Vishal Madaan

Innovations and recent trends in the treatment of ADHD

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

Assessing the Efficacy of Treatments for ADHD Overview of Methodological Issues

Attention-deficit hyperactivity disorder (ADHD) is a common and impairing psychiatric condition that affects significant numbers of children, adolescents and adults. Clinicians in a variety of practice settings (hospital, outpatient, residential, research) strive to diagnose, treat and monitor ADHD in an efficient and evidence-based manner. Tools that facilitate the gathering and interpretation of information from a variety of sources can effectively augment a diagnostic assessment, and can also be useful for longitudinal monitoring. Multiple assessment tools are available, with varying degrees of psychometric validity, clinical utility and overall feasibility (time and cost).This review provides an overview of several available ADHD rating scales and continuous performance tests, and offers a discussion of potential strengths and weaknesses of the instruments. While these tools do not in and of themselves make a diagnosis of ADHD, they can certainly assist in the diagnostic assessment, be crucial in assessing the efficacy of medications in clinical trials, and be a useful adjunct in the clinical management of ADHD.

Review of Pediatric Attention Deficit/Hyperactivity Disorder for the General Psychiatrist

Attention deficit/hyperactivity disorder (ADHD) is a common and impairing psychiatric condition, affecting significant numbers of children and adolescents. General psychiatrists serve, both by choice and out of necessity, in the assessment and treatment of children and adolescents who have ADHD and in the education of patients and their families. For many clinicians, however, there are numerous unanswered questions regarding the diagnosis and therapeutic interventions for ADHD. This article provides general psychiatrists with a practical overview and update on the assessment, diagnosis, and treatment of pediatric ADHD. Background information, recent relevant research, current evidence-based practice guidelines, and tips for clinical practice are reviewed in this article. The information is presented in a question-answer format.

Pharmacotherapeutic strategies for pediatric bipolar disorder

There has been a recent increase in recognition and diagnosis of pediatric bipolar disorder (PBD), along with an increase in prescriptions for psychotropic medications for treating children suffering from this chronic, potentially disabling disorder. Lithium remains the only FDA-approved mood stabilizer for use in children > 12 years of age and along with valproic acid and carbamazepine, forms the triad of traditional mood stabilizers used for initiation of treatment for PBD. There has been a recent surge in the use of atypical antipsychotics in PBD, which may be due to their relative ease of administration and lack of requirement for serum level monitoring. A combination of traditional mood stabilizers along with atypical antipsychotics is commonly used in clinical practice, despite a lack of compelling empirical data. Although there is an urgent need for controlled studies on the available treatment options and strategies in PBD, recent expert consensus guidelines and emerging controlled pharmacotherapy data on PBD will lay the platform for future scientific research in the area.

Management of tics and Tourette's disorder: an update

Importance of the field: Tic disorders are fairly prevalent neuropsychiatric disorders. While a proportion of children may not present to the clinicians office for management of tic disorders, another proportion may present with severe symptoms that impair social and occupational functioning. A combination of psychosocial interventions and pharmacological approaches are required in these cases. While alpha-2 agonists and dopamine antagonists constitute the mainstay of pharmacological agents for tic disorders, advances in neurobiology and psychopharmacology have discovered newer avenues for treatment of tic disorders. Areas covered in this review: Apart from reviewing evidence based literature and recent updates on alpha-2 agonists and dopamine antagonists in treating tic disorders, the review also includes novel treatment approaches such as glutamate modulators, nicotinic agents, antiandrogens and botulinum injection. In addition, a brief overview of electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS) and habit reversal training is also provided. What the reader will gain: A clear and concise review of the therapeutic options and advances in management of tic disorders. Take home message: In addition to psychosocial interventions, alpha-2 agonists and dopamine antagonists constitute the mainstay of treatment approaches for treating tic disorders. Additional treatment options such as ropinirole, pramipexole and tetrabenazine may be useful if patients do not respond to the primary agents. Severe intractable cases might need a referral to specialist centers to consider the possibility of using ECT, TMS or DBS.

