Minding the Mind: Diagnosing Common Psychiatric Disorders

From Facing and Managing Change in Family Medicine, presented June 2008 by the Maryland Academy of Family Physicians

Educational Objectives

The goal of this program is to improve the diagnosis and management of major depression and adult attention-defi­cit/hyperactivity disorder (ADHD). After hearing and assimilating this program, the clinician will be better able to:

1.   Differentiate between major depression, demoralization, and dysthymia.

2.   List effects of major depression on medically ill patients.

3.   Select appropriate therapy for major depression.

4.   Distinguish adult ADHD from personality disorder.

5.   Prioritize treatment of comorbid diagnoses in patients with adult ADHD.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Treisman is on the Speakers’ Bureaus for Boehringer Ingelheim and Abbott Laboratories. Dr. Goodman has received research grants and/or honoraria from Cephalon, Forest Laboratories, Lilly, New River Pharmaceuticals, Novartis, Ortho-McNeil-Janssen Pharmaceuticals, Shire, and Wyeth. Dr. Goodman is also on the Speakers’ Bureau and/or is a consultant for: GlaxoSmith­Kline, Forest Laboratories, Lilly, New River Pharmaceuticals, Novartis, Ortho-McNeil-Janssen Pharmaceuticals, Shire, and Wyeth. The planning committee reported nothing to disclose.

Acknowledgments

Drs. Treisman and Goodman spoke in Cumberland, MD, on June 25, 2008, at the Maryland Academy of Family Physicians’ 2008 Annual Assembly, Facing and Managing Change in Family Medicine. The Audio-Digest Foundation thanks the speakers and the Maryland Academy of Family Physicians for their cooperation in the production of this program.

Differential Diagnosis of the Unhappy Patient

Glenn J. Treisman, MD, PhD, Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and Director, AIDS Psychiatry Services, Johns Hopkins Hospital, Baltimore, MD

Demoralization: disorder “everybody has”; one phase of overcoming psychologic insult (eg, romantic disappoint­ment); does not respond well to pharmacologic treatment; responds best to encouragement and support

Mood disorder: dysfunction of ascending mesolimbic dopaminergic reward circuit (mood regulator in brain); can present as sadness, feelings of emptiness, or crankiness; no feelings of joy; can be activated by stress of demoraliza­tion, leading to major depression

Dysthymia: may refer to mild (subsyndromal) major depression, chronic major depression, or patients with depres­sive personality (eg, “Eeyore” personality [“oh, it’s going to rain”]); patients usually not disordered by personality, until placed in certain conditions and circumstances; different from demoralization or mood disorder

Patient’s experiences and assumptions: life experiences lead to meaning, assumption, behavior, and more experi­ences; eg, patients may present with hostility under assumption (based on past experience) that established medical care not on their side; intervention that changes behavior, experiences, and assumptions improves function of pa­tient

Effect of paroxetine (Prozac): improves mood in patients with mood disorders with depression; some side effects useful (eg, can help with anxiety); most effective in patients with depression

Major depression: fourth greatest disease burden worldwide; in United States, second leading cause of disability from chronic illness; economic burden in 1990, $43 billion (mainly due to lost function [eg, absenteeism, decreased productivity] rather than treatment); 1 in 20 people have major depression; lifetime prevalence, »15%; peak onset, 20 to 40 yr of age; risk for recurrence high; 20% to 25% of patients have unremitting chronic depression; suicide in depression seventh leading cause of death in United States, third for young adults; 1 in 5 patients with depression commits suicide

Symptoms of major depression: low mood (feelings of sadness or flatness); low vital sense (feelings of illness), and low self-attitude (feelings of guilt or self-criticism); of limited usefulness for diagnosing depression in patients with physical illness, eg, cancer, hepatitis, AIDS; loss of ability to experience pleasure  — anhedonia; most sensitive and specific symptom in medically ill patients; patients feel hopeless and do not believe medications help; talk with pa­tients who have suicidal ideation and hospitalize those who cannot promise not to kill themselves; other signs and symptoms  —  early morning awakening; disrupted sleep; change in eating habits

Effect of depression on medically ill patients: decreased quality of life; decreased function; poor response to medi­cal treatment; increased morbidity; increased cost of care; increased consumption of resources; cycle  —  depression worsens physical illness and physical illness worsens depression; common in patients with chronic medical condi­tions; disability score  —  no illness, 4.6; major depression, 13; major depression plus second medical condition, 17; marital distress  — increases from 7.7% to 42.1% with diagnosis of major depression (decreases to 28.6% with di­agnosis of second major medical problem; spouses understand medical problems, but do not understand major de­pression); explaining major depression helpful

