What is the appropriate initial dosing regimen for the stimulant combination colloquially called "California rocket fuel"?

"California Rocket Fuel" Dosing: Not a Recognized Medical Regimen

"California rocket fuel" is not a standard medical term found in clinical guidelines, and no evidence-based dosing protocols exist for this colloquial phrase. The term appears in informal contexts but lacks FDA approval or guideline support as a defined treatment regimen.

What the Term Likely References

Based on psychiatric practice patterns, "California rocket fuel" typically refers to one of two combinations:

1. Venlafaxine + Mirtazapine (Most Common Usage)

This combination is sometimes used off-label for treatment-resistant depression, but no guidelines provide specific starting doses for this combination as a named regimen. If this combination is being considered:

• Venlafaxine: Standard starting dose is 37.5-75 mg daily, titrated based on response
• Mirtazapine: The NCCN Palliative Care guidelines suggest mirtazapine may be especially effective in patients with depression and anorexia, typically started at 7.5-15 mg at bedtime 1
• Critical caveat: Mirtazapine causes dose-dependent sedation even at sub-therapeutic doses, and should be administered 1-2 hours before desired sleep time 2

2. Stimulant + Antidepressant (Less Common Usage)

If the term refers to combining a stimulant with an antidepressant for ADHD with comorbid depression:

• Methylphenidate: Start at 5 mg twice daily (after breakfast and lunch), titrating weekly by 5 mg increments up to 20 mg three times daily as needed 1
• Dextroamphetamine/mixed amphetamine salts: Start at 2.5-5 mg once or twice daily, titrating by 2.5-5 mg weekly up to 10 mg twice daily (20 mg total daily) 1, 3
• SSRI addition: If mood symptoms persist after 6-8 weeks of optimized stimulant therapy, add an SSRI such as sertraline 25-50 mg daily or fluoxetine 20 mg daily 3

Critical Safety Warnings

Do not prescribe based on colloquial terminology alone. The American Academy of Child and Adolescent Psychiatry explicitly states that no single antidepressant is proven to effectively treat both ADHD and depression 3. Any combination therapy requires:

• Baseline cardiovascular assessment: Blood pressure and pulse measurement before starting stimulants 1, 3
• Weekly monitoring during titration: ADHD rating scales, blood pressure, pulse, and side-effect assessment 1
• Suicidality screening: Particularly when combining medications or using atomoxetine 3
• Contraindication screening: Never combine with MAO inhibitors (14-day washout required), avoid in active psychosis, uncontrolled hypertension, or symptomatic cardiovascular disease 3

Evidence-Based Alternative Approach

Rather than using informal terminology, follow this algorithmic approach:

1. Establish the primary diagnosis: ADHD, depression, or both
2. For ADHD with mild mood symptoms: Start stimulant monotherapy first (70-80% response rate within days) 3
3. For severe depression: Address mood disorder first before ADHD treatment 3
4. For persistent symptoms: Add SSRI to optimized stimulant after 6-8 weeks if mood symptoms remain 3
5. Monitor systematically: Use standardized rating scales, not subjective impressions 1

The strongest recommendation is to avoid prescribing based on slang terms and instead use evidence-based, guideline-directed sequential treatment algorithms with proper monitoring.