ADHD

Attention-deficit/hyperactivity disorder (ADHD) is one of the most widely diagnosed disorders: an estimated 8% to 12% of children are affected worldwide. Although many studies about treatment options have been published, the genetic components that underlie the disorder are still being discovered. A special issue of the American Journal of Medical Genetics, Part B: Neuropsychiatric Genetics, highlights recent research and includes results from the first genome-wide study of patients with ADHD. Genome-wide studies have successfully identified variants associated with obesity and such diseases as age-related macular degeneration, diabetes, and prostate cancer.

I first met 22-year-old “Linda” when she was brought to the emergency department (ED) after a drug overdose. Although the drug Linda had ingested-clonazepam-was a CNS depressant, she did not appear groggy or sedated. In fact, her speech was rapid and pressured; she showed marked psychomotor agitation, which was demonstrated by her twitching feet and the incessant twisting of her hair. This presentation suggested a paradoxical response to her medication. Her chief concern was, “I feel as if I am going to come out of my skin.” I was puzzled.

For many antidepressants, the issue of brand-name versus generic has no practical significance. Elavil was first marketed almost a half century ago, and its patent has long expired. It lives on, however, but as generic amitriptyline. Today, only a few antidepressants are still fully protected by patents, namely, Cymbalta (2010), Lexapro (2012), and Pristiq (2022) for major depressive disorder (MDD); and Seroquel (2011) and Symbyax (2017) for bipolar depression.

In a highly charged environment in which reports of potential conflicts of interest between physicians and pharmaceutical companies dominate the headlines almost daily, we want to point out that the supplements that were mailed with this month’s issue of Psychiatric Times were based on meetings funded by drug companies. The supplement on treatment-resistant depression, which was sponsored by Lilly USA,includes an article that focuses on the company’s drug Symbyax.

Lecturing around the country has left us with the powerful impression that both psychiatrists and primary care physicians are hungry for new ways to think about and treat depression and the myriad symptoms and syndromes with which it is associated-including attention deficit disorder, insomnia, chronic pain conditions, substance abuse, and various states of disabling anxiety. Primary care physicians also seem especially excited to learn that depression is not just a psychiatric illness but a behavioral manifestation of underlying pathophysiological processes that promote most of the other conditions they struggle to treat-including cardiovascular disease, diabetes, cancer, and dementia.1,2

Autism spectrum disorders (ASDs) are a group of 5 neuro developmental conditions (autism, Asperger syndrome, pervasive developmental disorder not otherwise specified [PDD-NOS], Rett syndrome, and disintegrative childhood disorder).1 Once thought to be rare, the incidence of these disorders is now estimated to be 1 in 150 children in the general population.2 Furthermore, the number of recognized cases has increased markedly in recent years.

I almost destroyed the backseat pocket of an airline seat this summer. The vandalism was inadvertent, assuredly, though the anger that fueled it was not. While waiting for my plane to take off, I had read a magazine article claiming to show that fMRI (functional magnetic resonance imaging) studies were “uncovering” the voting preferences of test subjects. An adjacent article announced that researchers could now predict the buying preferences of other test subjects using the same imaging technologies.

Over the past century, the syndrome currently referred to as ADHD has been conceptualized in relation to varying cognitive problems including attention, reward response, executive functioning, and other cognitive processes.

Any person who once “drew a blank” during an exam is familiar with the horrors of cognitive difficulties: that terrible moment is for most of us so rare that it remains a traumatic memory for years to come. Imagine those who suffer from protracted cognitive difficulties.

In my January column (“Fishing Expeditions and Autism: A Big Catch for Genetic Research?” Psychiatric Times, January 2009, page 12), I described the great difficulties research­ers face characterizing the genetic basis of the disease. Complexities range from trying to establish a stable diagnostic profile to making sense of the few isolated mutations that show clear associations (either with disease or syndrome variants).

