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(BQ) Part 1 book Prescribing mental health medication the practitioner''s guide presents the following contents: The need for this book, medication management start to finish, medicating special populations.
Praise for the first edition This book is a MUST ADD to any practicing physician’s set of in office clinical references It answers virtually all the questions that come up in the day-to-day use of psychoactive medications in primary care and other clinical settings – the author provides pragmatic, well researched guidance coupled with loads of practical suggestions for ways to talk with patients and improve the effectiveness of treatment Larry Culpepper, MD, M.P.H., Professor Chairman of Family Medicine, Boston University Medical Center, USA I am very impressed both with the form and content of this book A great deal of the discussion is drawn from clinical practice and the concerns that patients have about medication It has the potential to become a much referenced text Peter Nolan, Professor of Mental Health Nursing, University of Staffordshire Learning psychopharmacology can represent a daunting challenge for the non-psychiatrist In Prescribing Mental Health Medication, Christopher Doran MD has struck the right balance in describing patient focused technique and “art” while detailing comprehensive and expert information in a masterful mix of text and table Jerrold Rosenbaum, MD, Chief of Psychiatry, Massachusetts General Hospital, Professor Psychiatry Harvard Medical School, USA Although there are countless textbooks and guidelines about psychopharmacology this book, to my knowledge, is a unique guide about how to prescribe and manage psychiatric medication It is engaging, easy to read, intelligent and incredibly useful to mental health practitioners Richard Gray, Research Fellow, Institute of Psychiatry Prescribing Mental Health Medication Prescribing Mental Health Medication is a text for practitioners who treat mental disorders with medication It is the unique text to explain the entire process of medication assessment, management and follow up for general medical practitioners, mental health practitioners, students, residents, prescribing nurses and others who are perfecting this skill Already used by providers and training institutions throughout the world, the newly revised second edition is completely updated and focuses on the following key issues: N N N N N N N N N N N how to determine if medication is needed how to start and stop medication how to dose when to change medication dealing with “difficult” medication patients specific mental health symptoms and appropriate medication special populations including: N pregnancy N substance abusers N children and adolescents N the elderly management of medication side effects practical issues such as: N monitoring medication with blood levels N managing the misuse of medication N appropriate prescription of generic preparations N safely avoiding areas of medication risk Internet prescription, telemedicine and electronic medical records organizing a prescriptive office and record keeping Completely updated, this text includes information on all psychotropic medications in use in the United States and the United Kingdom It incorporates clinical tips, sample dialogues for talking about medications to patients and information specifically relevant for primary care settings Christopher M Doran MD is a Psychiatrist and a Clinical Associate Professor at the University of Colorado School of Medicine, USA He has taught the principles and practice of psychotropic medication prescription around the globe to practitioners of all disciplines Prescribing Mental Health Medication The Practitioner’s Guide Second Edition Christopher M Doran First edition published 2003 by Routledge This edition published 2013 by Routledge Park Square, Milton Park, Abingdon, Oxon OX14 4RN Simultaneously published in the USA and Canada by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2013 Christopher M Doran The right of Christopher M Doran to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988 All rights reserved No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Doran, Christopher M., 1946– Prescribing mental health medication : the practitioner’s guide / Christopher M Doran – 2nd ed p ; cm Includes bibliographical references and index I Title [DNLM: Psychotropic Drugs–administration & dosage Drug Prescriptions– standards Mental Disorders–drug therapy Psychopharmacology–methods QV 77.2] 615’.78–dc23 2012026592 ISBN: 978-0-415-53503-8 (hbk) ISBN: 978-0-415-53609-7 (pbk) ISBN: 978-0-203-11182-6 (ebk) Typeset in Bembo by Wearset Ltd, Boldon, Tyne and Wear To my patients whose patience, strength and perseverance have taught me much of what is written here Contents List of tables xviii Preface xxii Acknowledgments xxiv A note on the icons used in this book xxv Part I The need for this book General principles of medication management The scope of the problem Mental health in the spotlight Myths and truths about mental health medication Myth 1: Mental health medication is a placebo Myth 2: Mental health medication is addictive Myth 3: Mental health medication will change personality Myth 4: Stopping mental health medicine as soon as possible is competent practice Myth 5: Mental health medication will overcome bad habits Myth 6: If side effects occur, the medication must be working Myth 7: Taking medication for depression means weakness Myth 8: Antidepressants