Shrinks In Sneakers

Tag: Stimulants

  • Substance-Induced Psychosis vs. Primary Psychosis: Treatment, Prognosis, and the Cannabis Connection

    Substance-Induced Psychosis vs. Primary Psychosis: Treatment, Prognosis, and the Cannabis Connection

    Psychosis can emerge from a range of causes, but distinguishing between substance-induced psychosis (SIP) and primary psychotic disorders like schizophrenia is critical for effective treatment and prognosis. While the clinical presentation often overlaps—hallucinations, delusions, disorganized thinking—the underlying etiology, treatment approach, and long-term outcomes can diverge significantly.

    Defining the Two

    Substance-Induced Psychosis (SIP) occurs when symptoms of psychosis are directly caused by intoxication with or withdrawal from substances such as cannabis, amphetamines, alcohol, hallucinogens, or synthetic cannabinoids (e.g., spice or K2). The psychosis typically emerges during or shortly after substance use and resolves with abstinence.

    Primary Psychosis, on the other hand, refers to psychotic disorders that are not directly attributable to substances or medical conditions. This includes schizophrenia, schizoaffective disorder, and brief psychotic disorder, among others.

    Treatment: Overlapping Tools, Different Emphasis

    1. Acute Management
    Both SIP and primary psychosis are often treated with antipsychotic medications during acute episodes. The initial goals are the same: reduce agitation, manage delusions or hallucinations, and ensure safety.

    • Commonly used antipsychotics include risperidone, olanzapine, haloperidol, and quetiapine. In SIP, short-term use is typically sufficient.
    • In cases involving severe agitation or aggression, benzodiazepines (like lorazepam) may be used adjunctively, especially if stimulant intoxication is suspected.

    2. Long-Term Strategy

    • SIP: After stabilization, the primary strategy is abstinence from the offending substance and psychosocial support (e.g., CBT, motivational interviewing, relapse prevention).
    • Primary psychosis: Typically requires ongoing antipsychotic treatment, often for life. Psychosocial interventions, supported employment, and cognitive remediation are also central to recovery.

    Conversion to Schizophrenia: What’s the Risk?

    One of the key concerns with SIP is whether the episode is a harbinger of an underlying primary psychotic disorder.

    • Approximately 20–50% of individuals with substance-induced psychosis later develop a primary psychotic disorder, such as schizophrenia.
    • Amphetamine- and cannabis-induced psychosis carry the highest risk of conversion, particularly when psychosis occurs in adolescence or early adulthood.
    • A meta-analysis by Niemi-Pynttäri et al. (2013) found that 46% of people with SIP later developed schizophrenia-spectrum disorders over a follow-up of 8 years.

    Predictors of conversion include:

    • Younger age at first psychotic episode
    • Family history of psychotic illness
    • Persistent psychotic symptoms after substance clearance
    • Poor premorbid functioning

    Do Antipsychotics Work in SIP?

    Antipsychotics reduce acute psychotic symptoms in SIP, but their long-term utility is less clear.

    • Studies show rapid resolution of psychosis within days to weeks in most SIP cases when abstinence is achieved.
    • Long-term antipsychotic treatment does not reduce the conversion rate to schizophrenia in confirmed SIP, suggesting their role should be time-limited unless ongoing symptoms or risk factors emerge.
    • A 2020 review in Psychological Medicine emphasized that monitoring over the 6–12 months post-episode is essential for risk stratification and avoiding premature chronic medication exposure.

    Cannabis: A Powerful Catalyst

    Cannabis has become the most studied and most controversial substance linked to psychosis. Here’s what the evidence says:

    • Daily cannabis users are 3–5 times more likely to develop a psychotic disorder compared to non-users, especially with high-THC strains (≥10% THC).
    • A 2019 Lancet Psychiatry study by Di Forti et al. showed that strong cannabis use accounts for 12% of new psychosis cases in Amsterdam, and 30% in London.
    • Adolescents who use cannabis, particularly those with a family history of psychosis, are at dramatically increased risk.

