Something that helped for months seems to have stopped. It is a demoralising experience and the conclusion people jump to is that the treatment has failed and the next one will too.
Sometimes that is what has happened. Frequently it is not, and the alternatives are worth working through first because several of them are straightforwardly fixable.
The list, in rough order of how often it explains things
1. Doses have been missed more than you think. The most common explanation and the one hardest to see from inside. Not deliberate — a few here and there, weekends, a busy fortnight. The effect accumulates and it looks exactly like loss of efficacy.
This is worth checking honestly and without self-reproach before anything else. A written record from the last month, if you have one, will usually settle it.
2. Something else has changed and is masking it. Sleep has got worse. A new job. A bereavement. More alcohol. A new medication for something unrelated. An illness. A new supplement.
The medication may be doing exactly what it did; the load it is working against has increased. This is extremely common and it is why the first question is usually "what else has changed?" rather than "shall we increase the dose?"
3. The benefit is still there and has become invisible. Improvement normalises fast. Something that lifted you from unmanageable to manageable stops feeling like a change within weeks, and the remaining difficulty becomes the whole of your attention.
A useful test: think about what specifically was happening before you started. Not how you felt — what was happening. Were you missing appointments? Unable to start work? Awake at four? If those specific things are still better, the medication is still working and the problem is something else.
4. The formulation or timing no longer fits your day. A medication that lasted through your old working day may not cover a new one. Something that was fine taken at eight is a problem taken at ten.
5. Something physical has changed. Weight change, a new medication that interferes, a change in something being metabolised, pregnancy, a thyroid change, and — for some people — a cyclical pattern that has always been there and has become more pronounced.
6. A new or different problem has appeared. Attention treatment working perfectly while a depressive episode develops looks like the attention treatment failing. Treating the wrong thing harder will not help.
7. The supply changed. A different generic, a different pharmacy, a different pack. Usually not the explanation, occasionally is, and worth mentioning because it is easy to check.
8. Genuine loss of effect. This does happen with some medications and is a real clinical phenomenon. It is also the last thing on the list rather than the first, because the seven above are collectively much more common.
What to do before asking for an increase
Reconstruct the last month honestly. Doses taken and missed, sleep, alcohol, anything new, anything stressful. If you have a record, read it. If not, write down what you can.
Name what specifically has changed. "It stopped working" is not usable. "I could start work in the mornings and now I cannot, and that changed about three weeks ago" is.
Establish when. Gradually over months, or suddenly in a fortnight. Sudden changes usually have a findable cause.
Check the specific things that were better. One by one. Often some are still better and some are not, and that pattern is highly informative.
Consider the obvious confounder you do not want to consider. Usually sleep, usually alcohol, occasionally both.
The message to send
Something has changed in the last three weeks. The mornings were reliably manageable since the spring and now I am back to not being able to start. Afternoons are unchanged. I have missed maybe four doses this month, mostly weekends. Sleep has got worse — I have been waking at five for about a month, which started before this did. Nothing else new. Is this worth looking at before we change the dose?
That is a report with a time course, a specific loss, a partial preservation, honest adherence, a candidate confounder with its own timing, and a clear question. It will get a considered reply rather than a default increase.
Why the order matters
Because increasing the dose is the path of least resistance and it is not always the right move.
If four missed doses a week are the explanation, a higher dose makes the missed days worse and the taken days over-treated. If deteriorating sleep is the explanation, increasing an attention medication may make sleep worse and produce a spiral. If a depressive episode has developed, treating attention harder addresses nothing.
Doses do go up for good reasons, and sometimes that is exactly the answer. It is a better answer when it is the conclusion of the list rather than the first item on it.
The record, again
All of this is far easier with a few weeks of one-line notes and nearly impossible without them. Whether doses were missed, whether sleep changed first, whether the loss was gradual or sudden, whether the good days correlate with anything — none of it is answerable from memory, and all of it is answerable from six lines a week.
If you take one thing from this: start the notes now, not when something goes wrong. The value of a record is almost entirely in having the period before the problem written down.