frequently cause suicidal or homicidal thoughts Myth 9: All antidepressants are alike Myth 10: Alcohol is prohibited while taking psychotropic medicine Myth 11: Mental health medication will treat alcoholism Myth 12: A person must be substance-free to be assessed/treated accurately for mental illness 10 10 11 12 13 13 14 15 17 17 18 18 256 MEDICATING SPECIAL POPULATIONS PRIMARY CARE The necessity of extensive data collection and comprehensive evaluative procedures when diagnosing ADHD are often not feasible for busy family/general practitioners Clinicians who see large numbers of children and adolescents would benefit from the establishment of a consistent relationship with one or more mental health providers who can assist with, or provide, the necessary evaluation These clinicians can then also participate in a team-oriented approach to treatment Large practices might find it useful and cost-effective to contract with a mental health clinician on an ongoing basis Beyond this historical information, a thorough medical examination of the child must be performed to rule out other causes unrelated to ADHD for the child’s behavior These can include: N N N N N undetected seizures middle ear infections causing hearing problems learning disabilities undetected hearing or vision problems anxiety, depression or other independent mental health diagnoses Because of concern about possible cardiac effects of stimulants, some clinicians have considered an electrocardiogram (EKG) as a necessary component of the prescriptive evaluation process The latest recommendation which carries the backing of the American Academy of Child and Adolescent Psychiatry is that routine EKGs are not necessary unless a cardiac history and/or a physical examination suggest cardiac risk.27 Rating charts and evaluation forms for the child and/or parents and teachers are often used by many clinicians These include: N N N N Attention Deficit Disorders Evaluation Scale – third edition (ADDES-3)28 ADHD Rating Scale-IV (ADHD-IV)29 Vanderbilt ADHD Diagnostic Parent Rating Scale30 SNAP-IV Rating Scale-Revised (SNAP-IV-R).31 When assessing many mental health diagnoses, the use of the DSM-IV criteria or the use of ICD-10 criteria (which is used in the UK and the rest of Europe) makes little difference With ADHD, this is not the case The ICD-10 uses different terminology for these syndromes, listing them as “Hyperkinetic Disorders.” Statistically, the use of DSM IV criteria (listed in Tables 16.1 through 16.4) makes the diagnosis three to four times more likely than if the ICD-10 parameters are used.32 As can be seen in Table 16.5, however, there is significant overlap between the two classifications INATTENTION, HYPERACTIVITY AND ADHD Table 16.5 ICD-10 wording of criteria for hyperkinetic disorders “This group of disorders is characterized by: Early onset; a combination of overactive, poorly modulated behaviour with marked inattention and lack of persistent task involvement; and pervasiveness over situations and persistence over time of these behavioural characteristics Hyperkinetic disorders always arise early in development (usually in the first years of life) Their chief characteristics are lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing any one activity, together with disorganized, ill-regulated, and excessive activity These problems usually persist through school years and even into adult life, but many affected individuals show a gradual improvement in activity and attention Several other abnormalities may be associated with these disorders Hyperkinetic children are often reckless and impulsive, prone to accidents, and find themselves in disciplinary trouble because of unthinking (rather than deliberately defiant) breaches of rules Their relationships with adults are often socially disinhibited, with a lack of normal caution and reserve; they are unpopular with other children and may become isolated Cognitive impairment is common, and specific delays in motor and language development are disproportionately frequent.” Source: available at: www.who.int/classifications/icd/en/ ADHD in adults Depending on the study used, 30–60 percent of children diagnosed with ADHD are thought to show continued symptoms as adults.33–36 For a significant period of time, however, this purported incidence was not uniformly accepted by clinicians Since the diagnosis of “Adult ADHD” did not appear until the late 1980s and because of the rapid and somewhat sensationalistic presentation by print and video media, some professionals felt that this diagnosis did not represent individuals with a true mental illness Their perspective was that Adult ADHD represented a “medicalization” of poor performance and lack of personal responsibility.37 This skepticism notwithstanding, the advent of functional and structural neuro-radiological evidence of changes in the brains of these individuals, as well as genome-wide association studies, twin, family and adoption studies have led to common acceptance of the diagnosis.38 Professional bodies such as the American National Institutes of Mental Health39 and the World Health Organization,40 now endorse the validity of Adult ADHD as a recognizable and treatable mental disorder.41,42 The incidence of Adult ADHD, like that of children, has been increasing with time and is now estimated to affect 4.4 percent of the adult population in America Comorbidities with ADHD are common and include social anxiety disorder, bipolar disorder, major depressive disorder and