Attention Deficit Hyperactivity Disorder (ADHD)

Diagnosis

-ADHD is the most common physiocratic disorder in children. 

-Its prevalence is 5-11% in school-aged children 

-It often presents with a classic triad of inattention, hyperactivity, and impulsivity 

– However, it can present as mixed, or primarily inattentive or hyperactive 

-Symptoms must include at least 6 signs of inattention and/or six signs of hyperactivity/impulsivity for 6 months. 

-For patients 17 years and older on 5 symptoms are required 

Symptoms of inattention include

-failure to pay close attention 

-difficulty sustaining attention on tasks or activities 

-failure to listen when spoken to 

-difficulty organizing tasks 

-avoidance of activities that require mental effort 

-losing things necessary for tasks or activities 

-distractibility and forgetfulness in daily activities 

Symptoms of hyperactivity

-fidgeting with hands or feet 

-inability to sit still 

-running around when not appropriate 

-difficulty engaging quietly in activities 

-feeling on the go or driven by a motor 

-talking excessively 

Symptoms of Impulsivity

-answering questions before they are completely asked 

-having trouble waiting ones turn 

-interrupting others 

The pattern of behavior must be more severe and occur more often than in other children of the same age. The symptoms of the disorder must be present before the age of 12 years. The diagnosis can be made after 12 years of age but there must be evidence of symptoms before the age of 12. The last important point is the symptoms must occur in two different settings (e.g., home and school). 

Many patients may be familiar with screening scales like the Vanderbilt or Conners which can be used to help confirm the diagnosis usually one is completed by the parent the other by a teacher. 

Most Commonly Prescribed Psychiatric Medications: Desvenlafaxine/Pristiq

Desvenlafaxine is the active metabolite O-desmethylvenlafaxine (ODV) of venlafaxine and is formed as a result of CYP450 2D6. It shares many of the same properties as venlafaxine. 

  • It’s FDA approved for Major depressive disorder 
  • Mechanism of action: This medication will boost the neurotransmitters serotonin, norepinephrine, and dopamine. It does so by blocking the serotonin reuptake pump, the norepinephrine reuptake pump, and increases dopamine in the frontal cortex because dopamine is largely inactivated by the norepinephrine reuptake pump in the frontal cortex. 
  • The dosing is a little easier than venlafaxine. You can start with 50 mg/day with a maximum dose of 100 mg/day. In some cases, doses of 400 mg/day have been shown to be effective but there is increased risk for side effects at higher doses. 
  • Desvenlafaxine is more potent at the serotonin transporter but has greater norepinephrine transporter inhibition relative to venlafaxine. This is one advantage along with lower does required to achieve that inhibition. 
  • These tablets should not be broken, crushed, or chewed, it will alter the controlled release.
  • It has some of the same issues as venlafaxine when it comes to withdrawal or discontinuation. It can be difficult to taper off and may require starting fluoxetine prior to tapering. 
  • Blood pressure must be monitored regularly during treatment.
  • Most common side effects include: nausea (most common 12%), dizziness (8%), increased sweating (6%), constipation (5%).
  • Other side effects: decreased appetite, decreased libido, erectile dysfunction, abnormal dreams, tinnitus, vertigo 
  • I’ve had many questions about combining this with mirtazapine. It can be combined with mirtazapine. Trazodone and bupropion are other popular medications to combine with desvenlafaxine if monotherapy does not result in remission. 
  • Desvenlafaxine offers some benefits over venlafaxine including more consistent plasma levels due to lack of metabolism by CYP 2D6, it has more potent action at the norepinephrine transporter than venlafaxine. It may be a better option if you are targeting the norepinephrine system. 

