Non-stimulant treatment of attention-deficit/hyperactivity disorder

Cost-effectiveness and budget impact analysis of lisdexamfetamine versus methylphenidate for patients under 18 with attention-deficit/hyperactivity disorder in Iran

BACKGROUND

Lisdexamfetamine (LDX) and Methylphenidate (MPH) are stimulant agents that have been shown to provide significant benefits in the management of attention-deficit/hyperactivity disorder (ADHD) in patients.

AIM

This study aimed to assess the cost-effectiveness and the budget impact of LDX compared to MPH as the first-line treatment for ADHD.

METHODS

A one-year cost-effectiveness analysis (CEA) was conducted to compare the effects of LDX and MPH in reducing disease symptoms and patient costs and improving quality of life (QoL) from a social perspective. Clinical data were obtained using the EQ-5D questionnaire. In contrast, economic data were sourced from the official website of the Iranian Food and Drug Association (FDA), the national book of tariffs, and specific questionnaires designed to evaluate patients' direct and indirect costs. 197 patients were included in the study, including individuals who sought psychiatric evaluation at a hospital in Mashhad and those who obtained ADHD medications from governmental pharmacies. The cost-effectiveness of the study medicine was assessed using the decision tree method, and the results were presented as the Incremental Cost-Effectiveness Ratio (ICER). Deterministic Sensitivity Analysis (DSA) and Probabilistic Sensitivity Analysis (PSA) were performed to assess the robustness of the findings. Additionally, a Budget Impact Analysis (BIA) was conducted over five years, considering three different scenarios, to evaluate the financial implications of incorporating LDX into the national pharmaceutical system.

RESULTS

The ICER for LDX therapy compared to MPH was estimated at USD 264.28 (with an incremental cost of USD 54.9, incremental effectiveness of 0.208, and Quality-Adjusted Life Years (QALYs) gained of 0.765). The PSA indicated a 0.994% probability of LDX being cost-effective, considering a threshold of USD 2450 per QALY. Furthermore, the DSA revealed that the acquisition cost of LDX influenced the model's sensitivity. The BIA demonstrated that incorporating LDX into Iran's healthcare system would result in a financial burden of approximately $368,566 in the first year, representing an additional cost of $11,154 compared to the non-availability of this medicine and the use of previous medications. It is projected that by 2027, the financial burden of treating ADHD with LDX will reach approximately USD 443,879 over five years, amounting to an increase of $71,154 compared to the absence of this medicine.

CONCLUSION

From a social perspective, the inclusion of LDX in the treatment regimen for ADHD is associated with higher costs and an increased financial burden. However, based on our analysis, LDX appears to be a cost-effective choice for managing ADHD in Iran when compared to MPH.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

The use of attention-deficit hyperactivity disorder medications in cardiac disease

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with onset usually in childhood characterized by inattention, impulsivity, and hyperactivity causing a functional impairment. Untreated ADHD, or treatment delay is associated with adverse outcomes and poor quality of life. Although conservative management strategies such as behavioral and psychological interventions are important, pharmacological treatment has a strong evidence base with improved outcomes. ADHD medications are broadly divided into stimulant and non-stimulant medications. Stimulant medications are generally more effective than non-stimulants. Cardiovascular safety of ADHD medication has been a matter of debate for decades. Treatment guidelines advise the careful consideration of risks and benefits in people with cardiovascular diseases such as congenital heart disease or cardiomyopathy. Although stimulants can increase systemic blood pressure and heart rate, no significant associations were found between their use and serious cardiovascular events. Concerns regarding QT effects and attendant sudden cardiac death risks deter clinicians from initiating much-needed ADHD medications in patients with heart disease. This overly cautious approach is potentially depriving low-risk individuals from significant benefits associated with timely ADHD drug treatment. This review discusses the cardiovascular risks reportedly associated with ADHD medications, the evidence base for their safe usage in persons with established cardiovascular disease, and highlights future research directions.

Concomitant Use of Psychotropic Medication With Stimulants for the Treatment of ADHD in Children and Adolescents: A Retrospective Insurance Claims Study in the United States

Objective: To evaluate annual concomitant psychotropic medication use among stimulant-treated children/adolescents with ADHD. Method: Children/adolescents with ≥1 primary ADHD diagnosis who had received ≥30 days of stimulant medication were identified from insurance claims for each calendar year (2011-2014). Use of 15 psychotropic medications concomitantly with stimulants was evaluated and their prevalence in each year was calculated overall and by medication category for children (6-12 years) and adolescents (13-17 years). Results: Each year 133,354 to 157,303 children and 95,632 to 111,280 adolescents were included. Annual period prevalence of any concomitant psychotropic medication use was 22.9% to 25.0% for children and 25.2% to 28.2% for adolescents. The most common medication categories included selective serotonin reuptake inhibitors (children: 6.8%-7.9%; adolescents: 12.7%-14.9%), atypical antipsychotics (4.2%-5.4%; 5.3%-6.3%), and guanfacine extended release (5.1%-7.0%; 2.3%-3.6%). Conclusion: Around a quarter of children/adolescents with ADHD were prescribed psychotropic medication concomitant to stimulant treatment, although only 2 of the 15 medication classes studied were Food and Drug Administration (FDA)-approved for adjunctive use.

Treatment of Adult ADHD without Stimulants: Effectiveness in A Dually Diagnosed Correctional Population

Adult ADHD has received increased attention in the past two decades. There is a complex relationship between ADHD and substance use disorders, with ADHD being a risk factor for and a moderator in the treatment of addiction. ADHD is also a risk factor for the development of antisocial personality disorder. As a result, ADHD is prevalent in a correctional dually diagnosed population. This retrospective chart review reports on the effectiveness of the treatment for ADHD in a population with substance use disorders, residing in a correctional community center for treatment and reintegration purposes. Only patients with a primary diagnosis of ADHD were included and only nonstimulants were used. After an average of four visits, or approximately four months, patient showed a moderate response with a pretreatment to posttreatment effect size of 1.4. Sixty-four percent of patients responded and 35% remitted, according to the Clinical Global Index Severity Scale as the primary outcome measure. While stimulants are considered the first-line treatment for ADHD, they clearly present challenges in certain populations, especially in patients with significant antisocial and addiction histories. It does appear that non-stimulants are effective in this population. It is speculated that the response and remission rate could be improved by adding ADHD specific psychosocial interventions.

Toxoplasma gondii Exposure and the Risk of Attention Deficit Hyperactivity Disorder in Children and Adolescents

BACKGROUND

Evidence suggests that Toxoplasma gondii, which causes toxoplasmosis, changes the metabolism of neurotransmitters, especially dopamine, resulting in both neurologic and psychiatric disorders. On the other hand, the dysregulation of catecholamines, especially of both norepinephrine and dopamine, has been proposed in the pathophysiology of attention deficit hyperactivity disorder (ADHD). The aim of the present study was to investigate anti-toxoplasma antibodies in children and adolescents with ADHD and compare it with a control group, to determine whether toxoplasmosis is a risk factor for ADHD.

METHODS

A total of 200 children and adolescents (117 patients with ADHD and 83 individuals without ADHD) participated in the study. Participants were tested for the presence of anti-T. gondii antibodies by enzyme-linked immunosorbent assay. A Parent ADHD Rating Scale and Clinical Global Impression-severity Scale were also completed. Data were analyzed using a χ test and Fisher exact test.

