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Brancati GE, Magnesa A, Acierno D, Carli M, De Rosa U, Froli A, Gemignani S, Ventura L, Weiss F, Perugi G. Current nonstimulant medications for adults with attention-deficit/hyperactivity disorder. Expert Rev Neurother 2024:1-17. [PMID: 38915262 DOI: 10.1080/14737175.2024.2370346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/16/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Stimulants, including methylphenidate and amphetamines, are the first-line pharmacological treatment of ADHD in adults. However, in patients who do not respond or poorly tolerate stimulants, non-stimulant medications are usually recommended. AREAS COVERED The authors provide a narrative review of the literature on non-stimulant treatments for adult ADHD, including controlled and observational clinical studies conducted on adult samples. Atomoxetine has been extensively studied and showed significant efficacy in treating adult ADHD. Issues related to dosing, treatment duration, safety, and use in the case of psychiatric comorbidity are summarized. Among other compounds indicated for ADHD in adults, antidepressants sharing at least a noradrenergic or dopaminergic component, including tricyclic compounds, bupropion, and viloxazine, have shown demonstratable efficacy. Evidence is also available for antihypertensives, particularly guanfacine, as well as memantine, metadoxine, and mood stabilizers, while negative findings have emerged for galantamine, antipsychotics, and cannabinoids. EXPERT OPINION While according to clinical guidelines, atomoxetine may serve as the only second-line option in adults with ADHD, several other nonstimulant compounds may be effectively used in order to personalize treatment based on comorbid conditions and ADHD features. Nevertheless, further research is needed to identify and test more personalized treatment strategies for adults with ADHD.
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Affiliation(s)
- Giulio Emilio Brancati
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Anna Magnesa
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Donatella Acierno
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Marco Carli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ugo De Rosa
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Alessandro Froli
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Samuele Gemignani
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Lisa Ventura
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Francesco Weiss
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Giulio Perugi
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
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MacDonald L, Sadek J. Management Strategies for Borderline Personality Disorder and Bipolar Disorder Comorbidities in Adults with ADHD: A Narrative Review. Brain Sci 2023; 13:1517. [PMID: 38002478 PMCID: PMC10669289 DOI: 10.3390/brainsci13111517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
This narrative review examines two of the common comorbidities of attention-deficit/hyperactivity disorder, bipolar disorder (BD), and borderline personality disorder (BPD), which each share several common features with ADHD that can make assessment and diagnosis challenging. The review highlights some of the key symptomatic differences between adult ADHD and these disorders, allowing for more careful consideration before establishing a formal diagnosis. When the disorders are found to be comorbid, further complications may arise; thus, the review will also help to provide evidence-based treatment recommendations as well as suggestions on how to minimize adverse events. Incorporating evidence from systematic reviews, journal articles, randomized controlled trials, and case reports, this review highlights that the diagnosis of ADHD and some of its common comorbidities is challenging and requires full, in-depth assessment and management. The management strategies of these comorbidities will also be addressed, with emphasis on achieving mood stabilization for BD prior to initiating appropriate ADHD pharmacotherapy. Medications, specifically mood stabilizers, antipsychotics, and antidepressants, are fundamental in treating symptoms seen in BD and some cases of BPD, alongside psychotherapy and lifestyle modifications when appropriate. The review highlights the effectiveness of specific medications, including psychostimulants, atomoxetine, and bupropion, as add-on therapies to mood-stabilizing treatments for addressing ADHD symptoms in patients with these comorbidities. Despite limited research, the review will address various pharmacological and psychotherapeutic approaches for managing comorbid ADHD and BPD, emphasizing the need for further investigations to better understand the unique needs of this patient population.
