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Verbeeck W, Bekkering GE, Van den Noortgate W, Kramers C. Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev 2017; 10:CD009504. [PMID: 28965364 PMCID: PMC6485546 DOI: 10.1002/14651858.cd009504.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Wim Verbeeck
- Centrum ADHD/ASS, GGZ Vincent van Gogh Instituut Venray, Noordsingel 39, Venray, Netherlands, 5801 GJ
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Adult ADHD: Questioning Diagnosis and Treatment in a Patient with Multiple Psychiatric Comorbidities. Case Rep Psychiatry 2017; 2017:1364894. [PMID: 28695034 PMCID: PMC5485267 DOI: 10.1155/2017/1364894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/19/2017] [Accepted: 04/30/2017] [Indexed: 12/28/2022] Open
Abstract
Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is a contentious diagnostic issue, which has been increasing in prevalence in recent years, and is often comorbid with other psychiatric disorders. This report presents a detailed account of a clinical case involving a middle-aged man with a history of recurrent depressive episodes and an unsubstantiated diagnosis of ADHD, treated with stimulants. There is persistent debate around the use of psychostimulants both in adult ADHD and in the treatment of depression. Despite promising activating properties, psychostimulants carry significant risks of misuse and substance use disorder. In this report, we consider the potential benefits and adverse effects of stimulants in the treatment of adult ADHD and mood disorders and review the learning points of this complicated, but not uncommon, clinical case.
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Heins MJ, Bruggers I, Dijk LV, Korevaar JC. ADHD medication prescription: Effects of child, sibling, parent and general practice characteristics. J Child Health Care 2016; 20:483-493. [PMID: 27708116 DOI: 10.1177/1367493515620913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many children receive attention-deficit hyperactivity disorder (ADHD) medication, but factors that determine medication prescription are largely unknown. This study aimed to determine the relative impact of factors on the child, family and general practitioner (GP) practice level on ADHD medication prescription. We included 1259 Dutch children aged 6-18 years with a diagnostic code of ADHD or related behavioural problems (ICPC codes P20-P22) in NIVEL primary care database. Using multilevel analyses, we examined predictors of ADHD medication prescription. Children diagnosed as 'hyperactive' were 16 times more likely to be prescribed ADHD medication than those with 'behavioural concerns'. Children with a parent or sibling receiving ADHD medication were three to four times more likely to be prescribed ADHD medication themselves. Children from GP practices with a high percentage of children with ADHD were twice as likely to be prescribed ADHD medication. Concluding, factors on the individual, family and GP practice level determine ADHD medication prescription. Future research into the decision-making process for ADHD medication is warranted.
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Affiliation(s)
- Marianne J Heins
- 1 Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Inge Bruggers
- 1 Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Liset van Dijk
- 1 Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Joke C Korevaar
- 1 Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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Abstract
Since publication of DSM-IV in 1994, the prevalence of parent-reported diagnosed attentiondeficit/hyperactivity disorder (ADHD) has tripled to more than 10% of children. Although it is hard to know for sure whether ADHD is overdiagnosed, underdiagnosed, or misdiagnosed, it is argued that ADHD is especially prone to diagnostic inflation and overdiagnosis. Therefore, we propose a model of stepped diagnosis for childhood ADHD, which may reduce overdiagnosis without risking undertreatment. Calling attention to stepped diagnosis and formalizing the steps may improve its application in clinical practice.