alcohol dependence.43 A confounding factor in ADHD diagnosis in adults is that there have been no formally drafted 257 258 MEDICATING SPECIAL POPULATIONS diagnostic criteria for adults The DSM criteria were developed for children only, although many clinicians have presumed that they apply equally to adults ADHD symptoms in adults can be subtle and the assessment process subjective from clinician to clinician Evaluation of adults with symptoms of ADHD requires integration of a range of data, including patient history, patient self-report of current symptoms and mental status testing (see Chapter and Appendix 1) A thorough history should include an emphasis on past school performance and conduct, previous and current psychiatric therapies, and reports of specific symptoms of inattention, distractibility and disorganization.11 Adult patients should be asked to provide any available school records and to gather information from parents and other adults who knew them as children A family history of possible ADHD symptoms should also be obtained as siblings, parents or children frequently have similar behaviors Because adults with ADHD may not appreciate their symptoms, the patient’s spouse or partner should ideally be included in the evaluative interview Even though patients with ADHD may have difficulty accurately recalling relevant history, an extended, consistent pattern of ADHD symptoms, dating to early childhood is essential in making the diagnosis A recent onset of symptoms or sporadic episodes of symptoms should raise concern about the appropriateness of an ADHD diagnosis The medical evaluation should include a neurologic examination There are suggestions that patients with ADHD exhibit a greater incidence of “soft neurologic signs” including problems with right–left discrimination, motor overflow movements and sequencing difficulties Laboratory tests may include a serum lead level and thyroid function tests.44 There are numerous questionnaires developed for clinician use in diagnosing ADHD in adults (see Table 16.6.) Corroborative information on organization, Table 16.6 Rating evaluation forms for ADHD in adults N N N N N N The Wender Utah Rating Scale1 The Copeland Symptom Checklist2 The Brown Adult ADD Scale3 The Connors Adult ADHD Rating Scales (CAARS – one for patients and a second for observers)4 The ADHD-RS-IV Rating Scale with Adult prompts (this scale can also be used to track patient progress)5 The Barkley Adult ADHD Rating Scale6 Sources: McCann et al (2000) Discriminant validity of the Wender Utah Rating Scale for attentiondeficit/hyperactivity disorder in adults J Neuropsychiatry and Clinical Neurosciences 12: 240–245 Copeland ED (1991) Medications for Attention Disorders (ADHD/ADD) and Related Medical Problems (Tourette’s Syndrome, Sleep Apnea, Seizure Disorders) SPI Press Brown TE (1996) ADD Scales Psychological Corp., pp 5–6 Available at: http://psychologyafrica.com/pdf/Products/Conners DuPaul GJ et al (1998) ADHD Rating Scale–IV: Checklists, Norms, and Clinical Interpretation Guilford Press Available at: www.russellbarkley.org/ INATTENTION, HYPERACTIVITY AND ADHD attention to detail and capacity for accuracy can be obtained from the manner and thoroughness with which a patient completes one of these questionnaires The report of a spouse or significant other may also help the prescriber A patient may subjectively report that they have difficulty at work or in school, but there is often no objective work or school performance information available to the clinician Therefore, at this time, the diagnosis of Adult ADHD is solely a clinical assessment and formulation Stimulant medication and its appropriate uses While the diagnosis of ADHD can be somewhat complicated and challenging, the medication prescription decisions for this disorder are relatively simple While not the only treatment, medication is a central feature of ADHD treatment for many patients At least two-thirds of children with current ADHD are taking medication for the disorder and the percentage is increasing.45,46 Stimulant medications (sometimes referred to as “psychostimulants”) are generally thought to be the medication treatment of choice by most clinicians.47 As noted later in this chapter, other medications are also prescribed, but with less frequency The general term “stimulant” refers to properties of certain drugs or medications which “stimulate” or enhance a particular body system, such as cardiac stimulants or respiratory stimulants In mental health, however, the term is used specifically to identify a group of medications which have a variety of neurological and physical effects and are postulated to act by affecting brain catecholamine neurotransmitters, especially norepinephrine and dopamine Benzedrine was first used with behaviorally disturbed children in 1937 Eleven years later, Dexedrine was introduced, with the advantage of having equal efficacy at half the dose Methylphenidate (marketed as Ritalin) was introduced in 1954 with the hope that it would have fewer side effects and less abuse potential Currently, there are numerous branded stimulant medications (see Table 16.7) although the underlying chemicals contained in these brands are closely related and/or stereoisomers of the parent compounds – amphetamine, dextroamphetamine, lisdexamphetamine, methylphenidate and dexmethylphenidate Other than the speed with which the medication enters the system (immediately or time release) and the modality of preparation (pills, capsules, liquid or