“ Joyful Beginnings”  – mixed media, January, 2004 Amy Musia – Evansville, Indiana www.ajmusia.com
 
Zoned, Stoned and Blown: The Emotional Tsunami of Psychiatric Disorders Coupled Chemical Dependency Louis B. Cady, MD – CE...
 
ADD – inattentive, without Rx ADD – inattentive, on Adderall Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newp...
Never mind the pictures.  Adult ADD isn’t  real,  is it? <ul><li>Study of 24 ADHD adults vs. 18 controls </li></ul><ul><li...
Volumetric Adult ADHD study, cont. <ul><li>Relative to controls, ADHD adults had: </li></ul><ul><ul><li>Significantly smal...
 
ADHD – A Family Practice Perspective  Montano, B – Un. Of CT Medical School Dept of Family Practice <ul><li>Adult prevalen...
 
ADHD: Course of the Disorder  Hyperactivity Impulsivity Inattention * Loss of productivity  Tardiness, mistakes  Disorgani...
Horrigan J, et al. Presented at 47 th  Annual AACAP Meeting: October 24-29, 2000.  New York, NY.
Kids and Adults – Differences in HYPERACTIVE domain <ul><li>AS A CHILD: </li></ul><ul><li>Squirming, fidgeting </li></ul><...
Persistence of ADHD Into Adulthood <ul><li>ADHD is a heterogeneous disorder associated with considerable disability and co...
Occupational functioning of ADHD children followed into adulthood <ul><li>most are employed full time </li></ul><ul><li>lo...
Unemployment, underemployment are also problems…
What happens if ADHD isn’t treated?
Psychiatric disorders (lifetime) in adults with ADHD  [multiple sources, % is estimated;  N.B. – this is WITHOUT TREATMENT...
% of patients with ADHD presenting with OTHER psychiatric disorders [“Reverse comorbidity”] <ul><li>Major depression:  20%...
Earlier Initiation of  Smoking with ADHD 237  6 to 17-year-old boys 0.6 0.5 0.4 0.3 0.2 0.1 0 Smoking probability 0 2 4 6 ...
SUD’s in Adolescents with ADHD <ul><li>75% - non medicated ADHD (n=19)  [p<.001] </li></ul><ul><li>25% - medicated ADHD (n...
Pharmacotherapy Significantly Reduces Substance Abuse in  Adults   with ADHD Biederman J, et al.  Pediatrics.  1999;104:e2...
Increased Lifetime Substance Abuse  in Untreated Adults with ADHD Biederman, et al.  Biol Psychiatry.  1998;44:269-273. Li...
The 3 Big Reasons for substance abuse – Louis B. Cady, M.D. <ul><li>Looking for help </li></ul><ul><ul><li>Something to ma...
 
AD H D vs. Bipolar Disorder <ul><li>Mood lability </li></ul><ul><li>Bursts of energy </li></ul><ul><li>Restlessness </li><...
ADHD vs. BPD in Adults <ul><li>ADHD </li></ul><ul><li>Constant </li></ul><ul><li>Lifelong </li></ul><ul><li>Moods triggere...
ADHD Comorbidity with bipolar disorder – how to tell’em apart <ul><li>Adults with ADHD </li></ul><ul><ul><li>Lack severe m...
How to Commit Malpractice <ul><li>Send a bipolar/ADHD patient into orbit with stimulants! </li></ul><ul><li>Potential erro...
“ Strattera  [coupled with Prozac or Paxil]  has been great for our admissions.” -Dr. William Beute, MD Pine Rest Campus C...
OTHER DIAGNOSTIC STUFF…..
LOW ENERGY – frequently occurring with depression.  A “no duh,” KNOWN finding. <ul><li>People with depression have LOW ENE...
Depression & Anxiety Dx in 1 Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li></ul><ul><li>Sadnes...
Depression & LOW ENERGY in One Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li></ul><ul><li>Sadn...
Continuum of Depression and Anxiety Anxiety disorders Stahl SM.  J Clin Psychiatry .  1993;54(1 suppl):33-38. Major depres...
Depression & Anxiety By the Numbers: <ul><li>Depression </li></ul><ul><li>2 – 4 % of US population/year </li></ul><ul><li>...
Overlapping Symptoms of Depression and GAD Major Depressive Disorder (MDD) Generalized Anxiety Disorder (GAD) Depressed mo...
Adrenal Burnout
 
Diagnostic Pearls - Cady <ul><li>How’s work? </li></ul><ul><ul><li>How has your employment history been? </li></ul></ul><u...
An Higelian Dialectical blend of therapeutic alternatives - Cady <ul><li>Thesis:  “you  can’t be treated if you are using ...
Methylphenidate Efficacy in Adult ADHD Controlled Comparison of MPH in Adult ADHD  * P  <.0001. Adapted with permission fr...
Efficacy of a Mixed Amphetamine Salts Compound in Adult ADHD Adapted with permission from  Spencer et al.  Arch Gen Psychi...
Atomoxetine Efficacy in Adult ADHD CAARS-Inv ADHD = Investigator-rated Conners Adult ADHD Rating Scale. Adapted from Miche...
Current medications available for Adult ADHD <ul><li>Atomoxetine Nov.  2002 </li></ul><ul><li>Mixed amphetamine salts XR A...
Response to Psychostimulants -  Arnold et al.  J Attention Dis.  2000;3:200.   Best Response (Percent) AMP MPH Equal respo...
Treatment Pearls <ul><li>Don’t be afraid to treat/refer.  You can actually be sued if you DON’T (and you have obtained the...
LISA
People at Risk <ul><li>PSYCHIATRIC </li></ul><ul><li>ADHD </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety disorders...
“ The phenomenon of craving” William Duncan Silkworth, MD
David L. Ohlms, MD <ul><li>“ Few other major primary  diseases produce the range  of emotional and physical  complications...
