With more than one million South

Transcription

1 PSYCHITRY Surviving the rollercoaster With more than one million South fricans between the ages of 20 and 50 affected by adult DHD, there is a need for a comprehensive guideline. Drs Renata Schoeman and Rykie Liebenberg of the South frican Society of Psychiatrists (SSOP) Special Interest Group (SIG) for adult DHD, have complied the guidelines that include assessment procedures, drug treatment options and a treatment plan for long-term health. Schoeman said despite the known efficacy of treatment and the substantial costs of untreated attention-deficit/hyperactivity disorder (DHD), access to healthcare and treatment is not a given for many patients in South frica. Comprehensive assessment is not possible during the average 15 minute general practitioner consultation, and it is therefore strongly advised that the diagnosis of adult DHD and treatment initiation should be made by a psychiatrist well versed in the complexities of DHD and the comorbidity thereof. In S, there is poor identification and treatment of common mental disorders at primary healthcare level and limited access to specialist resources with a service delivery and treatment gap of up to 75%. Medication options are also often limited in emerging markets and in S psychiatrists, and patients do not have access to the medication armamentarium available in established markets. Furthermore, the majority of South fricans currently utilise the public healthcare sector and may not have access to treatment options referred to in these guidelines, state the authors. ackground ccording to Schoeman et al, Mental restlessness was first described by Sir lexander Crichton in 1798, while Fidgety Philip (a popular storybook character and now also an allegory for children with attentiondeficit/hyperactivity disorder [DHD]) was created by Heinrich Hoffmann in ccording to the authors of the guidelines, the belief that DHD is a childhood disorder prevailed until the 1990s. Rigorous research, including longitudinal studies, and public awareness highlighted the presence of ongoing symptoms in 65% of adult patients. This has lead to the idea that adult DHD is now a recognised problem. ssociated symptoms of DHD include behavioural, cognitive, emotional and social problems. Problems with planning, task initiation, task completion, impatience and impulsivity can cause numerous work-related and interpersonal problems, states the guidelines. Prevalence DHD is the most common psychiatric disorder in children, affecting 2% to 16% of the school-age population. The population prevalence for DHD is estimated as 3% to 5%, said the authors. It is projected that between 60% and 70% of patients symptoms persist into adulthood, with the estimate of the occurance of adult DHD between 2.5% and 4.3%. DHD is more frequent in men than in women in the general population, with a ratio of approximately 1.6:1 in adults. Women are more likely than men to present primarily with inattentive features. The increased diagnosis of DHD over the past decade seems to reflect improved criteria for the identification of DHD in adults and female patients, explains Schoeman et al. The specific prevalence of DHD in S is unknown. The South frican Stress and Health study, a nationally representative household survey of 4351 adults, conducted between 2002 and 2004, investigated the prevalence and treatment access and use for mental health disorders. Unfortunately, results were grouped as anxiety disorders, mood disorders, substance use disorders Guidelines outlining the requirements for adult attentiondeficit/hyperactivity disorder that covers comprehensive diagnostic assessement and treatment, have been published for the first time in the South frican Journal of Psychiatry. July

2 PSYCHITRY Figure 1: Management process Initiating treatment Previously diagnosed in childhood: comprehensive assessment by general psychiatrist First presentation: comprehensive assessment by psychiatrist with special interest or experience in adult DHD Drug treatment should be chosen and adapted to best fit the individual, including the patients preferences and concerns Drug treatment should not be initiated if the diagnosis is uncertain or benefit is unlikely. Maintaining a response Individualised multi-modal treatment plan, which include medication and psychosocial interventions Regular review of efficacy and tolerability of medication with tritration according to individual s needs ddressing and treating comorbidity ddressing compliance. Managing partial response