Most Commonly Prescribed Psychiatric Medications: Trazodone

  • The only FDA approved use of trazodone is for depression. However, this medication is rarely prescribed for this purpose. The higher dose requirements and lower affinity for the serotonin transporter allows the side effect profile to make the medication intolerable for most patients. 
  • The most common way it’s used is as an adjunctive therapy for sleep disturbances secondary to depression. 
  • The mechanism of action is blockade of serotonin 2A receptors and blockade of the serotonin reuptake pump. 
  • Dosing: To take advantage of the sedating properties you want to use a lower dose. A dose of 25-150 mg/night is appropriate. For depression the dose must be much higher anywhere from 150-600 mg/day 
  • For depression start with 150 mg/day in divided doses (short half-life) and increase every 3-4 days by 50 mg/day as needed to a target dose of 400 mg/day. For insomnia start with 25-50 mg/night and increase as tolerated to a target dose of 50-150 mg/night. That same target range of 50-150 mg/day can be used if trazodone is being added as an adjunct therapy for depression. 
  • It’s very important to start low and go slow when increasing the dose. Patients can have carryover sedation, ataxia, and intoxicated like feeling if titrated too rapidly. 
  • Do not stop the medication prematurely. In difficult to treat patients’ higher doses may be required 150-300 mg or up to 600 mg in some cases. 
  • It’s ideal to try and limit dosing to once nightly at bedtime to avoid daytime sedation 
  • Notable Side effects: Nausea, vomiting, constipation, dry mouth, dizziness, sedation, fatigue, headaches, life threatening side effects include priapism (1 in 8,000 men), seizures, activation of suicidal ideation in patients under 24 years of age.
  • The onset of therapeutic actions for insomnia should be immediate once an adequate dose is reached. There is no evidence of tolerance, abuse potential, or withdrawal
  • Therapeutic action for depression is delayed by 2-4 weeks if it’s not working by 6-8 weeks consider a dosage increase or switch depending on dosage reached 
  • Trazodone offers a nonaddictive option for insomnia treatment and can be used as an adjunct for depression treatment. It’s less likely than other antidepressants to cause sexual dysfunction. It may be less likely to precipitate hypomania or mania and may have some benefit for treating agitation and aggression associated with dementia. 

How to Sleep Better: Prescriptions From Your Psychiatrist

I will talk about sedative and hypnotic medications in future videos, but I want to start a discussion on sleep with sleep hygiene. I recommend all my patients start here and follow this process at least 90% of the time prior to talking about medication. I find most patients are not doing these things and if they are it’s not consistent enough to see a noticeable improvement. 

  1. Stick to a routine by waking up at approximately the same time each day. Do this for seven days, and do not alter the time on weekends. This will help you gradually set your internal clock. You have more control over your wake times than your sleep time as you may not feel tired. Try to avoid taking a nap during the day even on nights where you do not get much sleep.
  2. Avoid all caffeine after 12 PM, the effects of caffeine are long lasting and can interrupt sleep. If you can completely stop caffeine that would be best, but at the very least minimize consumption before 12 PM. 
  3. Try to exercise daily (seven days per week), preferably early in the day and not too close to bedtime. Start with 15 minutes per day and gradually work your way up. A combination of resistance training and cardiovascular training is best.
  4. Stop doing active mental work at least one hour before bed. 
  5. Avoid watching TV, using a phone, laptop, or tablet before bed. The blue light from screens has been shown to worsen sleep. The bed should be used for sleep and sex only. 
  6. Create a bedtime ritual to follow every night before bed, warm bath, mindfulness exercise, gratitude journal, reading, or listening to music. 
  7. Do not use alcohol as a way to promote sleep. Alcohol negatively impacts sleep architecture and the sleep you do get will be unsatisfying. 
  8. The bedroom should be dark, quiet, and the temperature should be cool but not cold around 65 degrees is ideal. Consider blackout curtains, a fan to cool the room, and ear plugs to facilitate these conditions. 
  9. Restrict Food and drink 2-3 hours prior to bedtime. This will reduce the chances of sleep being interrupted to use the bathroom.
  10. If you have any pain, take appropriate pain medications prior to bed. 

Lifestyle Psychiatry and the Gut Microbiome

  • The gut microbiome consists mostly of bacteria and that is largely the portion of the microbiome we are focusing on (fungi and viruses exist but their function is largely unknown) 
  • Communication pathways exist between the microbiota-gut-and brain. 
  • Multiple mechanisms exist that allow gut microbiota to signal to the brain and control physiological processes. 
  • These include release of gut peptides from enteroendocrine cells which activate receptors of the immune system and vagus terminals in the gut. 
  • Studies indicate that these bacteria can manufacture and secrete essential neurochemicals including serotonin, dopamine, NE, GABA, and acetylcholine 
  • Depression and anxiety have been linked to a less well diversified gut microbiome.
  • What can help diversify the gut microbiome? Diet, processed food, sugar, saturated fats, and red meat. Medication can also alter the gut microbiome, a good example is oral antibiotics used to treat an acute infection, sleep, exercise. Sounds a lot like a healthy lifestyle will get you the microbiome you need for optimal mental health. 
  • However, if you want a treatment there have been several studies that looked at fecal transplant to treat psychiatric disorders. Fecal transplants are much easier these days and now there is a capsule version that you take orally. There is not enough data to recommend this as a practical treatment and if the patient goes back to eating a poor diet, sleeping poorly, not exercising then the gut microbiome will revert after the transplant. 
  • What are the practical things you can do? Stop eating processed food, sugar, and red meat. Increase your fiber intake and select a diet like the Mediterranean diet or a plant based whole food diet that will provide those prebiotics. You could supplement with a probiotic but most of what you need can be had from a good diet alone and I think it’s far better to change the diet then to try using supplements to treat a poor diet. Fermented products like kimchi, kombucha and sauerkraut are good sources of live bacteria.
  • If you choose to take a probiotic make sure it’s a quality, 3rd party tested product. 
  • Increase aerobic activity, I think if you goal is overall general health and you have limitted time, I think aerobic activity is a better bang for your buck. 
  • The way I believe you get and keep a healthy gut microbiome is through lifestyle modification. Improving your diet, exercise, and sleep is a good place to start. If you want to supplement with food products like kimchi or kombucha, go for it. I do not believe there is enough evidence to support a probiotic supplement for psychiatric disorders at this point, but if you want to spend $30 or more per month on a product if it’s a quality one that’s fine. Remember you cannot supplement away a bad diet. 