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Haervig KB, Mortensen LH, Hansen AV, Strandberg-Larsen K. Use of ADHD medication during pregnancy from 1999 to 2010: a Danish register-based study. Pharmacoepidemiol Drug Saf 2014; 23:526-33. [DOI: 10.1002/pds.3600] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Katia Buch Haervig
- Section of Social Medicine, Department of Public Health; University of Copenhagen; Copenhagen K Denmark
| | - Laust Hvas Mortensen
- Section of Social Medicine, Department of Public Health; University of Copenhagen; Copenhagen K Denmark
| | - Anne Vinkel Hansen
- Section of Social Medicine, Department of Public Health; University of Copenhagen; Copenhagen K Denmark
| | - Katrine Strandberg-Larsen
- Section of Social Medicine, Department of Public Health; University of Copenhagen; Copenhagen K Denmark
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Gajria K, Lu M, Sikirica V, Greven P, Zhong Y, Qin P, Xie J. Adherence, persistence, and medication discontinuation in patients with attention-deficit/hyperactivity disorder - a systematic literature review. Neuropsychiatr Dis Treat 2014; 10:1543-69. [PMID: 25187718 PMCID: PMC4149449 DOI: 10.2147/ndt.s65721] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Untreated attention-deficit/hyperactivity disorder (ADHD) can lead to substantial adverse social, economic, and emotional outcomes for patients. The effectiveness of current pharmacologic treatments is often reduced, due to low treatment adherence and medication discontinuation. This current systematic literature review analyzes the current state of knowledge surrounding ADHD medication discontinuation, focusing on: 1) the extent of patient persistence; 2) adherence; and 3) the underlying reasons for patients' treatment discontinuation and how discontinuation rates and reasons vary across patient subgroups. We selected 91 original studies (67 with persistence/discontinuation results, 26 with adherence results, and 41 with reasons for discontinuation, switching, or nonadherence) and 36 expert opinion reviews on ADHD medication discontinuation, published from 1990 to 2013. Treatment persistence on stimulants, measured by treatment duration during the 12-month follow-up periods, averaged 136 days for children and adolescents and 230 days for adults. Owing to substantial study heterogeneity, comparisons across age or medication type subgroups were generally inconclusive; however, long-acting formulations and amphetamines were associated with longer treatment duration than short-acting formulations and methylphenidates. The medication possession ratio, used to measure adherence, was <0.7 for all age groups and medication classes during a 12-month period. Adverse effects were the most commonly cited reason for discontinuation in all studies. Original research studies reported the lack of symptom control as a common discontinuation reason, followed by dosing inconvenience, social stigma associated with ADHD medication, and the patient's attitude. In summary, although there was a lack of consistency in the measurement of adherence and persistence, these findings indicate that drug adherence and persistence are generally poor among patients with ADHD. Clinicians may be able to help improve adherence and persistence to ADHD treatment by educating caregivers and patients on treatment goals, administering long-acting medications, and following-up with patients to verify if medication is still effective and well-tolerated.
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Affiliation(s)
- Kavita Gajria
- Global Health Economics, Outcomes Research and Epidemiology, Shire, Wayne, PA, USA
| | - Mei Lu
- Health Economics and Outcomes Research, Analysis Group, Inc., Boston, MA, USA
| | - Vanja Sikirica
- Global Health Economics, Outcomes Research and Epidemiology, Shire, Wayne, PA, USA
| | - Peter Greven
- Institute of Child and Adolescent Psychiatry, Psychotherapy and Social Pediatrics, Berlin, Germany ; Department of Psychology and Mental Health, H:G University of Health and Sport, Technology and Arts, Berlin, Germany
| | - Yichen Zhong
- Health Economics and Outcomes Research, Analysis Group, Inc., Boston, MA, USA
| | - Paige Qin
- Health Economics and Outcomes Research, Analysis Group, Inc., Boston, MA, USA
| | - Jipan Xie
- Health Economics and Outcomes Research, Analysis Group, Inc., Boston, MA, USA
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Abstract
Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Osvaldo Fustinoni
- INEBA Institute of Neurosciences, Buenos Aires, Argentina; Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina.
