MANAGING STRESS IN OUR LIVES

Sunday
Jul282019

DOSING OF ADHD MEDICATIONS

Questions are sometimes raised about exceeding the maximum recommended doses of medications used to treat ADHD. I have reviewed the research studies for these medications and it is clear that the studies were to determine efficacy and were not dosing studies.  Specific doses were chosen to assess the benefit and minimize risk of side-effects.  Once efficacy was determined the study ended and there was no motivation to do further studies addressing the range of doses that were therapeutic. Thus, doses involved in efficacy studies can be mistakenly seen as being studies to determine limits of what is therapeutic. The studies could not recommend a different dose because they did not assess different [higher] doses.  Also, each person is unique and this uniqueness can include how they respond to medications with some people responding to higher doses and others to lower doses. The U.S. Food and Drug Administration recognizes this when they state “the dosing regimen [for stimulant and related medications] is adjusted according to a patient’s individual response to pharmacotherapy."

I believe that it is important to work with my patients to assess their response to medications and in collaboration with them determine an optimal dose. At times this dose may be higher than is “recommended.”  I hope that it is clearer now why this is the case and why it is necessary to prescribe higher doses for these patients.

 

Monday
Apr292019

WHY I AM AGAINST "GOOD INTENTIONS"

I have recently had a number of my patients say that they know that a person [family member or friend] had good intentions but that what they said or did was not helpful. So, what is wrong with good intentions? Most people are familiar with the proverb [aphorism?] that the road to hell is paved with good intentions. This has been explained as it is not enough to intend to do good things but one must actually do them.  Another has to do with possible unintended consequences after one acts on their good intentions. It seems that one can have good intentions for themselves as well as for others. So, it is considered bad if we have good intentions but never act on those intentions. This may be true for good intentions for ourselves but my concern is that good intentions for others may represent thinking we know what is best for others and by acting on these intentions end up taking over and making it harder for others to make decisions for themselves.  

I believe that we can't know what is best for other people because we are not them. People must take responsibility for themselves and make their own decisions. There seems to be no other way to live our lives.  Related to this, I have blogged a number of times about the importance of being supportive and encouraging towards others but to not tell others what to do or take over for them in any way, no mattter how good our intentions are. I believe that we must choose how we will live our lives and that this is easier if we are connected to others who are supportive and encouraging but respect our independence.  

What do you think?

Sunday
Mar172019

WHY DO AMPHETAMINES HELP PEOPLE WITH ADHD?

There has been a lot of concern expressed about amphetamines being prescribed for ADHD in children and adults. There is concern about addictions and dependence on these medications. It had been thought that these medications work by influencing neurotransmitters [serotonin, norepinephrine and dopamine]. These neurotransmitters are influenced by amphetamines. However, my patients have never responded to these medications as if they were amphetamines when they are helping them to focus. In fact, if my patients do respond to these medications as amphetamines [typically with increased energy, restlessness and irritability, appetite supression and difficulty falling asleep], they interfere with focusing and concentration and if they persist indicates a need to try another medication in the other group of medications for ADHD. When my patients respond to these amphetamine medications with improved focusing and concentraton, they are calmer, more alert, more able to complete tasks, less likely to finish tasks at the last minute and are less socially anxious. My patients who have problems with concentration [are ADHD], do not respond to these medications like they are amphetamines.