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Affiliation(s)
- Luke MacDonald
- Faculty of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Joseph Sadek
- Department of Psychiatry, Dalhousie University, Halifax, NS B3H 4R2, Canada
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Tyree SM, Jennings KJ, Gonzalez OC, Li SB, Nicholson JR, von Heimendahl M, de Lecea L. Optogenetic and pharmacological interventions link hypocretin neurons to impulsivity in mice. Commun Biol 2023; 6:74. [PMID: 36658362 PMCID: PMC9852239 DOI: 10.1038/s42003-023-04409-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
Neurons in the lateral hypothalamus expressing the neuropeptide Hypocretin, also known as orexin, are known critical modulators of arousal stability. However, their role in the different components of the arousal construct such as attention and decision making is poorly understood. Here we study Hypocretin neuronal circuit dynamics during stop action impulsivity in a Go/NoGo task in mice. We show that Hypocretin neuronal activity correlates with anticipation of reward. We then assessed the causal role of Hypocretin neuronal activity using optogenetics in a Go/NoGo task. We show that stimulation of Hypocretin neurons during the cue period dramatically increases the number of premature responses. These effects are mimicked by amphetamine, reduced by atomoxetine, a norepinephrine uptake inhibitor, and blocked by a Hypocretin receptor 1 selective antagonist. We conclude that Hypocretin neurons have a key role in the integration of salient stimuli during wakefulness to produce appropriate and timely responses to rewarding and aversive cues.
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Affiliation(s)
- Susan M. Tyree
- grid.168010.e0000000419368956Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA USA ,Present Address: Atlantia Clinical Trials, Cork, Ireland
| | - Kimberly J. Jennings
- grid.168010.e0000000419368956Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA USA ,grid.55460.320000000121548364Present Address: University of Texas, Austin, TX USA
| | - Oscar C. Gonzalez
- grid.168010.e0000000419368956Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA USA
| | - Shi-bin Li
- grid.168010.e0000000419368956Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA USA
| | - Janet R. Nicholson
- grid.420061.10000 0001 2171 7500Boehringer Ingelheim Pharma GmbH & Co.KG, Biberach, Germany
| | - Moritz von Heimendahl
- grid.420061.10000 0001 2171 7500Boehringer Ingelheim Pharma GmbH & Co.KG, Biberach, Germany
| | - Luis de Lecea
- grid.168010.e0000000419368956Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA USA
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Sesso G, Brancati GE, Masi G. Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management. Curr Neuropharmacol 2023; 21:911-934. [PMID: 35794777 PMCID: PMC10227908 DOI: 10.2174/1570159x20666220706104117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/14/2022] [Accepted: 06/13/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment. METHODS This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders. RESULTS These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches. CONCLUSION The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.
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Affiliation(s)
- Gianluca Sesso
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiat., Calambrone (Pisa), Italy
| | | | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiat., Calambrone (Pisa), Italy
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Shindo T, Shikanai H, Watarai A, Hiraide S, Iizuka K, Izumi T. D-serine metabolism in the medial prefrontal cortex, but not the hippocampus, is involved in AD/HD-like behaviors in SHRSP/Ezo. Eur J Pharmacol 2022; 923:174930. [PMID: 35364072 DOI: 10.1016/j.ejphar.2022.174930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 03/03/2022] [Accepted: 03/25/2022] [Indexed: 12/26/2022]
Abstract
Attention-deficit/hyperactivity disorder (AD/HD) is a mild neurodevelopmental disorder with inattention, hyperactivity, and impulsivity as its core symptoms. We previously revealed that an AD/HD animal model, juvenile stroke-prone spontaneously hypertensive rats (SHRSP/Ezo) exhibited functional abnormalities in N-methyl-D-aspartate (NMDA) receptors in the prefrontal cortex. D-serine is an endogenous co-ligand that acts on the glycine-binding site of NMDA receptors, which is essential for the physiological activation of NMDA receptors. We herein performed neurochemical and pharmacological behavioral experiments to elucidate dysfunctions in D-serine metabolism (namely, biosynthesis and catabolism) associated to AD/HD. The serine enantiomers ratio (D-serine/D-serine + L-serine, DL ratio) in the medial prefrontal cortex (mPFC) and hippocampus (HIP) was lower in SHRSP/Ezo than in its genetic control. The level of D-amino acid oxidase (DAAO, D-serine degrading enzyme) was higher in the mPFC, and the level of serine racemase (SR, D-serine biosynthetic enzyme), was lower in the HIP in SHRSP/Ezo. Thus, changes in these enzymes may contribute to the lower DL ratio of SHRSP/Ezo. Moreover, a microinjection of a DAAO inhibitor into the mPFC in SHRSP/Ezo increased DL ratio and attenuated AD/HD-like behaviors, such as inattention and hyperactivity, in the Y-maze test. Injection into the HIP also increased the DL ratio, but had no effect on behaviors. These results suggest that AD/HD-like behaviors in SHRSP/Ezo are associated with an abnormal D-serine metabolism underlying NMDA receptor dysfunction in the mPFC. These results will contribute to elucidating the pathogenesis of AD/HD and the development of new treatment strategies for AD/HD.
