Nestor Szerman

Risk of Serious Cardiovascular Problems with Medications for Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity and/or impulsivity. The proportion of patients diagnosed with ADHD receiving pharmacological treatments has increased enormously in recent years. Despite the well established efficacy and the good safety and tolerability profile, there is concern about the potential for rare but serious cardiovascular adverse events, as well as sudden cardiac death, with pharmacotherapies used for treating ADHD in children, adolescents and adults. The present paper aims to comprehensively and critically review the published evidence on the controversial association between medications approved for treating patients with ADHD and the risk of serious cardiovascular problems, specifically the risk of corrected QT interval (QTc) prolongation, and the risk of sudden cardiac death. A comprehensive search of relevant databases (PubMed, EMBASE and PsychINFO) was conducted to identify studies published in peer-reviewed journals until 21 July 2012. Clinical reports, as well as retrospective or prospective population-based studies with children, adolescents or adults as participants, of pharmacotherapies for ADHD reporting cardiovascular adverse events were included. Stimulant medications for ADHD, including methylphenidate and amphetamine derivatives, are generally safe and well tolerated. Small but statistically significant increases in blood pressure (BP) and heart rate (HR) are among the adverse events of stimulant treatment in all age groups. Similarly, the non-stimulant medication atomoxetine has also been associated with increased HR and BP, although as is the case with stimulants, these are generally minor, time limited and of minor clinical significance in children, adolescents or adults. Growing evidence suggests that these medications do not cause sudden and unexpected cardiac death or serious cardiovascular problems including statistically or clinically significant increases in QTc, at therapeutic doses in ADHD patients across the lifespan. Small decreases in mean systolic BP, diastolic BP and HR have been observed in studies with guanfacine-extended release (-XR) or clonidine-XR, two α2-adrenergic receptor agonists, administered alone or in combination with psychostimulants to children and adolescents with ADHD. There are also no statistically or clinically significant increases in QTc associated with clonidine or guanfacine. There are no reports of torsades de pointes clearly and directly related to medications used for treating ADHD in patients of all age groups. The risk for serious cardiovascular adverse events, including statistically or clinically significant increases in QTc, and sudden cardiac death associated with stimulants, atomoxetine or α2-adrenergic agonists prescribed for ADHD is extremely low and the benefits of treating individual patients with ADHD, after an adequate assessment, outweigh the risks. However, great caution is advised when considering stimulant and non-stimulant medications for patients of any age with a diagnosis of ADHD and a personal or family history or other known risk factors for cardiovascular disease.

Dual Diagnosis and Suicide Risk in a Spanish Outpatient Sample

The present study compares dual-diagnosis patients with other groups of psychiatric patients to determine the differential characteristics in suicide risk and other clinical variables between them. During 2008 in Madrid, 837 outpatients were evaluated in addiction and mental health services. Three comparison groups were created according to current diagnosis: (i) dual patients, (ii) patients with substance use disorders but no other mental disorders, and (iii) patients with mental disorders but no substance use disorders. A multinomial logistic regression model was built to explore the risk associated with dual diagnosis. Criteria for dual diagnosis were met at the time of the study by 440 patients (52.6%). Dual patients showed several demographic and clinical differences and a higher risk for suicide than the other two comparison groups. Further research is needed to define suicide preventive strategies for dual patients.

Estudio Madrid sobre prevalencia y características de los pacientes con patología dual en tratamiento en las redes de salud mental y de atención al drogodependiente

Se valora la prevalencia y caracteristicas de los pacientes de patologia dual (diagnostico actual de un trastorno mental y de un trastorno por uso de sustancias (TUS)): en las redes asistenciales de Salud Mental y Drogodependencias de la Comunidad de Madrid. Se consigue una muestra de 837 sujetos (208 de la red de Salud Mental y 629 de la red de Drogodependencias). Se uso la entrevista MINI (Mini International Neuropsychiatric Interview) y el cuestionario PDQ4+ (Personality Disorder Questionnaire) para la valoracion de los trastornos del eje I y II. Se hallaron 517 (61,8%) pacientes con patologia dual (un 36,1% en la red de salud mental y un 70,3% en la red de drogas). Al compararlos con el grupo de sujetos con TUS sin patologia dual (n=194), habia entre los duales menos varones y peor situacion laboral, siendo las drogas mas consumidas el alcohol y cannabis. Al compararlos con el grupo de trastornos mentales sin uso de sustancias (n=126), encontramos diferencias en todas las caracteristicas sociodemograficas analizadas y los casos de patologia dual son diagnosticados mas frecuentemente como trastorno bipolar, agorafobia, trastorno por ansiedad generalizada, trastorno por estres postraumatico, mayor riesgo de suicidio y distintos trastornos de personalidad. Por lo tanto, la presencia de patologia dual es elevada en sujetos en tratamiento y presentan unas caracteristicas diferenciales, tales como mayor riesgo de suicidio y situacion laboral precaria que hacen pensar en un peor pronostico, cuestion a considerar para el desarrollo de recursos asistenciales adecuados.

