these variants in patients and/or the mechanisms through which the medicines work. With this information, drug familes can be eliminated or recommended based upon likelihood of effectiveness or adverse reaction. Being neurochemistry, however, it's still not exact and trying different medications may still be necassary.
Now, my personal experience. I started on an SNRI last year, after hitting what turned out to be weird hormonal issues that caused me to have periodic bouts of extreme anxiety. The one that I've used is closely related to the one mentioned by the previous commenter, desvenlafexine. It's an active metabolite of venlafexine, meaning that it has a more rapid onset for effectiveness as the body doesn't need to metabolize venlafexine into its active form. I found that improved my resilience significantly with hormone-driven issues (since mostly corrected) and with the overlap in activity with ADHD meds (stims act as dopamine and norepinepherine reuptake inhibitors) there seems to be improvement in those symptoms as well. Note however, that SNRIs can also modulate how stimulants work, even caffeine. So, it's important to be careful with those - I've mostly stopped having morning coffee.
Just wanted to note as well that this is a very good and thorough response.
This is a really great response. The truth is, you need a good psychiatrist who is willing to look at evidence and try different things to work out what works for you.
Caffeine can definitely cause mania. If you have any sort of mental illness that involves psychosis of any degree, stimulants are usually bad. I don't drink caffeine daily anymore and I've had way less psychotic issues.