Psychiatrists Are More Than Just Prescribers

Introduction:

I get a lot of comments that go something like this “All psychiatrists do is prescribe medications.” Naturally, people are shocked when I talk about nutritional psychiatry, lifestyle modification, or the value of psychotherapy. I cover a lot of medication information on social media because there is significant confusion, misinformation, and a general benefit for patients to know more about the medications they routinely use. 

While medication management is a substantial portion of the work most psychiatrists do it’s not the only things we do. 

Psychotherapy

Most psychiatrists are well trained in at least one type of psychotherapy. The most common ones include cognitive behavioral therapy, interpersonal therapy, and motivational interviewing. Some are trained extensively in psychoanalysis which usually requires a 5-year commitment and engagement in psychoanalysis as a patient.

Procedures

Many psychiatrists offer procedure-based interventions such as electroconvulsive therapy (ECT), and trans cranial magnetic stimulation (TMS). We may also consult on cases of vagus nerve stimulation or deep brain stimulation used to treat severe depression. 

Neurological Disorders

As a psychiatrist you are trained to handle some of the common neurological disorders (e.g. migraine). One third of our board examination is focused on neurological disease. In rural parts of the United States sometimes there is no one else to treat these disorders and the responsibility falls to psychiatry. 

Medical Disorders

Most psychiatrists can treat things like hypertension or hypothyroidism. Many make the choice not to if the patient has a primary care physician. Like the treatment of neurological disorders sometimes there is no choice, and a psychiatrist will need to treat the medical condition. 

Social Work

Not everyone is lucky enough to have designated social workers so they can focus exclusively on the treatment of patients. We all know how important social determinates of mental health are, and sometimes altering these circumstances is the responsibility of the psychiatrist. 

Introducing Shrinks In Sneakers on YouTube

I’ve done a soft rollout of the Shrinks In Sneakers YouTube channel over the past several months. I think I’m finally comfortable introducing it on the blog. I made the decision to start making videos because I can create content at a more rapid rate, and I can connect with the viewer in a more personal and intimate way. Please subscribe to the channel for updates. If you have specific topics you want covered, or have questions about existing content please comment. I will try to answer all questions and continue creating engaging content based on your interests. 

Cheers,

Dr. G

Link to YouTube Channel

https://www.youtube.com/channel/UCaaywi6nWB4zzpqBCMvxbsA

Medication Side Effects: Doctor my mouth is a little dry

Regular Dental Care and Oral Hygiene

Dry mouth is another common side effect from psychiatric medication. Patients on psychiatric medication often have poor dental care and poor dental outcomes. There is increased incidence of dental caries and oral ulcers in this population. This patient population is also three times more likely to lose all their teeth. Let that sink in for a moment. Now some of this is related to not following the recommended dental hygiene guidelines such as regular cleanings at least every 6-months. Thus, this is the first step in the process. Ensure the patient first has a dentist, and second be sure they are making regular 6-month appointments, and if they have issues with dental health, they should be going for cleanings as often as every 3 months. Oral hygiene is the foundation for the remainder of the interventions.

Gum, Candy, and Pilocarpine

Most patients are told to carry a bottle of water around and take frequent sips throughout the day. This does not work. It provides temporary relief, and does not address the underlying issue. You can educate the patient about drinking more water while eating which can help facilitate the swallowing process especially when dry mouth is an issue. Carrying a cup of ice can be helpful but is not convenient. What I prefer is the use of sugarless gum or candy which can be easily carried and chewed as needed. Studies have demonstrated that xylitol containing gum can reduce the levels of Mutans streptococci and lactobacilli in saliva and plaque. This has the potential to reduce the incidence of dental caries, and is an inexpensive option for most patients. I will also recommend as a second line using a mouth wash for dry mouth such as Biotene. If these interventions are not effective a medication to stimulate saliva production such as pilocarpine. In many cases pilocarpine eye drops which act locally is a better option than a medication that acts systemically. 