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Affiliation(s)
- Tsugumi Shindo
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Japan
| | - Hiroki Shikanai
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Japan; Advanced Research Promotion Center, Health Science University of Hokkaido, Japan.
| | - Akane Watarai
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Japan
| | - Sachiko Hiraide
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Japan
| | - Kenji Iizuka
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Japan
| | - Takeshi Izumi
- Department of Pharmacology, Faculty of Pharmaceutical Sciences, Health Science University of Hokkaido, Japan; Advanced Research Promotion Center, Health Science University of Hokkaido, Japan
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Comparelli A, Polidori L, Sarli G, Pistollato A, Pompili M. Differentiation and comorbidity of bipolar disorder and attention deficit and hyperactivity disorder in children, adolescents, and adults: A clinical and nosological perspective. Front Psychiatry 2022; 13:949375. [PMID: 36032257 PMCID: PMC9403243 DOI: 10.3389/fpsyt.2022.949375] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Abstract
Bipolar Disorder (BD) and Attention Deficit and Hyperactivity Disorder (ADHD) are mental disorders with high degree of lifetime comorbidity. Both BD and ADHD are disorders with onset in childhood and early adolescence. Both disorders are often undiagnosed, misdiagnosed, and sometimes overdiagnosed, leading to high rates of morbidity and disability. The psychiatric and behavioral symptoms associated with ADHD and BD have significant overlap. Albeit the existence of a large body of literature, it is far from being clear whether comorbidity can be explained by the confounding overlap of operationally defined criteria or whether it reflects a genuine comorbidity of two biologically distinct disorders. The aim of this paper is to recognize and/or differentiate the pattern of ADHD across the course of BD from a nosological point of view, focusing on specific clinical and neurobiological dimensions. We found that some critical issues may help to fulfill the purpose of our perspective. We suggest that the relationship between ADHD and BD, based on clinical, developmental, and epidemiological commonalities, can be better clarified using four different scenarios.
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Affiliation(s)
- Anna Comparelli
- Department of Psychiatry, Sant'Andrea Hospital of Rome, Rome, Italy
| | - Lorenzo Polidori
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Sarli
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Andrea Pistollato
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Maurizio Pompili
- Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Suicide Prevention Centre, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Bartoli F, Callovini T, Calabrese A, Cioni RM, Riboldi I, Crocamo C, Carrà G. Disentangling the Association between ADHD and Alcohol Use Disorder in Individuals Suffering from Bipolar Disorder: A Systematic Review and Meta-Analysis. Brain Sci 2021; 12:brainsci12010038. [PMID: 35053783 PMCID: PMC8773515 DOI: 10.3390/brainsci12010038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/17/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
Attention Deficit-Hyperactivity disorder (ADHD) may influence rates of Alcohol Use Disorder (AUD) among individuals suffering from Bipolar Disorder (BD). The aim of this systematic review and meta-analysis was to estimate the strength and consistency of the potential association between ADHD and AUD in BD. We searched main electronic databases for studies indexed up to November 2020. We included observational studies investigating the association between ADHD and AUD among individuals with BD. The association between ADHD and AUD was estimated using odds ratios (ORs) with 95% Confidence Intervals (CIs). Eleven studies, involving 2734 individuals with BD (516 with ADHD), were included in the meta-analysis. Individuals with both BD and ADHD had higher rates of AUD as compared with subjects with BD only (34.0% vs. 18.3%). The estimated OR of AUD for ADHD was 2.50 (95% CI: 1.91 to 3.27; I2 = 13.0%). Study-level characteristics did not influence the effect size. No risk of publication bias was estimated. Despite some limitations, this meta-analysis estimated an association between ADHD and AUD among individuals suffering from BD. At least a portion of the high rates of AUD in BD may, thereby, be related to comorbid ADHD. Longitudinal studies are needed to clarify the nature of this relationship.
