The assessment and treatment of patients with comorbid 

 (SUD) can be straightforward, except when it is not. The real world of clinical practice is often not as cut-and-dry as the controlled world of clinical research that typically informs our decision-making processes. When does it make sense to prescribe an abusable medication to a patient who may also suffer from SUD? What clinical circumstances dictate prudence and, perhaps, limit-setting? In this case-based review, I will utilize a series of fictionalized clinical anecdotes to help psychopharmacologists determine how to approach prescribing stimulants to patients who may or may not be using psychoactive substances such as cannabis, alcohol, and cocaine.

ADHD in school-age children is known to be a risk factor for the subsequent emergence of SUDs in young adults,

 especially when the ADHD has not been effectively treated.

 Armed with knowledge that untreated ADHD affects children adversely, many pediatricians and child psychiatrists routinely prescribe stimulant medications for children diagnosed with ADHD—to an extent that now suggests the possibility that this condition is sometimes being overdiagnosed and, consequently, overtreated.

 In the following case, trusting parents and clinicians did not detect an emerging SUD in a high school freshman.

A well-spoken boy, aged 14 years, from a “good” family was referred to a child psychiatrist by his pediatrician after failing to respond to methylphenidate extended-release (ER) for “mild ADHD.” The child psychiatrist reviewed the electronic health record, where the social history indicated “no concerns about alcohol, pot, other drugs.” The boy’s history revealed declining school performance throughout eighth grade, and he appeared distracted and unkempt during the interview. Over the next several months, increasing doses of immediate-release (IR) amphetamine/dextroamphetamine were prescribed with an equivocal response. The patient’s mother called for an early refill, stating that her son’s gym locker had been broken into. The psychiatrist met with the patient and obtained a urine drug screen, which came back with a THC level of 584 ng/mL. When confronted, the young man broke down, begged the psychiatrist not to tell his parents, and eventually admitted that he was selling some of his stimulants to pay for weed, and that he himself had crushed and snorted his amphetamine pills on at least a few occasions.

This situation is concordant with my experience in a variety of ambulatory psychiatric settings. In many real-world outpatient psychiatric settings, empirical stimulant trials to treat presumed ADHD are often undertaken, and urine drug screening may be underutilized at the outset of treatment, especially for younger patients.

 It may appear to the addiction psychiatrist that some patient-centered clinicians possess an alarmingly low index of suspicion that SUD either may be contributing to attentional difficulties or is perhaps the primary problem. Unfortunately, many child psychiatrists receive little to no training in child and adolescent addiction psychiatry,

 despite the fact that there may be much merit in conceptualizing addiction as a pediatric disease.

 Although clear-cut ADHD in a younger child may presage the emergence of SUD in teenagers and young adults, patients like this 14-year-old may appear, at first glance, to be more straightforward than they are. This boy’s primary diagnosis may be SUD, not ADHD.

Psychopharmacologists treating adult patients should routinely endeavor to enrich the fact pattern when they are called upon to prescribe controlled substances for individuals who carry a history of ADHD. Additional assessment strategies come to mind when considering Anecdote 2.

A new male clinic patient, aged 25 years, tells his psychiatrist that he suffers from ADHD. He shows the psychiatrist a prescription bottle of prescribed stimulants (IR amphetamine/dextroamphetamine) with 3 pills left. His previous psychiatrist is known to have retired from practice a few months back. The stimulant dose is average, and he assures his new psychiatrist that he takes his medication by mouth, as prescribed. He has a negative medical history, and other than ADHD diagnosed in elementary school, he has no known psychiatric history. When asked about alcohol consumption, he acknowledges drinking “a beer or two” on weekends, but he otherwise denies substance use. He is the father of an infant who is napping in a stroller in the waiting area, tended to by the patient’s girlfriend. The patient works as a manager in a call center, and he attributes his promotion to the medication’s efficacy.

A seemingly straightforward patient with known ADHD, he is continued on the medication he received from his previous psychiatrist, and a follow-up meeting in 1 month is scheduled. He fails to keep the follow-up appointment, and when called, his girlfriend answers his phone at his bedside in the hospital. She informs the psychiatrist that he had a grand mal seizure at work on Monday morning. Later on, it becomes known that he drank nearly a full 12-pack of beer at a bachelor party over the weekend. After a thorough workup, the consulting neurologist concludes that the seizure may have resulted from a combination of alcohol withdrawal and stimulant medication. The patient’s girlfriend confirmed that his weekend binge drinking has progressed since she gave birth to their son.