    Mechanistically, THC may dysregulate the dopamine system in vulnerable brains, tipping the balance toward psychosis. Cannabidiol (CBD), in contrast, may be protective, but commercial cannabis typically contains very little CBD.

    Final Thought: Clinicians must balance vigilance and restraint—treating psychosis aggressively when needed but also avoiding unnecessary chronic antipsychotic exposure in what may be a reversible, substance-driven episode.

  • Adult ADHD: Current Trends and Emerging Research (2025 Update)

    Adult ADHD: Current Trends and Emerging Research (2025 Update)

    Attention-deficit/hyperactivity disorder (ADHD) has traditionally been seen as a childhood condition — but in recent years, there has been an explosion of interest in ADHD among adults. As awareness grows, so does research. New studies are reshaping how we diagnose, treat, and understand ADHD in the adult population.

    1. 🔥 Rising Rates of Adult ADHD Diagnosis

    Recent studies show that adult ADHD diagnoses have sharply increased over the past decade. According to a 2023 analysis published in JAMA Psychiatry, the diagnosis rate for adults aged 18–45 rose by more than 80% between 2011 and 2022.

    Why the surge?

    • Greater public awareness
    • Better screening tools for adults
    • A cultural shift toward recognizing executive dysfunction in adulthood

    However, there are concerns that overdiagnosis is also happening, particularly when ADHD is diagnosed after brief evaluations without thorough history-taking.

    2. 🧠 Expanded Understanding of Adult ADHD Symptoms

    The symptom profile in adults differs significantly from children. While hyperactivity often fades, issues like emotional dysregulation, disorganization, and executive dysfunction persist.

    Recent research emphasizes that adult ADHD often presents as:

    • Chronic procrastination
    • Low frustration tolerance
    • Difficulty managing responsibilities (work, home, finances)
    • Persistent inner restlessness

    A 2024 review in The American Journal of Psychiatry noted that emotional impulsivity may actually be a core symptomin adults, not just a secondary feature.

    3. 💊 Treatment Shifts: Caution Around Stimulants

    While stimulant medications (like amphetamines and methylphenidate) remain the gold standard, new studies highlight the importance of careful prescribing, especially in adults with:

    • Comorbid substance use disorders
    • Cardiovascular risk factors
    • Poor diagnostic workups

    Non-stimulant treatments are gaining ground:

    • Atomoxetine (Strattera) remains a mainstay.
    • Viloxazine (Qelbree) was approved for adult ADHD in 2024 and shows promise with lower abuse potential.
    • Bupropion (Wellbutrin) continues to be an important off-label option, especially when depression coexists with ADHD.

    According to a 2024 meta-analysis in Lancet Psychiatry, non-stimulants now account for about 30% of new ADHD prescriptions in adults — a significant jump compared to previous years.

    4. 🧬 Precision Psychiatry and Biomarkers on the Horizon

    Emerging studies are exploring neuroimaging and genetic markers to better understand adult ADHD subtypes.

    • A 2023 study using fMRI found distinct prefrontal cortex dysfunction patterns in adults with ADHD compared to controls.
    • Genetic research continues to implicate genes related to dopamine transmission and synaptic plasticity.

    Although these findings are not yet ready for clinical application, the future of ADHD diagnosis may involve biomarkers, moving beyond subjective questionnaires alone.

    5. 🌿 Lifestyle Interventions Are Getting More Attention

    There’s a growing body of evidence supporting complementary approaches:

    • Cognitive-behavioral therapy (CBT) for ADHD-specific skills
    • Exercise as a way to enhance executive function and mood
    • Mindfulness practices to improve emotional regulation

    A 2024 RCT published in Behavior Therapy showed that an 8-week mindfulness-based intervention led to significant improvements in attention and working memory in adults with ADHD — with effect sizes comparable to pharmacotherapy in some cases.

    Final Thoughts

    Adult ADHD is real, complex, and often misunderstood.
    The field is evolving rapidly, with a push toward better diagnostics, safer treatments, and a broader understanding of how ADHD affects life across the lifespan.

