SOURCE: MPR
February 25, 2014 | JAMA Pediatrics

Children whose mothers took acetaminophen during pregnancy may be at a higher risk for developing hyperkinetic disorders (HKDs) and attention-deficit/hyperactivity disorder (ADHD)-like behavioral problems, according to a study published online on February 24 in JAMA Pediatrics.

Zeyan Liew, MPH, from the University of California, Los Angeles, and colleagues studied data from 64,322 live-born children and mothers enrolled in the Danish National Birth Cohort from 1996–2002. The team analyzed parental reports of behavioral problems in children at age 7, HKD diagnoses from the Danish National Hospital Registry or the Danish Psychiatric Central Registry before 2011, and children's ADHD prescriptions the Danish Prescription Registry.

Over 50% of mothers reported taking acetaminophen during pregnancy. Children whose mothers used acetaminophen were at a higher risk for having ADHD-like behaviors, receiving a hospital diagnosis of HKD, or being prescribed ADHD medications. Use of acetaminophen for more than a trimester had a stronger association and response trends were found with increasing use of acetaminophen during pregnancy for HKDs and ADHD-like behaviors.

>>> For more information, visit the JAMA Pediatrics website

Today, one of my clients successfully completed his benzodiazepine taper after 10 years of being on Ativan! Now, he is benzo-free and happy about it. 

SOURCE: Current Psychiatry 
Michael I. Casher, Daniel Gih & Joshua D. Bess
*article abbreviated

Although benzodiazepines and stimulants have well-documented efficacy for numerous psychiatric disorders, psychiatrists hesitate to prescribe these medications to patients with substance use disorders (SUDs)—even to those with a comorbid condition that likely would respond to a benzodiazepine or stimulant—because of risk of abuse or dependence. 

Conventional practice typically has focused on treating active substance use first rather than using simultaneous treatments. Prejudice, fear, and misinformation can influence
this decision. We believe these cases lie on a continuum. At one extreme, ignoring
a past or present SUD may lead a remitted patient toward relapse, or further delay recovery for an active user. At the other end, psychiatrists who overreact to a remote history of substance use may deprive patients of legitimate pharmacologic symptom relief. Most cases lie somewhere in the middle.

A literature review does not support the assertion that the use of these medications leads to future substance use or worsens active use, especially for stimulants. In fact, stepwise—as opposed to concurrent— treatment for both conditions actually may delay recovery and increase patients’ risk for morbidity. We outline issues involved in these complex clinical situations, point out controversies, review relevant research data, and offer guidelines for treatment

There are multiple legitimate uses of
benzodiazepines in general medicine and psychiatric practice, based upon their considerable sedative/hypnotic, anxiolytic, anticonvulsant, and muscle-relaxant properties.
Recommendations regarding benzodiazepine use for anxious patients with a history of SUD are not clear-cut. First, it often is difficult to determine whether the patient truly has an anxiety disorder or is suffering anxiety symptoms secondary to substance use and/or withdrawal. In addition, even if a diagnosis of a separate anxiety disorder is established, psychiatrists debate how to treat such patients. Some clinicians maintain that benzodiazepines should be used only for acute detoxification, and that ongoing benzodiazepine use will lead to relapse or benzodiazepine dependence. However, in a prospective study of 545 alcohol use disorder (AUD) patients receiving benzodiazepines for anxiety disorders, Mueller et al found no association—at 12 months or at 12 years—between benzodiazepine use and AUD recurrence. Furthermore, there was no
difference in benzodiazepine usage when comparing patients with and without an AUD.

Although widely prescribed—and despite their efficacy in numerous conditions— both acute or long-term benzodiazepine use frequently causes adverse effects. Patients may develop tolerance, which can lead to escalating dosages and/or to withdrawal symptoms when patients attempt to cut back. Benzodiazepines eventually become ineffective for sleep, and continued use can cause rebound insomnia. Also, with many patients taking benzodiazepines long-term, clinicians struggle to differentiate between “real” anxiety symptoms and subtle states of withdrawal from fluctuating benzodiazepine blood levels.
Geriatric patients who take benzodiazepines are at risk for falls and hip fractures. Although older dementia patients are at particular risk for cognitive problems— including frank delirium—secondary to benzodiazepine use, patients of all ages are susceptible to these medications’ deleterious neurocognitive effects. 
Benzodiazepines can lead to excessive sedation, thereby impairing performance at work or school, and have been implicated as a cause of motor vehicle accidents. Finally, a serious drawback to benzodiazepine use is possible lethality in overdose, especially when combined with alcohol. 
Benzodiazepine prescribing should not be taken lightly. Always analyze the difference between benzodiazepines’ well-documented efficacy and their adverse effect profile. This risk-benefit analysis becomes much more complex for patients with SUDs. 

