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Published on : Mar 14, 2014
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Slide 1 - ADHD in Adults: Separating the Wheat from the Chaff James Chandler, MD FRCPC
Slide 2 - Why the current interest? Pharmaceutical companies Psychiatry Cultural
Slide 3 - Pharmaceutical companies ADHD is a chronic disease, thus a great market Adults with ADHD are directed to take medications even longer than depressed patients Many ADHD drugs are now indicated for adults
Slide 4 - Concerta, Adderall, Strattera, Ritalin, Alertec No disorder, no drug Where would Viagra be without Erectile Dysfunction?
Slide 5 - Selling ADHD drugs requires Identifying more consumers Direct to consumer ads with “signs of ADHD” Promoting the effectiveness of the treatment Pharmaceutical company managed studies which have little application in the real world
Slide 6 - Pharmaceutical Strategy Producing a demand Making people think that not paying attention is abnormal
Slide 7 - Psychiatry’s Interest in ADHD
Slide 8 - Developmental interests Adult psychiatry research now focuses on early forms of adult illnesses Depression, Bipolar Disorder, Psychosis, Anxiety Disorder
Slide 9 - Developmental Interest Child Psychiatry research follows up child illness into adult ADHD, Autism, Tourettes, Separation Anxiety Disorder, Traumatized Children
Slide 10 - Clinical Observations Adult psychiatrists see the hyperactive children of their adult patients Child psychiatrists attempt to have a conversation or appointment with the parents of their ADHD patients.
Slide 11 - Cultural More and more aspects of human behavior are now categorized as disorders requiring treatment Aspergers, ED, and now EDS (Excessive Daytime Sleepiness)
Slide 12 - Cultural Disorder means less responsibility, so having a diagnosis might lessen consequences for misbehavior in general. I can’t help it, I have ADHD
Slide 13 - What is ADHD in adults? The same two symptom dimensions as in children: Hyperactive-Impulsive Inattentiveness
Slide 14 - Hyperactive-Impulsive often fidgets with hands or feet or squirms in seat, often leaves seat in classroom or in other situations in which remaining seated is expected often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).”
Slide 15 - Hyperactive-Impulsive often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).”
Slide 16 - Hyperactive-Impulsive often has difficulty playing or engaging in leisure activities quietly, is often ‘on the go’ or often acts as if ‘driven by a motor,’ and often blurts out answers before questions have been completed
Slide 17 - Hyperactive-Impulsive often has difficulty awaiting turn often interrupts or intrudes on others (eg, butts into conversations or games)”
Slide 18 - Decreased Attention often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities; often has difficulty sustaining attention in tasks or play activities; often seems to be not listening when spoken to directly,
Slide 19 - Decreased Attention often has difficulty organizing tasks and activities, often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework), often loses things necessary for tasks or activities,
Slide 20 - Decreased Attention often is distracted easily by extraneous stimuli, and is often forgetful in daily activities” [2] .
Slide 21 - All present since childhood
Slide 22 - What are the neuropsychological basis for these symptoms? 10 years ago this was quite clear, but not any more There are no psychological tests which all adults with ADHD do poorly on. The neuropsychology of ADHD is so heterogeneous that some patients do poorly on just about any test
Slide 23 - Psychological tests can not diagnose ADHD. Nevertheless, the more executive function problems, the worse the academic and occupational outcome:
Slide 24 - Executive dysfunction Organization and planning Working memory deficits The ability to hold information “ïn your mind” so you can compare scenarios, solutions, and consequences
Slide 25 - Executive dysfunction Response Inhibition Problems Can’t resist an impulse to move, act, or think while on another task Sustained attention Shifting/Mental Flexibility Interference control
Slide 26 - What are functional deficits in ADHD in adults?
Slide 27 - Occupational and Academic More dropouts, lower occupational achievement More likely fired More likely to quit More bankruptcies Not as wealthy
Slide 28 - Family More Separations Divorce
Slide 29 - Legal More driving accidents, arrests for all causes
Slide 30 - Psychiatric Increased bipolar disorder, depression, anxiety disorder, substance abuse, smoking, Antisocial behavior
Slide 31 - Medical Increased accidents, head trauma, fractures, poisonings
Slide 32 - What are the causes of ADHD?
Slide 33 - Genetic 75% heritability, but no one gene causes this 50% of children of ADHD patient will have some signs of ADHD
Slide 34 - Biological Adversity Prematurity Smoking or drinking in pregnant mother Food additives? Obstetrical Complications
Slide 35 - Psychosocial Adversity Poverty Single parenthood Social class Chronic family conflict Low family cohesion Exposure to current, not past, parental psychopathology Abuse
Slide 36 - What looks like ADHD but isn’t? Drug abuse Depression Hypomania Head Injury syndromes Post encephalitis, structural brain lesions
Slide 37 - What looks like ADHD but isn’t? Other toxins Horrible home issues Neurodegenerative On and on………..
Slide 38 - How does it classically appear? Parents of clearly diagnosed patients of yours with ADHD Pearl: if someone has three or more children and none of them have ADHD, probably the parents don’t either. Clearly diagnosed ADHD children grown up.
Slide 39 - How does it present? About 1/3 will still be disabled as adults, with very few growing out of it after age 30. Addiction Treatment Centres and follow up Depending on the centre, 25-35% of the people in treatment programs have ADHD, too. Severe accident follow up
Slide 40 - Hyperactive in a wheelchair or rehab unit?
