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ADHD Statistics

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ADHD Statistics Options and more Options: Psychopharmacology for Behavioral Health Concerns Peter F. Bidey, DO, MSEd, FACOFP Vice Chair and Assistant Professor, Department of Family Medicine Philadelphia College of Osteopathic Medicine Prepared with Assistance by Deana M. Bidey, DO Child, Adolescent, and Adult Psychiatrist Faculty Disclosure It is the policy of the Intensive Osteopathic Update (IOU) organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Outline – The Usual Suspects • Depression • Anxiety • ADHD Statistics • Primary care offices provide about half of all mental health care for common psychiatric disorders such as anxiety, ADHD, depression, behavioral problems, and substance use. • Adults with serious mental illness and substance use disorders also have higher rates of chronic physical illnesses and die earlier, often by 13-30 years, than the general population. • When a referral is made to a mental health provider, only about 50% of patients follow through with making an appointment. • About half of all mental health disorders begin by the age of 14y/o, therefore most children with mental health conditions are first treated in the primary care setting instead of a specialized mental health setting. Keys to Remember 1. What is my first line therapy? 2. Do I have other options • Preferably Non-controlled substances • What do I have to monitor 3. Do I need Psychology? 4. Do I need Psychiatry? Case #1 Amanda is a 23y/o caucasian female who recently graduated from college with a degree in early childhood education. She is to begin her first job at a local elementary school in the fall. Over the summer, Amanda admitted to feeling fatigued, slow and sluggish during the day despite having an increase in sleep over the last few weeks. She admits to having a difficult time preparing her curriculum plan for the school year due to an inability to focus/concentrate. Her appetite has been diminished as she just “doesn’t feel hungry.” In the past, Amanda always enjoyed spending time with her friends at the lake but recently she has been more withdrawn and isolative. “I just don’t enjoy being around others right now because I don’t want to bring them down with my bad attitude.” She admits to feeling easily irritated and sometimes thinks, “people would be better off without me.” She denies self-injury but admits to sometimes hoping that she doesn’t wake up in the morning. Amanda admits to feeling this way almost everyday for several weeks now. She was reluctant to ask for help as she felt this way before during her freshman year in college when she was able to just “work through it even though my friends suggested I go talk to someone.” She seeks treatment today at the request of her parents who noticed that she has not been acting like herself recently. She was seen briefly by her PCP where she completed a PHQ9 form with a score of 18. She denies substance use or any past medical problems. She denies daily medications other than a MVI. She denies the use of birth control. Home and serum pregnancy tests came back negative. Case #1 What is the suggested treatment plan for Amanda? a) These symptoms are likely secondary to her adjustment from college and her transition into her first job, she is likely to be fine and will not need further treatment following her initial assessment. b) Initiate medication management c) Begin combination medication management with intensive psychotherapy d) Admit to an inpatient psychiatric unit for safety and risk assessment Case #1 What medication would be first line in treating Amanda’s symptoms? a) Selective Norepinephrine Reuptake Inhibitors (SNRIs) b) Selective Serotonin Reuptake Inhibitors (SSRIs) c) Antipsychotics d) Mood Stabilizing Agents Case #1 After being on SSRI treatment for the past 6 weeks with appropriate dose titration and overall good tolerance/no ADRs, Amanda has shown a slight improvement in her symptoms of depression. She denies feelings of passive SI and has had a better outlook about her future. Her PHQ9 score improved as well indicating a score of 13 (original 18). She is still having difficulty with an increase in sleep as well as lack in energy and motivation to complete her school work. She recently started seeing a local psychotherapist for weekly supportive therapy and initiation of CBT. The psychotherapist has Amanda on a waitlist for a recommended psychiatrist. What