<ul><li>“ The fact that the majority of people can drink without losing control reinforces the [erroneous] opinion that th...
People at Risk <ul><li>High Risk/High Need </li></ul><ul><li>Middle stages of CD </li></ul><ul><li>Unemployment </li></ul>...
People at risk – legal woes <ul><li>Legal </li></ul><ul><ul><li>Repeat drunk driving </li></ul></ul><ul><ul><li>Repeat dru...
Psychosocial: <ul><ul><li>History of “ODD”, conduct problems as child </li></ul></ul><ul><ul><li>“ terminally unique” </li...
Risky behaviors <ul><li>“ people places and  things” </li></ul><ul><li>“ lying, cheating, and  stealing” </li></ul><ul><li...
Patients at risk <ul><li>Family biology/genetics </li></ul><ul><ul><li>(psychiatric AND/or addictive disorders) </li></ul>...
 
RELAPSE PREVENTION STRATEGIES <ul><li>“ Alcoholism doesn’t go away, like diabetes heart disease, cancer, blindness, paraly...
Step ONE!! <ul><li>“ We admitted that we were  [are?]  powerless over alcohol – and that our lives had become unmanageable...
What happens when you slip?
Key concepts of relapse prevention <ul><li>Alcoholism/ CD don’t go away </li></ul><ul><li>Ongoing recovery is great but a ...
Medication/Meditation <ul><li>MEDICATION: </li></ul><ul><ul><li>INITATION: </li></ul></ul><ul><ul><ul><li>Axiom: “Treat th...
Medication CONDITION CONFOUNDS APPROPRIATE INAPPROPRIATE ADHD Prev. Meth, Cocaine Strattera, Intuniv, Bupoprion Ritalin, A...
Know When to Fold’Em
Team Approach <ul><li>COMMUNICATION between members: </li></ul><ul><ul><li>Physician (frequently not a psychiatrist) </li>...
&quot;If I hadn't believed it, I wouldn't have seen it.&quot; - Yogi Berra Personal collection  Louis B. Cady, M.D.
“ For me, the practice of medicine has opened the door to the greatest adventure in life.  Medicine is like a hallway line...
Thanks for coming! Please fill out evaluations!   Contact info: Dr. Cady and Lisa Seif, LCSW –  812-429-0772  ( [email_ad...
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Zoned, Stoned And Blown - by Louis B. Cady, M.D. and Lisa Seif, LCSW, CADAC02 17 2010 Slideshare

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This presentation reviews the diagnosis, treatment, and sobriety maintenance of dual diagnosis disorders ( psychiatric disorders coupled with chemical dependency and/or alcoholism), using a synthetic blend of two talented clinicians' experiences, humor, and review of precision diagnosis, treatment formulations, and interventions.

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  • ADHD is recognized as a combination of 3 behavior types: inattention, impulsivity, and hyperactivity DSM-IV characterizes 3 subtypes of ADHD based on the preponderance of these behaviors [Biederman, 1998 p4] Inattentive Hyperactive-impulsive Combined inattentive and hyperactive-impulsive In many patients, hyperactive and impulsive symptomatology tend to decrease with age; however, inattention is persistent throughout the lifespan [Biederman1998 p5, 7-8] Hyperactive-impulsive subtype occurs with the lowest frequency and in the youngest patients The inattentive subtype is most commonly recognized in older adults, but can occur at all ages The combined subtype occurs most frequently [Biederman, 1998 p4-5]
  • ADHD is a heterogeneous disorder associated with considerable disability and comorbidity that, in many cases, persists into adulthood. 1 Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD. 2 ADHD in adults is more prevalent than once thought. The National Comorbidity Survey found the estimated lifetime prevalence of ADHD in adults to be 8.1%. 3 According to DSM-IV criteria, adults diagnosed with ADHD must have had childhood onset and persistent and current symptoms, although allowance is made for partial remission. 4 Due to the great syndromatic continuity between childhood and adult ADHD, much of the medication management of adults with ADHD can be based on the experience gained from treating children and adolescents. 5 Barkley RA, Fischer M, Smallish L, Fletcher K. The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. J Abnormal Psychol. 2002;111:279-289. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry . 1993;150:1792-1798. Kessler RC, Berglund P, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry . 2005;62:593-602. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. ( DSM-IV  ). Washington, DC: American Psychiatric Association; 1994:78-85. Dodson WW. Pharmacotherapy of adult ADHD. J Clin Psychol . 2005;61:589-606.
  • Weiss &amp; Hechtman, 1993; Mannuzza et al, 1993, Barkley et al, 1990
  • 237 boys 6 to 17 years old were followed prospectively for 4 years and into mid-adolescence Information on smoking history was determined using the Diagnostic Interview for Children and Adolescents/Parents’ version at the 4-year follow-up assessment only [Milberger 1997 p39] Information on frequency of cigarette smoking, age at onset/offset of smoking, and associated impairments were determined by trained interviewers blind to the subjects’ clinical status [Milberger 1997 p39] ADHD is a significant predictor of early smoking in adolescence At the end of 4 years 19% of ADHD boys were smoking compared with 10% of controls ( P =0.003)
  • The incidence of drug abuse was compared in 56 medicated ADHD patients, 19 non-medicated ADHD patients, and 137 non-ADHD control subjects [Biederman 1999 pe21] Non-medicated ADHD patients were at a significantly higher risk for substance abuse than controls or medicated ADHD patients [Biederman 1999 pe22-23] There was no significant difference between medicated ADHD patients and controls (chi-squared=3.7, P =0.15) [Biederman 1999 pe22-23] Medication is associated with an 85% reduction in the risk of substance abuse in ADHD patients [Biederman 1999 pe22-23] Poor compliance is often a more significant problem than addiction [Garland, 1998 p 387-388]
  • Onset of substance abuse in subjects with ADHD averaged 3 years earlier than controls (late adolescence/early adulthood) ADHD was a significant risk factor independent of comorbid diagnoses
  • As described in the DSM-IV and as shown on the slide, ADHD and bipolar disorder (BPD) have 12 features in common. 1 This creates questions as to whether adults with ADHD and comorbid BPD actually have both disorders and can be distinguished clinically. 2 Whether patients with ADHD and comorbid BPD have ADHD, BPD, or both has important clinical implications because the treatments for each disorder are very different and may adversely impact on one another. 2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. ( DSM-IV  ). Washington, DC: American Psychiatric Association;.1994:78-84, 350-363. Wilens TE, Biederman J, Wozniak J, Gunawardene S, Wong J, Monuteaux M. Can adults with attention-deficit hyperactivity disorder be distinguished from those with comorbid bipolar disorder? Findings from a sample of clinically referred adults. Biol Psychiatry . 2003;54:1-8.