Although this patient appeared “straightforward,” he did not reveal his history of binge drinking to his new psychiatrist. On the contrary, he minimized his alcohol use. This situation underscores the limitations of self-reported historical information. Denvir

 has described the not-uncommon circumstance of patients who put their best foot forward by minimizing their use of alcohol and drugs when interviewed by physicians, who often move forward quickly in taking the substance use history at face value without seeking details beyond the superficial information provided by the patient. In the case described, a recent binge, combined with a proconvulsant medication,

 had a serious and potentially catastrophic impact on the patient.

To what extent should the prescribing physician or clinician dig deep in such cases? One can readily speculate, in retrospect, about the measures the new psychiatrist might have taken. Records from the previous psychiatrist might have been obtained. Reviewing primary care records or speaking with the primary care provider often adds helpful data. In this case, information from the patient’s significant other could have been incorporated into the initial interview—she was right there in the waiting room and could have been artfully engaged in the initial evaluation session. When it comes to ruling out a current SUD, more information from multiple data sources is almost always clarifying. This takes time, but it is good medicine—good psychiatry. Because adults with ADHD are 3 times more likely to suffer from an SUD than those without ADHD,

 psychopharmacologists should routinely conduct a thorough substance use history, with multiple data inputs. This is a best practice that helps to protect patients, who may not be disclosing important information to the prescribing clinician.

A homeless female veteran, aged 30 years, was incarcerated after her fourth shoplifting arrest. She appeared unwell, with hypertension, tachycardia, diaphoresis, agitation, and confusion. Alcohol-withdrawal delirium was diagnosed, and she responded to benzodiazepines and supportive treatment. A toxic screen was positive for cocaine. During her 3 months of incarceration, she was seen by a mental health counselor with experience in the special education system. The inmate’s mental status and school history were consistent with a diagnosis of adult ADHD. The prison psychiatrist opted not to initiate pharmacotherapy, and the patient was discharged, while remaining on probation, to a halfway house for veterans with co-occurring disorders. An addiction psychiatrist affiliated with the Veterans Health Administration opted to treat her with methylphenidate hydrochloride ER tablets, provided she remained in the halfway house, which has daily 12-Step meetings and a robust urine drug screening program. Frequent drug random drug testing was also a condition of her probation. Within 6 months, the veteran was working gainfully and fully engaged in outpatient treatment, and she expressed a strong desire to stay on track and remain a productive member of society.

Despite the severity of this homeless veteran’s co-occurring SUDs, this case is a success story that demonstrates the efficacy of an integrated treatment approach.

 This anecdote underscores “what good looks like” when it comes to treating an individual with significant ADHD and a severe psychoactive SUD. It is saddening, but not shocking, when patients receive excellent care as a byproduct of the severity of their disorders and the extreme consequences of untreated psychopathology. In this case, arrest and incarceration allowed for a careful longitudinal assessment, including urine drug screening, and this fostered the ability of a savvy clinician to make accurate diagnoses. The need for structured postincarceration treatment was extremely clear, and the patient’s veteran status afforded her access to an appropriate residential treatment program, along with specialized services to treat co-occurring disorders. Her impressive response to structure and accountability is further promoted by her enrollment in a tightly structured monitoring program that utilizes urine drug screening to support a robust abstinence-based recovery program.

The anecdotes that have been presented and discussed demonstrate that when approaching the pharmacotherapy of ADHD in patients who may be misusing psychoactive substances, artful clinical decision-making should be evidence-based and informed by best practices that are routinely utilized by addiction professionals in the assessment and treatment of patients who suffer from SUDs. Because a history of ADHD is a risk factor for SUDs,

 it is clinically prudent to carefully assess all ADHD patients for current substance misuse. Gourlay’s

 universal precautions for treating pain (and minimizing addiction liability) have been utilized to develop “Universal Precautions for Psychiatrists” for safe, addiction-savvy treatment of anxiety disorders.

