MINISTRY OF CHILDREN AND YOUTH SERVICES Practical Psychopharmacology for More Complex Mental Health Presentations Part 1: Stimulants Dr. Ajit Ninan & Joel Lamoure 1
Practical Psychopharmacology for More Complex Mental Health Presentations: A 3 part series Part 1: Stimulants Part 2: Antipsychotics and Mood Stabilizers (Jan 31, 2018) Today Part 3: Anti-Depressants/Anti-Anxiety Medications (April 11, 2018) 2
Objectives By the end of this presentation, participants will be able to Identify why a stimulant would be prescribed, and how it works, in family-friendly language Describe the differential diagnosis for ADHD Discuss factors that contribute to the selection of a stimulant for a young person with a complex presentation Describe the safety profile of stimulant medications, including side effects and interactions 3
https://commons.wikimedia.org/wiki/file:neuronal_signal_transmission.gif HOW DO STIMULANTS WORK? 4
Neurotransmitters in ADHD The dopaminergic and the noradrenergic systems are the primary drivers in the ADHD picture There are interfaces at several areas of the brain with dopamine-norepinephrine and serotonin This may explain the affective mood components and some of the dopaminergic and limbic-driven behaviours Trauma-informed clinical understanding Stimulant agents affect dopaminenorepinephrine in the synapse, and serotonin downstream. https://commons.wikimedia.org/wiki/file:dopamin e_norepinephrine_serotonin_venn_diagram.png Solanto. Behav Brain Res 1998;94:127.
Medications: Stimulants Methylphenidate Biphentin, Concerta, Ritalin, Ritalin-SR, Methylin Lisdexamfetamine Vyvanse Dextroamphetamine Dexedrine Dextroamphetamine/ amphetamine Well studied in school-aged children Over 150 studies https://c1.staticflickr.com/9/8382/8579826302_6bd84aa54 0.jpg
Functional Impairment in Patients with ADHD Compared to Those Without Repeat a grade < high school Teen pregnancy STD Substance abuse Accident prone Serious car accident Arrested Incarcerated Fired from job ADHD ADHD Typical Normal 0% 10% 20% 30% 40% 50% 60% Subjects (%) Barkley RA. Attention-Deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment, 1998. Barkley RA, et al. JAACAP. 1990;29:546-557. Biederman J, et al. Arch Gen Psychiatry. 1996;53:437 446. Weiss et al. J Am Acad Child Psychiatry. 1985;24:211-220. Satterfield, Schell. JAACAP. 1997;36:1726-1735. Biederman J, et al. Am J Psychiatry. 1995;152:1652-1658.
Learning Through. HOW IS A STIMULANT CHOSEN? 8
What Doctors Consider When Choosing a First-Line Medication Medical considerations Treatment guidelines Urgency of treatment Duration of effect Patient preference Co-morbid symptoms Previous treatment success History of drug abuse (individual or family) Practical considerations Adherence Stigma Cost / insurance Administration: By parent / guardian? For child in foster care? Pliszka SR, et al. J Am Acad Child Adolesc Psychiatry 2006;45(6):642-57.
CASE STUDY 1 10
Differential Diagnosis Developmentally appropriate inattention and hyperactivity Intellectual Disability Learning disorders Neglect and/or Abuse Oppositional behavior Anxiety Depression Mania Caffeine and other substances - especially important in adolescents. Movement Disorder Autism Spectrum Disorder
Differential Diagnosis Medical conditions Hyperthyroidism Hypothyroidism Seizure disorders Sleep disorders Genetic conditions Head trauma Toxic exposures Certain prescription medications In utero substance exposure
Psychiatric Disorders to Consider in the Differential Diagnosis of ADHD Psychiatric Disorder Features Shared with ADHD Differential Features Major Depression Bipolar Disorder Subjective report of poor concentration, attention, and memory Difficulty with task completion Increased activity, difficulty with maintaining attention and focus Irritability Substantial and episodic dysphoria Enduring dysphoric or euphoric mood Insomnia Psychotic symptoms Generalized Anxiety Fidgetiness Difficulty concentrating Exaggerated apprehension and worry Somatic symptoms of anxiety Searight HR, et al. Am Fam Physician 2000;62:2077-2092.