Abuso o dependencia a la cocaína y otros trastornos psiquiátricos. Estudio Madrid sobre la prevalencia de la patología dual

OBJECTIVES The main objective of this study was to analyse the cocaine addict subgroup from the Madrid study of prevalence of dual disorders in community mental health and substance misuse services. MATERIAL AND METHODS The sample consisted of 837 outpatients from Madrid, Spain. We compared 488 subjects who had a lifetime diagnosis of cocaine abuse or dependence, and 222 subjects who did not have a cocaine substance use disorder. We used the Mini International Neuropsychiatric Interview to evaluate axis I mental disorders, and the Personality Disorder Questionnaire to evaluate personality disorders. RESULTS Almost three-quarters (73.4%) of cocaine addicts had a current dual disorder. Most prevalent were mood and anxiety disorders. Almost half (49.6%) had a personality disorder. Most of them (94.9%) had other substance use disorders. Cocaine addicts did not have higher prevalence rates of dual pathology than addicts with no cocaine abuse or dependence. Cocaine addicts were associated to a diagnosis of antisocial personality disorder, agoraphobia, and post-traumatic stress disorder, and they had an early age of onset of alcohol and cannabis use. CONCLUSIONS Dual pathology is no higher in cocaine addicts in treatment than in addicts who do not use cocaine, however cocaine addicts started other drugs earlier, and were associated with specific mental disorders.

Rethinking Dual Disorders/Pathology

Objective:Comorbidity of addictive disorders and other psychiatric disorders is very common. The optimal treatment of patients with addiction disorders requires awareness of their comorbid mental disorders and vice versa. The operational and contextual definitions of the different terms used vary significantly. To address this terminology problem the present document proposes and, therefore, has chosen the term ‘dual pathology.’ Methods:The present paper aims to discuss the most current evidence regarding the multiple genetic, developmental, and environmental factors underlying the complex interactions that modulate the vulnerability and trajectories of patients with dual pathology. It, thus, goes beyond the current prevailing view of considering patients as having primarily either an addictive disorder or any other mental disorder and may have an additional comorbid psychiatric disorder. Results:It is time to rethink mental disorders, including addictive disorders and dual disorders or dual pathology, recognizing that these are disorders of brain circuits likely caused by developmental processes shaped by a complex interplay of genetics and experience, and may therefore be considered neurodevelopmental disorders. The view of dual pathology as a neurobiological systems failure should help us to develop more comprehensive interventions for optimizing the ways in which we prevent and treat a complex, multifactorial, likely neurodevelopmental disorder such as dual pathology. Conclusions:Despite the scientific evidence, there are beliefs and, as a result, certain resistance or barriers that have hindered the recognition and acceptance of dual pathology in daily clinical practice or in research. Twelve of these common barriers are addressed and discussed.

Dual Diagnosis Resource Needs in Spain: A National Survey of Professionals

Objective: Since provision of integrated services for patients with dual pathology or dual disorders (coexistence of an addictive disorder and another mental health disorder) is an important challenge in mental health, this study assessed health care professionals’ perceptions and knowledge of the current state of specific resources for patients with dual pathology in Spain. Methods: We conducted a national survey of health care professionals seeing patients with dual pathology in treatment facilities throughout Spain. Participants completed a specific online questionnaire about the needs of and available resources for patients with dual pathology. Results: A total of 659 professionals, mostly psychologists (n = 286, 43.4%) or psychiatrists (n = 217, 32.9%), participated in the study. Nearly all participants who responded to these items reported that specific resources for dual pathology were needed (n = 592/635, 93.2%); 76.7% (n = 487) identified intermediate resources, 68.8% (n = 437) acute detoxification units, and 64.6% (n = 410) medium-stay rehabilitation units as particularly necessary. In the opinion of 54.0% of respondents (n = 343), integrated mental health and addiction treatment services were available. Of the participants who answered these items, only a small proportion (n = 162/605, 26.8%) reported that there were appropriate outpatient programs for dual pathology, 30.4% (n = 184/605) specific hospitalization units, 16.9% (n = 99/587) subacute inpatient units, 34.2% (n = 201/587) outpatient intermediate resources, 15.5% (n = 91/587) day hospitals, and 21.5% (n = 126/587) day centers. Conversely, 62.5% (n = 378/587) of participants reported a greater presence of specific detoxification/withdrawal units, 47.3% (n = 286/587) psychiatric acute admission units, and 41.9% (n = 246/587) therapeutic communities. In the professionals’ opinion, the presence of specialty programs was low; 11.6% of respondents (n = 68/587) reported that vocational programs and 16.7% (n = 98/587) reported that occupational rehabilitation programs were available. Employee turnover was common: 51.9% of respondents (n = 314/605) stated that employee turnover was occasional to frequent. Conclusions: According to the professionals surveyed, specific health care resources for the management of dual pathology are currently insufficient, underlining the need for additional efforts and strategies for treating individuals with comorbid disorders.