RESULTS

Anti-toxoplasma antibodies were detected in 18.1% of patients with ADHD disorder and 24% of individuals without ADHD. There was no significant difference in seropositivity between the 2 groups (P > 0.05). The number of patients with T. gondii infection in the 3 subgroups was 0, 9 and 12, respectively. The differences in infection rate among subgroups were not statistically significant (P > 0.05).

CONCLUSION

Although not conclusive, the present study does not support the theory that T. gondii is a risk factor for ADHD.

Bupropion for attention deficit hyperactivity disorder (ADHD) in adults

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurobiological condition, characterised by behavioral and cognitive symptoms such as inattention, impulsivity and/or excessive activity. The syndrome is commonly accompanied by psychiatric comorbidities and is associated with educational and occupational underachievement.Although psychostimulant medications are the mainstay of treatment for ADHD, not all adults respond optimally to, or can tolerate, these medicines. Thus, alternative non-stimulant treatment approaches for ADHD have been explored. One of these alternatives is bupropion, an aminoketone antidepressant and non-competitive antagonism of nicotinic acetylcholine receptors. Bupropion is registered for the treatment of depression and smoking cessation, but is also used off-label to treat ADHD.

OBJECTIVES

To assess the effects and safety of bupropion for the treatment of adults with ADHD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and seven other databases in February 2017. We also searched three trials registers and three online theses portals. In addition, we checked references of included studies and contacted study authors to identify potentially relevant studies that were missed by our search.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that evaluated the effects (including adverse effects) of bupropion compared to placebo in adults with ADHD.

DATA COLLECTION AND ANALYSIS

Two review authors (WV, GB) independently screened records and extracted data using a data extraction sheet that we tested in a pilot study. We extracted all relevant data on study characteristics and results. We assessed risks of bias using the Cochrane 'Risk of bias' tool, and assessed the overall quality of evidence using the GRADE approach. We used a fixed-effect model to pool the results across studies.

MAIN RESULTS

We included six studies with a total of 438 participants. Five studies were conducted in the USA, and one in Iran. All studies evaluated a long-acting version of bupropion, with the dosage ranging from 150 mg up to 450 mg daily. Study intervention length varied from six to 10 weeks. Four studies explicitly excluded participants with psychiatric comorbidity and one study included only participants with opioid dependency. Four studies were funded by industry, but the impact of this on study results is unknown. Two studies were publicly funded and in one of these studies, the lead author was a consultant for several pharmaceutical companies and also received investigator-driven funding from two companies, however none of these companies manufacture bupropion. We judged none of the studies to be free of bias because for most risk of bias domains the study reports failed to provide sufficient details. Using the GRADE approach, we rated the overall quality of evidence as low. We downgraded the quality of the evidence because of serious risk of bias and serious imprecision due to small sample sizes.We found low-quality evidence that bupropion decreased the severity of ADHD symptoms (standardised mean difference -0.50, 95% confidence interval (CI) -0.86 to -0.15, 3 studies, 129 participants), and increased the proportion of participants achieving clinical improvement (risk ratio (RR) 1.50, 95% CI 1.13 to 1.99, 4 studies, 315 participants), and reporting an improvement on the Clinical Global Impression - Improvement scale (RR 1.78, 95% CI 1.27 to 2.50, 5 studies, 337 participants). There was low-quality evidence that the proportion of participants who withdrew due to any adverse effect was similar in the bupropion and placebo groups (RR 1.20, 95% CI 0.35 to 4.10, 3 studies, 253 participants). The results were very similar when using a random-effects model and when we analysed only studies that excluded participants with a psychiatric comorbidity.

AUTHORS' CONCLUSIONS

The findings of this review, which compared bupropion to placebo for adult ADHD, indicate a possible benefit of bupropion. We found low-quality evidence that bupropion decreased the severity of ADHD symptoms and moderately increased the proportion of participants achieving a significant clinical improvement in ADHD symptoms. Furthermore, we found low-quality evidence that the tolerability of bupropion is similar to that of placebo. In the pharmacological treatment of adults with ADHD, extended- or sustained-release bupropion may be an alternative to stimulants. The low-quality evidence indicates uncertainty with respect to the pooled effect estimates. Further research is very likely to change these estimates. More research is needed to reach more definite conclusions as well as clarifying the optimal target population for this medicine. Treatment response remains to be reported in a DSM5-diagnosed population. There is also a lack of knowledge on long-term outcomes.

Single-dose effects on the P3no-go ERP component predict clinical response to stimulants in pediatric ADHD

OBJECTIVE

Approximately 30% of children and adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) and treated with stimulants are considered non-responders (non-REs). Reliable predictors of response are missing. We examined changes in Event-Related Potentials (ERPs) induced by a single dose of stimulant medication in order to predict later clinical response.

METHODS

ERPs were registered twice during performance of a visual cued go/no-go task in 87 ADHD patients (27 girls) aged 8-18years; the second recording on a single dose of stimulant medication, followed by a systematic medication trial lasting 4weeks. Based on the four-week trial, participants were categorized as responders (REs, N=62) or non-REs (N=25). Changes among REs and non-REs in ERP components (cueP3, CNV, P3go, N2no-go, P3no-go) and behavioral-test variables were then compared.

RESULTS

REs and non-REs differed significantly in medication-induced changes in P3no-go, cue-P3, CNV, omission errors, reaction time, and reaction-time variability. The largest effect size was found for P3no-go amplitude (p<.001; d=1.76). Changes in P3no-go and omission errors correctly classified 90% of the REs and 76% of the non-REs, when controlling for the age of the participants.

CONCLUSION

Clinical response to stimulants can be predicted by assessing single-dose changes in the P3no-go ERP component amplitude.

SIGNIFICANCE

Changes in P3no-go may be a clinically useful marker of response to stimulants.

Is adjunctive pharmacotherapy in attention-deficit/hyperactivity disorder cost-effective in Canada: a cost-effectiveness assessment of guanfacine extended-release as an adjunctive therapy to a long-acting stimulant for the treatment of ADHD

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder in children, with worldwide prevalence of ADHD varying from 5.9 to 7.1 %, depending on the reporter. In case of inadequate response to stimulants, combination therapy of stimulants and an adjunctive medication may improve the control of ADHD symptoms, reduce the dose-limiting adverse events, and help control comorbidities. To date, the only medication to be used for adjunctive therapy to psychostimulants is guanfacine extended release (GXR). The aim of this study was to assess the economic impact of GXR as an adjunct therapy with long-acting stimulants (GXR + stimulant) compared to long-acting stimulant monotherapy (stimulant alone) in the treatment of children and adolescents with ADHD in Canada.

METHOD

A Markov model was developed using health states defined based on the clinician-reported Clinical Global Impression-Severity (CGI-S) score (normal, mild, moderate, severe). Transition probabilities were calculated based on patient-level data from a published study. Long-acting stimulants available in Canada were considered in the base-case model: amphetamine mixed salts, methylphenidate HCl formulations, and lisdexamfetamine dimesylate. Analyses were conducted from a Canadian Ministry of Health (MoH; Ontario) and a societal perspective over a 1-year time horizon with weekly cycles.