Patients at higher risk for benzodiazepine abuse include
those with:

• severe alcohol dependence (ie, long-term use)
  
• intravenous drug use
  
• comorbid alcoholism and antisocial personality disorder.
  

Exercise special caution when considering benzodiazepines for patients with severe psychiatric illness such as schizophrenia spectrum disorders, bipolar disorder, or severe depression. Patients with schizophrenia have high rates of alcohol, cocaine, cannabis, and benzodiazepine abuse. Bipolar disorder
patients show similar vulnerability—up to 56% of patients screen positive for substance substance abuse or dependence. 

Vulnerability to addiction in severely ill psychiatric patients is thought to be related to several factors, including: 

• use of drugs as self-medication 
  
• genetic predisposition 
  
• environment/lifestyle that supports substance abuse 
  
• neurobiologic deficits that lead to lack of inhibition of reward-seeking behaviors.
  

Bipolar disorder patients in particular score high on measures of sensation seeking, which leaves them vulnerable to abusing all classes of substances. 

In a 6-year study of 203 patients with severe psychiatric illnesses and SUDs, Brunette et al found that these patients were 2.5 times more likely than patients with severe psychiatric illness alone to abuse prescribed benzodiazepines. In an analysis of Medicaid records, Clark et al found similar vulnerability in patients with major depressive disorder (MDD) and SUD. Not only did these patients show a higher rate of benzodiazepine use than patients with MDD without SUD, but the dual-diagnosis group also gravitated toward more addictive high-potency/fast-acting benzodiazepines, such as alprazolam, estazolam, or triazolam. 

Despite many clinicians’ hesitance to prescribe controlled substances to patients with SUDs, psychostimulants should be considered in a variety of scenarios. Although nonstimulant options are available, stimulants consistently have demonstrated superior efficacy over other treatments and remain first-line agents for adult ADHD. 
Methylphenidate, mixed amphetamine salts, lisdexamfetamine, and atomoxetine are FDA-approved for adult ADHD. Both stimulant classes (methylphenidate and amphetamine-based products) are equally effective for ADHD. In addition, stimulants are used to treat narcolepsy, cognitive disorders such as traumatic brain injury, and as augmentation to antidepressants for MDD. ADHD affects 5% to 12% of children, and >60% of patients remain symptomatic into adulthood and require continued treatment. In particular, problematic inattention may persist throughout adulthood. ADHD does not appear to be an independent risk factor for SUDs in children and adolescents. However, substance use increases sharply as ADHD patients enter late adolescence and adulthood, and eventually becomes a problem for 20% of adolescents and adults with ADHD. Conversely, 17% to 50% of patients with alcohol, cocaine, or opioid dependence have co-occurring ADHD.
Withholding ADHD treatment based on concerns about future or increased current substance abuse is unfounded. A meta-analysis of 6 studies that included 674 medicated and 360 unmedicated patients with ADHD who were followed at least 4 years demonstrated that childhood treatment of ADHD with stimulants reduces the risk of developing alcohol and other drug disorders in adulthood. Regarding the effect stimulants have on active substance use, a 12-week, double-blind, randomized controlled trial of 48 cocaine-dependent adults with ADHD showed methylphenidate did not change cocaine abuse or craving, but did improve ADHD symptoms.
Clinicians also must assess whether untreated ADHD symptoms impair patients’ work or other activities. Driving is a particular concern because ADHD is associated with risky driving habits, motor vehicle accidents, traffic violations, and driving license suspensions. In a study that administered cognitive tests to adults with ADHD, methylphenidate treatment improved cognitive performance related to driving (eg, better visual-motor coordination under high-stress conditions, improved visual orientation, and sustained visual attention). It is likely this effect could be generalized to other activities where safety is important. Finally, appropriate stimulant treatment may improve participation in rehabilitative programs. Despite their positive effects, stimulants can have adverse effects and consequences. In routinely prescribed dosages, methylphenidate and amphetamines can cause symptoms related to sympathetic activation, including anxiety, tics, anorexia/ weight loss, and sleep disturbance. A 5-year study of 79 school-age children prescribed methylphenidate, dextroamphetamine, or pemoline, which is no longer available in the United States, showed a significant association between adherence to stimulants and persistence of physiological (eg, headaches, insomnia, anorexia) and mood-related (eg, irritability, dysphoria) side effects. Stimulants’ sympathomimetic properties also can lead to dangerous drug-drug interactions with monoamine oxidase inhibitors. For both methylphenidate and amphetamines, overdose can lead to seizures, cardiac toxicity, dysrhythmias, and hyperthermia. All stimulants carry an FDA “black-box” warning that lists increased risk of cardiac complications, sudden death, and psychiatric complications such as psychosis or mania

