1: Appl Neuropsychol. 2005;12(2):77-82.
Incidence of ADHD in adults with severe mental health problems.
Kennemer K, Goldstein S.
Neurology, Learning and Behavior Center, Salt Lake City, Utah 84102-2015, USA.
The purpose of this study was to determine the prevalence rates of attention
deficit hyperactivity disorder (ADHD) and comorbid disorders in an adult
inpatient psychiatric setting. Patient charts were reviewed from a state
hospital in the western United States. Of the 292 persons served in 2002, only 6
received a diagnosis of ADHD. Of these patients, 2 received additional diagnoses
for Major Depression, 1 for General Anxiety and 1 for Bipolar Disorder. Five of
the 6 ADHD participants had a history of substance abuse and 4 were diagnosed
with Personality Disorders. None of the 6 diagnosed with ADHD received a
diagnosis of Learning Disability. A variety of nonstimulant medications were
utilized to treat these patients. Characteristics of adult psychiatric
populations are reviewed. Prevalence, comorbidity and implications for future
research regarding adult ADHD are discussed.
PMID: 16083396 [PubMed - indexed for MEDLINE]
2: Pharmacoeconomics. 2005;23(1):93-102.
Comorbidities and costs of adult patients diagnosed with attention-deficit
hyperactivity disorder.
Secnik K, Swensen A, Lage MJ.
Lilly Research Laboratories, Indianapolis, Indiana, USA.
INTRODUCTION: The purpose of this retrospective study was to examine the
prevalence of comorbidities, resource use, direct medical costs, and the costs
associated with missed work for adults diagnosed with attention-deficit
hyperactivity disorder (ADHD). STUDY DESIGN: From a large claims database that
captures inpatient, outpatient and prescription drug services, individuals
diagnosed with ADHD between the years 1999 and 2001 were retrospectively
identified. The ADHD cohort (n = 2252) were matched with a non-ADHD cohort (n =
2252) on a 1 : 1 ratio, based upon age, gender, metropolitan statistical area
and type of insurance coverage. The ADHD cohort was compared with the non-ADHD
cohort for differences in comorbidities and direct medical costs (inpatient,
outpatient and prescription drug costs) using year 2001 prices. Using data from
six Fortune 200 employers, time missed from work and costs associated with
absenteeism, short-term disability and worker's compensation was examined for a
subsample (n = 354) of the employees diagnosed with ADHD. Chi-square and
t-statistics were used to compare the ADHD population with the control group
with regards to comorbidites and service use. Analysis of covariance and
multivariate regressions were used to examine differences in days missed from
work, direct medical costs and costs associated with missed work. RESULTS:
Adults diagnosed with ADHD were significantly more likely to have a comorbid
diagnosis of asthma (p = 0.0014), anxiety (p < 0.0001), bipolar disorder (p <
0.0001), depression (p < 0.0001), drug or alcohol abuse (p < 0.0001), antisocial
disorder (p = 0.0081) or oppositional disorder (p = 0.0022) compared with the
control group. Controlling for the impact of comorbidities, adults diagnosed
with ADHD had significantly higher outpatient costs (USD 3009 vs USD 1492; p <
0.0001), inpatient costs (USD 1259 vs USD 514; p < 0.0001), prescription drug
costs (USD 1673 vs USD 1008; p < 0.0001), and total medical costs (USD 5651 vs
USD 2771; p < 0.0001) compared with the non-ADHD cohort. Employees diagnosed
with ADHD missed significantly more days due to 'unofficial' absences (4.33 days
vs 1.13 days; p < 0.0001). CONCLUSIONS: The results demonstrate that adults
diagnosed with ADHD have a higher prevalence of comorbidities, higher medical
costs and more absences than matched individuals without ADHD. These findings
suggest that there may be an opportunity for the effective treatment of ADHD to
lead to cost-offsets.