Trastorno bipolar y trastorno por uso de sustancias. Estudio Madrid sobre prevalencia de patología dual

Given its prevalence and impact on public health, the comorbidity of bipolar and substance use disorders is one of the most relevant of dual diagnoses. The objective was to evaluate the characteristics of patients from community mental health and substance abuse centres in Madrid. The sample consisted of 837 outpatients from mental health and substance abuse centres. We used the Mini International Neuropsychiatric Interview (MINI) and Personality Disorder Questionnaire (PDQ4+) to evaluate axis I and II disorders. Of these patients, 174 had a lifetime bipolar disorder, 83 had bipolar disorder type I and 91 had type II. Most patients had dual pathology. Of the 208 participants from the mental health centres, 21 had bipolar disorder and 13 (61.9%) were considered dually-diagnosed patients, while 33.2% of non-bipolar patients had a dual diagnoses (p = 0.03). Of the 629 participants from the substance abuse centres, 153 patients (24.3%) had a bipolar diagnosis. Bipolar dual patients had higher rates of alcohol and cocaine dependence than non-bipolar patients. Moreover, age at onset of alcohol use was earlier in bipolar duallydiagnosed patients than in other alcoholics. Bipolar dually-diagnosed patients had higher personality and anxiety disorder comorbidities and greater suicide risk. Thus, alcohol and cocaine are the drugs most associated with bipolar disorder. Given the nature of the study, the type of relationship between these disorders cannot be determined.

Attention deficit hyperactivity disorder and dual disorders. Educational needs for an underdiagnosed condition

Abstract A wide range of comorbid psychiatric disorders overlap with attention-deficit hyperactivity disorder (ADHD) across the life span. There is a robust and complex link between ADHD and substance use disorders (SUD). The aim of this report was to review the neurobiological and other vulnerability factors explaining the comorbidity of ADHD and an addictive disorder, as well as the key aspects of the assessment and diagnosis of dually diagnosed ADHD patients. A comprehensive and systematic search of relevant databases (PubMed, Embase, and PsychINFO) was conducted to identify studies published in peer-reviewed journals until July 31, 2012, with the aim of exploring the association of ADHD and SUD with postgraduate training and residency education. Across the life span, ADHD is associated with significant impairment and comorbidity. Data from epidemiological, clinical and epidemiological studies show a very solid link between ADHD and SUD. Therefore, it is very important to carefully and systematically assess for any substance use in patients with suspected ADHD coming to initial assessment, and vice versa. While there are various valid and reliable rating and screening scales, diagnosis cannot solely rely on any of the instruments available for both SUD and ADHD in adult patients with dual pathology. The most important and effective tool in the assessment of dually diagnosed patients with ADHD and SUD is a full and comprehensive clinical and psychosocial assessment. Hence, it is essential to actively incorporate training opportunities on the assessment, diagnosis, and management of adult ADHD and dually diagnosed ADHD patients during postgraduate education residency or specialist training.

Alcohol abuse or dependence and other psychiatric disorders. Madrid study on the prevalence of dual pathology

The objective of this study was to analyse the alcohol addict subgroup from the Madrid study on the prevalence of dual pathology in community mental health and substance misuse services. The sample consisted of 837 outpatients from Madrid, Spain. We compared 528 subjects with a lifetime diagnosis of alcohol abuse or dependence and 182 with other substance use disorders (SUDs) not involving alcohol. The Mini International Neuropsychiatric Interview (MINI) was used to evaluate Axis I disorders and the Personality Disorder Questionnaire to evaluate personality disorders. It was considered that 76.1% of the alcohol addicts had a current dual diagnosis, the most prevalent being mood and anxiety disorders. Fifty-two per cent had a personality disorder and most of them (81.6%) had other SUDs. There was a greater prevalence of dual pathology in the alcohol addict subgroup than in the subgroup without problems of alcohol abuse or dependence. Alcohol addicts were associated with diagnoses of several types of person...

Repensando el concepto de adicciones: pasos hacia la patología dual

Since the 1980s, several epidemiological studies have demonstrated the existence of significant statistical associations showing the high prevalence of co-occurrence between Substance Use Disorders (SUD) and Other Psychiatric Disorders (OPD), which ranges between 20% and 50% in general population and between 40% and 80% in clinical population. Likewise, epidemiological studies suggest that in more than 80% of cases OPD started before the onset of SUD, so that people with OPD are up to 3 times more likely to develop SUD later.