Final Words

Dry mouth is a common side effect patent’s experience but may not always bring to the clinician’s attention. There are interventions to treat this side effect that range from simple interventions like xylitol containing gum to pharmacological interventions such as pilocarpine eye drops. Most patients will experience relief with the above treatments. This highlights the importance of asking about specific side effects so they can be treated early and prevent long term Complications such as tooth loss. 

What Can We Do to Help Prevent Alzheimer’s disease (AD)

Introduction

The other day I had a conversation with a friend, and the topic of Alzheimer’s disease (AD) came up. My friend’s opinion was basically why would I want to know I have a disease that results in steady decline in function, and lacks any disease modifying treatments? This is in large part true, there have been multiple clinical trials of both symptomatic and disease modifying drugs that failed to produce adequate results. However, this is a very limitted view and neglects the benefits of focusing on modifiable risk factors and primary prevention. We know approximately 1/3rd of AD cases are due to modifiable risk factors, and the implementation of lifestyle modification early may prevent or delay the onset of AD. 

Modifiable Risk Factors

Common modifiable risk factors for AD include hypertension, hyperlipidemia, diabetes, obesity and smoking. Management of these risk factors as early as possible may offer a preventative approach for AD. Equally important are lifestyle modifications such as physical exercise, diet, mediation/mindfulness, and social activity.

Physical Activity

Physical inactivity has a significant influence on the development of AD. Twenty-one percent of AD cases are attributable to physical inactivity. There is a significant number of studies in the literature that indicate physical activity is neuroprotective. We know one of the areas in the brain affected by physical activity is the hippocampus which is involved in memory. Exercise leads to increased neurogenesis and neuroplasticity in the hippocampus. Other benefits of exercise on the brain include increased blood flow, modulation of inflammatory markers, and increased brain-derived neurotrophic factor (BDNF). The exact definition of adequate exercise varies in the literature. Any activity that is sufficient to increase heart rate and can be sustained for 30-60 minutes is my definition. A basic example would be brisk walking for 30-60 minutes. Physical activity two times a week beginning in middle age is associated with reduced risk of AD. Aerobic exercise is associated with additional cognitive benefits including improved processing speed, attention, and memory in adults with mild cognitive impairment. This recommendation is especially important for ApoE4 carriers, as exercise is associated with reduced amyloid deposits. 

Physical activity should be a recommendation for all patients without major health concerns preventing physical activity. The earlier in life a patient begins an exercise routine the better. Some of these studies have looked specifically at starting exercise routines in middle age, but there is no reason to wait. The physical and cognitive benefits of exercise are beneficial regardless of age. It’s much easier to begin training when you are young and healthy. If you build healthy lifestyle habits earlier in life, they are likely to last as you age. Guidelines for regular exercise can be found on the American Heart Association or American College of Sports Medicine websites. 

Meditation

Meditation or mindfulness is a topic that is beginning to get more attention in the medical literature. Chronic stress is believed to effect brain structures involved in memory and may contribute to AD. Psychological stress increases oxidative stress and telomere shortening which could contribute to the neuronal loss seen in AD. Meditation has emerged as a possible way to reduce the stress associated with daily life. The techniques of mindfulness involve directing one’s attention to the present moment to reduce the stress associated with constant thinking and worrying. Randomized controlled trials (RCTs) have shown significant improvements in overall well-being and attention. Improved executive function and reduced inflammatory processes implicated in AD. Additional research and larger RCTs are needed to improve the evidence base. Given the data we currently have there is no reason to not begin mindfulness practices. The techniques are relatively simple and can be learned from a variety of sources. If you are looking for low cost options for learning mindfulness, YouTube has a variety of guided mediations available. I personally like Headspace for beginners because it provides a solid foundation, has a variety of meditation courses, and allows you to track your progress. There is a fee for access to all the courses, but the first 10 sessions are free. Whichever route you choose, spending 10-15 minutes per day practicing mindfulness will lead to a happier and healthier brain. 