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Affiliation(s)
- Francesco Bartoli
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
| | - Tommaso Callovini
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
- Correspondence: ; Tel.: +39-02-5799-8644
| | - Angela Calabrese
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
| | - Riccardo M. Cioni
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
| | - Ilaria Riboldi
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
| | - Cristina Crocamo
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
| | - Giuseppe Carrà
- Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, Italy; (F.B.); (A.C.); (R.M.C.); (I.R.); (C.C.); (G.C.)
- Division of Psychiatry, University College London, Maple House 149, London W1T 7BN, UK
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Muneer A. The Discovery of Clinically Applicable Biomarkers for Bipolar Disorder: A Review of Candidate and Proteomic Approaches. Chonnam Med J 2020; 56:166-179. [PMID: 33014755 PMCID: PMC7520367 DOI: 10.4068/cmj.2020.56.3.166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/13/2022] Open
Abstract
Bipolar disorder (BD) is a severe psychiatric condition which affects innumerable people across the globe. The etiopathogenesis of BD is multi-faceted with genetic, environmental and psychosocial factors playing a role. Hitherto, the diagnosis and management of BD are purely on empirical grounds as we lack confirmed biomarkers for this condition. In this regard, hypothesis-driven investigations have been unable to identify clinically applicable biomarkers, steering the field towards newer technologies. Innovative, state-of-the-art techniques like multiplex immunoassays and mass spectrometry can potentially investigate the entire proteome. By detecting up or down regulated proteins, novel biomarkers are identified and new postulates about the etiopathogenesis of BD are specified. Hence, biological pathways are uncovered which are involved in the initiation and advancement of the disease and new therapeutic targets are identified. In this manuscript, the extant literature is thoroughly reviewed and the latest findings on candidate BD biomarkers are provided, followed by an overview of the proteomic approaches. It was found that due to the heterogeneous nature of BD no single biomarker is feasible, instead a panel of tests is more likely to be useful. With the application of latest technologies, it is expected that validated biomarkers will be discovered which will be useful as diagnostic tools and help in the delivery of individually tailored therapies to the patients.
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Affiliation(s)
- Ather Muneer
- Islamic International Medical College, Riphah International University, Rawalpindi, Pakistan
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10
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Greydanus DE, Cates KW, Sadigh N. Adverse effects of stimulant medications in children and adolescents: focus on drug abuse. Int J Adolesc Med Health 2019; 31:ijamh-2019-0175. [PMID: 31483757 DOI: 10.1515/ijamh-2019-0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/12/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Donald E Greydanus
- Department of Pediatric and Adolescent Medicine, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-1284, USA
| | - Kevin W Cates
- Western Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Nina Sadigh
- Western Michigan University, Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
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Perugi G, Pallucchini A, Rizzato S, Pinzone V, De Rossi P. Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD). Expert Opin Pharmacother 2019; 20:1457-1470. [PMID: 31112441 DOI: 10.1080/14656566.2019.1618270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: ADHD is characterized by a developmentally inappropriate level of inattentiveness, impulsivity and/or hyperactivity. In adults, the disorder is frequently accompanied by Emotional Dysregulation (ED), associated to a variety of related psychiatric comorbidities, complicating its recognition and treatment management. Areas covered: This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in adults with ADHD and ED, other neurodevelopmental disorders, Bipolar Disorder (BD) and Anxiety Disorders (ADs). When controlled data are unavailable, the authors have included open-label and observational studies. Expert opinion: ED in adult patients with ADHD is a very common and impairing problem that can be treated with stimulants or atomoxetine. ADHD studies in adults with other neurodevelopment disorders are scarce; stimulants seem to be the most effective and safe drugs in treating ADHD symptoms, without worsening the core features of other neurodevelopmental disorders. In patients with ADHD and comorbid BD, the treatment of BD alone may result in residual symptoms of ADHD. Patients should be treated hierarchically: BD should be treated first, while ADHD should be treated combining ADHD medications and mood stabilizers after mood stabilization. The available evidence for treating patients with ADHD and comorbid ADs in adults supports the idea of an anti-anxiety/ADHD-specific treatment association.