So why might that be the case. There is recent research suggesting that in people with ADHD, amphetamines influence the white matter [WM] portion of the brain that is deeper in the brain then the gray matter [GM] where our emotions, moods, anxiety, fears, etc., are. The WM is where the so called long tracks are located that function to connect different parts of the GM together and thus serve to help to coordinate brain activity and maintain stability, even when the emotions are activated. This location for concentration could serve to protect our ability to concentrate from the ups and downs of our emotional lives and preserve our ability to concentrate even if we are upset. This has not been demonstrated to occur in brains as it is difficult to see the WM with MRI's except by measuring the diffusional motion of water molecules using Diffusion Tensor Imaging [DTI] that assesses the micro-structural features of white matter studies that have found delays in brain white matter development in people with ADHD. This work has been added to by Bouziane, et.al. ADHD and maturation of brain white matter: A DTI study in medication naive children and adults" in Neuroimage Clin. 2018; 17: 53-59. who studied medication naive children and adults using DTI. They found that the WM of children with ADHD were the same as children without ADHD while adults with ADHD had reduced fractional anisotropy [FA] compared to adults without ADHD in several regions and the anterior thalamic radiation. FA is a normalized measure that quantifies the directional anisotropy of diffusion and is thought to reflect fiber density, axonal diameter and myelination in white matter. It is now thought that WM changes in people with ADHD occur in adults and not children. However, animal studies [van der Marel et al.Long-term treatment of adolescent and adult rats: differential effects on brain morphology and function. Neuropsychopharmacology; 2014;39:263-273] have shown that methylphenidate [a medication used to treat people with ADHD] in animals has upregulated the striatal genes that are involved in axonal myelination and thesse changes might be the changes seen in WM in people who are treated for their ADHD and thus supporting that these medications work in the WM part of the brian. 

So it seems that people with ADHD respond to amphetamine type medications with improved focus and concentration and not with responses that are typically associated with amphetamines. This would explain the benefit of these medications for people with ADHD and why they tolerate them without the problems that can be connected to taking amphetamines. In fact, research has repeatedly demonstrated that treating ADHD in young adolescents will reduce their risk of having an addiction. None of the thousands of people that I have treated with amphetamine type medicatons for ADHD have abused these medications.

Tuesday
Oct302018

IS LONELINESS AT THE HEART OF ADDICTION?

Recently I listened to a TED talk by Rachel Wurzman entitled: "How isolation fuels opioid addiction." She discribes her experience of having tics [Tourettes Disorder] that she calls "unvoluntary." Dr. Wurzman experiences her involuntary tics as unvoluntary meaning that she feels like she is doing the tic movement and not an external force. However, Dr. Wurzman recognizes that her tics are not related to her conscious intentions or attention. Dr. Wurzman then makes the point that we all have things that we do in healthy ways and other things that are not healthy and this can help us to understand what others are experiencing, including those with tic disorders and addiction. So, why is it important that we can understand each other? Dr. Wurzman goes on to talk about the opioid epidemic and it's connection to being lonely. She states that this epidemic is killing 91 people every day and it is getting worse. Dr. Wurzman understands that addiction is a medical, neurobiological problem and yet she feels that we can help people with addictions by changing how we respond to them. To change how we respond to people with addictions she feels that it is helpful if we understand how and why our brains cause behaviors like urges to use substances. Dr. Wurzman's research suggests that loneliness may be reinforcing the brains of addicts to seek comfort from substances as their striatum's are seeking things that have most frequently been associated with reducing their feelings of loneliness. These responses [seeking things] are like they are on autopilot, so that when there is a stimulus there is then a very rapid and automatic response from their brains. 

Importantly, according to Dr. Wurzman, feeling socially connected to others is part of what the striatum does. The experience of feeling pleasure in social interactions is modulated by opioid receptors in the striatum. If some one is experiencing intense loneliness the opioid receptors are sensitized so that anything that reduces this sense of loneliness, such as taking opioids, is intensely and very rapidly sought. Therefore, loneliness may keep people addicted and social connections may help people not be addicted. However, those social connections need to be strong enough to convince the striatum that it is safe to let go of the immediate and reliable relief that taking opioids [and other drugs] represents. Dr. Wurzman also believes that to establish powerful social connections, it is better to connect with each other not focused on one aspect of ourselves/others [like addictive behavors] but recognize how we all have unvoluntary or automatic type behaviors. This helps us to realize that we are connected to people who happen to have different unvoluntary or automatic type behaviors. 

