Focusing in on Adult ADHD

Transcription

1 Focusing in on Adult ADHD Diagnosis, Psychopharmacology, and Therapeutic Interventions Sharon Praissman Fisher, MS, APRN-A, APRN-PMHNP Balance Point Wellness

2 Disclosures I have no financial/professional relationships to disclose.

3 Objectives The learner will correctly identify diagnostic criteria for ADHD in adults. The learner will identify 3 common ADHD medications and appropriate dosing ranges for them The learner will gain an increased understanding of the mechanism of action for three common ADHD medications.

4 DSM-5 Diagnostic Criteria A. A persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, as characterized by (1) and/or (2): American Psychiatric Association, 2013

5 Inattention Symptoms 6 of the following for 6 months (5 if over age 17) Lack of attention to details Poor focus Does not appear to be listening Does not finish assignments Difficulty organizing tasks Avoids activities that require sustained attention Loses things Easily distracted by stimuli or random thoughts Forgetful American Psychiatric Association, 2013

6 Hyperactivity & Impulsivity Symptoms 6 of the following for 6 months (5 if over age 17) Squirms, fidgets, taps hands Cannot remain seated Feels restless Cannot be quiet while participating in restful activities Driven by a motor Talks excessively Interrupts Intrudes American Psychiatric Association, 2013

7 DSM V (Con) MUST HAVE SYMPTOMS PRESENT BEFORE AGE 12! SYMPTOMS OCCUR IN 2 OR MORE SETTINGS CLEARLY SIGNIFCALTY AFFECTS FUNCTIONING CONSISTENT, NOT IN CONTEXT OF OTHER MOOD/ANXIETY ISSUES OR SUBSTANCE USE American Psychiatric Association, 2013

8 Max The Unicorn Presenting Info Max is a 35 yo male. He is newly married, new job, new home. He has sought treatment for anxiety and his therapist is concerned he may have ADHD. Max s wife is increasingly frustrated with him for not completing projects, constant lateness, feels he does not listen to her. Max notes forgetfulness and difficulty organizing tasks Max likes his job and recently transferred from another department because it was to hectic. He is doing well with work and loves his boss because he is patient with him. He wears headphones at work. History Therapy in 4 th grade Average grades 2013 restarted treatment Wellbutrin trial insomnia Lexapro 2015 Focus my boy, focus

9 ADHD is defined by lack of compensation during the childhood years not by successful compensation during those years! -Russell A. Barkley, PhD

10 ASRS-v1.1

11 Max The Unicorn

12 Epidemiology 4.4% of adults (5% of children) Males > females, 1.6:1 in adults Inattentive more common in females Risk factors: Temperament (thrill seeking) Low birth weight, in utero exposures Significant heritability Burkey & Perry-Parrish 2014

13 Differential Diagnoses Depression Anxiety Sleep Deprivation Substance Use Epilepsy Autism Spectrum Learning Disabilities Stress* Burkey & Perry-Parrish, 2014 *SPF s Opinion

14 The Brain on ADHD Delayed prefrontal cortex development Inattention, hyperactivity, and impulsivity are products of insufficient arousal networks Dopamine and norepinephrine improve synaptic actions that result in more efficient information processing. Stahl 2008; Thapar & Cooper 2016

15 ADHD Medications FDA Approved amphetamine atomoxetine clonidine lisdexamfetamine methylphenidate Other Medicaitons armodafinil bupropion guanfacine (approved for children) modafinil reboxetine NKOTB: Mydayis, Adzenys XR-ODT

16 amphetamine (d) Dexedrine, Dexedrine Spansules, Zenzedi, ProCentra Class: DN-RIRe, Stimulant Dose: 5-40mg divided, once daily for Spansules Side Effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss, sexual dysfunction in long term use MOA: Blocks reuptake and facilitates release of dopamine and norepinephrine Stopping: taper down Stahl, 2014

17 amphetamine (d,l) Adderall, Adderall XR, Evekeo Class: DN-RIRe, Stimulant Dose: 5-40 mg/day divided doses or once daily for long acting* Side effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss, sexual dysfunction in long term use MOA: Blocks reuptake and facilitates release of dopamine and norepinephrine Stopping: taper down Stahl, 2014

18 atomoxetine Straterra Class: N-RI Dose: mg/day in adults, once daily or divided Side effects: Decrease appetite, inc HR & BP, insomnia, dizziness, irritability, urinary retention (older men), sexual dysfunction, activation. MOA: Blocks norepinephrine pumps, secondary effect inc dopamine in PFC Stopping: taper not necessary Stahl, 2014