RESULTS

Over a 1-year time horizon, GXR + stimulant was associated with 0.655 quality-adjusted life year (QALY), compared to 0.627 QALY with stimulant alone, for a gain of 0.028 QALY. From a MoH perspective, GXR+ stimulant and stimulant alone were associated with total costs of $CA1,617 and $CA949, respectively (difference of $CA668), which resulted in an incremental cost-effectiveness ratio (ICER) of $CA23,720/QALY. From a societal perspective, GXR + stimulant and stimulant alone were associated with total costs of $CA3,915 and $CA3,582, respectively (difference of $CA334), which resulted in an ICER of $CA11,845/QALY. Probabilistic sensitivity analysis (PSA) of GXR + stimulant showed that it remains a cost-effective strategy in 100 % of the simulations from both perspectives in numerous PSA and one-way sensitivity analyses, relative to a willingness to pay threshold of $50,000/QALY.

CONCLUSIONS

This economic evaluation demonstrates that GXR +  stimulant is cost-effective compared to stimulant alone in the treatment of children and adolescents with ADHD in Canada.

ADHD & Pharmacotherapy: Past, Present and Future: A Review of the Changing Landscape of Drug Therapy for Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is the most common neurobiological disorder in children, with a prevalence of ~6-7%^1,2 that has remained stable for decades². The social and economic burden associated with patients³, families, and broader systems (healthcare/educational) is substantial, with the annual economic impact of ADHD exceed $30 billion in the US alone⁴. Efficacy of pharmacotherapy in treating ADHD symptoms has generally been considerable with at least ¾ of individuals benefitting from pharmacotherapy, typically in the form of stimulants⁵. In this review, we begin by briefly reviewing the history of pharmacotherapy in relation to ADHD, before focusing (primarily) on the state-of-the-field on themes such as biophysiology, pharmacokinetics, and pharmacogenomics. We conclude with a summary of emerging clinical and research studies, particularly the potential role for precision therapy in matching ADHD patients and drug types.

Period prevalence of concomitant psychotropic medication usage among children and adolescents with attention-deficit/hyperactivity disorder during 2009

OBJECTIVE

Stimulants are recommended as a first-line treatment for attention- deficit/hyperactivity disorder (ADHD); however, a subset of the patient population augments their stimulant treatment with other medications. The objective of this study was to estimate the 1 year period prevalence of concomitant psychotropic medication use among children and adolescents with ADHD during 2009.

METHODS

Patients 6-17 years of age with one or more primary ADHD diagnoses between July 1, 2008 and December 31, 2009 and one or more stimulant prescription fills during 2009 were identified from a large United States commercial claims database. Concomitant psychotropic medication use, defined as 30 days of continuous medication supply overlap between the augmenting agent and stimulant, was evaluated for 14 distinct psychotropic medication categories (6 with a United States Food and Drug Administration (FDA) approved indication for ADHD, 8 without an indication for ADHD). The 1 year period prevalence of concomitant psychotropic medication use (both overall and within each medication category) was calculated and compared between patients with and without psychiatric or neurologic comorbidities. Children (6-12 years) and adolescents (13-17 years) were evaluated separately.

RESULTS

A total of 71,201 children and 49,959 adolescents met the inclusion criteria. The 1 year period prevalence of concomitant psychotropic medication use among children and adolescents was 20.3% and 23.4%, with 5.7% and 6.7% augmenting with two or more medication categories, respectively. The most common concomitant medication categories were selective serotonin reuptake inhibitors (SSRIs) (children: 6.2%; adolescents: 11.4%), atypical antipsychotics (5.8%; 6.8%) and clonidine immediate release (5.4%; 2.9%). Children and adolescents with psychiatric or neurologic comorbidities had higher rates of augmentation than did those without comorbidities (all p<0.001).

CONCLUSIONS

This epidemiologic study found that the prevalence of concomitant psychotropic medication use in children and adolescents ranged from 12.6% for noncomorbid ADHD to 41.7% for comorbid ADHD, in 2009. Future research is warranted to evaluate the rationale for, and clinical benefit of, concomitant psychotropic medication usage in patients with ADHD.

Atomoxetine in the treatment of attention deficit hyperactivity disorder

Atomoxetine (Strattera, Eli Lilly & Co.) is a highly selective noradrenaline reuptake inhibitor and the first nonstimulant medication to be approved for the treatment of attention deficit hyperactivity disorder. Currently, nine published clinical trials have documented the safety and efficacy of atomoxetine in the treatment of children, adolescents and adults with attention deficit hyperactivity disorder and data presented throughout the past year at national scientific meetings has further addressed its utility. This article reviews the available information on atomoxetine, accompanied by a discussion of its clinical use.

Innovations and recent trends in the treatment of ADHD

Initiatives to develop better-tolerated, more efficacious pharmacological agents with improved drug delivery systems have driven recent research in attention-deficit hyperactivity disorder (ADHD). While stimulants are the primary pharmacotherapy for ADHD, these drugs have a limited duration of action and a subset of patients will either fail to respond to these medications or have side effects that preclude their use. The development of atomoxetine, the first nonstimulant approved for ADHD, has been followed by additional innovative research, such as the methylphenidate transdermal system, modafinil, NRP-104 and cholinergic agents. This review highlights some of the recent trends in ADHD treatment and the current status of promising treatment options that may help to shape the future of ADHD treatment.

Targeting the dopamine system in the treatment of attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a highly heritable condition that affects a significant number of children and adults worldwide. During the past 30 years, the diagnosis and treatment of ADHD has relied on clinical assessment and empirical experience with stimulant medications. More recently, advances in family genetic studies, molecular genetic studies, preclinical research, radiographic imaging techniques and neuropsychological evaluation have significantly enhanced our understanding of the neurobiology of ADHD. This review highlights the current central role of dopamine in the pathophysiology and treatment of ADHD and implications for future advances in diagnosis and treatment.

A Review of the Pathophysiology, Etiology, and Treatment of Attention-Deficit Hyperactivity Disorder (ADHD)

Objective: To review the pathophysiology, etiology, and treatment of attention-deficit hyperactivity disorder (ADHD). Data Sources and Data Extraction: A literature search was conducted in PubMed and EMBASE using the terms attention deficit hyperactive disorder, ADHD, pathophysiology, etiology, and neurobiology. Limits applied were the following: published in the past 10 years (January 2003 to August 2013), humans, review, meta-analysis, and English language. These yielded 63 articles in PubMed and 74 in EMBASE. After removing duplicate/irrelevant articles, 86 articles and their relevant reference citations were reviewed. Data Synthesis: ADHD is a neurological disorder that affects children, but symptoms may persist into adulthood. Individuals suffering from this disorder exhibit hyperactivity, inattention, impulsivity, and problems in social interaction and academic performance. Medications used to treat ADHD such as methylphenidate, amphetamine, and atomoxetine indicate a dopamine/norepinephrine deficit as the neurochemical basis of ADHD, but the etiology is more complex. Moreover, these agents have poor adverse effect profiles and a multitude of drug interactions. Because these drugs are also dispensed to adults who may have concomitant conditions or medications, a pharmacist needs to be aware of these adverse events and drug interactions. This review, therefore, focuses on the pathophysiology, etiology, and treatment of ADHD and details the adverse effects and drug interaction profiles of the drugs used to treat it. Conclusions: Published research shows the benefit of drug therapy for ADHD in children, but given the poor adverse effect and drug interaction profiles, these must be dispensed with caution.

