Practical Psychopharmacology

Basic to Advanced Principles

Thomas L. Schwartz

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317449683
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Practical Psychopharmacology takes the novel approach of writing at three different levels—beginning, intermediate, and advanced—to give the practicing psychopharmacologist a tailored experience. Each chapter focuses on a specific DSM-5 disorder and outlines abbreviated treatment guidelines to help the reader understand where their knowledge base and clinical practice currently resides. At the first level, the book teaches novice prescribers practical diagnostic skills and provides a brief overview of pertinent genetic and neuroimaging findings to increase prescribing confidence. Next, it provides mid-level clinicians with intermediate techniques and guidelines for more difficult cases. The final level provides nuanced guidance for advanced practitioners or those who see the most treatment-resistant patients. This approach allows a clinician to access this book periodically throughout the care of an individual patient and to gradually progress through a series of more advanced psychopharmacological techniques for making accurate and efficient diagnoses. Readers can also visit the book's eResource page to download a bonus chapter on eating disorders as well as case studies and multiple-choice questions for each chapter.

Chapter 1
Adult Attention Deficit-Hyperactivity Disorder

Section 1 Basic Prescribing Practices

Essential Concepts

• ADHD is a heritable illness that is clinically diagnosed with a persistent longitudinal pattern of
  • inattention and/or
  • hyperactivity-impulsivity
• Diagnosis should be based on careful history demonstrating impaired functioning in multiple settings (school, home, community) starting before the age of 12.
• Comorbid learning disability and other psychiatric disorders are common in adults.
• Pharmacotherapy is the centerpiece to ADHD treatment.
• First line medications are often stimulants.
• Second line medications are alpha-2 agonists and possibly certain anti-depressants.
• Consider using rating scales at baseline and during follow-up sessions.

Phenomenology, Diagnosis, Clinical Interviewing

For any new practitioner in any field, the goal is to be able to make an accurate diagnosis. All of psychiatric prescribing at this beginning level is based on regulatory findings, approvals, and indications that are psychiatric disorder specific. Psychotropics will only deliver the outcomes promised if the patient at hand actually has been accurately identified as having adult ADHD. Inattention, poor concentration, and impaired vigilance are all symptoms that are not unique to adult ADHD. These symptoms are also prevalent in major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). This can make diagnosis complicated but also should alert the reader that one psychotropic may be able to improve inattention regardless of which categorical psychiatric disorder the inattention is being attributed to. Sometimes an antidepressant, like bupropion (Wellbutrin XL/Aplenzin), can treat adult ADHD. Alternatively, an ADHD medication like lisdexamfetamine (Vyvanse) can treat non-ADHD conditions (binge eating disorder [BED]). As this chapter progresses to discuss intermediate and advanced psychopharmacologic prescribing, the use of off-label, less well-studied approaches becomes more apparent. Prescribers need to appreciate that certain discrete psychiatric symptoms can cross the apparent boundaries of categorical diagnostic and regulatory processes. Understanding and appreciating this concept is often needed to treat the more treatment resistant or comorbidly afflicted patient.

Commonly, ADHD in adults is confounded by other psychiatric disorders such as anxiety, substance misuse, depression, and personality disorder. This chapter assumes the reader is comfortable with descriptive, DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) interviewing and diagnostic assessment, or is willing to learn. Furthermore, in the absence of DSM-5 mastery, patient administered rating scales should become more the standard of care. Outside of aiding in diagnosis, routine use of validated scales likely will aid in obtaining outcomes found in regulatory trials which utilize these scales to drive treatment and can motivate the prescriber to address residual symptoms, much like abnormal lab values that prompt action in the primary care setting (ex. monitoring hypertension, hyperglycemia, etc.).

The key to diagnosis is confirming the longitudinal and impairing presence of a combination of (a) inattention, (b) hyperactivity, and/or (c) impulsivity that cannot be explained by another psychiatric disorder, substance misuse, personality disorder, or medical condition. During a routine interview, use of an initial screening question is warranted. If the patient answers positively, this should trigger the use of a full DSM-5 symptom interview or use of a validated, reliable ADHD rating scale.

TIP: Screening Questions

Screening for inattention

• Do you often make careless mistakes at home, work, or school because you aren’t paying attention? Do you have difficulty concentrating or focusing more often than not?

Screening for hyperactivity

• Is it hard for you to sit still?

Screening for functional impairment

• What problems do [these behaviors] cause at school, work, or home?

Screening for longitudinal history

• How old were you when you began [these behaviors]?

Remember to screen for other psychiatric illnesses, ex. mood disorder, anxiety disorder, substance use, etc.

The use of the DSM-5 model may seem tedious or effortful in regard to memorization and the implementation of a rigorous systematic, symptom-based approach to adult ADHD diagnosis. Nevertheless, it does promote a very sensitive and specific validated way to make the diagnosis and apply accurate, efficacious treatments. Following this approach should allow the prescriber and patient to obtain the pharmacological outcomes that are reported in the literature. Use of rating scales for each psychiatric disorder will be discussed in later chapters as well. Scales generally allow the clinician to rely less on the DSM-5 clinical interview and more on patient-driven, self-reporting measures. Ideally, both approaches will be used.

DSM-5 Diagnosis

People with ADHD show a persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development characterized by (1) and/or (2) (see below) starting before the age of 12.

• (1) Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least six months and are inappropriate for developmental level:
  • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
  • Often has trouble holding attention on tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, gets side-tracked).
  • Often has trouble organizing tasks and activities.
  • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
  • Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
  • Is often easily distracted.
  • Is often forgetful in daily activities.
• (2) Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least six months to an extent that is disruptive and inappropriate for the person’s developmental level:
  • Often fidgets with or taps hands or feet, or squirms in seat.
  • Often leaves seat in situations when remaining seated is expected.
  • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
  • Often unable to play or take part in leisure activities quietly.
  • Is often “on the go” acting as if “driven by a motor.”
  • Often talks excessively.
  • Often blurts out an answer before a question has been completed.
  • Often has trouble waiting his/her turn.
  • Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more settings, (e.g., at home, school, or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

• Combined presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past six months
• Predominantly inattentive presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
• Predominantly hyperactive-impulsive presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.

TIP: Interviewing an ADHD Patient

• Adult practitioners usually find comorbidities, such as ADHD, in their adult patients who present with initial complaints of anxiety, depression, or substance abuse. In this way, ADHD may be a secondary finding.

How to screen for ADHD

• Screening for ADHD often occurs secondarily in the Psychiatric Review of Systems while taking a full psychiatric history, as part of the Social History interview segment, especially when inquiring about psychosocial development from childhood through young adulthood.
• For example: Asking patients how they performed in grade school, middle school, high school, and college is a productive approach. Did the patient do well or have problems in school? Were they labeled or felt like a bad kid or difficult student? Could they focus and pay attention to the teacher, stay on task, complete assignments, etc.? Were they disruptive to the class, make impulsive decisions that caused problems? Did they often forget to “look before they leaped”? Would their friends, teachers, parents say they were always moving, “hyper,” climbing, or fidgeting? Did they day dream or drift off?

Obtain longitudinal history of the symptoms

• If these patterns are found, it is important to identify if they have carried through to adulthood and to clearly delineate if these symptom clusters both appear in multiple spheres of life (home, work, social, etc.) and presently cause psychosocial distress...