Despite their positive effects, stimulants can have adverse effects and consequences. In routinely prescribed dosages, methylphenidate and amphetamines can cause symptoms related to sympathetic activation, including anxiety, tics, anorexia/ weight loss, and sleep disturbance. A 5-year study of 79 school-age children prescribed methylphenidate, dextroamphetamine, or pemoline, which is no longer available in the United States, showed a significant association between adherence to stimulants and persistence of physiological (eg, headaches, insomnia, anorexia) and mood-related (eg, irritability, dysphoria) side effects. Stimulants’ sympathomimetic properties also can lead to dangerous drug-drug interactions with monoamine oxidase inhibitors. For both methylphenidate and amphetamines, overdose can lead to seizures, cardiac toxicity, dysrhythmias, and hyperthermia. All stimulants carry an FDA “black-box” warning that lists increased risk of cardiac complications, sudden death, and psychiatric complications such as psychosis or mania

All stimulants have potential for diversion or abuse. Pay close attention to these issues, especially in vulnerable populations and situations where rates of abuse and diversion are elevated. Among college students, white patients, fraternity/sorority members, and individuals with lower grade point averages may be at higher risk for nonmedical stimulant use. Adults who misuse or divert stimulants commonly have a history of substance abuse and conduct disorder. Short-acting stimulants are abused 4 times more often than extended-release preparations

Being aware of the medicolegal issues of benzodiazepine and/or stimulant prescribing is crucial because a court may find a psychiatrist liable for negative outcomes (eg, suicide) when controlled substances are prescribed to a patient with a history of addiction. The most prudent course is to weigh the pros and cons for each patient individually, taking into consideration the factors described above. This is consistent with guidelines from the American Psychiatric Association and the British Association for Psychopharmacology, both of which call for extreme caution in these cases. 

Educate patients and caregivers about the risks of taking a controlled substance, including misuse, diversion, and theft. Provide and document explicit instructions that the patient will receive stimulants from only a single provider. Remind patients that state and federal authorities closely track controlled medications. Finally, a “stimulant contract” or “benzodiazepine contract,” similar to a pain or narcotic contact, may be useful to formally document discussions about appropriate medication use. 

SOURCE: HealthDay News 
January 22, 2014 | Brenda Goodman

Stricter new criteria for autism may change how frequently the condition is diagnosed, a new study suggests.

The study estimates that if the new diagnostic guidelines had been in place in 2008, they would have lowered the prevalence of the disorder in a nationally representative database to one in 100 children.

The most recent estimate of autism prevalence from this database, according to the U.S. Centers for Disease Control and Prevention, is one in 88 children with the diagnosis.

Researchers say it's hard to tell how quickly the new guidelines will be put into practice. But some fear this change to how the condition is diagnosed may mask true increases in the number of children who develop symptoms that have been consistent with the disorder.

"The trend in the incidence of autism spectrum disorders has been one of pretty steady increases. Whether the switch to DSM-5 would offset that yearly increase remains to be seen," said study author Matthew Maenner, an epidemiologist with the CDC.

But advocates for children with autism say the ramifications of the new guidelines go beyond research. They say they're starting to see signs that children are being reclassified under the new criteria and that some may be losing access to needed services as a result.