PMID: 15693731 [PubMed - indexed for MEDLINE]
3: J Clin Psychiatry. 2003 Oct;64(10):1170-6; quiz, 1274-6.
Occult mood disorders in 104 consecutively presenting children referred for the
treatment of attention-deficit/hyperactivity disorder in a community mental
health clinic.
Dilsaver SC, Henderson-Fuller S, Akiskal HS.
Rio Grande City Texas Community Mental Health Mental Retardation Clinic, Rio
Grande City, TX, USA. StevenDilsaver@aol.com
OBJECTIVE: To ascertain the prevalence of mood disorders among consecutively
evaluated prepubertal children presenting for the treatment of
attention-deficit/hyperactivity disorder (ADHD) in a community mental health
clinic. METHOD: 104 children received systematic assessments designed to
identify individuals meeting the DSM-IV criteria for major depressive disorder
(MDD), mania, and ADHD. "Standard" and "modified" criteria for mania were
employed. Modified criteria, in an effort to minimize false-positive diagnoses
of mania, required the presence of euphoria and/or flight of ideas. A child
meeting the criteria for MDD or either set of criteria for mania was categorized
as having a mood disorder. Mood disorders in first-degree relatives were
assessed using a systematic interview. Data were gathered from 2000 to 2002.
RESULTS: Sixty-two children (59.6%) had a mood disorder. Compared with those who
did not have a mood disorder, they were 3.3 times more likely (54.8% vs. 16.7%)
to have a family history of any affective disorder (p <.0001) and 18.3 times
more likely (43.5% vs. 2.4%) to have a family history of bipolar disorder (p
<.0001). Twenty (32.3%) of the children with and none without a mood disorder
had psychotic features (p <.0001). Compared with those meeting only the standard
criteria for mania, those meeting the modified criteria were 9.1 times more
likely (69.8% vs. 7.7%) to have a family history of an affective disorder (p
<.0001) and 7.3 times more likely (55.8% vs. 7.7%) to have a family history of
bipolar disorder (p =.002). CONCLUSION: Children who presumably have ADHD often
have unrecognized affective illness. Our findings support the view that children
meeting the modified criteria for mania have veritable bipolar disorder. These
findings, which were derived in the course of delivering routine clinical
services in a community mental health clinic, are consistent with those obtained
in research settings suggesting that children presenting with ADHD often have
occult mood disorders, especially unrecognized bipolarity. We suggest that
clinicians encountering children with prominent features of ADHD inquire about
the presence of euphoria and flight of ideas. We submit that the presence of
these "classic" manifestations of mania strongly suggests the presence of occult
bipolarity, even if course of illness otherwise markedly deviates from "classic"
descriptions.
PMID: 14658964 [PubMed - indexed for MEDLINE]
4: Bipolar Disord. 2003 Jun;5(3):217-25.
Erratum in:
Bipolar Disord. 2003 Aug;5(4):307.
Combination treatment in bipolar disorder: a review of controlled trials.
Zarate CA Jr, Quiroz JA.
The Mood and Anxiety Disorders Program, National Institute of Mental Health,
Bethesda, MD 20892, USA. zaratec@intra.nimh.nih.gov
OBJECTIVES: Monotherapy is often inadequate and combination drug regimens have
become the norm for the treatment of bipolar disorder. Virtually all classes of
psychotropic drugs have been used in bipolar disorder in combination for a
variety of indications. This article reviews the available published data from
controlled, blinded studies regarding combination treatments in the different
treatment phases of bipolar disorder. METHODS: Articles for this review were
obtained from a search of the Medline database (1966-2002), using the following
keywords and phrases: add-on, antipsychotic, anticonvulsant, antidepressant,
combination treatment, lithium, neuroleptic, and polypharmacy. The search was
augmented by data presented at scientific meetings. Data included in this
article were only from controlled studies that evaluated combinations of two or
more agents. RESULTS: For acute mania, the most useful combination treatments as
determined by controlled studies, appear to be an antipsychotic drug with a
mood-stabilizer. The combination of lithium and valproate, even though widely
used for acute mania, is lacking in controlled data. For acute bipolar
depression, the controlled combination studies reviewed fail to show clear
advantages in efficacy of an antidepressant with a mood-stabilizer versus two
stabilizers or a mood-stabilizer alone. Large, controlled, randomized, long-term
studies with modern antidepressants are not available. Controlled combination
studies of mood-stabilizers suggest gains in efficacy over monotherapy in the
long-term treatment of bipolar disorder. CONCLUSIONS: Controlled combination
studies in bipolar disorder are uncommon. Increased attention should be given to
study combination treatments in all phases of bipolar illness to determine the
most efficacious and safest combinations.