Diet

A great deal of research has been conducted over the last several years on the role of diet with respect to cognition. People with high calorie diets, specifically those high in fat are at higher risk for AD. Traditional western diets high in processed carbohydrates, simple sugars, and saturated fatty acids can impact the hippocampus and memory. When Japan transitioned to western diet the incidence of AD increased. Lower calorie diets with lower saturated fat content are linked to lower oxidative stress, decreased Beta amyloid burden, and decreased inflammation. One diet with proven benefits for preventing AD is the Mediterranean diet. This diet is rich in fruits, vegetables, whole grains, olive oil, and fish. There is moderate intake of low-fat dairy products and low intake of red meat, saturated fats, and sugar. Most of the data supporting the reduce risk of AD with this diet comes from epidemiological studies. Studies have shown combining this diet with exercise further reduces the risk of AD. The Mediterranean diet is associated with better cognitive function and reduced cognitive decline. This is one specific example, but the basic principles can be applied without the need to adhere to one specific named diet. 

Some specific foods you may want to add to your diet to prevent AD include fresh berries which have the highest amounts of antioxidants among the fruits. They are also low in calories and work well in diets where weight loss is a goal. Green leafy vegetables and tomatoes have the highest nutritional value when it comes to brain health amongst the vegetables. Foods high in omega-3 fatty acids are considered to be helpful in supporting brain function. The omega-3 fatty acid most important in brain function is docosahexaenoic acid (DHA), which is mostly found in fish. The anti-inflammatory and antioxidant properties of DHA are thought to be responsible for its role in preventing AD. Patients with diagnosed AD are known to have low levels of DHA. Omega-3 fatty acids recommendations from the American Heart association for adults is to eat fish rich in omega-3s two or more times per week. If using a supplement 1-3 grams per day is an adequate dose. Over 3 grams per day, you should consult with your doctor before moving above 3 grams per day. 

Finally, curcumin which is derived from turmeric has anti-inflammatory, antioxidant, and anti-amyloid properties. There is low bioavailability of the curcumin lead to mixed results in the initial trials. A new more bioavailable form called Theracumin demonstrated positive results in a randomized double-blind placebo-controlled study on memory, attention, and amyloid plaques in older adults without dementia. 

Conclusion

While there is no guarantee that lifestyle modification alone will prevent AD, there are some promising studies indicating it plays a role in the development of this disorder. Most of these interventions are things patients can implement in their lives immediately. They will not only improve cognitive function and lower the risk of developing AD, but it will improve and potential reverse other diseases of lifestyle. 

What to Expect When You Visit the Psychiatrist: Part One

The initial psychiatric interview is the beginning of an important relationship. Many things will be determined in the first encounter by both the patient and the psychiatrist. At times this can feel overwhelming. A large amount of information must be gathered, processed, and incorporated into a cohesive treatment plan. This series of posts is designed to shed some light on the process, and reduce the anxiety associated with undergoing a psychiatric evaluation. 

The interview consists of five key parts: (1) introduction, (2) opening, (3) the body, (4) closing, and (5) termination. A good psychiatrist will blend these sections into each other, so it feels more like a conversation than a formally structured interview. 

Part 1: The Introduction

This is an important phase and begins as soon as the psychiatrist and patient see each other. The primary goal is to engage the patient and get them comfortable before asking sensitive questions. Like other first encounters the patient will form an impression of the psychiatrist which will shape the rest of the interview and treatment process. 

One way to ensure patient comfort is to address anything in the office setting that can be altered prior to starting the evaluation. For example, closing a shade due to light from the window shining directly on the patient’s seat. Another example would be offering a drink of water or tea before starting. A simple gesture of kindness goes a long way in helping the patient feel comfortable in the setting. 

The psychiatrist should then proceed with a formal introduction and offer a few details about himself or herself. One fear many patients have is a friend or family member finding out that they are under the care of a psychiatrist. It’s always a good idea to clarify and ensure confidentiality. Confidentiality is strictly maintained with the exception two primary scenarios (may vary by state). If a patient informs the psychiatrist of a plan to kill themselves or someone else, there is a duty to warn and protect the patient. 

Once these parts are complete a brief description of how the interview process works is in order. 

An example of this interaction may occur as follows:

The purpose of today’s interview is to learn about your concerns and the types of stressors you are dealing with. As the interview progresses, I will get a better idea of the primary concerns. We will then transition to some background questions about your family, medical health, schooling, and any previous psychiatric care you received. At the end of the discussion we can work together on a treatment plan. This process will take approximately one hour. Do you have any questions before we get started?

We want to convey two things to the patient, (1) a sense of understanding about the interview process to reduce fear, and (2) altering the patient to the fact that many questions will be asked, and it will take a fair amount of time. 

The structure of the introduction is not set in stone and may be modified. It should take around five to seven minutes to complete. 

In the next post we will tackle the opening of the interview process. 

 

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