In May, the American Psychiatric Association published sweeping new guidelines for the diagnosis of autism spectrum disorders in its Diagnostic and Statistical Manual of Mental Disorders, or DSM-5.

In the past, children who met six of 12 possible criteria could be diagnosed with one of several related conditions including autistic disorder, childhood disintegrative disorder, pervasive developmental disorder not otherwise specified (PDD-NOS) and Asperger disorder, according to study background information.

Now, those categories have been folded into a single condition -- autism spectrum disorders. In order to be diagnosed, kids must demonstrate all of three recognized deficits in social communication, and they have to show two of four different kinds of restricted or repetitive patterns of behavior.

The new study applied the updated criteria to the medical records kept in a database of nearly 645,000 8-year-old children who are being tracked by the Autism and Developmental Disabilities Monitoring Network (ADDM).

Of the 6,577 children who were classified as having an autism spectrum disorder under the old diagnostic criteria, researchers found 5,339, or 81 percent, would have kept their diagnosis under the new guidelines.

"Most of the children who didn't make the cut, they didn't miss by a lot," Maenner said. "They only needed one additional criterion to meet the DSM-5 definition. They had four of the five."

Most kids who wouldn't have met the new definition missed because they didn't show problems with nonverbal communication, which means they didn't have trouble reading or using body language or facial expressions. The study findings were published online Jan. 22 in the journal JAMA Psychiatry.

Researchers caution that it's still not clear how the changes will play out in the real world. Doctors, for example, could change how they look for symptoms to better fit the new criteria. It's also possible that kids who don't qualify for an autism diagnosis could receive a new designation -- something called social communication disorder.

The latter is what seems to be happening, said Michael Rosanoff, associate director of public health research at Autism Speaks, a nonprofit advocacy group.

Autism Speaks is surveying parents to find out how the changes are affecting their children. Though the results are still early, and it's not a scientifically rigorous sample, he said they are seeing indications that children are being reclassified using the new criteria.

"What we've seen from the first 600 persons participating in the survey, is that there is a percentage of individuals being asked to be re-evaluated by school districts or insurers using DSM-5 criteria," he said. About one-third of those who were reclassified said they had lost access to services.

"Our sense, from our survey and previous studies that have been published, is that individuals who are losing their autism diagnosis are getting a diagnosis of social communication disorder. The concern is there are no clinical guidelines for how to treat social communication disorder," Rosanoff said, which means that kids who get the diagnosis may not qualify for any services to treat it. "We're concerned about this," he said.

A client handout on the need-to-knows of NMS or Neuroleptic Malignant Syndrome

A client handout on the need-to-knows of Serotonin Syndrome

A client handout on the need-to-knows of EPS and Tardive Dyskinesia

Just the other day, I had an overwhelming feeling of gratitude rush through me as I was sitting with a client who I was meeting for the first time. This client had years of refractory depression and anxiety symptoms. She had been on numerous meds with either minimal efficacy or notable adverse effects. As she recounted her treatment history, she looked visibly defeated. Years of therapy from numerous providers had left her with coping skills and insight, but still her symptoms persisted. 

Then it struck me - she was putting her faith in me. Once more, she was willing to dare a new treatment and a new provider not knowing what the consequences would be. She had placed her trust in my knowledge and skills... and I felt honored.
 
Now each morning, as I boot up my computer, sort through the numerous refill requests and review my client schedule, I try to take a moment and remember that feeling of trust. To spend just little time to acknowledge the courage that it takes to step through the door and share one's story with a relative stranger. 

SOURCE: MPR
February 14, 2014 | Batya Swift Yasgur MA, LMSW

Smoking is one of the leading causes of morbidity and mortality in the United States and worldwide. Nearly 41% of smokers report having a current mental health diagnosis, and 60% of smokers report a mental health diagnosis at some point in their lifetimes. 

Adults with mental illness have a smoking rate that is 70% higher than adults without mental illness and die approximately 25 years earlier than the general population, due largely to their high rates of substance use—including cigarette smoking. Quit rates among smokers with mental illness are significantly lower than those among the general population. 

Individuals with both mild and severe mental illness are frequently interested in and capable of smoking cessation. Evidence-based pharmacotherapy and nonpharmacologic interventions provide the best chance for this population to achieve both short-and long-term abstinence.