 This specific set of universal precautions is further adapted and generalized in the 

These universal precautions, initially developed by Gourlay

 to facilitate the addiction-informed treatment of chronic pain and then adapted to promote the addiction-informed treatment of anxiety disorders,

 are now presented in a format that can be utilized whenever a physician or other prescribing professional is considering whether or not to prescribe a potentially abusable psychoactive medication to any patient.

 indicate that individuals with ADHD and co-occurring SUDs, with or without antisocial personality disorder, often respond positively to nonstimulant medications that are prescribed for ADHD. Some addiction psychiatrists make it a practice to begin the pharmacotherapy of ADHD with trials of nonaddictive medications. In fact, this practice may be particularly useful when a new patient presents with a sense of urgency in requesting a schedule II stimulant. When the use of stimulants clearly seems indicated, ER formulations and the prodrug lisdexamfetamine

 may be a safer first choice than IR stimulant compounds with greater abuse liability.

In conclusion, ADHD and SUDs are common conditions that frequently co-occur. A carefully conceived and executed integrated treatment plan that pays adequate attention to ADHD symptoms and also to possible psychoactive substance misuse is a universal best practice. When clinicians without addiction expertise notice problematic behaviors that may indicate that there is more going on than initially meets the eye, a subspecialty consultation may be useful in helping the patient while mitigating risk.

 is a coaching and consulting psychiatrist who is board certified in psychiatry, addiction medicine, and coaching (BCC). He launched 

 after 8 years directing Physician Health Services, Inc. He is on the faculty of the University of Massachusetts Medical School as well as a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School.

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https://www.psychiatrictimes.com/view/the-case-for-caution-when-prescribing-benzodiazepines

Treatment of adult ADHD without stimulants: effectiveness in a dually diagnosed correctional population

Long-acting stimulants for treatment of attention-deficit/hyperactivity disorder: a focus on extended-release formulations and the prodrug lisdexamfetamine dimesylate to address continuing clinical challenges

Articles

How can psychopharmacologists effectively (and safely) prescribe stimulants to patients with ADHD who may be using psychoactive substances?

Helping Patients With Attentional Difficulties and Maladaptive Use of Psychoactive Substances

The average patient with bipolar disorder (BD) spends half their life struggling with mood symptoms and the other half struggling with sleep.

 Insomnia persists in 70% of patients even when their mood is stable, and these sleep problems put them at risk for more episodes of mania and depression (

 Some clinicians are liberal with hypnotics, while others prefer the lower abuse potential of sedating antidepressants like trazodone. Both these approaches have problems. Fortunately, there are also new therapies that improve mood and sleep by entraining the circadian rhythm (

 or z-hypnotic (eg, eszopiclone, zaleplon, zolpidem) could halt the progression of insomnia into mania, but the idea has never been adequately tested. These GABAergic hypnotics lack controlled trials in BD, and the few observational studies paint a mixed picture. A chart review of 278 z-hypnotic trials in adolescents with BD concluded that the drugs improved 

 in 40% to 60% of patients and did not lead to abuse with long-term use.

 On the other hand, reports document 30 cases of high doses of zolpidem and regular doses of alprazolam and triazolam inducing mania.

In contrast, clonazepam and lorazepam appear safer, with small controlled trials suggesting that these agents do not worsen, and may improve, manic symptoms (the 

 were not used as hypnotics in these trials).

 However, over the long term, benzodiazepines carry risks of tolerance and dependence, and long-term use may worsen cognition and mood in BD, according to nonrandomized studies that attempted to control for the confounding tendency to prescribe benzodiazepines in more severe cases.

 in BD is to choose mood stabilizers with sedative effects. Many antipsychotics are sedating, but some have more meaningful benefits in sleep quality; these include quetiapine in particular, and possibly lumateperone, olanzapine, 

Lithium is rarely sedating, but it does have positive effects on the circadian system, such as dampening the phase-advance (“night owl”) tendency that is associated with poorer health and greater risk of depression.

Sedating antidepressants are more problematic, particularly in bipolar I disorder, in which the risk of manic induction is high. Most, including trazodone and 

, are associated with case reports of triggering mania. In a retrospective study, patients with BD who used sedating antidepressants for sleep were significantly more likely to develop mania and episode acceleration than those who took traditional hypnotics.

Melatonin agonists have captured the interest of investigators because of their potential to realign the circadian system, which is often disrupted in BD. Pure melatonin failed to improve sleep, 

, or rapid cycling in 2 small controlled trials,

 but the melatonin agonist ramelteon has intriguing results from 3 industry-sponsored, randomized, placebo-controlled trials in BD. Although ramelteon failed to improve sleep or mania, it did prevent depression in patients who struggled with insomnia.