Frequency of celiac disease in attention-deficit/hyperactivity disorder

OBJECTIVE

Although it is well known that celiac disease (CD) is associated with neurologic disorders, association with psychiatric problems is not well defined. In this report, we aimed to detect CD prevalence in patients with attention-deficit hyperactivity disorder (ADHD).

METHODS

A total of 362 patients between the ages 5 and 15 years with the diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria and 390 sex- and age-matched healthy children were included in the present study. Serum levels of tissue transglutaminase (tTg) immunoglobulin (Ig) A and IgG were studied in both groups. Serum IgA levels were also studied in patients with positive tTG IgG for the exclusion of selective IgA deficiency. Endoscopic duodenal biopsy was provided in seropositive patients, whose parents approved the procedure. Biopsy samples were evaluated according to Marsh-Oberhuber classification.

RESULTS

tTg IgA was positive in 4 patients with ADHD (1.1%). Endoscopic duodenal biopsy was suggestive of CD in one of them (0.27%). tTg IgA was positive in 3 of control group patients (0.8%). Duodenal biopsy of the only patient from control group, who underwent upper gastrointestinal endoscopy, revealed normal intestinal mucosa.

CONCLUSIONS

The seropositivity rates for CD were found similar in ADHD and control groups. Thus, neither routine screening for CD nor empirical recommendation of gluten-free diet seems necessary in children with ADHD.

Pharmacotherapy of pediatric attention-deficit/hyperactivity disorder

This article describes the practical use of available attention-deficit/hyperactivity disorder (ADHD) pharmacotherapies, their formulations and durations of action, and the extent of Food and Drug Administration approvals. It provides data on short-term and long-term safety of these medications, their use in ADHD with comorbid conditions, and strategies for formulating individualized, effective, and well-tolerated pharmacotherapy treatment plans. A clinical vignette focusing on a male child with ADHD is presented. Summaries are presented of ADHD pharmacotherapies and Food and Drug Administration approval status, atomoxetine and stimulant comparator trials, adverse effects and ADHD pharmacotherapy, and delivery system and duration of effect.

Atomoxetine modulates spontaneous and sensory-evoked discharge of locus coeruleus noradrenergic neurons

Atomoxetine (ATM) is a potent norepinephrine (NE) uptake inhibitor and increases both NE and dopamine synaptic levels in prefrontal cortex, where it is thought to exert its beneficial effects on attention and impulsivity. At the behavioral level, ATM has been shown to cause improvements on the measures of executive functions, such as response inhibition, working memory and attentional set shifting across different species. However, the exact mechanism of action for ATM's effects on cognition is still not clear. One possible target for the cognitive enhancing effects of ATM is the noradrenergic locus coeruleus (LC), the only source of NE to key forebrain areas such as cerebral cortex and hippocampus. Although it is known that ATM increases NE availability overall by blocking reuptake of NE, the effects of this agent on impulse activity of LC neurons have not been reported. Here, the effect of ATM (0.1-1 mg/kg, ip) on NE-LC neurons was investigated by recording extracellular activity of LC neurons in isoflurane-anesthetized rats. ATM caused a significant decrease of the tonic activity of LC single-units, although leaving intact the sensory-evoked excitatory component of LC phasic response. Moreover, the magnitude of the inhibitory component of LC response to paw stimulation was increased after 1 mg/kg of ATM and its duration was prolonged at 0.3 mg/kg. Together, these effects of ATM produced an increase in the phasic-to-tonic ratio of LC phasic response to sensory stimulation. ATM also modulated the average sensory-evoked local field potential (LFP) and spike-field coherence in LC depending on the dose tested. The lower dose (0.1 mg/kg) significantly decreased early positive and negative components of the sensory-evoked LFP response. Higher doses (0.3-1 mg/kg) initially increased and then decreased the amplitude of components of the evoked fields, whereas the spike-field coherence was enhanced by 1 mg/kg ATM across frequency bands. Finally, coherence between LC fields and EEG signals was generally increased by 1 mg/kg ATM, whereas 0.1 and 0.3 mg/kg respectively decreased and increased coherence values in specific frequency bands. Taken together these results suggest that ATM effects on LC neuronal activity are dose-dependent, with different doses affecting different aspects of LC firing. This modulation of activity of LC-NE neurons may play a role in the cognitive effects of ATM. This article is part of a Special Issue entitled 'Cognitive Enhancers'.

Bupropion versus methylphenidate in the treatment of children with attention-deficit/hyperactivity disorder: randomized double-blind study

OBJECTIVE

To compare the safety and efficacy of bupropion with methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a 6-week randomized double-blind study, 44 patients with a DSM-IV-TR diagnosis of ADHD were randomly assigned to receive bupropion 100-150 mg/day (100 mg/day for <30 kg and 150 mg/day for >30 kg) or methylphenidate 20-30 mg/day. Symptoms were assessed using Teacher and Parent Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV) at baseline and weeks 3 and 6.

RESULTS

Forty patients had at least one post-baseline measurement, and 38 patients completed the trial. No significant difference was found between the two groups on the Parent and Teacher ADHD-RS-IV scores ([F(1, 38) = 0.266, p = 0.609] and [F(1, 38) = 0.001, p = 0.972], respectively). By week 6, 18 patients (90%) in each group achieved response on the Parent scale (Fisher's exact test p-value = 1.0). With the Teacher ADHD-RS-IV used, eight (40%) patients in the bupropion group and 12 (60%) patients in the methylphenidate group achieved response by week 6 (χ(2) (1) = 1.600, p = 0.206). Headache was observed more frequently in the methylphenidate group. Frequency of other side effects was not significantly different between the two groups.

CONCLUSIONS

Bupropion has a comparable safety and efficacy profile with methylphenidate in children and adolescents with ADHD.

The evidence-based pharmacological treatment of paediatric ADHD

Attention deficit hyperactivity disorder (ADHD) is common in children, adolescents, and adults, with extensive research establishing it as a valid neurobiological disorder. Without intervention, ADHD can result in significant impairment throughout the lifespan for the individuals it afflicts. Fortunately, multiple evidence-based options are available for the treatment of ADHD, including several efficacious pharmacotherapies. The role of medication, including stimulants as well as non-stimulants, is well-documented by an extensive body of literature. Although there may be less enthusiasm for behavioural and other psychosocial interventions as stand-alone treatments for moderate to severe ADHD, they are recommended as first-line treatment for ADHD management in preschool-aged children, for those patients with mild symptoms, and as an adjunct to medication in patients with comorbid disorders or suboptimal responses to pharmacotherapy. When planning treatment for individuals with ADHD, the potential risks associated with the available interventions must be carefully balanced against the risks of not treating, or not treating adequately. The treatment plan must also include ongoing re-assessment of the effectiveness of and the need for continued therapy. Recent practice parameters provide further specific guidance for the evidence-based assessment and treatment of children and adolescents with ADHD.

Prescribing of psychotropic medication to the intellectually disabled by community paediatricians - a survey

BACKGROUND

Children with intellectual disability are often managed by community paediatricians and have a high prevalence of mental disorder. We do not know whether community paediatricians feel adequately trained to treat this group although we know that paediatricians contribute significantly to psychotropic prescribing for children.