Publication Types:
Review
PMID: 12780875 [PubMed - indexed for MEDLINE]
5: Curr Psychiatry Rep. 2002 Apr;4(2):146-52.
Familial links between attention deficit hyperactivity disorder, conduct
disorder, and bipolar disorder.
Doyle AE, Faraone SV.
Massachusetts General Hospital, 15 Parkman Street, ACC-725, Boston, MA 02114,
USA. doylea@helix.mgh.harvard.edu
Although family, twin, and adoption studies indicate that attention deficit
hyperactivity disorder (ADHD) is a familial condition with a robust genetic
component, molecular genetic studies of candidate genes have produced
inconsistent findings. One of the challenges to elucidating the genetic
architecture of ADHD is its potential genetic heterogeneity. Therefore, efforts
are needed to identify etiologically homogeneous subgroups of subjects with ADHD
for use in genetic studies. The current article reviews evidence suggesting that
parsing ADHD subjects based on comorbidity with conduct and bipolar disorders
may yield familial subtypes that are suitable for genetic analyses.
Publication Types:
Review
PMID: 11914177 [PubMed - indexed for MEDLINE]
6: J Child Adolesc Psychopharmacol. 2002 Spring;12(1):11-25.
DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder
phenotype compared to attention-deficit hyperactive and normal controls.
Geller B, Zimerman B, Williams M, Delbello MP, Bolhofner K, Craney JL, Frazier
J, Beringer L, Nickelsburg MJ.
Department of Psychiatry, Washington University School of Medicine, St Louis,
Missouri 63110, USA. gellerb@medicine.wustl.edu
OBJECTIVE: To compare the prevalence of Diagnostic and Statistical Manual of
Mental Disorders, 4th edition (DSM-IV) mania symptoms in a prepubertal and early
adolescent bipolar disorder phenotype (PEA-BP) to those with attention deficit
hyperactivity disorder (ADHD) and normal community controls (CC). METHODS: To
optimize generalizeability, subjects with PEA-BP and ADHD were consecutively
ascertained from outpatient pediatric and psychiatric sites, and CC subjects
were obtained from a random survey. All 268 subjects (93 with PEA-BP, 81 with
ADHD, and 94 CC) received comprehensive, blind, baseline research assessments of
mothers about their children and of children about themselves. PEA-BP was
defined by DSM-IV mania with elation and/or grandiosity as one criterion to
ensure that subjects had one of the two cardinal symptoms of mania and to avoid
diagnosing mania only by criteria that overlapped with those for ADHD. RESULTS:
Five symptoms (i.e., elation, grandiosity, flight of ideas/racing thoughts,
decreased need for sleep, and hypersexuality) provided the best discrimination
of PEA-BP subjects from ADHD and CC controls. These five symptoms are also
mania-specific in DSM-IV (i.e., they do not overlap with DSM-IV symptoms for
ADHD). Irritability, hyperactivity, accelerated speech, and distractibility were
very frequent in both PEA-BP and ADHD groups and therefore were not useful for
differential diagnosis. Concurrent elation and irritability occurred in 87.1% of
subjects with PEA-BP. Data on suicidality, psychosis, mixed mania, and
continuous rapid cycling were also provided. CONCLUSION: Unlike late
teenage/adult onset bipolar disorder, even subjects with PEA-BP selected for
DSM-IV mania with cardinal symptoms have high rates of comorbid DSM-IV ADHD.