Slide 41 - When should you be very suspicious that this is not ADHD? Stable family life, occupation, and just psychological distress New onset problems as adult
Slide 42 - When should you be very suspicious that this is not ADHD? Come in on their own – not brought by spouse, friend, parent, etc Have a list of questions and an organized presentation of their history
Slide 43 - Treatment
Slide 44 - Three equally challenging issues
Slide 45 - Compliance Missed appointments Drop ins script refills lost prescriptions vs. diversion
Slide 46 - Dealing with the illness Dealing with the financial, legal, familial, and physical sequale Dealing with having a chronic psychiatric illness Dealing with comorbid disorders
Slide 47 - Psychotherapy Few trials, but the only success stories so far are for skill training with modules on organizing and planning, distractibility, adaptive thinking, and procrastination this one has been used in a double blind trial of persons who were treated with medications and partially responded.
Slide 48 - This is the manual from that study and a copy is on the table
Slide 49 - This is the therapist manual - copy on the table
Slide 50 - Medical Treatment of ADHD in Adults First step is to match the drug to the person, given that almost everyone will have some comorbid problem.
Slide 51 - Medications
Slide 52 - Stimulants Work immediately
Slide 53 - Short acting Stimulants Good points: Most potent of ADHD medications Bad Points: Abusable need to take three times a day can cause depression High street value in academic settings
Slide 54 - Short acting Stimulants Good choice for: extremely reliable persons with ADHD that doesn’t respond to long acting drugs with no history of substance abuse or depression Dose is 1mg/kg – about 20-30 mg tid of Ritalin or 10-20mg tid of Dexedrine. No insurance
Slide 55 - Long Acting Stimulants Good points: once a day and potent. not abusable Bad points: need to take it before 9am still can cause mood disorder doesn’t cover late night High street value in schools and University
Slide 56 - Long Acting Stimulants Cost for concerta and Adderall can be over 200 dollars a month at high doses, which are often the case in large persons. Dosages Concerta and biphentin: roughly 1mg/kg, Adderall roughly .5 mg/kg, Dexedrine Spansules, .5mg/kg,
Slide 57 - Non-Stimulants All work on the time frame of antidepressants – 8 weeks.
Slide 58 - Strattera- Good points 24 hour coverage, once a day Not abusable May help comorbid anxiety
Slide 59 - Strattera- Bad points Not that potent Still can cause mood disorders expensive- over 270 dollars a month for full doses. Dosage – start at .5mg/kg, increase to 1-1.2 mg/kg
Slide 60 - Welbutrin Good points Also an antidepressant Unlikely to cause depression Decreases smoking Can be combined with stimulants Works all day
Slide 61 - Welbutrin Bad points Not that potent Dosages -300mg/d Seizures with Bulimia, Pot
Slide 62 - Alertec (Provigil, Modafinil) Good points: Works all day Not abusable Bad points: Not that potent More GI side effects Not that cheap: 200 dollars a month Dosages 200-400 mg/d
Slide 63 - Drugs that do not work: Effexor SRIs Atypical antipsychotics Mood stabilizers Nicotine patch cannibis
Slide 64 - Realistic outcomes Three main possiblilties:
Slide 65 - Most likely outcome Non-compliant – miss appointments, forget scripts
Slide 66 - Next most likely outcome Combination of side effects and improvement usually balancing insomnia, depression, and effect. Or doesn’t cover enough of the day. Usually has less effect on higher level problems in my experience: organization, time management, procrastination
Slide 67 - Least likely outcome Completely transforms their life with minimal side effects
Slide 68 - A realistic approach Step 1. proper diagnosis is made ( one visit)
Slide 69 - A realistic approach Step 2. patient actually comes back a second time to discuss treatment and life management issues with some other responsible adult( tests whether they really can come back)
Slide 70 - A realistic approach Step 3. Start medication with the understanding that most likely skills training will be needed or couple script with skills training. “Assuming the drug does not work miracles, you will need extra help learning some new skills”
Slide 71 - A realistic approach Step 4. Monitor comorbid problems
Slide 72 - Do not: Refill scripts before they are due for stimulants, no matter what the reason Refill scripts without the patient coming in more than once in a row
Slide 73 - Do not: Hesitate to link scripts to drug screens Give stimulants directly to patients who live in dormitories Get too focused on trying to find the magic drug.
Slide 74 - References Genetics of adult attention-deficit/hyperactivity disorder.Faraone SV - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 303-21From NIH/NLM MEDLINE Driving impairments in teens and adults with attention-deficit/hyperactivity disorder.Barkley RA - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 233-60From NIH/NLM MEDLINE Brain function and structure in adults with attention-deficit/hyperactivity disorder.Seidman LJ - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 323-47From NIH/NLM MEDLINE Neuropsychological function in adults with attention-deficit/hyperactivity disorder.Seidman LJ - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 261-82From NIH/NLM MEDLINE Nonstimulant treatment of adult attention-deficit/hyperactivity disorder.Spencer T - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 373-83From NIH/NLM MEDLINE Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder.Adler L - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 187-201From NIH/NLM MEDLINE Psychosocial treatments for adults with attention-deficit/hyperactivity disorder.Safren SA - Psychiatr Clin North Am - 01-JUN-2004; 27(2): 349-60From NIH/NLM ME