Leadership and Professional Workforce Development

On an average, 4% of medical students from medical schools in the United States choose psychiatry as an option. Although in recent years psychiatry residency match statistics have improved, in general terms it is less competitive to enter this specialty. Most psychiatrists practice as generalists, either in private practice or in the public mental health system. There are marked shortages in child psychiatry and in upcoming new subspecialties. There are ongoing efforts to enhance the core competency of psychiatrists-in-training, with particular emphasis on research literacy to foster lifelong learning skills and (for some) to stimulate interest in a research career track. This article chronicles the trajectory of workforce development and professional growth in psychiatry.

Early Onset Schizophrenia

Early onset schizophrenia (EOS) describes onset of the first episode of psychosis before age 18 years. Such an earlier onset of symptoms is often associated with a severe and chronic course of the illness, a poorer prognosis and a potentially significant negative impact on recovery and rehabilitation. A recent emphasis on early intervention by utilizing the advances in neurobiological and psychosocial domains along with psychopharmacological effectiveness research in managing this chronic psychotic disorder is paving the way for a more rigorous study of this chronic disabling disorder. This chapter reviews recent literature on diagnostic assessment and management of schizophrenia when it strikes during formative years, and provides future directions for further research in the area.

Autistic Spectrum Disorders and Schizophrenia

Autism spectrum disorders are a group of complex neurodevelopmental disorders that primarily present with deficits in social interactions, communication, and repetitive behaviors. With a progressive evolution in understanding this unique group of disorders, a variety of phenotypes have been postulated, with variability in both biological features and response to treatment. Etiologically, autism is believed to involve a genetic predisposition that may be triggered by environmental factors. While there is no known cure for autism, many treatment approaches are available that potentially improve certain core and associated symptoms. In the past decade, research in the etiology and treatment of these disorders has grown tremendously, as evident by the increasing number of publications in this area. This chapter will review some of the recent advances in the current understanding of these disorders. In addition, a historical background regarding the clinical diagnosis of autism spectrum disorders, including the development of diagnostic concepts and definitions, will be reviewed. Clinical features of autism, its course, prognosis, interventions, including psychosocial and educational interventions, and pharmacological treatments, will also be highlighted. This will be followed by an outline of standard clinical assessment of individuals with a suspected diagnosis of autism. Furthermore, epidemiological data along with recent advances in the understanding of autism’s etiology and pathogenesis, including genetic influences, neuropsychological research, and neurobiological mechanisms, will also be briefly discussed. Finally, although autism can be separated from early onset psychosis and recent data suggest that individuals with autism are probably not at higher risk for developing schizophrenia, it is striking that children with childhood onset schizophrenia show high rates of early social, language and motor developmental abnormalities, with premorbid social impairment being the most common feature. Beginning with Kanner’s use of the term autism that suggested a similarity to schizophrenia, the question of comorbid association or phenotypic variations between autism and schizophrenia has been frequently asked. This chapter will also aim to clarify the similarities and differences in presentation between autism and childhood onset schizophrenia.

Lisdexamfetamine: Stimulant Prodrug for ADHD in Children and Adults

Lisdexamfetamine (LDX) is the only available stimulant prodrug formulation that has been approved by the Food and Drug Administration (FDA) for treatment of ADHD in children and adults. It is enzymatically hydrolyzed to the active d-amphetamine and essential amino acid L-lysine. This rate limited enzyme mediated step underlies the consistent, predictable levels throughout the day and limits its potential for misuse. It is effective, safe and well tolerated and has an adverse effect profile comparable to other extended release stimulant formulations. The d-amphetamine levels from LDX are more consistent than that from extended release mixed amphetamine salts. LDX has shown efficacy for ADHD in clinical trials involving children and adults. Ongoing research studies are attempting to establish its long term efficacy and tolerability in patients with ADHD and also its use for some novel applications in patients with depression and other psychiatric disorders.