The first study tested ramelteon in 21 patients with acute mania and found a reduction in depressive symptoms but no benefit in mania or sleep.

 Next, ramelteon was tested in 83 patients with BD who had active 

 but stable mood. For 6 months, they took either placebo or a nightly dose of ramelteon 8 mg. As in the first trial, ramelteon did little to improve sleep (there was only a nonsignificant trend), but it did lower the risk of depression, more than doubling the time to a new episode from 84 to 188 days (P = .02).

 A larger study attempted to replicate that finding, but the results were negative across all outcomes.

One explanation for these intriguing results is that the positive trials enrolled patients with active insomnia, while the negative trial did not, suggesting that ramelteon might have preferential effects in patients with disturbed circadian rhythms. But then why didn’t the drug improve their sleep? These studies relied on subjective measures of sleep, and ramelteon has a poor track record on subjective outcomes. In primary insomnia, it improved subjective sleep onset by only 4 minutes over placebo and objective sleep onset by 9 minutes. 

 showed the reverse pattern, improving subjective onset by 14 minutes but objective onset by only 4 minutes (placebo, by the way, is no dud, and improved sleep onset by 8 to 20 minutes).

One thing to take away from this is the importance of setting realistic expectations when starting patients on ramelteon. This hypnotic is not like the others: It is relatively nonsedating and has no anxiolytic, amnestic, or rewarding effects. On the one hand, those qualities improve on its safety, but they are unlikely to endear it to patients with BD, who often want a hypnotic to quiet the anxious, racing thoughts that rev up as they try to fall asleep. Ramelteon will do none of that, but nor will it cause patients to fall, overuse their medication, or engage in complex sleep behaviors like cooking or driving in the middle of the night. One positive aspect that most patients appreciate is the lack of tolerance and withdrawal with ramelteon. Rather than wearing off, ramelteon’s sleep benefits built up over weeks to months in some studies.

While ramelteon is a melatonin agonist, dark therapy is a behavioral treatment that enhances endogenous melatonin by keeping patients in a pitch-dark room overnight. Dark therapy was developed by Thomas Wehr, MD, who speculated that evening darkness might improve sleep and mania in the same way that morning light improves 

 and circadian rhythms. In the 1990s, he recruited normal participants with mild sleep problems to the National Institute of Mental Health, where they stayed in a pitch-dark room overnight from 6:00 pm to 8:00 am. After a few weeks of this dark therapy, their sleep improved.

 Next, he turned his attention to BD, and found that the same protocol stabilized refractory rapid cycling.

Further studies supported Wehr’s observation, but it was not until the discovery of blue light–blocking glasses that dark therapy became practical for everyday use. In theory, the physiologic changes associated with total darkness might be achieved by 

, because the receptor that regulates melatonin secretion—melanopsin—responds only to the blue spectrum. The hope in that theory is that patients might be able to practice dark therapy while still being able to see in the evening.

Psychiatrist James Phelps, MD, first tested that hope in private practice, and his results were later confirmed in a randomized, placebo-controlled trial in Norway. For the entire evening from 6:00 pm to 8:00 am, patients hospitalized with acute mania wore blue light–blocking glasses or, if sleeping or trying to sleep, stayed in a pitch-dark room without the glasses. Within a week, their 

 improved with a large effect size (1.86) compared with a placebo group that wore gray glasses.

The dark therapy protocol can be gradually relaxed after recovery, allowing patients to put the glasses on a few hours before bed to prevent future episodes. That relaxed protocol also improves the sleep, according to 3 randomized controlled trials in primary insomnia. Wearing blue light–blockers 1.5 to 3 hours before bed helped patients fall asleep earlier and stay asleep longer, and improved sleep quality as well as mood and 

 However, blue light blockers do not have a strong sedative effect. In line with their circadian mechanism, they improve the regularity of sleep more than they improve subjective measures of insomnia.

A critical step in dark therapy is finding glasses that filter close to 100% of blue light. Lenses that were tested in clinical trials include Uvex Skyper S1933X, Uvex Ultra-spec 2000 ($10 to $15) and, for more comfort at a higher price, glasses at lowbluelights.com ($50). More information on the nuts and bolts of dark therapy is available in the Psych Pearls podcasts from August and October 2021.