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Affiliation(s)
- Giulio Perugi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa , Pisa , Italy
| | - Alessandro Pallucchini
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa , Pisa , Italy
| | - Salvatore Rizzato
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome , Rome , Italy
| | - Vito Pinzone
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome , Rome , Italy
| | - Pietro De Rossi
- NESMOS Department (Neurosciences, Mental Health, and Sensory Organs), Sapienza University of Rome, School of Medicine and Psychology, Sant'Andrea Hospital , Rome , Italy.,Department of Neurology and Psychiatry, Sapienza University of Rome , Rome , Italy.,Department of Psychiatry, ASL Roma 5 , Rome , Italy
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Meyers KJ, Upadhyaya HP, Goodloe R, Kryzhanovskaya LA, Liles-Burden MA, Kellier-Steele NA, Mancini M. Evaluation of dystonia in children and adolescents treated with atomoxetine within the Truven MarketScan database: a retrospective cohort study. Expert Opin Drug Saf 2018; 17:467-473. [DOI: 10.1080/14740338.2018.1462333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Geffen J, Forster K. Treatment of adult ADHD: a clinical perspective. Ther Adv Psychopharmacol 2018; 8:25-32. [PMID: 29344341 PMCID: PMC5761907 DOI: 10.1177/2045125317734977] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/21/2017] [Indexed: 12/22/2022] Open
Abstract
Adult attention deficit/hyperactivity disorder (ADHD) has moved from the blurred edge of clinical focus to clear recognition as a prevalent and significant disorder in its own right. It is a relatively common comorbidity which if identified and treated may open the door to better outcomes for hard-to-treat patients. Conversely, failure to identify and treat adult ADHD is linked to negative outcomes. The recognition of the importance of adult ADHD in a subset of our patients challenges us to overcome our anxiety about this diagnosis and prevent the societal marginalization of vulnerable patients. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. Its treatment responsiveness reduces disability and allows the comorbidity which is typically present to be addressed. Mastering this challenge can make the diagnosis and treatment of adult ADHD a rewarding experience.