METHODS

Psychotropic medication prescribing by community paediatricians to the intellectually disabled in the north-west and northern regions, community paediatricians' perceived training needs in this area and the availability of specialized psychiatric services were surveyed. Postal questionnaires were sent to all members of the British Association of Community Child Health in the north and north western regions (n= 155), between summer 2004 and autumn 2005.

RESULTS

A total of 70.1% (n= 110) of questionnaires were returned of which 66 were completed. The most common reason for non-completion was that the respondent did not look after the intellectually disabled. A total of 54.5% of respondents did not have access to specialist psychiatry services for children and adolescents with an intellectual disability. Community paediatricians were most likely to prescribe for sleep disorders and attention deficit hyperactivity disorder (ADHD). There was a significant relationship between perceived adequacy of training and paediatrics prescribing for ADHD, but there was no such relationship for sleep disorders. The vast majority of community paediatricians did not feel adequately trained to prescribe for challenging behaviour or depression, although a small minority did prescribe.

CONCLUSIONS

Community paediatricians play a substantial role in prescribing psychotropic medications for this group. A substantial minority of community paediatricians do not feel that they have enough training to prescribe for ADHD and sleep disorders, and perceived competency is more likely to inform prescribing for ADHD than for sleep disorders. This may have implications for training. Although these children pose complex difficulties, access to specialist mental health services for children and adolescents with intellectual disability remains patchy, especially in the north-west, and further development of these services is needed.

A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

The precise nature and etiopathogenesis of borderline personality disorder (BPD) continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core features of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD, with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based on recently accumulated data. In particular, we suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization, linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed.

Donepezil use in children and adolescents with tics and attention-deficit/hyperactivity disorder: an 18-week, single-center, dose-escalating, prospective, open-label study

BACKGROUND

Striatal cholinergic dysfunction may be important in tics and attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE

The purpose of this study was to determine the safety profile of donepezil and whether it improves chronic tics in young patients with comorbid ADHD.

METHODS

This 18-week (14 weeks of open treatment followed by a 4-week washout period), single-center, dose-escalating, prospective, open-label trial was conducted in patients aged 7 to 17 years with tics, including chronic motor or vocal tics and Tourette's syndrome, and ADHD. Patients were treated with once-daily oral donepezil doses of 2.5 mg for 2 weeks, 5 mg for the next 6 weeks, and 10 mg for the last 6 weeks, followed by a 4-week washout period. Patients were evaluated using the Children's Global Assessment Scale; the Yale Global Tic Severity Scale (YGTSS); the Revised Conners' Parent Rating Scale; the Symbol and Digit Wisconsin Card Sorting Test; the Stroop black/white, color, and interference tests; the Rey Complex Figure Test; and the Children's Yale-Brown Obsessive Compulsive Scale at 4 visits: baseline, week 8 (5-mg dose), week 14 (10-mg dose), and week 18 (washout).

RESULTS

Seventeen males and 3 females (mean [SD] age, 11.3 [1.9] years [range, 8-14 years]; tic duration, 5.3 [1.9] years; ADHD duration, 6.5 [1.7] years) were included in this study. Tics were significantly reduced at the 10-mg (week-14) donepezil visit compared with the baseline and washout visits based on the total mean (SD) tic score of the YGTSS (18.6 [9.3] vs 12.2 [11.0]; P = 0.006). Fifty percent of patients withdrew and 65% experienced adverse events.

CONCLUSIONS

These preliminary results suggest that donepezil significantly reduced tics in these children and adolescents with comorbid ADHD who completed the study. No significant improvement in the symptoms of comorbid ADHD was found with the use of donepezil 10 mg. Donepezil 5 and 10 mg were not well tolerated in these children and adolescents.

The current clinical management of Huntington's disease

Huntington's disease is a neurodegenerative condition, characterized by movement disorders, cognitive decline, and psychiatric disturbance. We review the pharmacological management of the various movement disorders associated with the disease, the cognitive decline and the commonly encountered behavioral disturbances. We discuss the nonclassical features of the disease, important in the management of these patients. Nonpharmacological support including genetic counseling and therapy and the importance of palliative care are also addressed. Finally, experimental approaches that may soon impact upon clinical practice are discussed.

Antidepressants in the treatment of adult attention-deficit hyperactivity disorder: a systematic review

INTRODUCTION

Stimulant medications are the most effective drugs in the treatment of attention-deficit hyperactivity disorder (ADHD) in children and in adults. However, some patients do not respond to this treatment and other patients suffer from adverse effects. Very often there are also comorbid disorders that warrant treatment or there is somatic comorbidity that precludes the prescription of stimulants. As a result, alternative treatments for the treatment of ADHD have been explored, such as antidepressant agents. In this systematic review the evidence base for the effect of antidepressants for ADHD in adult patients is determined.

METHODS

Electronic and hand searches were conducted in order to identify clinical trials studying antidepressants for the treatment of ADHD in adult patients. The trials were screened for methodological characteristics and treatment-effect sizes. The odds ratio was calculated for randomized controlled trials with bupropion. A descriptive review of all the randomized controlled studies and an overview of the nonrandomized studies was developed.

RESULTS

Only eight randomized controlled trials were retrieved with four different compounds. Five studies concerned bupropion and the meta-analysis indicates a beneficial effect for bupropion compared with placebo as measured with the Clinical Global Improvement Scale (odds ratio 2.42 [95% CI 1.09 to 5.36]). Several studies suffer from clinical and methodological shortcomings, such as exclusion of patients with comorbid disorders, short treatment duration, or a lack of information with respect to the randomization procedure.

CONCLUSION

Although there is a need for alternative interventions for the treatment of ADHD, such as with antidepressant agents, the evidence base is not large. Only treatment with bupropion seems to have a medium-range effect size, but this is less than that of stimulant medications.

Use of clonidine in children with autism spectrum disorders

Children with autism spectrum disorders (ASD) often exhibit sleep and behavioral disorders. Treatment of sleep disorders can be difficult in these children. Clonidine, an alpha2-adrenergic receptor agonist, has been shown to be effective in reducing impulsivity, inattention, and hyperactivity, as well as in serving as a sedative for medial procedures. An open labeled retrospective study of clonidine in treatment of insomnia, and/or hyperactivity, inattention, mood disorder, and aggressive behaviors was conducted using parent reports of sleep initiation and maintenance, as well as behaviors prior and during clonidine treatment. Clonidine was effective in reducing sleep initiation latency and night awakening, to a less degree in improving attention deficits hyperactivity, mood instability and aggressiveness in this cohort of 19 children with ASD. The side effects were largely tolerable. Further evaluation with placebo-controlled double-blind clinical trial of clonidine use in ASD will provide more insight into the clinical efficacy and safety of the medicine in ASD.