    As research continues to grow, clinicians are challenged not only to treat ADHD effectively but to do so thoughtfully — avoiding both underdiagnosis and overdiagnosis.

    Stay tuned — the future of ADHD care is just getting started.

  • Olanzapine vs. Quetiapine for Stimulant Psychosis: Is One the Clear Winner?

    Olanzapine vs. Quetiapine for Stimulant Psychosis: Is One the Clear Winner?

    There is limited high-quality randomized controlled trial (RCT) evidence specifically comparing Zyprexa (olanzapine) or Seroquel (quetiapine) for the treatment of stimulant-induced psychosis (SIP), including cocaine-induced psychosis. However, some RCTs and observational studies provide useful insights:

    Olanzapine (Zyprexa)

    • RCT Evidence:
      • A 2022 meta-analysis of antipsychotic treatments for stimulant-induced psychosis included olanzapine and found it to be effective in reducing positive psychotic symptoms, often comparable to haloperidol but with a better side effect profile (less extrapyramidal symptoms) 11.
      • A double-blind RCT comparing olanzapine vs. haloperidol in methamphetamine-induced psychosisfound that both were effective at reducing PANSS (Positive and Negative Syndrome Scale) scores, but olanzapine was associated with better tolerability 22.
      • Another RCT in methamphetamine-induced psychosis compared olanzapine and risperidone, showing similar efficacy but better tolerability with olanzapine 33.

    Quetiapine (Seroquel)

    • RCT Evidence:
      • A small RCT in methamphetamine-induced psychosis found that quetiapine was effective but tended to require higher doses to achieve symptom resolution 44.
      • A retrospective study on cocaine-induced psychosis suggested that quetiapine may help reduce symptoms, but data is weaker compared to olanzapine or risperidone 55.
      • Quetiapine has also been studied as an option for reducing cocaine cravings, but results are mixed and it is generally less preferred for acute agitation compared to faster-acting options like olanzapine.

    Head-to-Head Comparison

    There is no direct RCT comparing olanzapine vs. quetiapine for stimulant-induced psychosis, but based on available data:

    • Olanzapine is generally preferred for acute agitation and psychosis because of its faster onset and greater D2 blockade.
    • Quetiapine may be useful in milder cases or for individuals needing sedation, but higher doses are often required.

    Clinical Implications

    • For acute stimulant-induced psychosis, olanzapine (5–10 mg IM or PO) is a common first-line option due to rapid onset and favorable side effect profile.
    • Quetiapine (200–400 mg PO) can be considered, particularly for patients needing sedation or those with comorbid conditions like bipolar disorder.
    • Other antipsychotics with strong evidence include risperidone and haloperidol (though the latter has more extrapyramidal risk).

    After reviewing the available literature, direct randomized controlled trials (RCTs) comparing olanzapine (Zyprexa) and quetiapine (Seroquel) for stimulant-induced psychosis (SIP), including cocaine-induced psychosis, remain scarce. However, some studies provide relevant insights:

    Olanzapine (Zyprexa):

    • Efficacy: A randomized, double-blind trial compared olanzapine and haloperidol in patients with amphetamine-induced psychosis. Both medications effectively improved psychotic symptoms in the short term, with olanzapine showing a faster onset of action.

    Quetiapine (Seroquel):

    • Efficacy: A double-blind RCT compared haloperidol and quetiapine for methamphetamine-induced psychosis. While both medications reduced psychotic symptoms, quetiapine appeared to have a more favorable profile in reducing certain symptoms over time. 

    Indirect Comparisons:

    • First-Episode Psychosis: A 52-week randomized, double-blind study evaluated olanzapine, quetiapine, and risperidone in early psychosis patients. All three antipsychotics demonstrated comparable effectiveness, as indicated by similar rates of treatment discontinuation.

    Conclusion:

    While direct RCT evidence comparing olanzapine and quetiapine specifically for stimulant-induced psychosis is limited, existing studies suggest that both medications are effective in managing such conditions. Olanzapine may offer a faster onset of symptom relief, whereas quetiapine might present a more favorable side effect profile. Clinical decisions should be individualized, considering factors such as patient history, specific symptomatology, and potential side effects.