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Miranda A, Presentación MJ, Siegenthaler R, Jara P. Effects of a psychosocial intervention on the executive functioning in children with ADHD. JOURNAL OF LEARNING DISABILITIES 2013; 46:363-376. [PMID: 22064952 DOI: 10.1177/0022219411427349] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The purpose of this study was to analyze the effects of an intensive psychosocial intervention on the executive functioning (EF) in children with ADHD. The treatment was carried out in a coordinated manner over a period of 10 weeks with 27 children with ADHD aged 7 to 10, their parents, and their teachers. A battery of neuropsychological tasks was applied to evaluate attention, interference control, verbal and visuospatial working memory, planning ability, and flexibility. The comparative analysis of the treated group of ADHD children and an untreated ADHD group showed significant differences that were especially important in visuospatial memory and planning in favor of the treated children, even when the scores in the pretreatment phase were included as covariables. Likewise, improvements were observed in the parents' and teachers' behavioral ratings of hyperactivity or impulsivity and inattention. The conclusion was drawn that psychosocial interventions with children with ADHD can have a positive effect on some executive functions.
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Affiliation(s)
- Ana Miranda
- Departamento de Psicología Evolutiva y de la Educación, University of Valencia, Valencia, Spain.
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Verbeeck W, Bekkering GE, Van den Noortgate W. Bupropion for Attention Deficit Hyperactivity Disorder (ADHD) in adults. Hippokratia 2011. [DOI: 10.1002/14651858.cd009504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Wim Verbeeck
- GGZ Vincent van Gogh Instituut Venray; Centrum ADHD/ASS; Noordsingel 39 Venray Netherlands 5801 GJ
| | - Geertruida E Bekkering
- Belgian Centre for Evidence-Based Medicine - Cochrane Belgium; Kapucijnenvoer 33 Blok J Bus 7001 Leuven Belgium 3000
| | - Wim Van den Noortgate
- Katholieke Universiteit Leuven; Faculty of Psychology and Educational Sciences; Tiensestraat 102 Leuven Belgium 3000
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Merkel RL. Safety of stimulant treatment in attention deficit hyperactivity disorder: part II. Expert Opin Drug Saf 2011; 9:917-35. [PMID: 20615078 DOI: 10.1517/14740338.2010.503238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Attention deficit hyperactivity disorder (ADHD) is the most common childhood psychiatric disorder and in at least 50% of cases persists into adulthood. Treatment of ADHD with stimulants is one of the oldest and most effective pharmacological treatments in psychiatry. Yet, there continues to be controversy over the safety of stimulant medications in the treatment of ADHD. AREAS COVERED IN THIS REVIEW This paper is a continuation of an earlier paper that reviewed the safety profile of newer stimulant agents, especially in relation to special populations. This part II reviews, through essentially an organ-system approach, the various clinical concerns that have been raised over the safety of stimulant medications. This includes neuropsychiatric, cardiovascular effects on growth and development, and a number of other less common concerns. WHAT THE READER WILL GAIN A thorough review of safety concerns in stimulants that emphasizes clinical information, case reports, open series or controlled trials relating to stimulant use in the treatment of ADHD. TAKE HOME MESSAGE While many safety concerns have been raised in the use of stimulants, the vast majority of treatment complications are either quickly reversible or easily manageable with appropriate clinical care. The negative consequences of untreated ADHD clearly outweigh the risks of the stimulant medicines when used in an appropriate and careful manner.
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Affiliation(s)
- Richard Lawrence Merkel
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA 22908, USA.
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11
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Kooij SJJ, Bejerot S, Blackwell A, Caci H, Casas-Brugué M, Carpentier PJ, Edvinsson D, Fayyad J, Foeken K, Fitzgerald M, Gaillac V, Ginsberg Y, Henry C, Krause J, Lensing MB, Manor I, Niederhofer H, Nunes-Filipe C, Ohlmeier MD, Oswald P, Pallanti S, Pehlivanidis A, Ramos-Quiroga JA, Rastam M, Ryffel-Rawak D, Stes S, Asherson P. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 2010; 10:67. [PMID: 20815868 PMCID: PMC2942810 DOI: 10.1186/1471-244x-10-67] [Citation(s) in RCA: 499] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 09/03/2010] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. METHODS The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. RESULTS Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? CONCLUSIONS ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.