Opportunities and challenges of psychiatric drug discovery: roles for scientists in academic, industry, and government settings

Despite significant progress in understanding the biological systems and mechanisms involved in CNS disorders, use of this knowledge to realize practical gains in psychiatric care has been slow. To gain further insight into the reasons for failure and success in CNS drug discovery, preclinical predictors of success and failure for CNS drug discovery were evaluated for drugs developed for schizophrenia, depression, and anxiety. Specifically, we examined the success rate for drugs that had entered at least the later stages of preclinical research. Almost 500 compounds (140 antipsychotic; 211 antidepressant; 143 anxiolytic) were classified based on their molecular target(s) and evaluated based on preclinical validation, whether preclinical studies predicted clinical efficacy, and whether the compound displayed greater efficacy than 'conventional treatment' Results varied with indication but suggest that preclinical models have modest to good ability to predict overall clinical efficacy and adverse effect liability but are less able to predict efficacy greater than conventional treatment. In order to fully realize the potential therapeutic impact of recent basic science discoveries, it will be critical to increase attention on rigorous target validation at each step of the drug discovery process and focus efforts on developing new tools and clinical models that can be used for proof-of-concept studies in early clinical development. Also, increased attention should be focused on the development of early predictors of adverse effects of candidate compounds.

A randomized controlled trial of a novel mixed monoamine reuptake inhibitor in adults with ADHD

BACKGROUND

NS2359 is a potent reuptake blocker of noradrenalin, dopamine, and serotonin. The aim of the study was to investigate the efficacy, safety and cognitive function of NS2359 in adults with a DSM IV diagnosis of ADHD.

METHODS

The study was a multi-centre, double-blind, randomized placebo-controlled, parallel group design in outpatient adults (18-55 years) testing 0.5 mg NS2359 vs. placebo for 8 weeks. Multiple assessments including computerized neuropsychological evaluation were performed.

RESULTS

There was no significant difference between NS2359 (n = 63) versus placebo (n = 63) on the primary outcome measure reduction in investigator rated ADHD-RS total score (7.8 versus 6.4; p < 0.45). However, in subjects with the inattentive subtype, there were significantly more responders in the NS2359 group compared to placebo (41% versus 7%; p < 0.01). For all secondary variables (ADHD-RS patient rated; The Conners Adult ADHD Scale; The Brown Adult Scale, and CGI-improvement scale) there were no significant differences between the two groups; however, in the inattentive subgroup, the response to treatment was significantly larger than to placebo. NS2359 improved composite factor scores of attention, episodic- and working memory. No serious adverse events were reported with insomnia, headaches and loss of appetite most commonly reported as side effects.

CONCLUSION

No overall effect of NS2359 was found on overall symptoms of ADHD. There was also a modest signal of improvement in the inattentive adults with ADHD and cognition warranting further exploration using differing doses.

Switching from neurostimulant therapy to atomoxetine in children and adolescents with attention-deficit hyperactivity disorder : clinical approaches and review of current available evidence

This review provides practical information on and clinical reasons for switching children and young people with attention-deficit hyperactivity disorder (ADHD) from neurostimulants to atomoxetine, detailing currently available evidence, and switching options. The issue is of particular relevance following recent guidance from the National Institute for Health and Clinical Excellence and European ADHD guidelines endorsing the use of atomoxetine, along with the stimulants methylphenidate and dexamphetamine, in the management of ADHD in children and adolescents in the UK. The selective norepinephrine (noradrenaline) reuptake inhibitor, atomoxetine, is a non-stimulant drug licensed for the treatment of ADHD in children and adolescents, and in adults who have shown a response in childhood. Following the once-daily morning dose, its therapeutic effects extend through the waking hours, into late evening, and in some patients, through to early the next morning. Atomoxetine may be considered for patients who are unresponsive or incompletely responsive to stimulant treatment, have co-morbid conditions (e.g. tics, anxiety, depression), and have sleep disturbances or eating problems, for patients in whom stimulants are poorly tolerated, and for situations where there is potential for drug abuse or diversion. Atomoxetine has been shown to be effective in relapse prevention and there is suggestion that atomoxetine may have a positive effect on global functioning; specifically health-related quality of life, self-esteem, and social and family functioning. According to one study, approximately 50% of non-responders to methylphenidate will respond to atomoxetine therapy and approximately 75% of responders to methylphenidate will also respond to atomoxetine. Atomoxetine may be initiated by a schedule of dose increases and cross-tapering with methylphenidate. A slow titration schedule with divided doses minimizes the impact of adverse events within the first several weeks of treatment. Atomoxetine may be co-administered with methylphenidate during the switching period without undue concern for adverse events, such as cardiovascular effects (although monitoring of blood pressure and heart rate is necessary). Atomoxetine may be discontinued abruptly and patients may miss the occasional dose without rebound effects or discontinuation syndrome. A trial period of at least 6-8 weeks, perhaps longer, is recommended before evaluation of the overall tolerability and efficacy of atomoxetine. We conclude that patients with ADHD can be switched from neurostimulants, specifically methylphenidate, to atomoxetine, and may benefit from symptom improvement.

alpha2-Adrenergic receptor agonists for the treatment of attention-deficit/hyperactivity disorder: emerging concepts from new data

Recent developments in the field of neuroscience have illuminated the understanding of the neural circuits impaired in attention-deficit/hyperactivity disorder (ADHD) and the mechanism of action of treatments used to treat this condition. There is an exciting confluence between emerging studies in basic neurobiology and the genetic, neuroimaging, and neuropsychological analyses of ADHD. The following provides a brief review of this field, explaining how compounds like guanfacine and the traditional stimulant medications can reduce the core symptoms of ADHD by optimizing the neurochemical environment in the prefrontal cortex (PFC). Knowledge of these basic mechanisms may inform our medication choices and facilitate treatment of ADHD and related disorders.

Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder

This practice parameter describes the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) based on the current scientific evidence and clinical consensus of experts in the field. This parameter discusses the clinical evaluation for ADHD, comorbid conditions associated with ADHD, research on the etiology of the disorder, and psychopharmacological and psychosocial interventions for ADHD.

Semax, an analogue of adrenocorticotropin (4–10), is a potential agent for the treatment of attention-deficit hyperactivity disorder and Rett syndrome

Psychostimulants, such as methylphenidate, are currently the most common used drug therapy for children with attention-deficit hyperactivity disorder (ADHD). However, a number of patients with ADHD either fail to respond to these drugs or experience side effects that preclude their use. The heptapeptide Semax is an analogue of the N-terminal fragment (4-10) of adrenocorticotropic hormone, but is completely devoid of any hormonal activity. It has been found to stimulate memory and attention in rodents and humans after intranasal application. Evidence from animal studies revealed that Semax can augment the effects of psychostimulants on central dopamine release and also stimulates central brain-derived neurotrophic factor (BDNF) synthesis. In addition, Semax could improve selective attention and modulate brain development. Since ADHD is likely to be a neurodevelopmental disorder with disturbance in dopamine and BDNF function, it is proposed in this paper that Semax may have good therapeutic potential in ADHD. Furthermore, increased BDNF activity is found to improve Rett syndrome, a severe neurodevelopmental disorder which is, in the majority of cases, caused by mutations in the gene encoding methyl-CpG-binding protein 2 (MECP2). The potential therapeutic effect of Semax in Rett syndrome by increasing central BDNF activity may be of interest for further exploration in animal models of Rett syndrome.