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Affiliation(s)
- Josh Geffen
- Toowong Specialist Clinic, 2/54 Jephson St, Toowong, Brisbane, Queensland, 4066, Australia
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Viktorin A, Rydén E, Thase ME, Chang Z, Lundholm C, D’Onofrio BM, Almqvist C, Magnusson PKE, Lichtenstein P, Larsson H, Landén M. The Risk of Treatment-Emergent Mania With Methylphenidate in Bipolar Disorder. Am J Psychiatry 2017; 174:341-348. [PMID: 27690517 PMCID: PMC6641557 DOI: 10.1176/appi.ajp.2016.16040467] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors sought to determine the risk of treatment-emergent mania associated with methylphenidate, used in monotherapy or with a concomitant mood-stabilizing medication, in patients with bipolar disorder. METHOD Using linked Swedish national registries, the authors identified 2,307 adults with bipolar disorder who initiated therapy with methylphenidate between 2006 and 2014. The cohort was divided into two groups: those with and those without concomitant mood-stabilizing treatment. To adjust for individual-specific confounders, including disorder severity, genetic makeup, and early environmental factors, Cox regression analyses were used, conditioning on individual to compare the rate of mania (defined as hospitalization for mania or a new dispensation of stabilizing medication) 0-3 months and 3-6 months after medication start following nontreated periods. RESULTS Patients on methylphenidate monotherapy displayed an increased rate of manic episodes within 3 months of medication initiation (hazard ratio=6.7, 95% CI=2.0-22.4), with similar results for the subsequent 3 months. By contrast, for patients taking mood stabilizers, the risk of mania was lower after starting methylphenidate (hazard ratio=0.6, 95% CI=0.4-0.9). Comparable results were observed when only hospitalizations for mania were counted. CONCLUSIONS No evidence was found for a positive association between methylphenidate and treatment-emergent mania among patients with bipolar disorder who were concomitantly receiving a mood-stabilizing medication. This is clinically important given that up to 20% of people with bipolar disorder suffer from comorbid ADHD. Given the markedly increased hazard ratio of mania following methylphenidate initiation in bipolar patients not taking mood stabilizers, careful assessment to rule out bipolar disorder is indicated before initiating monotherapy with psychostimulants.
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Affiliation(s)
- Alexander Viktorin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eleonore Rydén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Michael E. Thase
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,
USA
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Lundholm
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Brian M. D’Onofrio
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik KE Magnusson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of medical sciences, Örebro University, Örebro, Sweden
| | - Mikael Landén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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15
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Wang HR, Jung YE, Chung SK, Hong J, Ri Kang N, Kim MD, Bahk WM. Prevalence and correlates of bipolar spectrum disorder comorbid with ADHD features in nonclinical young adults. J Affect Disord 2017; 207:175-180. [PMID: 27723541 DOI: 10.1016/j.jad.2016.09.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/20/2016] [Accepted: 09/27/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND We investigate the rate of bipolar spectrum disorder comorbid with ADHD features using two screening instruments, the Mood Disorder Questionnaire (MDQ) and the Wender Utah Rating Scale (WURS), in a nonclinical young adult population. METHODS College and graduate students aged 18 years or older from four universities in Korea were selected. Comorbidity was defined as both MDQ positivity and WURS positivity. To look for a trend in clinical characteristics according to the severity of the comorbid condition, we used the Jonckheere-Terpstra test and the linear-by-linear association test. We performed ordinal logistic regression analysis to identify predictors associated with the studied comorbid condition. RESULTS A total of 1948 subjects were included in the study, and 15 (0.8%) of them were found to have the comorbid condition defined as both MDQ positivity and WURS positivity. As the severity of the comorbid condition increased, we saw trends of lower socioeconomic status, higher history of suicidality, higher history of self-mutilating behavior, higher history of parental abuse or abuse by other people, more severe depression, and more severe problematic alcohol use. The ordinal regression analysis showed that history of parental abuse, depression, and problematic alcohol use predicted the comorbid condition. LIMITATIONS We did not use standardized diagnostic tools for case findings. CONCLUSION The condition of comorbid bipolar spectrum disorder with ADHD features had a notable prevalence of 0.8% in a nonclinical young adult sample. This comorbid condition was found to be related with serious clinical phenomenology.
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Affiliation(s)
- Hee Ryung Wang
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, 10, 63(yuksam)-ro, Yeongdeungpo-gu, Seoul, Korea
| | - Young-Eun Jung
- Department of Psychiatry, School of Medicine, Jeju National University, #15 Aran 13gil, Jeju 63241, Korea
| | - Sang-Keun Chung
- Department of Psychiatry, Chonbuk National University Medical School, Jeonju, Korea
| | - Jeongwan Hong
- Department of Psychiatry, Iksan Hospital, Iksan, Korea
| | - Na Ri Kang
- Department of Psychiatry, School of Medicine, Jeju National University, #15 Aran 13gil, Jeju 63241, Korea
| | - Moon-Doo Kim
- Department of Psychiatry, School of Medicine, Jeju National University, #15 Aran 13gil, Jeju 63241, Korea.