  • The Twin Epidemic: Rising Co-Prescriptions of Opioids and Stimulants in the U.S.

    The Twin Epidemic: Rising Co-Prescriptions of Opioids and Stimulants in the U.S.

    A recent 10-year longitudinal cohort study has unveiled concerning trends in the co-prescription of opioids and stimulants, shedding light on the escalating “twin epidemic” in the United States.

    Key Findings:

    • Prevalence of Co-Prescription: Approximately 5.5% of patients received both opioid and stimulant prescriptions during the study period. 
    • Increased Opioid Dosage: Patients co-prescribed stimulants were more likely to escalate their opioid doses over time, with the highest doses observed in the South and West regions.
    • Associated Conditions: Common diagnoses among these patients included depression, anxiety, attention-deficit/hyperactivity disorder (ADHD), and chronic pain

    Implications:

    The concurrent use of opioids and stimulants poses significant risks, including increased chances of overdose, cardiovascular events, and mental health complications. This study emphasizes the need for healthcare providers to carefully consider the implications of co-prescribing these medications and to monitor patients closely.

    Call to Action:

    It’s crucial to raise awareness about this emerging twin epidemic. Healthcare professionals, policymakers, and patients must collaborate to develop strategies that mitigate risks associated with co-prescriptions and ensure safer prescribing practices.

  • Evidence-Based Exercise Programs for ADHD

    Evidence-Based Exercise Programs for ADHD

    Exercise is a powerful, evidence-based strategy for managing ADHD symptoms. Research shows that regular physical activity can boost dopamine and norepinephrine levels, improving attention, executive function, and emotional regulation. 

    1. Aerobic Exercise Programs

    Aerobic activities are particularly effective for ADHD because they increase heart rate and stimulate brain chemicals associated with focus and mood.

    • Example:
      • Program: Preparing for 5K race
      • Duration: 3 times per week, 30–45 minutes per session
      • Benefits: Gradual progression helps build consistency, while running boosts executive functioning and decreases hyperactivity.

    2. High-Intensity Interval Training (HIIT)

    HIIT involves alternating short bursts of intense activity with periods of rest or lower-intensity activity. It’s time-efficient and highly engaging, which suits individuals with ADHD.

    • Example:
      • Program: 20-Minute HIIT Circuit (e.g., 30 seconds of jumping jacks, 15 seconds rest; repeat with squats, burpees, and mountain climbers)
      • Frequency: 3–4 times per week
      • Benefits: Improves impulse control and mood regulation through quick transitions and intense focus.

    3. Martial Arts Training

    Martial arts like karate, taekwondo, or judo combine physical activity with discipline and mindfulness, making them highly effective for ADHD.

    • Example:
      • Program: Weekly martial arts classes for 60 minutes
      • Key Features: Incorporates structure, focus on breathwork, and sequential movements that require attention.
      • Benefits: Enhances self-control, confidence, and attention.

    4. Yoga for ADHD

    Yoga combines movement with mindfulness, helping individuals develop better body awareness and emotional regulation.

    • Example:
      • Program: 20–30-minute yoga sessions using ADHD-focused videos (e.g., Cosmic Kids Yoga for children or Yoga with Adriene for adults).
      • Frequency: Daily or 3–5 times per week
      • Benefits: Reduces stress, improves attention span, and strengthens mind-body connection.

    5. Structured Strength Training

    Strength training involves repetitive, organized routines that build physical strength while requiring focus.

    • Example:
      • Program: 3-day split routine (e.g., arms, legs, core) at home or in the gym, using weights or resistance bands.
      • Benefits: Boosts discipline and executive functioning, while offering visible progress over time.

    6. Nature-Based Activities

    Activities like hiking, biking, or kayaking combine exercise with the calming effects of nature, reducing overstimulation.

    • Example:
      • Program: 60-minute nature walk or bike ride in a local park 2–3 times per week.
      • Benefits: Improves mood, reduces hyperactivity, and promotes relaxation.