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Affiliation(s)
- Sandra JJ Kooij
- PsyQ, psycho medische programma's, Department Adult ADHD, Carel Reinierszkade 197, Den Haag, The Netherlands
| | - Susanne Bejerot
- Department of Clinical Neuroscience, Karolinksa Institutet, Section Psychiatry, St. Goran, Stockholm, Sweden
| | - Andrew Blackwell
- University Department of Psychiatry, Addenbrookes Hospital, Cambridge, UK
| | - Herve Caci
- Pediatric Department, Hôpitaux Pédiatriques CHU-Lenval, 06200 Nice, France
| | - Miquel Casas-Brugué
- Servicio de Psiquiatria, Hospital Universitari Vall d' Hebron, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Pieter J Carpentier
- Reinier van Arkel Groep, Postbus 70058, 5201 DZ 's-Hertogenbosch, The Netherlands
| | - Dan Edvinsson
- Department of Neuroscience/Psychiatri Ulleråker, MK 75, S-750 17 Uppsala, Sweden
| | - John Fayyad
- Institute of Development, Research, Advocacy and Applied Care (IDRAAC), Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Centre, Balamand University, Beirut, Lebanon
| | - Karin Foeken
- Centre des Consultations, Institut A Tzanck, Mougins, France
| | - Michael Fitzgerald
- Department of Psychiatry, Trinity College Dublin (TCD), Dublin 2, Ireland
| | - Veronique Gaillac
- Clinique des Maladies Mentales et de l'Encéphale (CMME), Sainte Anne Hospital Paris, France
| | - Ylva Ginsberg
- Affektiva mottagningen, M 59, Psykiatri Sydväst, 141 86 Stockholm, Sweden
| | - Chantal Henry
- Département de Psychiatrie Adulte, Unité Lescure, CH Charles Perrens, Bordeaux, France
| | - Johanna Krause
- Private clinic for psychiatry and psychotherapy, 11a Schillerstrasse, Ottobrunn, Germany
| | - Michael B Lensing
- Department of Child Neurology, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Iris Manor
- Geha Mental Health Center, Petach-Tiqva, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Helmut Niederhofer
- Department of Child Psychiatry, Regional Hospital of Bolzano, Via Guncina, Bolzano, Italy
| | - Carlos Nunes-Filipe
- Faculty of Medical Sciences, New University of Lisbon, Campo dos Mártires da Pátria, 1169-056 Lisboa, Portugal
| | - Martin D Ohlmeier
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Germany
| | - Pierre Oswald
- Department of Psychiatry, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Stefano Pallanti
- Department of Neurosciences, Florence University, Florence, Italy
| | - Artemios Pehlivanidis
- Department of Psychiatry, National and Kapodistrian University of Athens Medical School, Eginition Hospital, Athens, Greece
| | - Josep A Ramos-Quiroga
- Programa Integral del Déficit de Atención en el Adulto (P.I.D.A.A), Servei de Psiquiatria, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Maria Rastam
- Department of Clinical Sciences, Lund, Child and Adolescent Psychiatry, Lund University, Sweden
| | | | - Steven Stes
- ADHD Program, University Psychiatric Center, Catholic University Leuven, Kortenberg, Belgium
| | - Philip Asherson
- MRC Social Genetic and Developmental Psychiatry, Institute of Psychiatry, Kings College London, London, UK
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Merkel RL, Kuchibhatla A. Safety of stimulant treatment in attention deficit hyperactivity disorder: Part I. Expert Opin Drug Saf 2010; 8:655-68. [PMID: 19785509 DOI: 10.1517/14740330903279956] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The safety profile of newer stimulant products is of interest. Because most studies focus on school-age children, there is also an increased interest in the treatment of other populations. Concern continues for the risk of substance abuse in the use of stimulants. OBJECTIVE The purpose of this paper is to review published data on the safety and tolerability of the newer forms of stimulants, treatment in special populations, and the risks of substance abuse and dependence in the treatment of attention deficit hyperactivity disorder. METHODS Literature obtained through Medline and Pubmed from 1995 were reviewed as well as key articles referenced in the literature. CONCLUSIONS The use of the newer stimulant agents shows a safety profile of frequent, but usually mild side effects. They are generally safe in special populations. The risk of developing long-term substance abuse with attention deficit hyperactivity disorder, without co-morbidities, is small and may decrease with proper treatment. More research is needed.
