Counseling Points - January 2009 - (Page 8)

ADHD and Bipolar Disorder An estimated 22% of children and adolescents with ADHD also have a diagnosis of bipolar disorder.38 Clinicians should always treat the bipolar disorder before managing the symptoms of ADHD because stimulants may exacerbate manic episodes of bipolar disorder. Once bipolar disorder is stabilized, the symptoms of ADHD can then be treated with stimulants.39 Many antipsychotics exist to manage bipolar disorder, but lithium has been studied well in pediatrics.40,41 The exact mechanism of action of lithium is unknown. Some researchers postulate that it can attenuate dopamine function, while others think that it potentiates gammaaminobutyric acid (GABA) activity. The serum concentration of lithium should be monitored every 5 days after initiation or dose changes until reaching therapeutic level. Target lithium serum concentrations range from 0.8-1.2 mEq/L in acute mania to 0.8-1 mEq/L during the maintenance phase.42 Potential side effects associated with lithium include tremor, confusion, GI upset, polydipsia, and polyuria. Long-term use may also cause hypothyroidism; thus thyroid function tests should be performed every 2 to 6 months.43 Fertile female adolescents should be counseled on abstinence or birth control prior to and throughout treatment with lithium due to its tetratogenicity.8 Other potential antipsychotic agents that can be used for pediatr ic bipolar disorder include divalproex (Depakote ® , Depakene ® ) olanzapine (Zyprexa ® ), and risperdone (Risperdal®).29,40,44 Divalproex is often utilized in patients with rapid-cycling bipolar disorder during the non-psychotic maintenance phase.40,45 Common side effects include nausea/vomiting, weight gain, and alopecia.Thrombocytopenia can also occur, and anecdotally, is more commonly observed in children/adolescents than adults. Both olanzapine and risperdone are considered atypical antipsychotics (Table 2). Atypical antipsychotics cause fewer extrapyramidal side effects (EPS) then the typical agents (e.g., haloperidol [Haldol®]).22 Both olanzapine and risperdone can cause weight gain and endocrine effects such as galactorrhea and menstrual changes. 22 Olanzapine is associated with a greater risk of new-onset diabetes.46 ulants have not been proven to be effective for co-morbid OCD. In fact, an animal study suggests that chronic stimulation of the dopaminergic receptors may actually contribute to OCD.50 Further studies need to be conducted to evaluate optimal treatment options for co-morbid OCD and ADHD. In the interim, clinicians may treat each of these clinical conditions separately. Medications for Adults When considering pharmacologic treatment for adults with ADHD, it is important for the clinician to know that no agreed-upon standards or guidelines exist and there has been very little research to support evidenced-based practice in this population. On the other hand, we have been using stimulants to treat adults for 30-plus years, so we know how adults will respond in general, and the medications have established efficacy and safety profiles. Treatment often improves the individual’s quality of life dramatically in a very short amount of time. The clinician’s experience will dictate practice, while understanding the guiding principals will provide tools to address most difficulties that arise. We have been using stimulants to treat adults for 30-plus years, so we know how adults will respond in general, and the medications have established efficacy and safety profiles. Therapeutic Alliance The first thing that needs to happen between the individual with ADHD and the clinician is the forging of a therapeutic alliance. The clinician needs to educate the person about the disorder of adult ADHD. As part of this process, it is important for the clinician to discuss available treatments, their side effects, risks, and benefits, and the alternatives. The discussion should include identified impairments, supportive therapies, and the risks of not treating.This will support the person in making an informed choice. Choosing the Initial Treatment The clinician needs to choose one agent to begin treatment with, preferably one that has been approved by the FDA (Table 1).There is no evidenced-based methodology for choosing the first agent. However, there are a few guiding principles that have emerged from the research over the years. First, initiating treatment with a long-acting stimulant improves adherence, reduces side effects, has less abuse potential, and provides for smoother delivery of the medication. Second, the clinician should start with a low dose 8 ADHD and OCD According to a study conducted by Geller and colleagues, 33% of patients with obsessive-compulsive disorder (OCD) also have co-morbid ADHD.47 The literature on treatments for co-morbid OCD and ADHD is limited. An SSRI is considered the drug of choice for OCD in the pediatric population, but thus far no studies have shown therapeutic benefit for ADHD.48,49 Similarly, stimCOUNSELING POINTS™

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Counseling Points - January 2009

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