Methylphenidate and its isomers: their role in the treatment of attention-deficit hyperactivity disorder using a transdermal delivery system

dl-threo-Methylphenidate is a highly efficacious drug for treating attention-deficit hyperactivity disorder (ADHD) that is currently administered as immediate- or controlled-release and osmotically controlled-released formulations. The drug exists as two enantiomers, d-threo-methylphenidate and l-threo-methylphenidate, with the former having been developed as a medication to treat ADHD in its own right. dl-threo-Methylphenidate undergoes enantioselective metabolism in the liver, which results in marked differences in the plasma concentrations of its isomers, depending on the route of administration and formulation. When dl-threo-methylphenidate is orally administered, the plasma concentrations of d-threo-methylphenidate are higher than those of l-threo-methylphenidate. However, with the recently developed methylphenidate transdermal system (MTS), 'first-pass' metabolism is circumvented and, as a consequence, plasma concentrations of d-threo-methylphenidate are consistent with those produced by oral formulations, but the relative concentrations of l-threo-methylphenidate are much higher, i.e. 50-60% of those of d-threo-methylphenidate. In this article, we review the pharmacokinetics and pharmacology of dl-threo-methylphenidate and its isomers to assess the extent to which their mechanism of action as noradrenaline (norepinephrine) and dopamine reuptake inhibitors is responsible for their efficacy and commonly occurring adverse effects. The major findings are that d-threo-methylphenidate and l-threo-methylphenidate share the same pharmacological profile as the parent racemate, i.e. catecholamine-selective reuptake inhibition with higher potency against dopamine versus noradrenaline reuptake in vivo. However, d-threo-methylphenidate is approximately 10-fold more potent than the l-isomer in this regard. For these drugs, their abilities not only to ameliorate the behavioural and cognitive dysfunctions in ADHD, but also to induce the common adverse effects of reduced appetite, nausea/vomiting and stomach ache, are almost certainly due to their ability to potentiate noradrenergic and/or dopaminergic function in the central and peripheral nervous systems. The sympathomimetic actions of ADHD drugs on cardiovascular function are currently an issue of concern. Since noradrenaline reuptake inhibition is the likely mediator for the effects of dl-threo-methylphenidate on blood pressure and heart rate, the more potent d-isomer will therefore be predominantly responsible. Motor and vocal tics are the other important adverse event to be considered in the treatment of ADHD. It is now accepted that tics are a frequently occurring behavioural manifestation of ADHD itself and the evidence for or against their exacerbation by treatment with dl-threo-methylphenidate or other stimulants remains highly contradictory. Focusing on the enantiomers of dl-threo-methylphenidate, it can be concluded that d-threo-methylphenidate, which is the more potent and abundant of the two isomers, is the major contributor of both efficacy and adverse effects, irrespective of the formulation or route of administration of the racemate. Moreover, for the oral, extended-release formulations of dl-threo-methylphenidate, the d-isomer represents the only pharmacologically active moiety when these medications are used in the clinic. With the MTS, plasma concentrations of l-threo-methylphenidate are higher than are achieved using oral formulations, but even in this case, it is likely that the contribution of this enantiomer to the efficacy and adverse effects of the racemate is no greater than 5-10% of the total.

A review of the use of modafinil for attention-deficit hyperactivity disorder

Modafinil (Provigil) is a novel wakefulness-promoting agent that has been shown to have greater efficacy than placebo in the treatment of attention-deficit hyperactivity disorder (ADHD) in children and adults. In particular, three large, drug-company sponsored trials of a film-coated formulation of modafinil (modafinil-ADHD; Sparlon) in children and adolescents with ADHD demonstrated consistent improvements in ADHD symptoms compared with placebo. Mean reductions in symptom ratings (measured using the ADHD-Rating Scale-IV school version questionnaire) ranged from 15.0 to 19.7 (7.3 to 10.1 for placebo). The most common adverse events were insomnia, headache and decreased appetite. Modafinil was generally well tolerated with most side effects considered mild to moderate in severity. Modafinil may have advantages over current therapies for ADHD in that it can be administered once daily and has fewer reinforcing properties than traditional stimulants. Modafinil could potentially be a valuable new treatment option for patients with ADHD. However, rigorous comparative studies with current first-line treatments for ADHD and longer-term independent studies are necessary before modafinil's role in the treatment of ADHD can be fully established.

The alpha(2C)-adrenergic receptor mediates hyperactivity of coloboma mice, a model of attention deficit hyperactivity disorder

Drugs that modify noradrenergic transmission such as atomoxetine and clonidine are increasingly prescribed for the treatment of attention deficit hyperactivity disorder (ADHD). However, the therapeutic targets of these compounds are unknown. Norepinephrine is also implicated in the hyperactivity exhibited by coloboma mice. To identify the receptor subtypes that regulate the hyperactivity, coloboma mice were systematically challenged with adrenergic drugs. The beta-adrenergic receptor antagonist propranolol and the alpha(1)-adrenergic receptor antagonist prazosin each had little effect on the hyperactivity. Conversely, the alpha(2)-adrenergic receptor antagonist yohimbine reduced the activity of coloboma mice but not control mice. Subtype-selective blockade of alpha(2C)-, but not alpha(2A)- or alpha(2B)-adrenergic receptors, ameliorated hyperactivity of coloboma mice without affecting activity of control mice, suggesting that alpha(2C)-adrenergic receptors mediate the hyperactivity. Localized in the basal ganglia, alpha(2C)-adrenergic receptors are in a prime position to impact locomotor activity and are, therefore, potential targets of pharmacotherapy for ADHD.

Integrative neuroscience approach to predict ADHD stimulant response

Despite high rates of prescription, little is known about the long-term consequences of stimulant medication therapy for attention-deficit hyperactivity disorder (ADHD) sufferers. Historically, the clinical use of stimulants for ADHD has been based on trial and error before optimal therapy is reached. Concurrently, scientific research on the mechanism of action of stimulants has influenced neurobiological models of ADHD, but has not always informed their prescription. Whilst the two main stimulant types (methylphenidate and dexamphetamine) have numerous similarities, they also differ (slightly) in mechanism and possibly individual response. A further issue relates to differences in cost and availability compounded by the expectation for stimulants to be effective in ameliorating a broad spectrum of ADHD-related symptoms. Thus, there is an increasing need for treating clinicians to prescribe not only the most effective drug, but also the most appropriate dose with the associated release mechanism and schedule for each ADHD patient presented. In this regard, the field is witnessing an emergence of the personalized medicine approach to ADHD, in which treatment decisions are tailored to each individual. This shift requires a new approach to research into treatment response prediction. Given the heterogeneity of ADHD, a profile of information may be required to capture the most sensitive predictors of treatment response in individuals. These profiles will also benefit from the integration of data from clinical rating scales with more direct measures of cognition and brain function. In conclusion, there is a need to establish a more robust normative framework as the baseline for treatment, as well as diagnostic decisions, and as discussed, the growth of integrated neuroscience databases will be important in this regard.