Cognitive behavioral therapy for insomnia (CBT-i) is thought to work by stabilizing the circadian system, making it a natural fit for mood disorders. In unipolar depression, CBT-i improves mood and sleep, but the therapy is often avoided in BD because it requires patients to limit their time in bed, raising concerns that this sleep deprivation could trigger mania. In 2015, Allison Harvey, PhD, and colleagues at the University of California – Berkeley modified the CBT-i protocol to include a built-in safety valve for BD (CBT-iBD). The newer therapy limits bed restriction to no fewer than 6.5 hours.

CBT-iBD also includes techniques to address common circadian rhythm abnormalities in BD, such sleep inertia (a prolonged sense of grogginess in the morning) and nocturnal hyperactivity. To counter these sleep-disrupting tendencies, patients develop a wake-up routine encompassing bright light and energizing activity, and an evening wind-down routine in which the lights are dimmed and 

To test the therapy, Harvey recruited 58 patients with stable BD but active insomnia and randomized them to CBT-iBD or a psychoeducational therapy. At the end of the 8-week therapy, patients in the CBT-iBD group were sleeping better compared with controls, but more profound changes came later. After 6 months, those who learned CBT-iBD had an 8-fold reduction in mood problems, spending an average of 3.3 days in a mood episode vs 25.5 days for controls.

Later, Bryony Sheaves, DClinPsy, BSc, CPsychol, and colleagues adapted CBT-iBD for patients with schizophrenia, major depression, and BD in an inpatient crisis unit. The 2-week program improved sleep and well-being, and it hastened discharge by 8.5 days compared to treatment as usual.

It can be difficult to find therapists who practice CBT-insomnia, but the core program is available through a prescription app (Somryst) or a free, VA-sponsored app (CBT-i Coach). These programs can be adjusted for BD with the modifications described above.

Dark therapy and CBT-i are safe in the young and old, and a few tips can help adapt these treatments for different ages. Adolescents often have severe night-owl tendencies, which can be corrected by having the patient wake up 15 to 30 minutes earlier each day and wearing blue light–blockers in the early evening (eg, 5:00 pm to 8:00 pm). Napping is common in older adults but is discouraged in the CBT-i protocol. One compromise is to have the patient eliminate naps during the therapy, and then gradually add them back in once regular sleep is restored. Then they can continue the naps as long as they do not cause a relapse into insomnia. Finally, for patients of all ages who are afraid of the dark, there are nightlights that emit zero blue light (at lowbluelights.com and Amazon).

Although no hypnotics are FDA approved in children and adolescents, lithium and several antipsychotics (eg, quetiapine) are approved for them. In the elderly, the risks of falls and cognitive impairment have placed most hypnotics on the “inappropriate” list of the Beers criteria, although ramelteon is well studied in older adults and approved by the Beers.

Treating insomnia in BD is both an art and a science, requiring practitioners to balance the patient’s goal of rapid sedation with the more therapeutic approach of retraining the circadian rhythm. Circadian therapies like ramelteon, dark therapy, and CBT-insomnia have a slow build, but they promise more lasting and substantial benefits for mood and sleep than fast-acting hypnotics.

is the Mood Disorders Section Editor for 

, Editor in Chief of The Carlat Psychiatry Report, and director of the Mood Treatment Center. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for The Depression and Bipolar Workbook and from W.W. Norton & Co for

 Bipolar, Not So Much: Understanding Your Mood Swings and Depression.

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The average patient with bipolar disorder struggles with sleep disorders. Here's how you can help. 

New Directions for Insomnia and Bipolar Disorder

Comorbidity: The concept is simple enough, but in practice, comorbidity drives complexity and presents the specters of diagnostic ambiguity and therapeutic unpredictability.

 The psychiatric community maintains a healthy fascination with symptom associations and relationships between diseases and conditions, both medical and psychiatric. In many ways, attention to these relationships and understanding how they affect disease trajectory and therapeutic effectiveness, for example, get to the heart of psychiatry and the human need to interpret reality for ourselves and others.

Reality must be described before it can be interpreted. Philosophical and medical efforts from the phenomenology of Karl Jaspers, MD, and Edmund Husserl, PhD, and the descriptive psychopathology of the DSM display the long-standing imperative to accurately describe and understand reality for patients, caregivers, and other clinicians.

 The comingling of comorbidities provides an enriching, descriptive sketch that should balance clinicians’ understanding of patients’ symptoms, conditions, vulnerabilities, and protective factors.

Mimesis: imitation, representation, expression, the act of resembling. Getting reality right has been the domain of not only a good psychiatric interview but art and literature since antiquity.