and non-response Review for comorbid conditions and stressors ddress compliance, stressors and lifestyle factors Review dosage and schedule of medication use Switch to second-line treatment, or combine treatment. (SUD), and any other disorder. DHD would be included within the last group, with a prevalence of 30.3%, said the authors. In the first South frican study exploring the situation with regard to the prevalence and treatment of adult DHD, extrapolating the known prevalence information to the South frican context, the expected number of adults between the age of 20 and 50 years affected by DHD was calculated to be between (3%) and (5%), states Schoeman et al. In this triangulated study, lack of knowledge of adult DHD and lack of funding for the treatment thereof were identified as the two main barriers to diagnosis and treatment. It is therefore possible that these prevalence rates are underestimating the true prevalence of adult DHD in S. Diagnosis and clinical characteristics ccording to the guidelines, the core triad of DHD is a persistent pattern of inattention or hyperactivity impulsivity that interferes with functioning. This is accompanied by associated behavioural, cognitive, emotional and social problems which can lead to work-related and interpersonal difficulties. These core symptoms should be evident since childhood, with evidence of several symptoms being present since before the age of 12. lso, substantial symptoms causing significant impairment should be present in more than one setting (e.g. home, school and work). Some of the impairments related to adult DHD include job failure or under-employment, complications such as drug dependence, driving accidents, unwanted pregnancies and sexually transmitted diseases, and even a life of perpetual failure said the authors. field trial in a representative large sample (N = 4000) of year-old adults indicated a 27% increase (from 2.8% to 3.55%) in the expected prevalence of DHD when comparing DSM-IV to DSM-5 criteria. However, the study supported lowering the symptomatic threshold for diagnosing DHD in adults, with the best symptomatic cut-off in the number of symptoms for predicting impairment being five symptoms of inattention and four symptoms of hyperactivity-impulsivity. ased on these criteria, three types of DHD are identified:» DHD combined type: If both criteria 1 and 1 are met for the past six months» DHD predominantly inattentive type: If criterion 1 is met, but criterion 1 is not met for the past six months» DHD predominantly hyperactive-impulsive type: If criterion 1 is met, but criterion 1 is not met for the past six months. Further distinctions are made with regard to severity:» Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.» Moderate: Symptoms or functional impairment between mild and severe are present.» Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe are present, or the symptoms result in marked impairment in social or occupational functioning. ssessment DHD is a clinical diagnosis, which should only be made by a specialist psychiatrist, paediatrician or other healthcare professionals with training and expertise in the diagnosis of DHD, states Schoeman. dults with suspected DHD whom have previously been diagnosed with DHD during childhood with symptoms suggestive to ongoing DHD can consult general adult psychiatric service for confirmation of diagnosis and ongoing treatment. It is important to consider the history of presenting complaints, but also to use (semi-) structured interviews, rating scales, school- or work-related assessments, social functioning assessments and collateral information in the diagnosis of the disorder. Screening The guidelines endorses the following rating scales for screening adult DHD:» The World Health Organization dult DHD Self-Report Scale (SRS) Symptom Checklist» The arkley adult DHD rating scale» The rown DD Scale Diagnostic Form (DDS)» The DHD Rating Scale» The Conner s dult DHD Rating Scale (CRS) (DSM IV)» The Wender Utah Rating Scale (WURS)» The Wender-Reimherr dult ttention Deficit Disorder Scale. Clinical evaluation The clinical interview is one of the cornerstones of the assessment process in diagnosing adult DHD. lthough various standardised, structured interviews and rating scales are available, these cannot replace the clinical assessment, but can add some rigor, standardisation and a quantifiable dimension to the areas being evaluated, the authors explained. For the main diagnostic assessment, the use of 16 July 2017