High rates of concurrent elation and irritability were similar to those in adult
mania.
Publication Types:
Clinical Trial
Controlled Clinical Trial
PMID: 12014591 [PubMed - indexed for MEDLINE]
7: Bipolar Disord. 2001 Dec;3(6):325-34.
Review of studies of child and adolescent offspring of bipolar parents.
DelBello MP, Geller B.
Bipolar and Psychotic Disorders Research Program, Department of Psychiatry,
University of Cincinnati College of Medicine, OH 45267-0559, USA.
delbelmp@email.uc.edu
OBJECTIVE: The authors reviewed studies of child and adolescent offspring of
bipolar (BP) parents. Findings from these studies are critically discussed with
respect to methodological issues that can inform future designs. METHODS: A
Medline search was performed to identify studies that examined child and
adolescent offspring of BP parents. Publications were excluded if they did not
separate offspring of BP parents from offspring of major depressive disorder or
schizoaffective parents ("affective offspring") or did not separately analyze
data from child- and adolescent-age versus adult offspring. RESULTS: Seventeen
studies fit these review criteria. Rates of mood disorders in child and
adolescent offspring of BP parents ranged from 5 to 67% compared with rates in
offspring of healthy volunteers of 0-38%. Rates of non-mood disordered
psychopathology ranged from 5 to 52% in offspring of BP parents and from 0 to
25% in offspring of healthy volunteers. Rates of mood disorders and of other
psychopathology were increased in offspring of BP parents compared with
offspring of healthy volunteers in all of the eight studies that included a
comparison group of offspring of healthy volunteers. CONCLUSIONS: Studies
suggest that children (< or =21 years) of BP parents are at increased risk for
developing mood and other disorders (e.g., disruptive, anxiety). Therefore,
additional investigations are clearly warranted. In the context of current
research on diagnosis, assessment, longitudinal course and comorbidity of
childhood mania, the following suggestions for the design of future studies
should be considered: 1) Phenotypic specification of bipolar manifestations
(e.g., BP-I, BP-II, BP-NOS) in child/adolescent offspring and in bipolar parents
themselves. 2) Control groups that are pediatric-age relevant and thus include
attention-deficit hyperactivity disorder. 3) Assessments that include items for
prepubertal mania and for onsets and offsets of all occurrences of symptoms and
of environmental factors (e.g., life events) in offspring and in parents so that
trajectories of overlap and sequence between child and parental mania can be
investigated. 4) These detailed onsets and offsets of symptoms are also
necessary to investigate prodromal manifestations of mania in the offspring. 5)
Unaffected offspring present a unique opportunity to study pre- and postmorbid
cognitive and physiological endophenotypes and structural and functional brain
abnormalities. Findings from offspring studies will be crucial to inform
research on the development of early intervention and prevention strategies.
Publication Types:
Review
PMID: 11843782 [PubMed - indexed for MEDLINE]
8: J Affect Disord. 2001 Dec;67(1-3):159-65.
Measures of attention and hyperactivity symptoms in a high-risk sample of
children of bipolar parents.
Duffy A, Grof P, Kutcher S, Robertson C, Alda M.
Dalhousie University, Department of Psychiatry, Halifax, Nova Scotia, Canada.