 Mimesis refers to the depiction of nature—its accuracy and reflection, which may provide additional perspective on reality as it exists. The aesthetic imperative to reflect reality can be traced back to Aristotle and Plato. The Aristotelean Poetics is essentially a treatise on mimesis and the poetic form to depict human nature as it is experienced.

Beginning with infancy, human nature is primed for mimicry. For the infant, it is integral for growth, understanding, and manipulating the environment. For the artist, mimesis provides clarity while appealing to the universal. For the psychiatrist, mimesis helps diagnostic accuracy and therapeutic sensitivity. Before engaging in dialogue (ie, the dialectic) about meaning and interpretation, agreement about what stands as reality is imperative.

Comorbidity is the rule rather than the exception and thusly complements psychiatric reality for most patients. A unifying definition has not been agreed upon, despite its ubiquitous use in psychiatry and medicine. Comorbidity can mean an associated diagnosis, symptom, or condition, and it may be medical, psychiatric, syndromal, or subsyndromal.

 It may also be diagnostic, pathogenic, or prognostic.

 Comorbidity might not even be the right term. For some clinicians, co-syndromal is a better descriptor, while other clinicians may highlight the benefits of using a primary-secondary rank order distinction to hierarchically distinguish their importance.

One issue seems clear. The presence of comorbidity suggests a process that is chronic and life altering. Acute symptoms are rarely referred to as comorbid. They may be significant and memorable, but their temporality does not lend itself to influencing the characterization of patients’ reality, conditions, and life trajectories. Comorbidity indices such as the Charlson Comorbidity Index or Kaplan-Feinstein index provide the clinician with a global impression of impairment, or inversely, functionality. But numerical scales do not provide the same texture or feeling of what the patient experiences.

The interplay of signs and symptoms, along with a patient’s reflections and interpretations of their realities, provides a palette from which the psychiatrist forms a visual representation of the patient’s world. This representation is mimesis and forms the basis from which interpretations arise and discussions can be productive and therapeutic. There is an aesthetic to mimicry that is seen through exemplary psychiatry. Understanding comorbidity is integral to this action and the practice of psychiatry.

is an oncologist who also works in the field of consult-liaison psychiatry at Northwell Health/Lenox Hill Hospital, in New York, NY.

is professor and chair of Psychiatry, University of Ferrara, Department of Biomedical and Specialty Surgical Sciences, and director, University Hospital Psychiatry Unit, S. Anna University Hospital and Health Authorities Ferrara, Italy. 

is professor, Department of Psychiatry, and director, PsychOncology, University of Michigan Rogel Cancer Center, Ann Arbor, MI; she also is former Deputy Editor in Chief Emeritus of 

They report no conflicts of interest concerning the subject matter of this Special Report.

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Primary versus secondary diagnosis of generalized anxiety disorder in youth: is the distinction an important one?

A Simple Concept With Complex Implications

Steven Pliszka, MD, chair of The American Professional Society of ADHD [attention-deficit/hyperactivity disorder] and Related Disorders (APSARD) annual program committee, joined Jeffrey Newcorn, MD, APSARD president, in welcoming attendees to their virtual 2022 Annual Meeting, noting the conference was putting attendees “on the ground floor of exciting developments in the field.” Pliszka said the conference would highlight issues in genetics, neuroimaging, psychological variables, and environmental variables. “I think we’re moving to really integrating all these different aspects so we can think much more broadly about where ADHD fits into psychopathology in general,” he added. “And it will get us thinking more about new ways to intervene and to treat people.”

The 4-day meeting was held January 13 to 16, 2022. In-depth coverage can be found online at 

www.psychiatrictimes.com/conferences/apsard

As separate groups, college students with ADHD and college students who identify as a sexuality and gender minority (SGM) have increased risk for functional impairments, psychiatric comorbidities, and risky behaviors.

 According to Destiny Orantes, PhD, from Syracuse University, and colleagues, previous research had not considered if these outcomes are further increased in SGM students who have ADHD. Orantes shared findings from their recent research in a poster presentation.

The study assessed functional impairments, psychiatric comorbidities, and engagement in risky behaviors in 4 groups: (1) SGM students with ADHD, (2) SGM students without ADHD, (3) non-SGM students with ADHD, and (4) non-SGM students without ADHD. Data from the American College Health Association-National College Health Assessment 2019-2021 III were used. The researchers also sought to examine the prevalence of ADHD in SGM college students.