patch) these medications have generally similar effects, uses, side effects and prescriptive patterns Although, as with all psychotropics, there is individual variability of response to any particular drug in this medication class, there is little statistical therapeutic advantage to one medication over another It is often useful for the beginning clinician initially to learn one or two preparations/medications well and be less concerned with the remainder of the list With experience, other preparations can be learned Other uses of stimulant medication This chapter focuses on Attention Deficit Hyperactivity Disorder and treatment with stimulants However, because of stimulant’s wide effects in the central and peripheral 259 260 MEDICATING SPECIAL POPULATIONS Table 16.7 List of currently available stimulant medications* Trade name Generic name Approved age Adderall Adderall XR Concerta Daytrana Desoxyn Dexedrine Dextrostat Focalin Focalin XR Metadate ER Metadate CD Methylin Ritalin Ritalin SR Ritalin LA Vyvanse amphetamine amphetamine (extended release) methylphenidate (long acting) methylphenidate patch methamphetamine hydrochloride dextroamphetamine dextroamphetamine dexmethylphenidate dexmethylphenidate (extended release) methylphenidate (extended release) methylphenidate (extended release) methylphenidate (oral solution and chewable tablets) methylphenidate methylphenidate (extended release) methylphenidate (long acting) lisdexamfetamine dimesylate 6 6 3 6 6 6 6 and and and and and and and and and and and and and and and and older older older older older older older older older older older older older older older older * Source: available at: www.nimh.nih.gov/health/publications/attention-deficit-hyperactivitydisorder/complete-index.shtml#pub11 nervous systems (such as increased alertness, wakefulness and arousal; enhanced endurance, productivity and motivation, increased motor activity, heart rate and blood pressure) they have been used in mental health practice in a variety of additional clinical situations These include: N N N N N N to counteract lethargy and fatigue to reduce sleepiness and increase wakefulness to decrease appetite and promote weight loss to treat narcolepsy off-label as a third or fourth line treatment for clinical depression as a remedy for the side effect of dizziness due to lowered blood pressure Dosing of stimulants The initial dosing of stimulants in immediate release and sustained release preparations can be seen for each specific medication in Appendices and In children and adolescents, the American Academy of Child and Adolescent Psychiatry recommends starting doses of 2.5 mg of mixed salt amphetamines (Adderall) or mg of methylphenidate (Ritalin and others) If symptom control is not achieved, the dose generally should be increased in weekly increments of 2.5 to mg for mixed salt amphetamines or to 10 mg per dose for methylphenidate.48 Full symptom control may require multiple doses during the day In general, patients are started on immediate release preparations When symptom control is INATTENTION, HYPERACTIVITY AND ADHD achieved, long-acting preparations may be substituted In individuals who are deemed to be at higher risk for abuse of medication, initial use of long-acting preparations may minimize the potential for abuse When long-acting preparations are used, their effect may not carry over into the late afternoon or early evening If concentration and attention is needed at those times of day (for homework or other activities), it may be useful to provide a small “tail” dose of an immediate release preparation later in the day When doing so, the clinician must be aware that such a “tail” may produce a delay in sleep onset Dosing strategies in adults vary, although one common practice is to start at modest doses (2.5 to mg of an immediate release product) and increase after a week, aiming for target doses of 0.5 mg per kilogram of body weight.49 Side effects of stimulants Because of the stimulatory effect of this class of medication on norepinephrine and dopamine, the common side effects of stimulants are relatively easy to predict They include: N N N N N N N N decreased appetite weight loss difficulty initiating or maintaining sleep irritability headache jitteriness and palpitations feeling flushed or sweating behavioral tics While clinicians and researchers have long been concerned about the cardiovascular effects of stimulants, recent studies have been reassuring Children followed over a 10-year period showed no increase in blood pressure or heart rate when treated with stimulants50 and cardiovascular events were rare.51–53 Other medications used in ADHD While stimulants are the mainstay of ADHD prescription, several other medications are used to treat this condition The most prominent of these is atomoxetine (Strattera) Atomoxetine, a non-stimulant norepinephrine re-uptake inhibitor, has been available since 2005 It has shown effectiveness in ADHD treatment for children above the age of six, as well as adolescents and adults It is not a controlled substance and has minimal abuse potential Unlike stimulants whose effects are seen quickly (often with a single dose), atomoxetine takes a minimum of a week to build up in the system and generally should be continued for to weeks to assess effectiveness It is often used in patients who have not responded to stimulants, are averse to taking stimulants or have side effects to them The starting atomoxetine dosage for adults, as well as children or teens weighing