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Affiliation(s)
- Richard Lawrence Merkel
- University of Virginia, Department of Psychiatry and Neurobehavioral Sciences, Charlottesville, 22908, USA.
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Koesters M, Becker T, Kilian R, Fegert JM, Weinmann S. Limits of meta-analysis: methylphenidate in the treatment of adult attention-deficit hyperactivity disorder. J Psychopharmacol 2009; 23:733-44. [PMID: 18562416 DOI: 10.1177/0269881108092338] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Guidelines for the treatment of attention-deficit hyperactivity disorder (ADHD) in adults advocate methylphenidate as first-line treatment. The aim of this study was to review the effectiveness of methylphenidate treatment of adult ADHD and to examine the influence of methods on meta-analytic results. Electronic databases were searched to identify clinical trials comparing methylphenidate with placebo in the treatment of adult ADHD. Studies were summarised with meta-analytic methods. Subgroup analyses were conducted with respect to parallel group versus cross-over trials and self versus observer ratings. The relationship between dosage and effect size was explored by weighted regression analysis. The results were tested for publication bias, and several sensitivity analyses were performed. Findings and methods were compared with a previous meta-analysis. Eighteen studies met the inclusion criteria of which 16 were included in the meta-analysis. The overall effect size (d = 0.42) was significantly different from zero, but was only half the size expected on the basis of a previous meta-analysis. No significant differences could be observed in the subgroup analyses. The regression analysis showed no significant influence of mean daily dose on effect size. These results contradict findings of a previous meta-analysis and challenge guideline recommendations. Methodological issues in meta-analyses are discussed.
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Affiliation(s)
- M Koesters
- Department of Psychiatry II, University of Ulm, BKH Guenzburg, Germany.
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Pohl GM, Van Brunt DL, Ye W, Stoops WW, Johnston JA. A retrospective claims analysis of combination therapy in the treatment of adult attention-deficit/hyperactivity disorder (ADHD). BMC Health Serv Res 2009; 9:95. [PMID: 19505334 PMCID: PMC2702287 DOI: 10.1186/1472-6963-9-95] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 06/08/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Combination therapy in managing psychiatric disorders is not uncommon. While combination therapy has been documented for depression and schizophrenia, little is known about combination therapy practices in managing attention-deficit/hyperactivity disorder (ADHD). This study seeks to quantify the combination use of ADHD medications and to understand predictors of combination therapy. METHODS Prescription dispensing events were drawn from a U.S. national claims database including over 80 managed-care plans. Patients studied were age 18 or over with at least 1 medical claim with a diagnosis of ADHD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 314.0), a pharmacy claim for ADHD medication during the study period July 2003 to June 2004, and continuous enrollment 6 months prior to and throughout the study period. Dispensing events were grouped into 6 categories: atomoxetine (ATX), long-acting stimulants (LAS), intermediate-acting stimulants (IAS), short-acting stimulants (SAS), bupropion (BUP), and Alpha-2 Adrenergic Agonists (A2A). Events were assigned to calendar months, and months with combined use from multiple categories within patient were identified. Predictors of combination therapy for LAS and for ATX were modeled for patients covered by commercial plans using logistic regression in a generalized estimating equations framework to adjust for within-patient correlation between months of observation. Factors included age, gender, presence of the hyperactive component of ADHD, prior diagnoses for psychiatric disorders, claims history of recent psychiatric visit, insurance plan type, and geographic region. RESULTS There were 18,609 patients identified representing a total of 11,886 months of therapy with ATX; 40,949 months with LAS; 13,622 months with IAS; 38,141 months with SAS; 22,087 months