  • An examination of the distinguishing features of ADHD and BPD shown on the slide will aid in diagnosing either of the disorders or the comorbidity. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. ( DSM-IV  ). Washington, DC: American Psychiatric Association; 1994:78-85, 350-363.
  • A randomized, 7-week, placebo-controlled, crossover study of 23 adult patients with ADHD was conducted using standardized instruments for diagnosis, separate assessments of ADHD and depressive and anxiety symptoms, and a robust daily dose of methylphenidate hydrochloride (1.0 mg/kg per day). The study consisted of two 3-week treatment periods with 1 week of washout between to avoid a carryover effect of medication. Study medication was titrated up to 0.5 mg/kg per day by week 1, 0.75 mg/kg per day by week 2, and up to 1.0 mg/kg per day by week 3. As shown on the slide, methylphenidate treatment was more effective than placebo after the first week of treatment, and improvement was increasingly robust in subsequent weeks with increases in daily doses. Only 3 subjects (13%) were unable to tolerate the target dose of 1.0 mg/kg. Study results indicated a marked therapeutic response for methylphenidate treatment of ADHD symptoms that exceeded the placebo response (78% vs. 4%; P &lt;.0001), leading investigators to conclude that robust daily doses of methylphenidate are effective and well tolerated in the treatment of ADHD in adults. Spencer T, Wilens T, Biederman J, Faraone SV, Ablon JS, Lapey K. A double-blind, crossover comparison of methylphenidate and placebo in adults with childhood-onset attention-deficit hyperactivity disorder. Arch Gen Psychiatry . 1995;52:434-443.
  • A 7-week, randomized, double-blind, placebo-controlled, crossover study evaluated the efficacy of a mixed amphetamine salts compound in 27 well-characterized adults satisfying full DSM-IV criteria for ADHD of childhood onset and persistent symptoms into adulthood. Medication was titrated up to 30 mg twice a day. Outcome measures included the ADHD Rating Scale and the Clinical Global Impression Scale scores. Treatment with the mixed amphetamine salts compound at an average oral dose of 54 mg (administered in 2 daily doses) was effective and well tolerated. Drug-specific improvement in ADHD symptoms was highly significant overall (42% decrease on the ADHD Rating Scale; P &lt;.001) and sufficiently robust to be detectable in a parallel-groups comparison restricted to the first 3 weeks of the protocol ( P &lt;.001). The percentage of subjects who improved (reduction in the ADHD Rating Scale of ≥30%) was significantly higher with treatment with the mixed amphetamine salts compound than with placebo (70% vs. 7%; P = .001). Spencer T, Biederman J, Wilens T, et al. Efficacy of a mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry . 2001;58:775-782.
  • Two identically designed, randomized, double-blind, placebo-controlled, multicenter studies evaluated the efficacy and safety of atomoxetine versus placebo in adult patients with ADHD over a 10-week treatment period. Exclusion criteria were current anxiety disorder or major depression, past or current psychotic or bipolar disorders, serious medical illness, and alcoholism or active substance abuse. Following an initial 1-week medication washout and evaluation period, patients entered a 2-week placebo lead-in phase. Patients who maintained the initial severity criteria required for study entry were randomized to receive atomoxetine or placebo for the 10-week period, during which visits were biweekly. The primary outcome measure was the sum of the Inattention and Hyperactivity/ Impulsivity subscales of the investigator-rated Conners Adult ADHD Rating Scale (CAARS), each item of which corresponds to one of the 18 DSM-IV symptoms for ADHD. In both studies, atomoxetine was statistically superior to placebo in reducing both inattentive and hyperactive and impulsive symptoms, as assessed by the primary outcome measure. No serious safety concerns were noted during the treatment period. Discontinuations due to adverse events were less than 10% for atomoxetine-treated patients in both studies. Michelson D, Adler L, Spencer T. Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry . 2003;53:112-120.
  • Studies comparing methylphenidate, dextroamphetamine, and pemoline have demonstrated equivalent efficacy. However, there is much individual variability in response to any one particular psychostimulant. That is, a particular patient may not respond to methylphenidate, but may respond well to an amphetamine medication. This slide shows results of a meta-analysis of six controlled within-subject comparisons of methylphenidate and amphetamine. Of the 174 subjects, 28% responded best to amphetamine, 16% responded better to methylphenidate, while the remaining 41% responded equally well to either stimulant. The response rate for any one particular stimulant medication is approximately 70%. No predictors of response have been identified; that is, there is no way to know whether a patient will respond to one stimulant vs. another. Because patients may have a preferential response to one stimulant medication, different stimulants should be tried before considering a patient to be a stimulant nonresponder.