FDA-Approved Options
Seven FDA-approved pharmacologic interventions are available to aid in smoking cessation—five nicotine replacement therapies (NRT), bupropion, and varenicline. A recent meta-analysis found higher rates of smoking cessation associated with NRT (17.6% )and bupropion (19.1%) compared with placebo (10.6%). Varenicline (27.6 percent) and combination NRT (31.5%) were most effective for achieving smoking cessation. None of the therapies was associated with an increased rate of serious adverse events.

Electronic Cigarettes
Electronic cigarettes are becoming increasingly popular, although their use remains controversial. Preliminary evidence suggests that e-cigarettes are likely safer than regular cigarettes and helpful to some smokers as a means of reducing or quitting smoking.

Psychosocial Interventions
Behavioral strategies "complement pharmacotherapy by enhancing the smoker's motivation to quit and teaching quitting skills such as managing relapse triggers."

>> Read the full article HERE

SOURCE: The Huffington Post  
February 17, 2014 | Lindsay Holmes

If you’ve ever suffered from severe anxiety, you’re probably overly familiar with the control it can have over your life. And you’re not alone -- it affects approximately 40 million adult Americans per year.

Anxiety and panic disorders can cause ceaseless feelings of fear and uncertainty -- and with that suffering often comes comments that are more hurtful than helpful. According to Scott Bea, clinical psychologist and assistant professor of medicine at the Cleveland Clinic, while it usually comes from a heartfelt place, a lack of understanding from others can make working through a panic attack incredibly challenging.

“So many of the things you might say end up having a paradoxical effect and make the anxiety worse,” Bea tells The Huffington Post. “Anxiety can be like quicksand -- the more you do to try to diffuse the situation immediately, the deeper you sink. By telling people things like ‘stay calm,’ they can actually increase their sense of panic.”

Despite everything, there are ways to still be supportive without causing more distress.
Here are seven comments you should avoid saying to someone who suffers from an anxiety disorder -- and how you can really help them instead.

SOURCE: DocGuide

The origin of ADHD is multifactorial and both the aetiology and pathophysiology of ADHD are as yet incompletely understood. The monoamine deficit hypothesis of ADHD postulates a dysbalance in the interaction of the neurotransmitters dopamine, noradrenaline and serotonin. 

Pathophysiological mechanisms involved in ADHD include alterations in fronto-striatal circuits. The currently proposed animal models of ADHD are heterogeneous with regard to their pathophysiological alterations and their ability to mimic behavioural symptoms and to predict response to medication. Some evidence points to a genetic basis for ADHD which is likely to involve many genes of small individual effects. In summary, specific neurobiological substrates of ADHD are unknown and multiple genetic and environmental factors appear to act together to create a spectrum of neurobiological liability.

AND SOME OTHER ARTICLES I'VE FOUND...

 February 13, 2014 | Michael Okun, MD

SOURCE: Dialogues in Clinical Neuroscience - 2012, Vol. 14

This review outlines pharmacologic treatments for the behavioral symptoms associated with autism spectrum disorders (ASDs) in children, adolescents, and adults.
Symptom domains include repetitive and stereotyped behaviors, irritability and aggression, hyperactivity and inattention, and social impairment. 

Medications covered include serotonin reuptake inhibitors (SRIs), mirtazapine, antipsychotics, psychostimulants, atomoxetine, -2 agonists,D-cycloserine, and memantine. Overall, SRIs are less efficacious and more poorly tolerated in children with ASDs than in adults. Antipsychotics are the most efficacious drugs for the treatment of irritability in ASDs, and may be useful in the treatment of other symptoms. Psychostimulants demonstrate some benefit for the treatment of hyperactivity and inattention in individuals with ASDs, but are less efficacious and associated with more adverse effects compared with individuals with ADHD. D-cycloserine and memantine appear helpful in the treatment of social impairment, although further research is needed.

To get a break down of each medication...

SOURCE: Psychopharmacology Institute
Flavio Guzman, MD

These videos discuss approved indications for antipsychotics in the treatment of bipolar disorder.

ANTIPSYCHOTICS FOR MANIA AND MIXED EPISODES

ANTIPSYCHOTICS FOR BIPOLAR DEPRESSION

SUMMARY

Just in time for Valentine's Day, Neil Hilborn, an award winning slam poet, performs a piece about love and OCD.