CASE STUDY 2 14
CADDRA Guidelines for Pharmacological Treatment of ADHD 1 st Line 2 nd Line 3 rd Line Long-acting + approved by Health Canada Adderall XR Biphentin Concerta Strattera Short-acting + approved by Health Canada Dexedrine Dex Spansules PMS or Ratio - MPH Ritalin Ritalin-SR "Off-label" if drugs fail Imipramine Buproprion Modafinil CADDRA. Canadian ADHD Practice Guidelines. www.caddra.ca.
Premises of Pharmaceutical Care: TAIDCC T Therapeutic A Allergies/ Accurate? I Interactions? D Duplications of therapy? C Compliance/change? C Cost/Coverage? 16
CASE STUDY 3 17
The Link between ADHD and Trauma Children/youth who experience traumatic stress reactions can sometimes have symptoms that look similar to ADHD (e.g., distraction, disorganization, hyperactive, sleep problems) This can proceed on to adulthood and links to limbic system reactions and dopamine * Image from Siegfried et al., 2016, Trauma in Ontario education 2017 18
You Might Be Asking Why / when to use ADHD medication combinations? When to choose non stimulants over stimulants? When to add non-adhd medications? 19
Texas CMAP: Algorithm for the Medication Treatment of ADHD Without Comorbid Psychiatric Disorder Stage 0 Stage 1 Diagnostic Assessment and Family Consultation Regarding Treatment Alternatives Methylphenidate or Amphetamine Non-Medication Treatment Alternatives Any stages can be skipped depending on the clinical picture Partial or Non-response Response Continuation Stage 2 Stimulant not used in Stage 1 Partial or Non-response Response Continuation Stage 3 Atomoxetine Partial or Non-response Response Continuation Stage 4 Bupropion or TCA Partial or Non-response Response Continuation Stage 5 Agent not used in Stage 4 Partial or Non-response Response Continuation Stage 6 Alpha Agonists** Maintenance *Plus liver function monitoring and substance abuse history, **cardiovascular side effects Pliszka et al. JAACAP, 45:6, June 2006, 642-57
ADHD and Aggression Assessment/ family consultation/ treatment planning Partial or nonresponse aggression 3. Add atypical antipsychotic to stimulant Partial or nonresponse aggression Non-medication treatments 1. Begin ADHD algorithm Response ADHD/ aggression 2. Add behavioral intervention Continue Partial or nonresponse aggression Partial or nonresponse aggression Partial or nonresponse aggression Partial or nonresponse aggression 4. Add lithium or divalproex sodium to stimulant 5. Use agent not used in stage 4 Consultation Pliszka SR, et al. J Am Acad Child Adolesc Psychiatry. 2006;45:6:642-57.
COMMUNICATING WITH CHILDREN, YOUTH, FAMILIES 22
Dis-ease within the Disease 23
NonRx/Complimentary Biofeedback (EMG or EEG) Neuroplasticity via memory training Mindfulness/ Meditation Time management skill enhancement Light therapy for SAD and delayed sleep Melatonin (circadian rhythms) Magnesium (anxiety) Omega 3 Food Supplements (fish oils and Krill oil)
Future of therapy- Pharmacological Nicotinic agents ABT 089 very small pilot study (N=11) Methylphenidate transdermal (USA) Very long acting mixed amphetamine salts SPD465, designed to provide up to 16 hours of effect through a triple-beaded delivery system Kollins S. Emerging Therapies for ADHD http://www.medscape.org/viewarticle/549974. Accessed March 27, 2017
Key Takeaways There are many medical and practical considerations that are considered in the selection of interventions Diagnosis and treatment of ADHD is a bio-psycho-social and family/client centered process that involves getting: The right intervention at the right time to the right person for the right condition with a minimum of side effects. Root cause trauma and history factors into treatment, which may combine therapeutic strategies Stimulant medications do not mean that there will be an enhanced risk of substance abuse 26
Side Effects & Monitoring Risk/Benefit Ratio Resources from CPRI Improving Safety with Psychotropic Medications (Archived Webinar) http://www.cpri.ca/professionals/education/webinars/2016-2017- webinars/ Resources for Professionals: Psychotropic Medication Monitoring Checklists Publications http://www.cpri.ca/professionals/education/pmm-ed/ Resources for Families: Psychotropic Medication Organizer Podcast http://www.cpri.ca/families/resources/pmm-ed/ 27
Resources Canadian ADHD Resource Alliance (CADDRA) https://www.caddra.ca/ ADHD Institute http://adhd-institute.com/ 28