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4 PSYCHITRY the following structured diagnostic interviews may be considered:» The rown dult DHD Diagnostic Interview» The Conners dults DHD Diagnostic Interview for DSM-IV (CDID)» The Diagnostic Interview for DHD in adults (DIV). systematic interview is needed, the symptoms need to be presented, as well as the functionality across all spheres of the patients life. The arkley Functional Impairment Scale for adults and the Weiss Functional Impairment Rating Scales (WFIRS) are useful measures to assess the impact of symptoms on clinically relevant domains of functioning, said the authors. Treatment ccording to the WHO, mental health is a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. The initial goal of any intervention is therefore symptoms relief, followed by ongoing alleviation of symptoms accompanied by decreasing functional impairment and working towards optimal functioning said Schoeman. Table 1: Medication schedule Substance Trade name Formulation Dosing strategy Methylphenidate Ritalin IR HCL Douglasmethylphenidate Immediate release. vailable in 10mg pproximately 1mg/kg/dose. Initiate at 5mg bd or tds with daily or weekly increments according to efficacy and tolerability (max 100mg/day po) Ritalin L Extended release. vailable in 10mg, 20mg, 30mg and 40mg capsules Concerta Osmotic release system. vailable in 18mg, 27mg, 36mg and 54mg capsules. tomoxetine Strattera vailable in 10mg, 18mg, 25mg, 40mg, 60mg and 80mg capsules Lisdexamphetamine Vyvanse *not available in South frica vailable in 10mg, 20mg, 30mg, 40mg, 50mg, 60mg and 70mg capsules upropion Wellbutrin vailable in 150mg slow release and 150mg and 300mg extended release Venlafaxine Effexor, Venlor Imipramine/ Desipramine Tofranil, Ethipramine vailable in 75mg and 150mg extended release capsules vailable in 10mg and 25mg Clonidine Dixarit vailable in 0.025mg Modafinil Provigil vailable in 100mg Once or twice daily dose at equivalent of total daily dose of IR Once or twice daily dose at equivalent of total daily dose of IR. Initiate at approximately 0.5mg/kg/day in patients <70 kg with recommended daily dose 1.2mg/kg/day. In patients >70 kg initiate at 40mg/day with monthly increments of 20mg/ day to a maximum of 100mg/day (maintain at least for 12 weeks before judging clinical response) Initiate at 30mg/day po. May be adjusted in increments of 10mg or 20mg at approximately weekly intervals up to maximum dose of 70mg/ day. In patients with severe renal impairment, the maximum dose should not exceed 50mg/ day po. Initiate at 150mg/day po. Dosage may be adjusted in increments of 150mg approximately monthly intervals up to maximum dose of 300mg/day. Initiate at 75mg/day po. Dosage may be adjusted in increments of 75mg at approximately monthly intervals up to maximum dose of 450mg/day. Initiate at 20mg to 70mg/day (10mg in elderly patients) and increase gradually to a maintenance dose of 100mg to 150mg/day po (50mg in elderly patients) Initiate at 0.025mg bd po and increase gradually to a maximum dose of 0.075mg bd po. Initiate at 100mg/day po. Can be increased to 200mg/day po. General aspects of treatment s highlighted by the ritish ssociation for Psychopharmacology (P) guidelines, Maudsley guidelines and Schoeman, a comprehensive assessment and diagnostic certainty prior to initiating pharmacological treatment is crucial and treatment should be initiated at specialist level. Pharmacotherapy remains the cornerstone of treatment. Contrary to the treatment of DHD in children, pharmacological interventions are always first line in adults based on the lack of efficacy of non-drug intervention in the absence of medical treatment. Drug treatment should be continued as long as clinically effective and should be reviewed at least annually. Effects of missed doses, planned dose reductions and periods of non-treatment should also be evaluated. lthough pharmacotherapy plays a primary role in the treatment of DHD, psychosocial interventions are also important as an essential part of the management approach for adult DHD. multi-modal approach is also encapsulated in international guidelines (e.g. P and National Institute for Health and Care Excellence (NICE) which recommend psychosocial treatments as complementary to psychopharmacological interventions. Pharmacological treatment The first evidence for the effectiveness of stimulants in the treatment of DHD dates back to 1937, when radley conducted a trial with enzedrine in children with DHD. The first double-blind placebo controlled trial in DHD examining the efficacy of Dexedrine was done in Subsequently, many studies have been conducted and established the efficacy of both stimulant- and non-stimulant medications in the treatment of DHD in children and adolescents, and more recently 18 July 2017