more than 154 pounds is 40 mg once 261 262 MEDICATING SPECIAL POPULATIONS daily or 20 mg twice daily Children and teenagers weighing less than 154 pounds typically start with 0.25 mg of atomoxetine per pound of body weight, rounded to the nearest available strength Side effects to the medication include dry mouth, nausea, decreased appetite, constipation, dizziness, sweating, decreased libido, urinary hesitancy, palpitations, increased in heart rate and blood pressure.54 Certain antihypertensive medications including guanfacine (Intuniv and Tenex) and clonidine (Catapres) have shown efficacy in treating ADHD Although guanfacine, an alpha-2 agonist, has been used off-label for several years to treat ADHD, it has recently received American FDA approval in an extended-release formulation It has shown effectiveness primarily in younger children with the hyperactive form of the condition and less so with the inattentive form Clonidine has been used to decrease impulsivity and aggression, primarily in children These medications also have been prescribed to reduce tics or insomnia caused by other ADHD medications Last, antidepressants have shown some treatment effectiveness Although the evidence is limited, there is support for utilizing tricyclic antidepressants and bupropion in ADHD.55–59 Additional treatments for ADHD beside medication As with virtually all mental health conditions, medication alone is less effective without additional treatment modalities ADHD is no exception Beyond the benefits that medication can provide, specific behavioral suggestions and interventions can be helpful to both the child and adult patient Depending on the arrangement for prescription, a mental health clinician may be primarily involved in providing non-medication treatment In other situations, the prescriber may also provide the patient with elements of non-medication treatment Types of non-medication interventions for ADHD are listed in Table 16.8 There are many books, authoritative pamphlets and articles which provide helpful strategies for patients and parents A selection of them is listed in Table 16.9, however a further Internet or bookstore search will reveal many more Other alternative/home remedies for ADHD As shown in Table 16.9 (which is only a partial listing), there are an extraordinary number of books and informational sites offering suggestions to improve the lives of people with ADHD Because of the intense media attention given to this diagnosis, it is important that the clinician be familiar with alternative/home remedies which may have some limited evidence-based support (Table 16.10) and those that have virtually none (Table 16.11) Patients and their families will almost certainly inquire Even though advocated by various sources (including some of those in the previously cited list of references), treatments listed in Table 16.13 have not conclusively been shown to be effective in ADHD For any given treatment modality, there may be case reports, anecdotal evidence or small studies To date though, none of these modalities has sufficient conclusive, replicable research to warrant recommendation for ADHD patients INATTENTION, HYPERACTIVITY AND ADHD Table 16.8 Non-medication interventions for ADHD patients N N N N N N N Behavior therapy – teachers and parents follow specific behavior changing strategies to deal with problematic behavior Such strategies can include reward/penalty systems to reinforce desired behaviors Individual psychotherapy – adult and child patients can benefit from exploring and sharing upsetting behaviors and situations They can explore negative behavioral patterns and ways to deal with their symptoms Patients learn to monitor themselves and their own behavior while giving themselves positive rewards when appropriate Practical skills training – individuals benefit from help in organizing tasks to complete schoolwork and/or occupational work while sustaining themselves through emotionally difficult events Social skills training – children need to learn how to wait their turn, share their toys/belongings, ask for help and respond to teasing Many ADHD patients have not learned to appropriately read facial expressions and voice tone from others and hence not respond appropriately These are, however, teachable and learnable skills Parenting skills training – many parents, particularly young parents or those with emotional problems themselves, have not learned the most effective ways to understand and guide their child’s behaviors Training parents often focuses on: N giving children immediate positive or negative feedback on specific behaviors N the use of “timeouts” N avoiding overstimulation of a child N showing the child considerable affection in spite of frustrating behavior N practicing patience and keeping events in perspective N keeping a regular schedule for meals, naps and bedtimes to assure that the child gets adequate rest N planning ahead to anticipate difficult or problematic situations for the child N finding ways to improve their child’s self-esteem N being simple and straightforward with directions and discipline N learning stress management techniques for themselves Family therapy – in addition to the above modalities, bringing the entire family constellation together including parents, the identified patient and siblings, can often further treatment goals most efficiently and effectively Support groups – most metropolitan areas have ADHD support groups for patients and families Abuse of stimulants As outlined