19 clonidine Kapvay Class: alpha 2 agonist, N-RA Dose: mg/day divided doses. 0.1mg QHS, inc by 0.1 mg/day weekly and in divided doses with largest QHS Side effects: Sedation, insomnia, hypotension, weakness, dry mouth, impotence MOA: Post synamtic alpha 2 agonist in prefrontal cortex Stopping: taper over 2-4 days minimally Stahl, 2014

20 lisdexamfetamine Vyvanse Class: DN-RIRe, Stimulant Dosing: 30-70mg/day, once daily Side effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss, sexual dysfunction in long term use MOA: prodrug of dextroamphetamine, enhances norepinephrine and dopamine in PFC by blocking reuptake and inc release. Stopping: taper Stahl, 2014

21 methylphenidate (d) Focalin XR Class: DN-RIRe, stimulant Dose: mg twice a day, XR Side Effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss MOA: Blocks reuptake and facilitates release of dopamine and norepinephrine Stopping: taper Stahl, 2014

22 methylphenidate (d,l) Concerta, Ritalin, Ritalin LA Class:DN-RIRe Dose: mg/day Side Effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss MOA: Blocks reuptake and facilitates release of dopamine and norepinephrine Stopping: taper Stahl, 2014

23 Buproprion Wellbutrin XL, Wellbutrin Class: NDRI, antidepressant Dose: once daily for XL, twice daily for IR Side Effects: Dry mouth, constipation, nausea, activaiton, headache, dizziness, anorexia, weight loss, myalgia MOA: Increases norepinephrine/noradrenaline and dopamine, nlocks reuptake Stopping: tapering preferred but not necessary Stahl, 2014

24 Mydayis Mydayis Class: DN-RiRe stimulant Dose: mg once daily Side Effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss, MOA: Blocks the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. Stopping: taper Shire, 2017

25 Adzenys XR-ODT Class: stimulant Dose: 12.5 Side Effects: Insomnia, headaches, nervousness, activation, anorexia, weight loss, MOA: Amphetamines are non-catecholamine sympathomimetic amines with CNS stimulant activity. The mode of therapeutic action in ADHD is not known. Amphetamines are thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. Stopping: taper

26 Contraindications/Warnings MAOIs slow metabolism of stimulants Straterra can cause sever liver damage and SI in young adults Cardiac screening if over age 50 or significant hx. Can increase risk of psychotic events or mania Current substance use including MJ Over diagnosing/over prescribing vs. stigma/under prescribing Gahemi vs. Goodman CMS 2013

27 Max The Unicorn Started on Vyvanse 20 mg daily F/U in 4 weeks Therapist saw him a week after initiated and he was very happy

28 Abuse, Misuse, Diversion: Breaking Bad Prescribing

29 Misuse, Abuse, & Diversion Misuse and diversion are biggest problems 5-35% college population misusing them 16.6% of meds diverted from yo with private pay insurance Estimated cost of diverted meds: million/year Random UDS Quarterly Visits at a minimum Aldridge et al. (2011); Deshpande et al. (2017)

30 Functional Impairment Inc MVA for non-medicated Inc marital/relationship problems Lower professional success Higher teen pregnancy rate Higher rates of SA (when not treated) Barkley, 2010; 2016;Despande et al., 2017; Mattingly & Anderson, 2017; Quinn et al Thapar &Cooper

31 Non Pharmacological Interventions Exercise Diet Controlling environment CBT Special accommodations in school

32 Resources/Support CHADD ADDitude Barkley

33 References Aldridge, A.P., Kroutil, L.A., Cowell, A.J. et al. Pharmacoeconomics (2011) 29: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, Barkley, R. (2010). Taking charge of adult ADHD. New York: The Guilford Press. Burkey, M & Perry-Parrish, C. (2014) Attention-Deficit / Hyperactivity Disorder. Johns Hopkins Psychiatry Guide. Retrieved from: Hyperactivity_Disorder?q=ADHD&ti=0#1 CMS (2013). Stimulant and Related Medicaitons: Use in Adults. Deshpande, Swapna et al. (2017). Managing Adult Attention-Deficit/Hyperactivity Disorder: To Treat or Not To Treat?. Psychiatric Annals 47: Mattingly, G & Anderson, R. (2016). Optimizing outcomes in ADHD treatment: from clinical targets to novel delivery systems. CNS Spectrums. 21: Quinn, P. ey al. (2017). ADHD medication and substance-related problems. American Journal of Psychiatry 174: Stahl, S. M. (2008). Stahl s essential psychopharmacology: Neuroscientific basis and practical applications. New York: Cambridge Unbiveristy Press. Stahl, S. M. (2014). The prescriber s guide: Stahl s Essential Psychopharmacology (5th ed.). New York: Cambridge University Press. Thapar A & Cooper, M (2016) Attention deficit hyperactivity disorder. Lancet 387:

34 Questions/Comments