  • As a consequence of his close contact with alcoholics (and he saw thousands in his lifetime), Dr. Silkworth believed that &amp;quot;something more than human power is needed to produce the essential psychic change&amp;quot; vital to sustained sobriety. Nor did he &amp;quot;hold with those who believe that alcoholism is entirely a problem of mental control.&amp;quot; For instance, he said, he had treated many men who had worked assiduously on an important business deal, only to have it fall apart because they picked up a drink. &amp;quot;Then the phenomenon of craving at once became paramount to all other interests. These men (by 1937 he would include women) were not drinking to escape; they were drinking to overcome a craving beyond their mental control.&amp;quot; When the chips are down, Dr. Silkworth concluded, &amp;quot;the only relief we have to suggest is entire abstinence.&amp;quot;
  • Zoned, Stoned And Blown - by Louis B. Cady, M.D. and Lisa Seif, LCSW, CADAC02 17 2010 Slideshare

    1. 1. “ Joyful Beginnings” – mixed media, January, 2004 Amy Musia – Evansville, Indiana www.ajmusia.com
    2. 3. Zoned, Stoned and Blown: The Emotional Tsunami of Psychiatric Disorders Coupled Chemical Dependency Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Clinical Lecturer – Indiana University School of Medicine Department of Psychiatry Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana Lisa Seif, LCSW, CADAC, CSAMS – CWI Therapist Director: Warrick County Drunk Driving and Drug Court Program Adjunct Professor – ITT Facilitator – Adventure Based Challenge Program for YOUTH FIRST
    3. 5. ADD – inattentive, without Rx ADD – inattentive, on Adderall Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA
    4. 6. Never mind the pictures. Adult ADD isn’t real, is it? <ul><li>Study of 24 ADHD adults vs. 18 controls </li></ul><ul><li>Comparable on age, SE status, sex, handedness, education, IQ and achievement tests </li></ul><ul><li>MRI on 1.5 T Siemens scanner; image parcellation of neocortex into 48 gyral based units </li></ul>Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80
    5. 7. Volumetric Adult ADHD study, cont. <ul><li>Relative to controls, ADHD adults had: </li></ul><ul><ul><li>Significantly smaller overall cortical gray matter </li></ul></ul><ul><ul><li>Smaller prefrontal cortex </li></ul></ul><ul><ul><li>Smaller anterior cingulate cortex </li></ul></ul><ul><li>CONCLUSIONS: </li></ul><ul><ul><li>Adults with ADHD have volume difference in brain regions in areas involved in attention and executive control. </li></ul></ul><ul><ul><li>These data, largely consistent with studies of children, support the idea that adults with ADHD have a valid disorder with persistent biological features. </li></ul></ul>Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80
    6. 9. ADHD – A Family Practice Perspective Montano, B – Un. Of CT Medical School Dept of Family Practice <ul><li>Adult prevalence rate 4.5% </li></ul><ul><li>Most adult sufferers have not been properly diagnosed or treated. </li></ul><ul><li>They have at least one comorbid psych. d.o. </li></ul><ul><li>This d.o. may offer the first clue of ADHD </li></ul><ul><li>Comorbidities may confound the diagnosis. </li></ul><ul><li>Use of available standardized rating scales helpful. </li></ul><ul><li>Primary caregivers encouraged to dx and tx. </li></ul>J Clin Psychiatry. 2004;65 Suppl 3:18-21.
    7. 11. ADHD: Course of the Disorder Hyperactivity Impulsivity Inattention * Loss of productivity Tardiness, mistakes Disorganization Disruption of work flow — Age —
    8. 12. Horrigan J, et al. Presented at 47 th Annual AACAP Meeting: October 24-29, 2000. New York, NY.
    9. 13. Kids and Adults – Differences in HYPERACTIVE domain <ul><li>AS A CHILD: </li></ul><ul><li>Squirming, fidgeting </li></ul><ul><li>Cannot stay seated </li></ul><ul><li>Cannot wait turn </li></ul><ul><li>Runs/climbs excessively </li></ul><ul><li>Cannot play quietly </li></ul><ul><li>On the go/driven by motor </li></ul><ul><li>Talks excessively </li></ul><ul><li>Blurts out answers </li></ul><ul><li>Intrudes, interrupts others </li></ul><ul><li>AS AN ADULT: </li></ul><ul><li>Work inefficiencies </li></ul><ul><li>Can’t sit through meetings </li></ul><ul><li>Cannot wait in line </li></ul><ul><li>Drives too fast </li></ul><ul><li>Self-selects very active job </li></ul><ul><li>Cannot tolerate frustration </li></ul><ul><li>Talks excessively </li></ul><ul><li>Makes inappropriate comments </li></ul><ul><li>Interrupts others </li></ul>Sources: DSM-IV (TR). APA 2000:85-93) Weiss MD, Weiss JR. J Clin Psychiatry 2004;65(Suppl 3):27-37.
    10. 14. Persistence of ADHD Into Adulthood <ul><li>ADHD is a heterogeneous disorder associated with considerable disability and comorbidity that, in many cases, persists into adulthood 1 </li></ul><ul><ul><li>Some studies have found persistence as high as 36.3% 2 </li></ul></ul><ul><li>Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD 3 </li></ul><ul><li>Current prevalence of ADHD persistent into adulthood 4.4% 4 </li></ul><ul><li>Much of the treatment of adult ADHD can be based on experience in treating children/adolescents 5 </li></ul><ul><li>Barkley et al. J Abnorm Psychol . 2002;111:279-289. </li></ul><ul><li>Kessler RC et al. Biol Psychiatry 2005 June;57(11):1442-51. [retrospective review of 3,197 14-44 yo respondents in NCS-R] </li></ul><ul><li>Biederman et al. Am J Psychiatry . 1993;150:1792-1798. 4. Kessler et al. Am J Psychiatry. 2006;163(4):716-23 . 5. Dodson WW. J Clin Psychol . 2005;61:589-606. </li></ul>
    11. 15. Occupational functioning of ADHD children followed into adulthood <ul><li>most are employed full time </li></ul><ul><li>lower occupational status and SES </li></ul><ul><li>change jobs more frequently </li></ul><ul><li>more firings and layoffs </li></ul><ul><li>more conflict with supervisors and coworkers </li></ul><ul><li>employer ratings of ADHD adults lower in </li></ul><ul><ul><li>completing work </li></ul></ul><ul><ul><li>independence </li></ul></ul><ul><ul><li>need for supervision </li></ul></ul><ul><li>great probability of being self-employed (Mannuzza) </li></ul>Weiss & Hechtman, 1993; Mannuzza et al, 1993, Barkley et al, 1990
    12. 16. Unemployment, underemployment are also problems…
    13. 17. What happens if ADHD isn’t treated?