above, the process for prescribing and monitoring stimulant medications is generally straightforward and not difficult There is, however, one significant area relevant to stimulant prescription that can potentially create significant problems – medication misuse, abuse and diversion Each of these terms is 263 264 MEDICATING SPECIAL POPULATIONS Table 16.9 ADHD therapy references Print books N Parenting Children with ADHD: 10 Lessons that Medicine Cannot Teach (APA Lifetools)1 N The ADD & ADHD Answer Book: Professional Answers to 275 of the Top Questions Parents Ask2 N Learning To Slow Down & Pay Attention: A Book for Kids About ADHD3 N More Attention, Less Deficit: Success Strategies for Adults with ADHD4 N Taking Charge of ADHD: The Complete, Authoritative Guide for Parents (Revised Edition)5 N The Disorganized Mind: Coaching Your ADHD Brain to Take Control of Your Time, Tasks, and Talents6 N ADD-Friendly Ways to Organize Your Life7 N The ADHD Bookstore8 Internet websites N ADHD Teacher Resources9 N Children and Adults with ADHD10 N The National Resource Center on ADHD11 N Attention Deficit Disorder Resources12 N ADDvance Resources13 Sources: Monastra VJ (2005) Parenting Children with ADHD: 10 Lessons that Medicine Cannot Teach (APA Lifetools) American Psychological Association Ashley S (2005) The ADD & ADHD Answer Book: Professional Answers to 275 of the Top Questions Parents Ask Sourcebooks Inc Nadeau KG et al (2004) Learning To Slow Down & Pay Attention: A Book for Kids About ADHD, 3rd edn Magination Press Tuckman A (2009) More Attention, Less Deficit: Success Strategies for Adults with ADHD Specialty Press Barkley RA (2000) Taking Charge of ADHD: The Complete, Authoritative Guide for Parents (Revised Edition) Guilford Press Ratey NA (2008) The Disorganized Mind: Coaching Your ADHD Brain to Take Control of Your Time, Tasks, and Talents St Martin’s Griffin Kolberg J and Nadeau K (2002) ADD-Friendly Ways to Organize Your Life Routledge Available at: http://add411.com/ Available at: www.attentiondeficitdisorder.ws/adhd_educator_resources.htm 10 Available at: www.chadd.org/ 11 Available at: www.help4adhd.org/ 12 Available at: http://w3.addresources.org/ 13 Available at: www.addvance.com/resources/index.html#links defined differently but all three apply to the inappropriate usage of stimulants “Misuse” is a generalized term in which a medication is utilized for a purpose or dose that is not consistent with medical guidelines With stimulants, this can involve unauthorized escalation of dose by the patient or utilizing the medication primarily to obtain a drug “high.” Drug “abuse” has been defined by the Diagnostic and Statistical Manual as repeated, recurrent use of a substance despite INATTENTION, HYPERACTIVITY AND ADHD Table 16.10 ADHD therapies that have some evidence-based support N N Fish oil (essential fatty acids) – as has been stated elsewhere in this text, the use of omega-3 fatty acids has shown a limited but useful role in minimizing symptoms of mood disorders As precursors of neuronal development, there is limited evidence that omega-3 fatty acids may have a beneficial effect in ADHD, but at the time of this writing the issue remains unclear and further research is necessary.1–3 EEG biofeedback/neurofeedback training – this modality involves connecting the patient to an electroencephalograph while performing designated tasks The patient “learns” to train his/her brain by monitoring changes in EEG wave patterns as certain behaviors are performed Although still early in its development and utilization, there is evidence-based support that this treatment may be helpful for ADHD Further larger-scale studies and refinement of the technique are necessary.4–6 Sources: Richardson AJ et al (2002) The Oxford-Durham study: a randomized, controlled trial of dietary supplementation in children with specific learning difficulties Progress in NeuroPsychopharmacology and Biological Psychiatry 26(2): 233–239 Sinn N and Bryant J (2007) Effect of supplementation with polyunsaturated fatty acids and micronutrients on learning and behavior problems associated with child ADHD Journal of Developmental & Behavioral Pediatrics 28(2): 82–91 Richardson AJ and Montgomery P (2005) Children with developmental coordination disorder Pediatrics 115(5): 1360–1366 Monastra VJ (2008) Unlocking the Potential of Patients with ADHD: A Model for Clinical Practice American Psychological Association Monastra VJ et al (2006) Electroencephalographic biofeedback in the treatment of attentiondeficit/hyperactivity disorder, investigations in neuromodulation, neurofeedback and applied neuroscience Journal of Neurotherapy 9(4): 5–34 Lubar JF et al (1995) Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in T.O.V.A scores, behavioral ratings, and WISC-R performance Applied Biofeedback and Psychophysiology 20(1): 83–99 adverse consequences of its use Some individuals, particularly those with chemical dependency or substance use disorder, are prone to abuse stimulants, and such patients require careful monitoring Both of these issues, as well as guidelines to clinicians for minimizing these possibilities, are covered in more depth in Chapter 20 on the Misuse of Medication “Diversion” of medication is a third clinical entity which is unfortunately common with stimulant prescription Diversion occurs when medication prescribed for one individual is given to another for whom it is not prescribed This happens with frequency in high schools, on college and university campuses, or in other