Major depression in primary care: affects 5% to 12% of patients; 34 studies found detection rate of major depres­sion, 33% (severe major depression, 75%); study found 34% of patients with known major depression received no treatment, 26% received benzodiazepine only, 50% received no treatment or benzodiazepine, and only 4% received therapeutic doses of antidepressant

Major depression in specific medical conditions: affects 5% to 15% of cancer patients (40%-50% of pancreatic cancer patients; cytokine-activating condition), »30% of patients with HIV, »20% of patients with coronary artery disease; £50% of patients with central nervous system (CNS) activating conditions  (eg, multiple sclerosis [MS]), but not amyotrophic lateral sclerosis ([ALS]; peripheral nerve disease); rates high in rheumatologic conditions; in­creases cardiac mortality by 3- to 4-fold, and death in patients with stroke by »50%

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs): SSRIs include fluoxetine (eg, Prozac), paroxetine (eg, Paxil), and sertraline (Zoloft); SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta); useful in chronic pain; easy to use; few drug interactions; well tolerated; side effects  —  agitation/activation; sexual dysfunction; feelings of flatness; paroxetine may cause weight gain; two-thirds of patients improve

Tricyclic antidepressants: inexpensive; help patients sleep; can cause weight gain; can stop diarrhea; useful in chronic pain disorders; monitor blood levels; doxepin (eg, Sinequan) more sedating than nortriptyline (eg, Pamelor) and desipramine (Norpramin; least sedating); doxepin useful for patients with insomnia

Atypical antidepressants: bupropion (eg, Wellbutrin)  —  fewest sexual side effects; most activating; trazodone  —  useful for insomnia and in patients refractory to other drugs; 500 to 600 mg/day required; mirtazapine (Remeron)  —  highly associated with weight gain (useful for patients with AIDS wasting syndrome); useful for chronic pain disorders; match drugs with patients (ie, “get the side effects to work for you”)

Considerations for refractory patients: wrong diagnosis; poor compliance with medications; underdosing  —  studies often use lowest possible dose that diverges from placebo at 8 to 12 wk; dose of fluoxetine approved by Food and Drug Administration (FDA), 20 mg/day (most patients need 40 mg/day to stay well); “if people start to slip on their medicines, push the dose”; check therapeutic levels of tricyclic antidepressants; patients often relapse

Personality disorders: extroverts  —  focus on “now” feelings and rewards; dramatic; histrionic; excitable; hypochon­driacal; intrusive; personality not affected by antidepressant; diagnosis of depression often missed because of per­sonality disorder; treatment of underlying depression can reduce intrusiveness of personality problem; introverts  —  ruminative; worried; similar to obsessive-compulsive disorder; clingy; whiny; hypochondriacal; depression  —  intensifies characteristics of both personality types

Diagnosis of Adult ADHD

David W. Goodman, MD, Assistant Professor, Department of Psychiatry and Behavioral Sciences, Johns Hop­kins University School of Medicine, and Director, Adult Attention Deficit Disorder Center of Maryland, Johns Hopkins Health Care and Surgery Center at Green Spring Station, Baltimore

Introduction: increasing awareness of attention-deficit/hyperactivity disorder (ADHD) in adults; in contrast to major depression or affective disorders, ADHD in adults remains controversial; symptom checklists for screening helpful in identifying red flags for further evaluation but not for making diagnosis

Prevalence in United States: ADHD in children, 8%; »50% of children with ADHD followed prospectively for 10 to 20 yr continue to have impairing symptoms at age 18 yr; ADHD in adults, 4.4% (9-10 million adults); »60% of children with ADHD treated in last year, 15% of adults with ADHD

Risk factors for ADHD: genetics  —  ADHD highly heritable; not function of bad parenting, bad character, or person­ality disorder; likely to continue in adulthood in child with ADHD who has father with ADHD; if father had ADHD as child but “grew out of it,” so will his child; psychosocial adversity  —  more chaotic and tumultuous environment increases likelihood of persistence of ADHD symptoms; psychiatric comorbidity  —  comorbid oppositional defiant disorder (ODD) or anxiety disorder increases likelihood of ADHD in adulthood