    14. 18. Psychiatric disorders (lifetime) in adults with ADHD [multiple sources, % is estimated; N.B. – this is WITHOUT TREATMENT GROWING UP ] <ul><li>Substance use disorders (all) 50% </li></ul><ul><li>Anxiety disorders 40% </li></ul><ul><li>Major depression 35% </li></ul><ul><li>Learning disabilities 20% </li></ul><ul><li>Bipolar disorder 10% </li></ul><ul><li>Antisocial disorder 10% </li></ul>
    15. 19. % of patients with ADHD presenting with OTHER psychiatric disorders [“Reverse comorbidity”] <ul><li>Major depression: 20% have ADHD </li></ul><ul><li>Bipolar disorder: 15% have ADHD </li></ul><ul><li>Generalized anxiety disorders: 20% have ADHD </li></ul><ul><li>Substance abuse: 25% have ADHD </li></ul><ul><ul><li>Sources: Alpert, et al. Psychiatry Res. 1996;62:213. Nierenberg et al. Presented at the 157 th Annual Meeting of the APA 2002. Faraone S et al. J . Affect Disorder 2000; 58:99. Wilens. Psych Clinic N. Am 2004. </li></ul></ul>
    16. 20. Earlier Initiation of Smoking with ADHD 237 6 to 17-year-old boys 0.6 0.5 0.4 0.3 0.2 0.1 0 Smoking probability 0 2 4 6 8 10 12 14 16 18 20 22 24 P <0.003 ADHD n=128 Control n=109 Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44. 4 year follow-up
    17. 21. SUD’s in Adolescents with ADHD <ul><li>75% - non medicated ADHD (n=19) [p<.001] </li></ul><ul><li>25% - medicated ADHD (n=56) </li></ul><ul><li>18% - Non-ADHD control (n=137) </li></ul>Biederman et al Pediatrics 1998; 104:e20
    18. 22. Pharmacotherapy Significantly Reduces Substance Abuse in Adults with ADHD Biederman J, et al. Pediatrics. 1999;104:e20-e25. 40 30 20 10 0 % of study population Unmedicated ADHD Medicated ADHD Control 32 12 10 P <0.001 (N=56) (N=19) (N=137) 3-fold!
    19. 23. Increased Lifetime Substance Abuse in Untreated Adults with ADHD Biederman, et al. Biol Psychiatry. 1998;44:269-273. Lifetime rate of substance abuse in referred ADHD adults 0 10 20 30 40 50 60 55% Control (n=268) ADHD (n=239) 27% P <0.001
    20. 24. The 3 Big Reasons for substance abuse – Louis B. Cady, M.D. <ul><li>Looking for help </li></ul><ul><ul><li>Something to make their minds work better </li></ul></ul><ul><ul><li>Looking for something to CALM DOWN with </li></ul></ul><ul><li>Looking for Mr. Good-Drug </li></ul><ul><ul><li>Something to take AWAY the pain of failure and lack of performance </li></ul></ul><ul><li>Hanging with the WRONG CROWD </li></ul><ul><ul><li>“ like attracts like”; “losers attract losers” </li></ul></ul>
    21. 26. AD H D vs. Bipolar Disorder <ul><li>Mood lability </li></ul><ul><li>Bursts of energy </li></ul><ul><li>Restlessness </li></ul><ul><li>Talkativeness </li></ul><ul><li>“ Racing thoughts” </li></ul><ul><li>Impatience </li></ul><ul><li>Impulsivity </li></ul><ul><li>Impaired judgment </li></ul><ul><li>Irritability </li></ul><ul><li>Chronic course </li></ul><ul><li>Lifelong impairment </li></ul><ul><li>Genetic clustering </li></ul>American Psychiatric Association. DSM-IV ; 1994:78-84, 350-363. 12 Features in Common:
    22. 27. ADHD vs. BPD in Adults <ul><li>ADHD </li></ul><ul><li>Constant </li></ul><ul><li>Lifelong </li></ul><ul><li>Moods triggered </li></ul><ul><li>Moods congruent </li></ul><ul><li>Instantaneous shifts </li></ul><ul><li>Thoughts “jump” </li></ul><ul><li>Family Hx of ADHD </li></ul><ul><li>Bipolar </li></ul><ul><li>Cyclical </li></ul><ul><li>Later onset (mean, 26 yrs) </li></ul><ul><li>Moods untriggered </li></ul><ul><li>Moods incongruent </li></ul><ul><li>Gradual shifts </li></ul><ul><li>Thoughts “race” </li></ul><ul><li>Family Hx of bipolar </li></ul>STEP-BD reports at least 19% comorbidity of bipolar disorder and ADHD. STEP-BD = Systematic Treatment Enhancement Program for Bipolar Disorder. American Psychiatric Association. DSM-IV ; 1994:78-85, 350-363.