BACKGROUND: To determine whether significant symptoms of inattention were
present among the offspring of well-characterized bipolar parents. METHODS: We
included 53 offspring of 30 parents meeting DSM-IV criteria for bipolar disorder
diagnosed by consensus on the basis of a SADS-L interview and a wealth of
longitudinal clinical data. The unaffected parent had no lifetime history of a
major psychiatric illness. Offspring, prospectively followed for up to 5 years,
completed psychometric measures of attention and mood when judged to be at a
good level of functioning (well, remitted or treated). RESULTS: Those offspring
with any lifetime psychiatric diagnosis endorsed more subjective problems with
attention. However, there was no measurable difference on tasks of sustained
attention between those with and those without a lifetime psychiatric illness
including affective disorder. There was a significant association between
self-reported symptoms of depression and inattention, but no association between
either self-report measure and an objective measure of sustained attention.
LIMITATIONS: This study was not intended to be a comprehensive
neuropsychological investigation of at risk offspring. CONCLUSIONS: In this
high-risk population, subjective difficulty with attention appeared to be
state-dependent, associated with the degree of subjective distress related to an
underlying psychiatric illness.
PMID: 11869763 [PubMed - indexed for MEDLINE]
9: J Child Adolesc Psychopharmacol. 2001 Fall;11(3):301-9.
Gabapentin and methylphenidate treatment of a preadolescent with attention
deficit hyperactivity disorder and bipolar disorder.
Hamrin V, Bailey K.
Yale University, School of Nursing, New Haven, Connecticut 06510, USA.
Gabapentin is an anticonvulsant drug released in the United States in 1993 for
use as adjunctive therapy in refractory partial epilepsy. The mechanism of
action of gabapentin is unknown, but the drug has very favorable
pharmacokinetics and a good safety profile, which allows its use in high-risk
patients. Several reports have described the successful use of gabapentin for
bipolar disorders in adults, but there are no controlled studies in the use of
gabapentin in children and adolescents. We describe a 12-year-old boy with a
history of attention deficient hyperactivity disorder (ADHD), reading disorder,
mixed receptive and expressive language disorder, encopresis, and bipolar
disorder II who was treated with gabapentin 200 mg/day added to methylphenidate
30 mg/day. Within 3 weeks the improvement and stabilization of mood symptoms was
remarkable, as noted by mother, teacher, and clinician, and remained so for 6
months of follow-up. Comorbid bipolar disorder and ADHD is a hotly debated topic
in the child and adolescent psychiatric literature, with rates of comorbid ADHD
and bipolar disorder ranging from 22% to 90%. Controlled studies are needed to
evaluate the possible antimanic mood stabilizing and/or antidepressant
properties or gabapentin in youths.
Publication Types:
Case Reports
PMID: 11642481 [PubMed - indexed for MEDLINE]
10: J Neuropsychiatry Clin Neurosci. 2001 Summer;13(3):385-95.
Impairments of attention and effort among patients with major affective
disorders.
Cohen R, Lohr I, Paul R, Boland R.
Department of Psychiatry and Human Behavior, Brown University School of
Medicine, Miriam Hospital, Providence, Rhode Island 02906, USA. rac@brown.edu
Impairments of attention are common among people with major affective disorders,
yet the influence of effortful task demands on attentional performance in
unipolar and bipolar illness has been little studied. The authors compared
psychiatric inpatients with primary diagnoses of unipolar or bipolar affective
disorder (n=27) and age-matched normal control subjects (n=20) on a battery of
eight neuropsychological tasks designed to measure different attentional
functions. There were low-effort and high-effort versions of each task.
Significant group differences were consistently observed on tasks demanding
sustained and focused attention, but not on tasks requiring visual selective
attention. Although affective disorder patients showed impairments on most tasks
regardless of level of task effort, group differences were greatest on
high-effort conditions. Results indicate that patients with major affective
disorders show significant attentional impairments on most measures of effortful
attention, and the magnitude of these impairments increases as the effortful
demands of the task increase.
PMID: 11514646 [PubMed - indexed for MEDLINE]
11: J Paediatr Child Health. 1999 Apr;35(2):199-203.
Confirmation that Child Behavior Checklist clinical scales discriminate juvenile
mania from attention deficit hyperactivity disorder.