After listening to Dr. Wurzman, I wondered about a connection between the social isolation experiences of people with addictions and those who suffer from Post Traumatic Stress Disorder [PTSD]. If so, then does the isolation theory apply to people who have PTSD? And how would this influence treatment of PTSD?

What do you think? 

Friday
Oct192018

WHAT CAN WE DO ABOUT SUICIDE?

Dr. Igor Galynker, who is the director of the Galynker Suicide Research Laboratory at the Icahn School of Medicine at Mount Sinai in NYC was quoted in Clinical Psychiatry News [Vol 46 No 8 August 2018] stating that "using suicidal ideation as a risk factor [for suicide] is flawed" as this will miss 75% of people who end up dying by suicide. He recommends using the patient's feeling entrapped and the clinicians own sense of the patient being at risk, instead. Dr. Galynker also noted that while hospitalizing suicidal patients can help them to feel more in control and mobilize support systems there is still a spike in suicides after hospitalization [250 x for women and 100 x for men]. Dr. Galynker also notes that according to the CDC, the suicide rate has been increasing since 2000 and has been increasing by 2% per year from 2006-2016. Additionally, Dr. Galynker also notes that suicide intent was disclosed by less than 25% of people who completed suicide. However, Dr. Galynker does see a benefit for safety planning such as limiting access to firearms, nets under bridges and smaller quantities of medications. He also mentions risk factors such as romantic rejection, terminal illness and humiliating failures in buisiness.

David Brent, M.D. in a paper entitled "Preventing Youth Suicide: Time to Ask How" in the Journal of the American Academy of Child Psychiatry.2010.09.017 identifies several risk factors for youth to become suicidal. These include: mood disorder, especially if linked with non-affective comorbidities [conduct disorder; substance abuse; etc.]; a previous suicide attempt, especially if the child is still depressed and suicidal; suicidal ideation combined with alcohol or substance abuse; other family members having been suicidal or completed suicide; family adversity such as abuse; and parental criticism for youth that are already self-critical [work by Wedig and Nock in the Journal of the American Academy of Child and Adolescent Psychiatry. 2007;46[9]:1171-1178 and in the same journal Nock. 2009;48:237-239].

Also, in the AACAP News [September/October 2018. Volume 49; Issue 5] Tracy Asamoah, M.D. writes about "Suicide in African Americans." She indicates that the rate for suicide in African American children had increased from ages 5-11 while it had decreased for white children [JAMA Pediatrics. 2012;169;673-677]. Also, the CDC Data and Statistics Fatal Injury Report for 2016 showed that while suicide rates for African American youth was less than that for white youth, the rate of increase in suicides was greater for African American youth. Primary factors for this include the under recognition of mental illness in these youth as problem behaviors are more likely to be punished versus treated, and the lack of resources for these youth in underserved communitieis.   

Wedig and Nock identified a risk factor and the possibility of an interventional approach to reduce the risk. Clearly reducing risk for suicide is important as well as efforts that focus on prevention of suicidal behaviors. Access to mental health treatment can reduce the risk of suicide. This will require that mental illness in African-American youth be recognized instead of seeing their behaviors as criminal and requiring punishment. In addition, access to preventative mental health services and screening tools can help reduce the suicidal behavior.  Unfortunately, these services are less available in underserved communities that have a higher percentage of African-American youth.

Finally, a study from 2016 [Walker R, et al. A Longitudinal Study of Racial Discrimination and Risk for Death Ideation in African American Youth. Suicide and Life-Threatening Behavior. 2016; 47: 86-102] found that experiencing racial discrimination was correlated with death ideation and depressive and anxiety symptoms. Therefore, it is important to be aware of the impact of racial discrimination and disenfranchisement on risk for suicidal thought and also on the access to mental health services. This highlights the critical role that supporting families and extended families and local communities as they will help to empower youth, who are at risk for suicidal behavior, to seek and make use of treatments.

What do you think?