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6 PSYCHITRY also in adults. Consistent with the catecholamine hypotheses of DHD, the drugs that effectively treat the disorder are known to modulate catecholamine pathways, said the authors. Medications used in the treatment of DHD include:» Psychostimulants [e.g. methylphenidate (MPH) and amphetamines]» Non-stimulants [e.g. atomoxetine, alpha2- adrenoceptor agonists (clonidine and guanfacine)» Tricyclic antidepressants (TCs)» upropion, modafinil and venlafaxine. Enhancement of dopaminergic and noradrenergic neurotransmission in the prefrontal cortex is probable critical to the therapeutic efficacy of DHD medication, stated the guidelines. The authors stress that many drugs that are mentioned in international guidelines as thirdline options for the treatment of adult DHD, are used off-label in S. lthough other drugs such as clonidine, guanfacine, TCs, modafanil and venlafaxine are mentioned, none of these are registered and use will be offlabel at the discretion of the treating physician. ccording to Schoeman et al, lthough pharmacotherapy plays a primary role in the treatment of DHD, psychosocial interventions [psycho-education, cognitive behavioural therapy (CT), supportive coaching or assistance with daily activities] are an integral part of management. Discussions on clinical efficacy are limited by the lack of head-tohead studies with adequate and unbiased methodology. In general, dopaminergic and noradrenergic agents can reduce the core symptomatology, though specific effects and side effects may vary between agents. Treatment choice would therefore also depend on factors such as patient preference and comorbid conditions, abuse potential, side effect profile and toxicity in overdose. References are available on request. SF 20 July Mental restlessness was first described by Sir lexander Crichton in -. a b c d Fidgety Philip (a popular storybook character and now also an allegory for children with attention-deficit/hyperactivity disorder [DHD]) was created by Heinrich Hoffmann in The expected number of adults between the age of 20 Signature Multiple choice questions SURNME YOUR HPCS REGISTRTION NO. ddress: Telephone: MP and 50 affected by DHD was calculated to be between (3%) and (5%). 5The is one of the cornerstones of the assessment process in diagnosing adult DHD. a. Clinical observation b. Clinical evaluation c. Clinical screening d. Clinical interview 6Pharmacological interventions are always second line in adults based on the lack of efficacy of non-drug intervention in the absence of medical treatment. 7The first evidence for the effectiveness of stimulants in the treatment of DHD dates back to, when radley conducted a trial with enzedrine in children with DHD. a b c d Enhancement of dopaminergic and noradrenergic neurotransmission in the prefrontal cortex is likely to be critical to the therapeutic efficacy of DHD medication. 9lthough other drugs such as clonidine, guanfacine, TCs, modafanil and venlafaxine are mentioned, none of these are and use will be at the discretion of the treating physician. a. Manufactured in S and on-label b. Manufactured in S and off-label c. Registered in S and C on-label d. Registered in S and D off-label Drug treatment should not 10be iniated if the diagnosis is certain or benefit is likely. This is to state that I have participated in the CPD-approved programme and that these are my own answers. INSTRUCTIONS: To complete the questionnaire online, go to and click on the CPD articles button. Click on the article on the right to access the online questionnaire. lternatively, complete the questionnaire manually and submit it via to john.woodford@newmediapub.co.za or fax it through to Your certificate will be send to you within working days. Date Fax: INITILS YES! I would like to receive The Specialist Forum for FREE monthly. Please note that the answer sheet for the CPD article is also available online. To complete the questionnaire go to click on the CPD button and select July. The article and the questionnaire will appear. C D 3It is projected that between of patients symptoms persist into adulthood, with the estimate of the occurance of adult DHD between. a. 50% and 80% and 2.5% and 4.3% b. 65% and 75% and 2.5% and 4.3% c. 60% and 70% and 2.0% C and 4.4% d. 60% and 70% and 2.5% D and 4.3% C D C D