    23. 28. ADHD Comorbidity with bipolar disorder – how to tell’em apart <ul><li>Adults with ADHD </li></ul><ul><ul><li>Lack severe mood lability symptoms </li></ul></ul><ul><ul><li>Moderate impairment in functions </li></ul></ul><ul><li>Adults with ADHD + BPD </li></ul><ul><ul><li>Prominent mood lability (think “rage-aholic”) </li></ul></ul><ul><ul><li>High rates of hyperactive/impulsive symptom </li></ul></ul><ul><ul><li>Episodicity of mood and overall symptoms </li></ul></ul><ul><ul><li>Severe impairment in function </li></ul></ul><ul><ul><li>Wilens et al. Biol Psychiatry 2003;54:1 </li></ul></ul>
    24. 29. How to Commit Malpractice <ul><li>Send a bipolar/ADHD patient into orbit with stimulants! </li></ul><ul><li>Potential errors: </li></ul><ul><ul><li>Failure to take a good enough history </li></ul></ul><ul><ul><ul><li>Failure to ask “the question” </li></ul></ul></ul><ul><ul><li>Failure to start REALLY LOW on ADD medication </li></ul></ul>
    25. 30. “ Strattera [coupled with Prozac or Paxil] has been great for our admissions.” -Dr. William Beute, MD Pine Rest Campus Clinic Grand Rapids, MI April 21, 2004 [quoted with permission] The “Take Home” – don’t prescribe a 2D6 drug-drug interaction.
    26. 31. OTHER DIAGNOSTIC STUFF…..
    27. 32. LOW ENERGY – frequently occurring with depression. A “no duh,” KNOWN finding. <ul><li>People with depression have LOW ENERGY…. </li></ul><ul><li>So you…. </li></ul>Prescribe (&quot;SIG:&quot;) &quot;E - caps&quot;!!
    28. 33. Depression & Anxiety Dx in 1 Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li></ul><ul><li>Sadness </li></ul><ul><li>Interest loss </li></ul><ul><li>Guilt </li></ul><ul><li>Energy </li></ul><ul><li>Concentration </li></ul><ul><li>Appetite </li></ul><ul><li>Psychomotor Sx </li></ul><ul><li>Suicidal thinking </li></ul><ul><li>Gen. ANXIETY D.O. </li></ul><ul><li>Somatic Sx (“ energy ”,etc.) </li></ul><ul><li>WORRY </li></ul><ul><li>Irritability </li></ul><ul><li>Concentration </li></ul><ul><li>Keyed up </li></ul><ul><li>Insomnia (“sleep”) </li></ul><ul><li>Restlessness </li></ul>SWICKIR is Quicker: Worry + 3 = GAD (Baughman) 5of 9 with 1 of 2 x 2 weeks
    29. 34. Depression & LOW ENERGY in One Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li></ul><ul><li>Sadness </li></ul><ul><li>Interest loss </li></ul><ul><li>Guilt </li></ul><ul><li>Energy </li></ul><ul><li>Concentration </li></ul><ul><li>Appetite </li></ul><ul><li>Psychomotor Sx </li></ul><ul><li>Suicidal thinking </li></ul><ul><li>OTHER FREQUENT CAUSES: </li></ul><ul><li>Hypothyroidism </li></ul><ul><ul><ul><li>Sub-syndromal or other </li></ul></ul></ul><ul><li>Low DHEA </li></ul><ul><li>Exhausted adrenals </li></ul><ul><ul><li>(can check with 4 cortisol levels) </li></ul></ul><ul><li>Low testosterone </li></ul><ul><li>Low micronutrients and vitamins </li></ul><ul><li>(low growth hormone) </li></ul>5 of 9 with 1 of 2 x 2 weeks w/o other causes!!! MUST EXCLUDE OTHER CAUSES, as well as treat for presumptive diagnosis.
    30. 35. Continuum of Depression and Anxiety Anxiety disorders Stahl SM. J Clin Psychiatry . 1993;54(1 suppl):33-38. Major depressive disorder Comorbid depression and anxiety
    31. 36. Depression & Anxiety By the Numbers: <ul><li>Depression </li></ul><ul><li>2 – 4 % of US population/year </li></ul><ul><li>Lifetime: </li></ul><ul><ul><li>21% of women </li></ul></ul><ul><ul><li>13& of men </li></ul></ul><ul><li>ANXIETY </li></ul><ul><li>4-8% of US population/year </li></ul><ul><li>60% with anxiety disorder come in with somatic symptoms! </li></ul>Adapted from Katon, W. Jounrl Clin Pysch, 1990, Depression & Chronic Mental Illness; and - Kessler, R et al. Lifetime & 12 Month Prevalence of DSM-IIIR Psychiatric Disorders in the U.S. (Ntl Comorb. Study). Arch Gen Psych, Jan 1994, 8-19 . Myers, Weissman, Tischler. Six month prevalence of psychiatric disorders in three communities. Arch Gen Psych 1984; 41:959-967. Goldberg, Bridges. The diagnosis of anixety in primary care settings. Br J Clin Pract Symp, 1985; 38 (suppl):28-33
    32. 37. Overlapping Symptoms of Depression and GAD Major Depressive Disorder (MDD) Generalized Anxiety Disorder (GAD) Depressed mood Anhedonia Appetite disturbance Worthlessness Suicidal ideation DSM-IV-TR. Washington, DC: American Psychiatric Association. 2000. Sleep disturbance Psychomotor agitation Concentration difficulty Irritability Fatigue Worry Anxiety Muscle tension Palpitations Sweating Dry mouth Nausea
    33. 38. Adrenal Burnout
    34. 40. Diagnostic Pearls - Cady <ul><li>How’s work? </li></ul><ul><ul><li>How has your employment history been? </li></ul></ul><ul><li>How’s your mood? Your marriage (relationship)? </li></ul><ul><li>How was school for you? </li></ul><ul><li>Are people nervous driving with you? </li></ul><ul><li>Are there periods of time when you have too much energy for no particular reason ? </li></ul><ul><li>Do you ever have to have a beer at the end of the day to relax? </li></ul><ul><ul><li>[gently lead in to other substances, especially stimulants that may have a CALMING effect] </li></ul></ul><ul><ul><li>“ Have you ever taken any of your child’s ADD Rx?” </li></ul></ul>