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, 10, 63(yuksam)-ro, Yeongdeungpo-gu, Seoul, Korea.
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Clemow DB, Bushe C, Mancini M, Ossipov MH, Upadhyaya H. A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities. Neuropsychiatr Dis Treat 2017; 13:357-371. [PMID: 28223809 PMCID: PMC5304987 DOI: 10.2147/ndt.s115707] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Attention-deficit hyperactivity disorder (ADHD) is a common neuropsychiatric disorder that is often diagnosed during childhood, but has also increasingly been recognized to occur in adults. Importantly, up to 52% of children (including adolescents) and 87% of adults with ADHD also have a comorbid psychiatric disorder. The presence of a comorbid disorder has the potential to impact diagnosis and could affect treatment outcomes. Atomoxetine is a nonstimulant treatment for ADHD. Despite numerous published studies regarding efficacy of atomoxetine in the treatment of ADHD in patients with comorbid disorders, there is limited information about the impact of individual common comorbid disorders on the efficacy of atomoxetine for ADHD, especially with regard to adults. Moreover, a cumulative review and assessment of these studies has not been conducted. For this reason, we performed a literature review to find, identify, and cumulatively review clinical studies that examined the efficacy of atomoxetine in the treatment of patients with ADHD and comorbid psychiatric disorders. We found a total of 50 clinical studies (37 in children; 13 in adults) that examined the efficacy of atomoxetine in patients with ADHD and a comorbid disorder. The comorbidities that were studied in children or in adults included anxiety, depression, and substance use disorder. Overall, the presence of comorbidity did not adversely impact the efficacy of atomoxetine in treatment of ADHD symptoms in both patient populations. In the studies identified and assessed in this review, atomoxetine did not appear to exacerbate any of the comorbid conditions and could, therefore, be an important therapy choice for the treatment of ADHD in the presence of comorbid disorders.
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17
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Kumar V, Varambally S. Atomoxetine Induced Hypomania in a Patient with Bipolar Disorder and Adult Attention Deficit Hyperactivity Disorder. Indian J Psychol Med 2017; 39:89-91. [PMID: 28250566 PMCID: PMC5329999 DOI: 10.4103/0253-7176.198954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Comorbidity of bipolar disorder (BD) with attention deficit hyperactivity disorder (ADHD) is frequent. The management of comorbid ADHD and BD is complicated by the risk of induction of (hypo) mania by the medications used for ADHD treatment. Earlier reports in children and adolescents with ADHD-BD suggest that the possibility of (hypo) mania induction is low when atomoxetine is used along mood stabilizers or antipsychotics. Here, we report induction of hypomania by atomoxetine when used for the treatment of comorbid ADHD in a BD patient while on prophylactic treatment with mood stabilizers. This report indicates that atomoxetine carries the risk of induction of (hypo) mania even in stabilized BD patients. Clinicians should closely monitor such patients for (hypo) mania symptoms.
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Affiliation(s)
- Vijaya Kumar
- Department of Psychiatry, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
| | - Shivarama Varambally
- Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Abstract
Several international guidelines indicate stimulants, including methylphenidate (MPH), amphetamines and derivatives, modafinil, and armodafinil among the second-third-line choices for bipolar depression. Efficacy of stimulants has been also reported for the management of residual depressive symptoms such as fatigue and sleepiness and for the management of affective, cognitive, and behavioral symptoms in children and adult bipolar patients with comorbid ADHD. Few case reports show positive results with MPH in the treatment of resistant mania. Finally, MPH might be an option in some bipolar forms observed in psychiatric presentations of frontotemporal dementia and traumatic brain injury. In spite of these preliminary observations, the use of stimulants in bipolar patients is still controversial. Potential of misuse and abuse and mood destabilization with induction of (hypo)manic switches, mixed states, and rapid cycling are the concerns most frequently reported. Our aims are to summarize available literature on this topic and discuss practical management implications.
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