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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Zoned, Stoned And Blown - by Louis B. Cady, M.D. and Lisa Seif, LCSW, CADAC02 17 2010 Slideshare
- 1. “ Joyful Beginnings” – mixed media, January, 2004 Amy Musia – Evansville, Indiana www.ajmusia.com
- 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
- 5. ADD – inattentive, without Rx ADD – inattentive, on Adderall Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA
- 11. ADHD: Course of the Disorder Hyperactivity Impulsivity Inattention * Loss of productivity Tardiness, mistakes Disorganization Disruption of work flow — Age —
- 12. Horrigan J, et al. Presented at 47 th Annual AACAP Meeting: October 24-29, 2000. New York, NY.
- 16. Unemployment, underemployment are also problems…
- 17. What happens if ADHD isn’t treated?
- 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
- 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!
- 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
- 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.
- 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
- 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
- 38. Adrenal Burnout
- 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
- 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
- 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.
- 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).
- 48. LISA
- 50. “ The phenomenon of craving” William Duncan Silkworth, MD
- 61. What happens when you slip?
- 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.
- 65. Know When to Fold’Em
- 67. "If I hadn't believed it, I wouldn't have seen it." - Yogi Berra Personal collection Louis B. Cady, M.D.
- 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.
- 69. Thanks for coming! Please fill out evaluations! Contact info: Dr. Cady and Lisa Seif, LCSW – 812-429-0772 ( [email_address] )
Notas del editor
- 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 & 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 <.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 <.001) and sufficiently robust to be detectable in a parallel-groups comparison restricted to the first 3 weeks of the protocol ( P <.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 &quot;something more than human power is needed to produce the essential psychic change&quot; vital to sustained sobriety. Nor did he &quot;hold with those who believe that alcoholism is entirely a problem of mental control.&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. &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.&quot; When the chips are down, Dr. Silkworth concluded, &quot;the only relief we have to suggest is entire abstinence.&quot;