    35. 41. An Higelian Dialectical blend of therapeutic alternatives - Cady <ul><li>Thesis: “you can’t be treated if you are using .” </li></ul><ul><li>Anti-thesis: “ Doc, I can’t stop using unless you can do something for me.” </li></ul><ul><li>Synthesis: “Let’s see if we can work something out.” </li></ul><ul><ul><ul><li>“ crossover titration” or replacement of illicit substance with RATIONAL alternative (e.g. – cocaine with Bupropion or atomoxetine; marijuana with clonazepam or Oxycarbazepine (Trileptal ®). Must be willing to ‘GET SOBER.’ </li></ul></ul></ul><ul><ul><ul><ul><li>REFINEMENT of pharmacotherapy as case unfolds </li></ul></ul></ul></ul><ul><ul><ul><li>Willingness to get into AA/NA and GET A SPONSOR, and WORK STEPS – if appropriate. </li></ul></ul></ul><ul><li>If you don’t want to fool with it, REFER, don’t just brand them as “hopeless” or untreatable. </li></ul>
    36. 42. Methylphenidate Efficacy in Adult ADHD Controlled Comparison of MPH in Adult ADHD * P <.0001. Adapted with permission from Spencer et al. Arch Gen Psychiatry . 1995;52:434-443. Baseline Week 1 Week 2 Week 3` ADHD Rating Scale Score Placebo Subthreshold ADHD MPH * * * N=23 42 36 0 6 12 18 24 30
    37. 43. Efficacy of a Mixed Amphetamine Salts Compound in Adult ADHD Adapted with permission from Spencer et al. Arch Gen Psychiatry . 2001;58:775-782. 40 30 20 10 Baseline Week 1 Week 2 Week 3 ADHD Rating Scale Subthreshold ADHD P <.001 P <.001 Placebo Mixed amphetamine salts compound N=27 DSM-IV ADHD Symptom Checklist
    38. 44. Atomoxetine Efficacy in Adult ADHD CAARS-Inv ADHD = Investigator-rated Conners Adult ADHD Rating Scale. Adapted from Michelson et al. Biol Psychiatry . 2003;53:112-120. CAARS-Inv ADHD Total 32 30 28 26 24 22 Baseline Week 2 Week 4 Week 8 Week 6 Week 10 Placebo Atomoxetine * ** † † † *P <.05; ** P <.003; † P ≤.001.
    39. 45. Current medications available for Adult ADHD <ul><li>Atomoxetine Nov. 2002 </li></ul><ul><li>Mixed amphetamine salts XR August 2004 </li></ul><ul><li>D-methylphenidate XR June 2005 </li></ul><ul><li>Methylphenidate OROS June 2008 </li></ul><ul><li>Lisdexamfetamine June 2008 </li></ul>
    40. 46. Response to Psychostimulants - Arnold et al. J Attention Dis. 2000;3:200. Best Response (Percent) AMP MPH Equal response to either stimulant Meta-analysis of Within-Subject Comparative Trials Evaluating Response to Stimulant Medications 28% 16% 41% AMP=Amphetamine (Adderall ® , Dexedrine ® , Dextrostat ® ); MPH=methylphenidate (Ritalin ® , others).
    41. 47. Treatment Pearls <ul><li>Don’t be afraid to treat/refer. You can actually be sued if you DON’T (and you have obtained the history, and then a catastrophe occurs). </li></ul><ul><li>RX: Pick the one best agent in each stimulant class </li></ul><ul><ul><li>Sustained effect throughout the day best </li></ul></ul><ul><li>RX: Start with the LOWEST PILL STRENGTH IT COMES IN (or DILUTE IT (Vyvanse). </li></ul><ul><ul><li>Go up from there. </li></ul></ul><ul><li>Push as high as needed, within PI. </li></ul><ul><li>If in doubt, refer. </li></ul>
    42. 48. LISA
    43. 49. People at Risk <ul><li>PSYCHIATRIC </li></ul><ul><li>ADHD </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety disorders </li></ul><ul><li>Bipolar d.o. </li></ul><ul><li>Self-described usage </li></ul><ul><li>FAMILY HISTORY </li></ul><ul><ul><li>(parent OR grandparent = 4 X the risk!!) </li></ul></ul><ul><li>LEGAL </li></ul><ul><li>High risk/high need </li></ul><ul><li>Low risk/no need </li></ul><ul><li>PSYCHOSOCIAL </li></ul><ul><li>PERSONALITY TRAITS </li></ul>
    44. 50. “ The phenomenon of craving” William Duncan Silkworth, MD
    45. 51. David L. Ohlms, MD <ul><li>“ Few other major primary diseases produce the range of emotional and physical complications caused by addiction to the drug, ALCOHOL.” </li></ul><ul><li>“ It is destructive to practically every major organ system in the human body compared to other drugs.” </li></ul>
    46. 52. <ul><li>“ The fact that the majority of people can drink without losing control reinforces the [erroneous] opinion that there is something very wrong with the basic character of those who d o lose control.” </li></ul><ul><ul><ul><li>- Cady & Seif </li></ul></ul></ul>
    47. 53. People at Risk <ul><li>High Risk/High Need </li></ul><ul><li>Middle stages of CD </li></ul><ul><li>Unemployment </li></ul><ul><li>UnEMPLOYABLE </li></ul><ul><li>Undereducated </li></ul><ul><li>Few law-abiding friends </li></ul><ul><li>No stable relationship </li></ul><ul><li>Hopelessness, homelessness </li></ul><ul><li>Low risk/low need </li></ul><ul><li>Early stages </li></ul><ul><li>Employed </li></ul><ul><li>Good support system </li></ul><ul><li>Has a vision of the future </li></ul><ul><li>Spiritual foundation </li></ul><ul><li>Able to conceptualize recovery concepts </li></ul><ul><li>Motivation to change </li></ul>