Screening for adult ADHD: ask, 1) were you ever diagnosed with ADHD as a child? 2) do you have a child who has been diagnosed with ADHD? 3) do you have chronic long-standing difficulty with focus, concentration, disorgani­zation, getting things done, follow-through, and consistency? follow up if patient answers yes to any of these

Risks associated with ADHD: 2-fold higher risk for tobacco smoking in children 12 yr of age; children with ADHD who smoke have 2-fold higher risk for substance abuse, compared to children with ADHD who do not smoke; 2-fold higher risk for substance abuse in children 13 yr of age; increase in sexual activity in adolescents 15 yr of age; 20-yr follow-up study saw higher risk (10-fold) for pregnancy, sexually transmitted diseases, multiple sex partners, unplanned pregnancy, and less use of contraception; discuss risk factors with parents and adolescents; ADHD asso­ciated with driving risks (educate parents about importance of medications [eg, “no meds, no keys”]); higher likeli­hood of dropping out of high school or college

Diagnostic criteria: core symptoms include inattention, hyperactivity, and impulsivity; before ascribing motivational or personality factors to symptoms, consider ADHD; chronic disorganization (eg, taking longer than others to ac­complish tasks); forgetfulness (eg, losing or misplacing things); poor perception of passage of time (eg, always run­ning late); unable to sit through meeting without getting up; easily frustrated; highly talkative; symptoms may be mistaken for personality disorder

Screening: ask questions specific to adult situation, eg, “do you have difficulty staying on task when it requires sus­tained effort over extended period of time?”; ask language- and context-specific questions, eg, “do you have diffi­culty focusing and concentrating on a task that requires focus for an extended period of time and which is otherwise boring?”; identify compensatory mechanisms (eg, patient able to sit through meeting by doodling or looking through day planner); compensation mechanisms break down when demands of environment (eg, entering college, promotion at work) exceed patient’s ability to compensate; ADHD is clinical diagnosis (no neuropsychologic test available)

Executive function: involves organization, prioritizing, strategizing, and working memory (ie, ability to hold infor­mation in head while manipulating other factors); occurs »35% of time in ADHD; defined by neuropsychologic testing (ADHD defined by clinical presentation); recognize executive dysfunction as separate from ADHD to re­duce risk of unnecessarily ramping up patient’s medication to control organization (executive dysfunction does not respond to pharmacologic intervention); behavioral intervention needed

Significance of childhood ADHD: “no such thing as adult-onset ADHD”; combined-type ADHD more likely to be diagnosed at 5 to 13 yr of age; disruptive behavior more common in boys and men; inattentive-type ADHD typi­cally not diagnosed until academic demands or ability to function in life compromised and impaired; ADHD chronic and unchanging (may worsen and fluctuate, depending on stressors or other acute psychiatric conditions)

Evaluation process: ADHD Adult Self-Report Scale (ASRS)  —standardized; available online; sponsored by World Health Organization; can be used at baseline to qualify and quantify target symptoms after ADHD diagnosis made; can be used as treatment evolves to assess movement of symptoms; complementary to clinical interview; look for symptoms that fulfill criteria, such as chronic and persistent course since childhood, positive family history (partic­ularly first-degree family member with ADHD), and other psychiatric and medical conditions (eg, obstructive sleep apnea)

Comorbid psychiatric conditions: 1 in 10 patients with major depression has ADHD; 1 in 5 patients with bipolar disorder has ADHD; mood disorders typically start in late adolescence and early adulthood (ADHD starts in child­hood; consider onset of symptoms); ask about comorbidities (eg, substance abuse, generalized anxiety disorder) to prioritize treatment; social anxiety common; anxiety disorders generally start in childhood and persist; prioritizing treatment  —  treat alcohol and substance abuse first, followed by severe mood disorder and severe anxiety disorders; ADHD treated last because cognitive impairments seen in ADHD can be produced by aforementioned untreated di­agnoses; stimulant medications used to treat ADHD can worsen untreated comorbidities