Hazell PL, Lewin TJ, Carr VJ.
Child and Youth Mental Health Service, Wallsend Hospital, NSW, Australia.
hazell@mail.newcastle.edu.au
OBJECTIVE: To determine whether boys meeting diagnostic criteria for juvenile
mania and attention deficit hyperactivity disorder (mania-ADHD) may be
distinguished from boys with ADHD alone on a range of clinical and family
variables. METHODOLOGY: Boys aged 9-13 years with mania-ADHD (n = 25), ADHD
alone (n = 99), or no psychiatric diagnosis (n = 27) were compared on parent and
teacher report Child Behavior Checklists (CBCL) and Conners Questionnaires,
self-report CBCLs, patterns of comorbidity, intellectual functioning, and family
variables. RESULTS: Mania-ADHD subjects had significantly higher mean ratings
than ADHD only subjects on the parent CBCL for the Withdrawn, Thought Problems,
Delinquent Behavior and Aggressive Behavior scales and significantly higher
rates of comorbid depression, anxiety and psychotic symptoms. Other variables
did not distinguish the mania-ADHD and ADHD only groups. CONCLUSIONS: These data
confirm previous research indicating that the CBCL may be used to assist in the
clinical identification of manic children.
Publication Types:
Clinical Trial
Controlled Clinical Trial
PMID: 10365361 [PubMed - indexed for MEDLINE]
12: J Child Adolesc Psychopharmacol. 1999;9(4):247-56.
Systematic chart review of the pharmacologic treatment of comorbid attention
deficit hyperactivity disorder in youth with bipolar disorder.
Biederman J, Mick E, Prince J, Bostic JQ, Wilens TE, Spencer T, Wozniak J,
Faraone SV.
Pediatric Psychopharmacology Unit of the Child Psychiatry Service, Massachusetts
General Hospital, Boston, USA. biederman@helix.mgh.harvard.edu
The objective of this study was to evaluate pharmacological approaches for
attention deficit hyperactivity disorder (ADHD) in children with bioplar
disorder and comorbid ADHD. The medical charts of 38 patients with diagnoses of
both Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised
ADHD and bipolar disorder were reviewed over multiple visits to assess
improvement and prescription patterns. Logistic regression was used to model the
probability of improvement at each visit, and robust standard errors were
estimated in order to account for correlation among individuals using Huber's
correction for clustered data. The proportion of visits at which ADHD symptoms
were rated as improved following initial improvement in manic symptoms was 7.5
times greater than before initial improvement of manic symptoms. The recurrence
of manic symptoms following their initial stabilization significantly inhibited
ADHD response to medication. Although tricyclic antidepressants (TCAs)
significantly increased the probability of ADHD improvement following mood
stabilization, there was also a significant association between treatment with
TCAs and relapse of manic symptoms. Our results support the hypothesis that mood
stabilization is a prerequisite for the successful pharmacologic treatment of
ADHD in children with both ADHD and manic symptoms. Although TCAs can be helpful
in the management of ADHD children with manic symptoms, these drugs should be
used with caution since they can also have a destabilizing effect on manic
symptoms.
Publication Types:
Case Reports
PMID: 10630454 [PubMed - indexed for MEDLINE]
13: Psychiatr Clin North Am. 1998 Dec;21(4):917-26, viii.
Frequently missed diagnoses in adolescent psychiatry.
Berenson CK.
Department of Psychiatry, University of New Mexico Health Science Center,
Albuquerque, USA.
Symptom overlap, comorbidity, disagreement among informants, and the impact of
development complicate psychiatric diagnoses in the adolescent patient. This
review of frequently missed diagnoses includes anxiety disorders, ADD without
hyperactivity, early-onset bipolar disorder, syndromes associated with trauma,
and substance abuse.
Publication Types:
Review
PMID: 9890130 [PubMed - indexed for MEDLINE]