They found ADHD prevalence increased in SGM populations: 15% compared with 8% in non-SGM individuals. Additionally, SGM students with ADHD reported the highest levels of functional impairments, substance use, and psychiatric comorbidities.

The research results suggest, Orantes said, that future studies should consider the underlying reasons for SGM students having high rates of ADHD, and how best to reduce these negative outcomes. Specifically, treatment plans should take into account the separate difficulties students face from their ADHD diagnosis and their SGM identities, as well as how best to target the risky behaviors and comorbidities. 

1. Auerbach RP, Mortier P, Bruffaerts R, et al; WHO WMH-ICS Collaborators. 

Mental disorder comorbidity and suicidal thoughts and behaviors in the World Health Organization World Mental Health Surveys International College Student initiative.

“The [APSARD] task force was launched in relation to the amazing societal changes that are happening...in association with the awareness that equity means creating fair, equitable opportunities for all of us,” Martin Katzman, MD, FRCP(C), APSARD Health Equity Task Force chair, told attendees. “We’re hoping to build connections within the APSARD community, to enhance diversity of the organization, and to reach out across boundaries as well as to partner within all of our communities to raise awareness and to increase opportunities for treatment for populations that may not get the same access to treatment.”

Amy Glasofer, DPN, RN, nurse scientist with Virtua, shared an analysis of 41 studies relating to ADHD, race, ethnicity, and disparity; Catherine Dingley, PhD, RN, FNP, FAAN, associate professor in the Nursing Department of the University of Las Vegas, Nevada, also worked on the project.

They found 66.7% of studies noted Black children were significantly less likely than white children to be diagnosed with ADHD, and 65% of Black children with ADHD were significantly less likely than white children to receive medication. In addition, compared to white children, she noted Black children were more likely to discontinue medication and more likely to experience gaps in treatment; less likely to receive an α2 agonist alone; and more likely to receive significantly lower doses of stimulant. The findings suggest that, although diagnostic disparities have been reduced over time, treatment disparities still exist for minority children with ADHD.

1. Katzman M, Higgins N, Glasofer A, et al. Introducing the APSARD Health Equity Task Force. Presented at 2022 APSARD Conference. January 14, 2022.

“ADHD in preschool children is a valid and reliable condition,” reported Ann Childress, MD, president of the Center for Psychiatry and Behavioral Medicine, Inc, in Las Vegas, Nevada.

According to the 2014 National Survey of Diagnosis and Treatment of ADHD and Tourette’s, 30% of children diagnosed with ADHD receive their diagnosis before age 6; 16% receive the diagnosis at 4 years or younger.

 Impairment can be great for these patients, Childress said. For example, an epidemiological review of preschoolers diagnosed with ADHD found more than 40% had been suspended from school or daycare and about 16% had been expelled.

 In comparison, less than 1% of young children without ADHD were suspended.

The actions of young children with ADHD pose safety risks to themselves due the higher levels of hyperactive impulsivity, she said. “These are kids who are running out in traffic. They’re jumping off of things and breaking bones. They’re doing things that are dangerous, and they really need treatment for their safety,” she explained.

Childress reviewed efficacy and safety data for a number of common medications, noting some small behavior improvements as a result of the study medications. However, medications were associated with adverse events, including insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted not all of these medications have been approved for the youngest patients.

Fortunately, there is good evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD, Childress reported. The New Forest Therapy, Helping the Noncompliant Child, and the Incredible Years series were among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

Catch up on all the latest in ADHD from the APSARD virtual 2022 Annual Meeting. 

Vol 39, Issue 2

Helping Patients With Attentional Difficulties and Maladaptive Use of Psychoactive Substances

New Directions for Insomnia and Bipolar Disorder

A Simple Concept With Complex Implications

Spotlight on Issues in ADHD

To Disclose or Not to Disclose? Lessons From a Dying Therapist

Over a Career, Female Physicians Earn Millions Less Than Male Counterparts, New Report Finds

Dress Rehearsal

Malingering as a Maladaptive Pattern of Survival During the Pandemic

Clozapine: Increased Risk of COVID-19 Severity?

10 Factors to Consider When Cross-Titrating Antipsychotics

Looking to the Future

Neuroplasticity and Smart Phones

Vaccine Mandate Exemptions for Anxiety: Ethical and Practical Considerations

Psychedelics and the Future of Psychiatry