would be your next step? a) Switch Amanda to another SSRI b) Switch Amanda to an SNRI c) Discuss adjunctive therapy to increase the effectiveness of current SSRI and treat residual symptoms d) Give Amanda a stimulant (ie. Ritalin/Adderall) to improve her focus/motivation/energy (Could this also be undiagnosed adult ADD?) Antidepressant Treatment Overview 1) Serotonin specific uptake inhibitors (SSRIs) - 1st line treatment - SSRIs that are FDA approved for depression include: Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Citalopram (Celexa), Escitalopram (Lexapro) - Escitalopram (Lexapro): FDA approved treatment for adolescent depression (ages 12-17y/o) - Fluoxetine (Prozac): FDA approved treatment depression in children and adolescents (ages 8-18y/o) - Note: a) Dose titration to most effective dose is often necessary; b) GI side effects are often breakthrough and are gone within 1-2 weeks after starting an SSRI; c) allow at least 4 weeks to see full therapeutic effect; d) black box warning issued for suicidal thoughts and behavior, not suicide itself. 2) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) - Venlafaxine (Effexor/Effexor XR) and Duloxetine (Cymbalta) - 2nd line treatment medications if two trials of SSRIs were ineffective in symptom control 3) Tricyclic Antidepressants (TCAs) - Imipramine, Amitryptiline, Clomipramine, Doxepin, Notriptyline, and Desipramine - Less commonly used due to high risk with overdose and heart related effects. Antidepressant Treatment Overview 4) Monoamine Oxidase Inhibitors (MAOIs) - Isocarboxazid, Phenelzine, Selegiline, Tranylcypromine - (treatment of atypical depression or MDD with atypical features) 5) Other antidepressants: - Buproprion (Wellbutrin), Trazodone (mainly bedtime dosing to aide in sleep), Vilazodone (Viibryd; serotonin modulator), Vortioxetine (Trintellix; serotonin modulator) 6) Augmenting agents sometimes used with antidepressant therapy include: - Aripiprazole (Abilify – FDA approved for multiple conditions in both children and adults), Brexpiprazole (Rexulti – FDA approved for treatment resistant/augmentation to antidepressant therapy and schizophrenia in adults), Quetiapine (Seroquel – FDA approved augment antidepressant therapy or for Bipolar depression), Lithium (more so Bipolar depression with high risk for suicide), T3 (liothyronine supplementation), and Methylphenidate (Ritalin) Adjunct to Antidepressant therapy – Aripiprazole (Abilify) Abilify • Second generation antipsychotic; Dopamine partial agonist • FDA approved for: - Depression (adjunct) - Acute mania/mixed mania (ages > 10y/o) - Bipolar maintenance - Schizophrenia (ages > 13y/o) - Schizophrenia maintenance - Autism related irritability in children ages 6-17y/o Aripiprazole (Abilify) • Before starting aripiprazole (or any atypical antipsychotic): - Weigh all patients and track BMI during treatment - Obtain waist circumference, blood pressure, fasting plasma glucose, and fasting lipid profile • After starting aripiprazole (or any atypical antipsychotic): - BMI monthly for 3 months, then quarterly - blood pressure, fasting plasma glucose and fasting lipids within 3 months of treatment and then annually (earlier and more frequent for patients with diabetes or who have gained > 5% of initial weight; monitor for diabetic ketoacidosis, DKA) - patients with low WBC or hx of drug induced leukopenia/neutropenia should have a CBC monitored monthly during initial treatment, any sign of decline in WBC, aripiprazole should be discontinued (stop if absolute neutrophil count < 1,000/mm3 - Abnormal Involuntary Movement Scale (AIMS) re: risk for akathisia/extrapyramidal symptoms (EPS) as an ADR to aripiprazole treatment/use • Scale available free of charge at: https://ucedd.georgetown.edu/DDA/documents/tool_aims.pdf Aripiprazole (Abilify) • Dosing and Use: - initial approved dose recommendation is 10-15mg/day; maximum approved dose 30mg/day (higher than 15mg/day likely for treatment of schizophrenia or bipolar illness) - dosing at 2-15mg/day is usual range as an adjunct to antidepressant therapy; increase by up to 5mg/day qweek, for slower dose titration increase by 2mg/week as to limit ADRs – discontinuation of medication/weaning should occur in a similar way - elderly and children, dosing should be started low and go slow with titration - no need for dose adjustment in renally or hepatically impaired - monitor BP in cardiac patients due to risk for orthostatic hypotension during
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