The prescription of psychotropic medications for children continues to be a controversial area of medical practice. In the United States, academic medical centers, medical researchers, prescribers, and the FDA are all ostensibly committed to the common goal of disseminating accurate information and promoting treatment based on scientific evidence. In the United States, however, medical treatment takes place in the context of legal and pervasive direct-to-consumer advertising (DTCA). There are concerns about the potential for DTCA to affect public health negatively and to increase health care costs.

Attention-deficit-hyperactivity disorder (ADHD) is one of the most widely diagnosed disorders: an estimated 8% to 12% of children are affected worldwide. Although many studies about treatment options have been published, we are still discovering the genetic components that underlie the disorder. A special issue of the American Journal of Medical Genetics, Part B: Neuropsychiatric Genetics, highlights recent research and includes results from the first genome-wide study of patients with ADHD. Genome-wide studies have successfully identified variants associated with obesity and such diseases as age-related macular degeneration, diabetes, and prostate cancer.

My first job after residency involved working at a large Veterans Affairs hospital in an outpatient dual diagnosis treatment program that focused on the comorbidity of schizophrenia and cocaine dependence. Having recently completed a chief resident position at the same hospital’s inpatient unit that focused on schizophrenia without substance abuse, I was struck by how “unschizophrenic” my new patients were. They were organized and social. Their psychotic symptoms were usually limited to claims of “hearing voices,” for which insight was intact and pharmacotherapy was readily requested.

The words attributed to Socrates resonate with the perspectives of many contemporary parents and clinicians.1 The endurance of the concern suggests something fundamental about the psychopathology of deviant, disruptive behavior of youth. Yet clinicians struggle to understand its origins, to help parents control their children, and to help the children control themselves. Clinically, this manifests in failed pharmacological treatments, incompleted courses of individual therapy, problems in engaging families in treatment, and controversies over which therapy is most effective.

Does adoption pose psychological risks? University of Minnesota researchers revisited this controversial issue recently and found that common DSM-IV childhood disorders are more prevalent in adoptees than nonadoptees.

A large percentage of youths use and abuse psychoactive substances. According to the 2007 Monitoring the Future (MTF) survey, the percentage of US adolescents who used illicit drugs or drank alcohol continued a decade-long drop, revealing that 19% of 8th grad­ers, more than 36% of 10th graders, and 47% of all 12th graders have taken an illicit drug (other than alcohol) during their lifetime.1 According to the National Survey on Drug Use and Health, the rate was 3.3% for misuse or nonmedical use of prescription drugs.2 The misuse of prescription drugs among adolescents was second only to marijuana use. In fact, prescription drugs increasingly have become a part of the repertoire of drug-using adolescents.

Youths aged 6 to 16 years with any subtype of ADHD participated in the study. Comorbid bipolar disorder, pervasive developmental disorder, psychotic illness, anxiety disorders, and tic disorders were exclusionary criteria. Patients with other comorbid psychiatric disorders, including major depressive disorder, were allowed to participate if ADHD was the primary diagnosis.

Major depressive disorder has become psychiatry’s signature diagnosis. Depression is diagnosed in about 40% of patients who see a psychiatrist. This percentage is double that of just 20 years ago.

Participants from around the globe recently came together to create an international consensus statement on bipolar disorder that was presented at the 21st Congress of the European College of Neuropsychopharmacology (ECNP).

Too often news headlines exert a major influence on our patients-and nothing in child psychiatry grabs headlines like the alleged overprescription of medicines. Physicians sidestep the debate, assuring their patients and themselves that each prescription is written only after careful consideration of risks and bene-fits.

Medication adherence, especially in children and adolescents, is a complex problem that is poorly understood and underresearched, yet it is a clear barrier to effective treatment and is frequently encountered in everyday clinical practice.

Two recent studies on the treatment of depression in children and adolescents will help guide clinicians’ treatment decisions.

ADHD, the most common diagnosis in child psychiatry, appears to be more challenging to diagnose and treat when there is a comorbid depressive disorder.

Elder abuse is a concern for all practitioners who care for elderly patients or their family members. An elderly person’s fears of aging and dependence may be heightened by stories and news accounts of abuse.

This article focuses on recent innovations in diagnostic issues, tactics, and strategy, and takes a brief look at the future.