Approved medications for adults: atomoxetine (Strattera; nonstimulant); dexmethylphenidate (Focalin XR); lisdex­amfetamine (Vyvanse; prodrug; recently approved for adults); mixed amphetamine salts (eg, amphetamine and dextroamphetamine [Adderall]); methylphenidate (eg, Concerta); mixed amphetamine salts study  —consider pa­tients treated in trial studies screened for candidacy with, eg, exclusion criteria; saw 6-point decrease on ADHD-Rating Scale (ADHD-RS) with use of placebo; saw 12- to 14-point drop with doses of 20, 40, and 60 mg of mixed amphetamine salts (FDA-approved recommended dose for adults, 20 mg/day; no statistical separation between doses; does not indicate “people who didn’t respond to 20 mg, wouldn’t respond to 40 mg”); dexmethylphenidate extended-release study  — 7-point drop on ADHD-RS seen with placebo; statistically significant and clinically rele­vant decreases in ADHD-RS points seen with doses of 20, 30, and 40 mg/day; recommended dose of Focalin XR for adults, 20 mg/day; atomoxetine trials  —  used Conners’ Adult Attention-Deficit Rating Scale; saw 3.5- to 4.0-point improvement (statistically significant and clinically relevant); lisdexamfetamine study  —  saw 8-point reduc­tion on ADHD-RS scale with placebo; large reductions in ADHD symptoms seen with 30, 50, and 70 mg/day; ac­cording to Amsterdam study, 45% reduction in ADHD-RS score required for functional improvement; study on methyphenidate saw 4-point improvement; consider that methodologic differences of studies can affect outcomes of trials

Use of medications: short-acting stimulant medications often sought by patients for misuse or abuse; consider start­ing patients on long-acting stimulant medication or nonstimulant medication; do not submit to patient’s request of, “I only want to take it when I feel I need it”; compliance rate at 9 mo, 15% to 20%

Safety concerns: cardiac risk  —  guidelines published by American Heart Association (AHA) recommended that children and adolescents considered for or taking stimulants should undergo electrocardiography (ECG; evaluated by physician with pediatric cardiologic experience) retracted after 3 wk; with acknowledgment from American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry, AHA stated that psychostimu­lants do not cause sudden death and ECGs should be considered in clinical situations when warranted by child’s physician; check vital signs routinely; refer for cardiac screening when warranted; cardiac abnormalities associated with sudden cardiac death highly genetic; ask about spontaneous syncope, exercise-induced syncope or chest pain, and sudden death in family members £35 yr of age (if yes, perform cardiac screening of entire family), and history of electrical or structural abnormalities; pregnancy and breastfeeding  —  psychostimulants and atomoxetine cate­gory C (contraindicated in pregnancy); amphetamines and methylphenidate detectable in breast milk (contraindi­cated in breast-feeding); other concerns  —  assess medications and address compliance at each session to reduce, eg, driving risk

Suggested Reading

Berger S et al: Sudden cardiac death in children and adolescents: introduction and overview. Pediatr Clin North Am 51:1201, 2004; Conners CK: Rating scales in attention-deficit/hyperactivity disorder: use in assessment and treatment monitoring. J Clin Psychiatry 59 Suppl 7:24, 1998; Faraone SV et al: A prospective four-year follow-up study of children at risk for ADHD: psychi­atric, neuropsychological, and psychosocial outcome. J Am Acad Child Adolesc Psychiatry 35:1449, 1996; Goodman DW et al: An interim analysis of the Quality of Life, Effectiveness, Safety, and Tolerability (QU.E.S.T.) evaluation of mixed amphetamine salts extended release in adults with ADHD. CNS Spectr 10:26, 2005; Katon W et al: Epidemiology of depression in primary care. Gen Hospital Psychiatry 14:237, 1992; Kessler RC et al: Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication. Biol Psychiatry 57:1442, 2005; Kessler RC et al: The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replica­tion. Am J Psychiatry 163:716, 2006; Koenig HG et al: Dosing recommendations and prescribing patterns for depressed medi­cally ill hospitalized older patients. J Am Geriatr Soc 45:1409, 1997; Lahey BB et al: DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Am J Psychiatry 151:1673, 1994; Michelson D et al: Atomoxetine in adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 53:112, 2003; Olfson M et al: Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry 154:1734, 1997; Schwenk TL et al: Differences be­tween detected and undetected patients in primary care and depressed psychiatric patients. Gen Hosp Psychiatry 18:407, 1996; Spencer TJ et al: Efficacy and safety of dexmethylphenidate extended-release capsules in adults with attention-deficit/hyperac­tivity disorder. Biol Psychiatry 61:1380, 2007; Weisler RH et al: Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 11:625, 2006.