with BUP; and 1,916 months with A2A. Combination therapy was present in 19.7% of continuing months (months after the first month of therapy) for ATX, 21.0% for LAS, 27.4% for IAS, 23.1% for SAS, 36.9% for BUP, and 53.0% for A2A.For patients receiving LAS, being age 25-44 or age 45 and older versus being 18-24 years old, seeing a psychiatrist, having comorbid depression, or having point-of-service coverage versus a Health Maintenance Organization (HMO) resulted in odds ratios significantly greater than 1, representing increased likelihood for combination therapy in managing adult ADHD.For patients receiving ATX, being age 25-44 or age 45 and older versus being 18-24 years old, seeing a psychiatrist, having a hyperactive component to ADHD, or having comorbid depression resulted in odds ratios significantly greater than 1, representing increased likelihood for combination therapy in managing adult ADHD. CONCLUSION ATX and LAS are the most likely drugs to be used as monotherapy. Factors predicting combination use were similar for months in which ATX was used and for months in which LAS was used except that a hyperactive component to ADHD predicted increased combination use for ATX but not for LAS.
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Abstract
Attention deficit hyperactivity disorder (ADHD) often persists into adulthood. Stimulant drugs, including methylphenidate, have showed efficacy in trials for ADHD in adults. Adult psychiatrists are likely to encounter increasing numbers of adult patients who may benefit from methylphenidate. A systematic review of the literature was made to examine the evidence on the safety of methylphenidate, when used therapeutically in adults. Twenty-six placebo-controlled trials were found, in which 811 adults received methylphenidate for ADHD and other conditions. In the short term, methylphenidate was well tolerated and no serious side effects were observed. There is little information on the long-term safety of methylphenidate in adults, although the number of serious adverse effects reported to regulatory authorities has, so far, been low. Methylphenidate is associated with a modest rise in blood pressure and heart rate. Surveys of stimulant use in US universities show that misuse of prescribed medication, for recreation or to enhance study, is fairly common although the level of harm that arises from this practice is unclear.
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Affiliation(s)
- J Godfrey
- Westhaven and Portland CMHT, Westhaven, Weymouth, Dorset, UK.
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Bibliography. Current world literature. Cardiovascular medicine. Curr Opin Pediatr 2007; 19:601-6. [PMID: 17885483 DOI: 10.1097/mop.0b013e3282f12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Nutt DJ, Fone K, Asherson P, Bramble D, Hill P, Matthews K, Morris KA, Santosh P, Sonuga-Barke E, Taylor E, Weiss M, Young S. Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2007; 21:10-41. [PMID: 17092962 DOI: 10.1177/0269881106073219] [Citation(s) in RCA: 185] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is an established diagnosis in children, associated with a large body of evidence on the benefits of treatment. Adolescents with ADHD are now leaving children's services often with no readily identifiable adult service to support them, which presents problems as local pharmacy regulations often preclude the prescription of stimulant drugs by general practitioners (GPs). In addition, adults with ADHD symptoms are now starting to present to primary care and psychiatry services requesting assessment and treatment. For these reasons, the British Association for Psychopharmacology (BAP) thought it timely to hold a consensus conference to review the body of evidence on childhood ADHD and the growing literature on ADHD in older age groups. Much of this initial guidance on managing ADHD in adolescents in transition and in adults is based on expert opinion derived from childhood evidence. We hope that, by the time these guidelines are updated, much evidence will be available to address the many directions for future research that are detailed here.
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Affiliation(s)
- D J Nutt
- Psychopharmacology Unit, University of Bristol, Bristol, and Bethlem Royal Hospital, Kent, UK.
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