    48. 54. People at risk – legal woes <ul><li>Legal </li></ul><ul><ul><li>Repeat drunk driving </li></ul></ul><ul><ul><li>Repeat drug offenses </li></ul></ul><ul><ul><li>“ Petition to revoke” </li></ul></ul><ul><ul><li>Failed urine drug screens </li></ul></ul><ul><ul><li>Antisocial behaviors (driving on suspended license, etc.) </li></ul></ul>
    49. 55. Psychosocial: <ul><ul><li>History of “ODD”, conduct problems as child </li></ul></ul><ul><ul><li>“ terminally unique” </li></ul></ul><ul><ul><li>Impatient (low impulse control – ADHD?!) </li></ul></ul><ul><ul><li>Resistant to change </li></ul></ul><ul><ul><li>No life purpose </li></ul></ul><ul><ul><li>no family support </li></ul></ul><ul><ul><li>No goals </li></ul></ul><ul><ul><li>No purpose </li></ul></ul><ul><ul><li>No pleasure </li></ul></ul>
    50. 56. Risky behaviors <ul><li>“ people places and things” </li></ul><ul><li>“ lying, cheating, and stealing” </li></ul><ul><li>Failure to follow through on recovery maintenance activities </li></ul><ul><li>Never grasping “step #1” in AA </li></ul><ul><li>Not dealing with dual diagnosis issues (medication noncompliance) </li></ul>
    51. 57. Patients at risk <ul><li>Family biology/genetics </li></ul><ul><ul><li>(psychiatric AND/or addictive disorders) </li></ul></ul><ul><li>Unenlightened, “un-shrunk” state: </li></ul><ul><ul><li>“ euphoric recall” never dealt with </li></ul></ul><ul><ul><li>“ Dry” but not “Sober.” (Not in recovery.) </li></ul></ul><ul><li>“ Hard wired” issues - Learning disabilities </li></ul><ul><li>Isolation – social, psychological, emotional </li></ul>
    52. 59. RELAPSE PREVENTION STRATEGIES <ul><li>“ Alcoholism doesn’t go away, like diabetes heart disease, cancer, blindness, paralysis… sooner or later you have to accept that you have no control over the PHYSICAL abnormalities. Counseling and support groups can’t change the way our bodies metabolize drugs, alcohol, and substances.” </li></ul><ul><li>- Cady and Seif </li></ul>
    53. 60. Step ONE!! <ul><li>“ We admitted that we were [are?] powerless over alcohol – and that our lives had become unmanageable.” </li></ul>
    54. 61. What happens when you slip?
    55. 62. Key concepts of relapse prevention <ul><li>Alcoholism/ CD don’t go away </li></ul><ul><li>Ongoing recovery is great but a drink can undo it. </li></ul><ul><li>Need to ACCEPT no control over this “physical allergy” (Silkworth) </li></ul>
    56. 63. Medication/Meditation <ul><li>MEDICATION: </li></ul><ul><ul><li>INITATION: </li></ul></ul><ul><ul><ul><li>Axiom: “Treat the problem, not the symptom.” (Cady) </li></ul></ul></ul><ul><ul><ul><li>“ Jump on it; don’t just look at it.” (Cady) </li></ul></ul></ul><ul><ul><li>MAINTENANCE: </li></ul></ul><ul><ul><ul><li>Drug screen- “Trust, but verify.” (Reagan) </li></ul></ul></ul><ul><li>MEDITATION: </li></ul><ul><ul><li>“ the principle of mindfulness” </li></ul></ul><ul><ul><li>Time alone for “reprogramming” – retrain the brain into a “sober brain” </li></ul></ul><ul><ul><li>Learn social and relaxation skills </li></ul></ul>
    57. 64. Medication CONDITION CONFOUNDS APPROPRIATE INAPPROPRIATE ADHD Prev. Meth, Cocaine Strattera, Intuniv, Bupoprion Ritalin, Adderall, Stimulants ADHD EtOH, MJ – to calm down Stimulant? sedatives Anxiety, Depression, ADHD Alcohol, MJ TREAT THE PROBLEM, NOT THE SX – eg., SSRI’s, focused Rx for ADHD which can cause anxiety, detc. “ brain dead benzo’s” (Xanax, Klonopin) Bipolar Mood stabilizers “ downers”(BZD’s) Chemically dependent Uppers/downers: Red Bull, etc.
    58. 65. Know When to Fold’Em
    59. 66. Team Approach <ul><li>COMMUNICATION between members: </li></ul><ul><ul><li>Physician (frequently not a psychiatrist) </li></ul></ul><ul><ul><li>Social worker/therapist </li></ul></ul><ul><ul><li>Probation/parole officer (judge) </li></ul></ul><ul><ul><li>School or supervisor, if appropriate </li></ul></ul><ul><li>Cross training: </li></ul><ul><ul><li>MD’s should know about recovery issues </li></ul></ul><ul><ul><li>CD workers – should know about Rx </li></ul></ul><ul><li>TIPS: </li></ul><ul><ul><li>Release of information’s need to be signed </li></ul></ul><ul><ul><li>Maintenance of collegiality </li></ul></ul>
    60. 67. &quot;If I hadn't believed it, I wouldn't have seen it.&quot; - Yogi Berra Personal collection Louis B. Cady, M.D.
    61. 68. “ For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room opening into another hallway, again lined with doors. Medicine is always wonderful and never will be finished. ” - Charles H. Mayo, M.D.
    62. 69. Thanks for coming! Please fill out evaluations!  Contact info: Dr. Cady and Lisa Seif, LCSW – 812-429-0772 ( [email_address] )

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