Attention-deficit hyperactivity disorder in girls: epidemiology and management

Attention-deficit hyperactivity disorder (ADHD) in girls is a topic of growing research and clinical interest. For many years, girls with ADHD have been ignored and overshadowed by hyperkinetic and impulsive boys, but they are now attracting interest in an effort to understand the similarities and differences in the prevalence, symptoms, familial risk, comorbidities and treatment of ADHD in the two sexes. A review of past and current literature finds that the symptoms of ADHD are not sex specific, but that identification of girls with ADHD is hampered by parental and teacher bias, and confusion. Girls are more likely to be inattentive without being hyperactive or impulsive, compared with boys. Girls and boys share the same familial risk patterns, as well as similar, although not identical, comorbidity or impairment patterns. The risk of non-treatment is as great in girls as it is in boys; up to 70-80% of identified children will have persistent symptoms and impairment that extends into adolescence and adulthood. Treatment modalities are equally effective in girls and boys. Stimulants, non-stimulants and behavioural modalities are the mainstays of effective treatment.

Attention deficit disorders: are we barking up the wrong tree?

Attention deficit disorder (AAD) and attention deficit/hyperactivity disorder (ADHD) are very frequent and protean developmental disorders without a definite biologic marker. This review proposes a framework to understand the enlarged spectrum of its manifestations based on current knowledge of the mechanisms underlying arousal and attention variations during sleep/wake cycle. The neuro-modulation's pivotal role in this process as well as in the fine tuning of synaptic architecture during development must be taken into account when trying to understand the marked fuzziness of the symptoms and the very high prevalence of reported co-morbidities. The series of related interactions includes a cyclic deactivation of the dorso-lateral portion of the prefrontal cortex (DLPFC) during sleep, suspending executive functions, co-occurring with rhythmic periods of decreased noradrenergic tonus. A protracted unbalance in modulation, with catecholaminergic relative deficiency, could explain less-than-optimum waking DLPFC activation and the most important manifestations of ADD. Beside the well documented dopaminergic effects of stimulant medication used in ADD and ADHD, a more important role must be assigned to noradrenaline (NA). At this light hyperactivity and impulsivity are less important dimensions. Rather, an attention deficit spectrum disorder should probably be regarded as a complication of a core defect in prefrontal cortex dependent inhibitory control, underlying inattention.

Predictors of selecting atomoxetine therapy for children with attention-deficit-hyperactivity disorder

STUDY OBJECTIVE

To investigate predictors of beginning treatment with atomoxetine, a new attention-deficit-hyperactivity disorder (ADHD) drug, shortly after it was introduced into the marketplace compared with well-established stimulants for children in a managed care setting.

DESIGN

Retrospective cohort analysis.

DATA SOURCE

Managed care claims database.

PATIENTS

A total of 45,144 patients aged 18 years or younger who filled a prescription for an ADHD-specific drug.

MEASUREMENTS AND MAIN RESULTS

For each patient, the most recent start of therapy between April 1 and December 31, 2003, was categorized by drug: atomoxetine; any stimulant; or short-, intermediate-, or long-acting stimulant. The categories were based on the first use of the drug without use of a drug in that same category in the previous 3 months. Logistic regression analysis of past-year administrative claims was applied to determine predictors of the start of specific pharmacotherapy. Patients with a claim of ADHD with hyperactivity were 1.50 times more likely to begin therapy with atomoxetine than with any stimulant (95% confidence interval [CI] 1.42-1.58). Patients with a history of tics (odds ratio [OR] 3.11, 95% CI 2.54-3.82), anxiety (OR 1.35, 95% CI 1.24-1.48), pervasive developmental disorders (OR 2.00, 95% CI 1.69-2.37), or frequent use of behavioral care services (OR 1.34, 95% CI 1.21-1.48) were predisposed to starting treatment with atomoxetine relative to any stimulant, but patients with obesity were not (OR 0.68, 95% CI 0.53-0.87). A short-acting stimulant was specifically preferred for patients with narcolepsy or hypersomnolence (OR 0.33, 95% CI 0.20-0.56). Alcohol dependence, but not drug dependence or drug abuse, was predictive of the selection of atomoxetine over a short-acting stimulant (OR 2.98, 95% CI 1.25-7.09).

CONCLUSION

Atomoxetine therapy was systematically preferred for patients with psychiatric comorbidities, contraindications to stimulants, or relatively heavy use of behavioral health care.

Attention deficit hyperactivity disorder, tics and Tourette's syndrome: the relationship and treatment implications. A commentary

Tourette's Syndrome (TS) is now recognised to be a common childhood onset neurodevelopmental disorder. Attention deficit hyperactivity disorder (ADHD) is also a common childhood disorder. There are many cases in which the two disorders are comorbid. The reasons for this are unclear, but the comorbidity does not necessarily point to one genetic cause. Sleep is also often disturbed in individuals with TS and ADHD. The treatment implications of ADHD in the setting of tics or TS are important. Clonidine is suggested as a first line treatment. It was once thought that stimulants were contraindicated in the treatment of ADHD in the setting of TS, whereas it is suggested that they may be safe, but should be used judiciously. In addition, it was once thought that the combination of stimulants and clonidine was contraindicated, but from a large study the combination does appear to be safe. A relatively new medication for ADHD is atomoxetine, and although not documented widely in the setting of tics and TS, it may prove useful in this setting; further research is required. This commentary briefly discusses the comorbidity between TS and ADHD and offers treatment suggestions.

[Principles of managing chemotherapy-induced nausea and vomiting]

Chemotherapy-induced nausea and vomiting (emesis) can significantly affect a patient's quality of life, leading to poor compliance with further chemotherapy treatment. For patients treated with emetogenic chemotherapy, it is very important to prevent nausea and vomiting completely. The incidence and severity of nausea and/or vomiting in patients receiving chemotherapy are affected by numerous factors, including: 1) the specific chemotherapeutic agents used; 2) their dosage; 3) the schedule and route of administration; and 4) individual patient variability. Approximately 70 to 80% of all cancer patients receiving chemotherapy experience emesis, whereas 10% to 44% experience anticipatory emesis. The following general principles are recommended. 1) A 5-HT3 receptor antagonist should be administered prior to each day's 1st dose of moderately or highly emetogenic chemotherapy. 2) Dexamethasone should be administered once daily either orally or intravenously for every day of moderately or highly-emetogenic chemotherapy and for 2-3 days after chemotherapy for regimens that are likely to cause significant delayed-emesis. 3) The most effective way to treat anticipatory nausea and/or vomiting is to prevent it by using optimal antiemetic therapy during every cycle of treatment.

The Psychopharmacologic Treatment of Violent Youth

Aggressive violence has been described as the greatest problem and the most frequent reason for referrals in child and adolescent psychiatry. In this country we have only partially emerged from an epidemic of violence that was really an epidemic of youth violence. Thus it is hardly surprising that psychiatrists are being asked more and more frequently whether psychiatric medications might help to diminish the toll from this behavioral plague. Medications are useful and appropriate for only a small minority of the people who commit serious violence. Even when they are indicated, they can never be the sole treatment modality, but should be supplemented by psychological and social therapies. When the violence is a byproduct or symptom of an underlying mental illness, treating that illness is generally the most effective method of preventing future violence on a long-term basis. However, most violence is not committed by those who are mentally ill, and most of the mentally ill never commit a serious act of violence. That is why many attempts have been made to discover whether there are drugs that diminish the symptom, violence, even when there is no underlying mental illness for which drugs would normally be prescribed. In fact there are several, and their indications and use are reviewed here. Different principles govern the acute short-term emergency treatment of a violent crisis and the long-term treatment of those who are chronically and repetitively violent, and these differences are also summarized here.