group settings where teens and young adults spend considerable time together Medications are “shared,” traded for other medications/good/services or sold for money Research surveys have documented the pervasive extent of medication diversion In a 10-year longitudinal study of youth to whom stimulants were prescribed for ADHD, it was found that 22 percent misused their medication and 11 percent 265 266 MEDICATING SPECIAL POPULATIONS Table 16.11 Purported ADHD therapies that in general are not adequately evidence based* N Yoga and meditation – while intuitively it might seem that activities such as yoga and meditation with their calming properties would reduce ADHD symptoms, but there is no conclusive evidence that this is so N Vitamin, mineral or herbal supplements – vitamins and mineral supplementation may be important for overall good health particularly in those children who have extremely poor diets There is no evidence, however, that supplemental vitamins and minerals including so-called “megadoses” of vitamins are helpful for ADHD “Megadoses” may actually be harmful St John’s Wort has specifically been shown not to be helpful ADHD special diets – a wide variety of dietary regimens have been suggested as treatment for ADHD, including those that limit caffeine, sugar, artificial food colorings and common allergens such as wheat, milk and eggs Although there are sporadic research studies for any given special diet, consistent and replicable evidence has not been shown for any one dietary plan being helpful Specifically, limiting refined sugar in the diet does not help ADHD children N * Sources: Sawni A (2008) Attention-deficit/hyperactivity disorder and complementary/ alternative medicine Adolescent Medicine: State of the Art Reviews 19(2): 313–326, xi; Brue AW and Oakland TD (2002) Alternative treatments for attention-deficit/hyperactivity disorder: does evidence support their use? Altern Ther Health Med 8(1): 68–70, 72–74; www mayoclinic.com/health/adult-adhd/DS01161/DSECTION=treatments-and-drugs diverted it.60 A survey of 11 000 college students at over 100 university campuses in the US calculated that percent of students had misused their stimulants for non-medical purposes during their lifetime and percent of them had done so in the past year.61 Stimulants in the higher education arena are seen as “study aids” and therefore as valuable commodities to increase concentration, wakefulness, study skills and exam performance Two different Internet surveys reported the incidence of stimulant misuse for the purpose of increased concentration at 6.0 percent and 5.4 percent, respectively.62,63 The clinician then, is caught in a bind Stimulant medications are helpful, targeted treatments which improve patient clarity, organization and attention to detail in those patients who have the diagnosed mental condition, ADHD Yet at the same time there is the widely documented possibility for medication misuse and diversion These are useful agents and it would be inappropriate for a clinician to avoid new stimulant prescriptions altogether solely because of possible abuse by some patients In certain situations, a prescriber may “inherit” a patient from another prescriber or setting who has benefited from stimulant use and has utilized them responsibly To pro forma stop such a prescription would also not be prudent Therefore, most prescribers prescribe stimulants, but maintain vigilance to the signs and behaviors of potential misuse These warning signs are listed in Table 16.12 INATTENTION, HYPERACTIVITY AND ADHD Table 16.12 Warning signs of possible stimulant misuse N N N N N N N N Frequent or continuous requests for increased dosage levels Missed appointments and inconsistent attendance at follow-up appointments Repeated lost prescriptions or requests for an early refill Calls for an emergency supply of medication Symptoms of psychosis (especially hallucinations which can occur at high doses of stimulants) Syncope, shortness of breath and palpitations (all of which can occur at elevated stimulant doses) Insistent demands for immediate release stimulants as opposed to time-release preparations Other behavioral signs of substance abuse (see Chapter 14) Several points are important to note in reading Table 16.12: N N N Virtually all of the statistical data collected on stimulant misuse shows that immediate release stimulants are abused almost exclusively in comparison to long-acting, time-release preparations While it might seem that by limiting stimulant prescriptions solely to long-acting preparations would solve the misuse problem, this is not a practical solution There are clearly some patients who not respond well to long-acting preparations and get full symptom relief only with immediate release preparations It is also easier to raise dosage and assess therapeutic effect with immediate-release preparations and switch later to time-release products In the statistical studies cited above, the vast majority of individuals who misuse and abuse stimulants had a history of chemical dependency and/or a substance use disorder Therefore, screening for these disorders is a critical part of initial ADHD treatment For those patients who have active signs of substance abuse and/or a strong history of abusing psychostimulants or other drugs, treatment for these issues must be undertaken or compliance assured prior to any prescription of stimulants When stimulant prescription is deemed appropriate for these individuals, it would be wise to avoid the use of immediate release preparations and begin treatment with time-release preparations only No clinician, no matter how diligent, can totally eliminate the possibility of medication misuse and diversion in his/her prescribing practice There are a number of strategies that a clinician should undertake to minimize and counteract medication misuse These are discussed in detail in Chapter 20 and it would be beneficial for the reader to proceed to that chapter before starting Chapter 17 Some clinicians, particularly those in institutional settings, advocate the use of patient “Contracts” or “Advisories” when prescribing stimulants These documents usually contain specifics about the necessity of adherence to prescribed medication dosing and the consequences for medication misuse or the divergence 267 268 MEDICATING SPECIAL POPULATIONS The effectiveness of such contracts is unclear In all likelihood the sociopathic, personality-disordered or drug abusing patient would not be dissuaded from inappropriate use of medication by having signed a contract Nevertheless, such documents alert patients to the clinician’s response for such behavior Usually two areas are covered: N N The clinician states how lost, stolen or otherwise misplaced prescriptions and doses will be managed With stimulants, the appropriate response is that no additional medications will be provided and no early renewals of the prescription will occur Unlike other abusable prescription medications (for example, benzodiazepines), abrupt stoppage of stimulants may be uncomfortable, but does not represent a serious health or safety concern Going without stimulant medication for a period of time may also serve to reinforce to the patient that they need to be more careful in the future A second area discussed in such contracts is especially useful in an institutional setting This section can describe how the clinician will respond to any documented occurrence of diversion or misuse The appropriate response in this situation is prompt and permanent discontinuation of stimulant prescription The prescriber should also report the incident to the institutional authorities for whatever further action is appropriate To make this policy effective, of course, the clinician must follow through on his/her policy quickly and consistently to establish an institutional climate of appropriate control If the clinician fails to so with the thought of being “lenient,” it only serves to increase the likelihood of future misbehavior on the part of the identified patient or others at the facility References Nair J et al (2006) Clinical review: evidence-based diagnosis and treatment of ADHD in children Mo Med 103(6): 617–621 Centers for Disease Control (2008) Diagnosed attention deficit hyperactivity disorder and learning disability: United States, 2004–2006 Vital and Health Statistics 10(237) Bruchmüller K et al (2012) Is ADHD diagnosed in accord with diagnostic criteria? 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Pediatrics 117(4): e601–609 33 National Institute of Mental Health Attention deficit/hyperactivity disorder Available at: www.nimh.nih.gov 34 Kates N (2005) Attention deficit disorder in adults: management in primary care Can Fam Physician 5: 53–59 35 Wilens TE et al (2002) Attention deficit/hyperactivity disorder across the lifespan Annu Rev Med 53: 113–131 36 Valdizán JR and Izaguerri-Gracia AC (2009) Attention deficit hyperactivity disorder in adults Revista de neurologia 48(Suppl 2): S95–99 37 Conrad P and Potter D (2000) Hyperactive children to ADHD Adults, 2000 Social Problems 4(4): 559–582 38 www.medscape.org/viewarticle/765528 39 Available at: www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder 40 Kessler RE et al (2005) The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population Psychol Med 35: 245–256 41 Tom CM (2005) Recognizing and treating ADHD in adolescents and adults US Pharmacist 30(1): 67–76 42 Gentile JA and Gillig PM (2006) Adult ADHD: diagnosis, differential diagnosis, and medication management Psychiatry 3(8): 25–30 43 Kessler RC et al (2006) The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication Am J Psychiatry 163: 716–723 44 Searight HA et al (2000) Adult ADHD: evaluation and treatment in family medicine Am Fam Physician 62(9): 2077–2086 45 Available at: www.cdc.gov/ncbddd/adhd/data.html 46 Available at: http://ego.thechicagoschool.edu/s/843/images/editor_documents/ childadolescent/Stimulant%20Medications.pdf 47 Wigal SB (2009) Efficacy and safety limitations of attention-deficit hyperactivity disorder pharmacotherapy in children and adults CNS Drugs 23(Suppl 1): 21–23 48 Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults, AACAP, Available at: http://ego.thechicagoschool.edu/s/843/images/editordocuments/childadolescent/Stimulant%20 Medications.pdf ... 16 .5 16 .6 16 .7 16 .8 16 .9 16 .10 16 .11 16 .12 17 .1 17.2 17 .3 17 .4 17 .5 17 .6 17 .7 17 .8 17 .9 17 .10 17 .11 17 .12 17 .13 17 .14 17 .15 17 .16 18 .1 18.2 18 .3 18 .4 18 .5 18 .6 18 .7 18 .8 18 .9 18 .10 Signs of impulsiveness... 8.4 8.5 8.6 8.7 8.8 8.9 8 .10 8 .11 8 .12 8 .13 8 .14 9 .1 10 .1 10.2 10 .3 12 .1 12.2 13 .1 13.2 13 .3 14 .1 14.2 14 .3 14 .4 15 .1 15.2 15 .3 15 .4 15 .5 15 .6 15 .7 15 .8 16 .1 16.2 Mental health treatments and modalities... considerations in the elderly 18 3 18 4 18 5 18 6 18 7 18 8 19 0 14 5 14 7 15 1 15 2 15 2 15 3 16 1 16 2 16 3 16 5 16 5 16 6 16 8 16 9 17 0 17 2 17 3 17 5 17 6 17 6 17 7 17 7 CONTENTS 13 Medication of sleep problems Facts and definitions