    How to Get Started

    • Start small: Begin with 10–15 minutes and gradually increase duration.
    • Make it fun: Choose activities you enjoy to sustain motivation.
    • Set a schedule: Consistency is key. Aim for at least 150 minutes of moderate-intensity exercise per week.
    • Monitor progress: Track improvements in focus, mood, or energy levels to stay motivated.
  • Evidence-Based Strategies to Reduce Distractions in ADHD

    Evidence-Based Strategies to Reduce Distractions in ADHD

    Managing distractions is a core challenge for individuals with ADHD and even for those without. Research-backed strategies, including environmental adjustments, behavioral techniques, and technological tools, have shown promise in helping individuals stay focused and minimize interruptions

    1. Environmental Modifications

    Declutter and Organize Your Space

    • Why: Visual clutter increases cognitive load and distractibility in ADHD.
    • Evidence: Studies show that simplified, organized environments improve task performance and reduce overwhelm.
    • Implementation:
      • Create a designated workspace with minimal visual and auditory distractions.
      • Use storage bins or labeled organizers to keep items out of sight.

    Sound Management

    • Why: Background noise can be highly distracting for individuals with ADHD.
    • Evidence: RCTs indicate that white noise or low-level background music can enhance focus in some ADHD individuals.
    • Implementation:
      • Use white noise machines or apps (e.g., “Noisli”).
      • Experiment with instrumental music or nature sounds to find what works best.

    2. Structured Task Management

    The Pomodoro Technique

    • Why: Short, timed intervals of work followed by breaks improve sustained attention.
    • Evidence: Studies show that structured time management strategies reduce procrastination and improve productivity in ADHD.
    • Implementation:
      • Work for 25 minutes, then take a 5-minute break. Adjust intervals based on your focus capacity.
      • Use timers or apps like “Forest” to track intervals.

    Chunking Tasks

    • Why: Breaking tasks into smaller steps prevents overwhelm and promotes task completion.
    • Evidence: Behavioral interventions involving task segmentation show significant benefits in ADHD.
    • Implementation:
      • Divide projects into 3–5 actionable steps.
      • Write each step on a checklist and celebrate small wins.

    3. Technology-Based Interventions

    Digital Focus Tools

    • Why: Apps that block distractions and guide focus provide real-time support.
    • Evidence: RCTs on apps like “Focus@Will” and browser extensions like “Freedom” show improvements in task engagement for ADHD.
    • Implementation:
      • Use website blockers to eliminate access to social media or other distractions during work.
      • Try ADHD-specific productivity apps like “TaskTuner” or “Asana.”

    Timed Alerts and Reminders

    • Why: Timers and reminders keep individuals on track and prevent attention drift.
    • Evidence: Digital prompts have been shown to improve task adherence in ADHD.
    • Implementation:
      • Use phone alarms or apps like “Remember The Milk” for task reminders.
      • Schedule alerts for transitions or breaks.

    4. Behavioral Techniques

    Mindfulness Training

    • Why: Mindfulness helps individuals recognize and redirect wandering attention.
    • Evidence: RCTs show that mindfulness-based interventions improve sustained attention and reduce impulsivity in ADHD.
    • Implementation:
      • Practice 5–10 minutes of mindfulness meditation daily using guided apps like “Headspace.”
      • Incorporate brief mindfulness exercises before starting tasks.

    Behavioral Reinforcement

    • Why: Positive reinforcement encourages task focus and reduces distractions.
    • Evidence: Token systems and reward strategies have proven effective in ADHD-focused behavioral studies.
    • Implementation:
      • Set up a reward system (e.g., complete 3 tasks to earn 15 minutes of free time).
      • Track progress with visual aids like charts or checklists.

    5. Workplace or School Accommodations

    Flexible Seating and Movement Breaks

    • Why: ADHD individuals focus better when they can move or choose a seating arrangement.
    • Evidence: Studies on flexible classroom setups and “active learning environments” report improvements in ADHD engagement.
    • Implementation:
      • Use standing desks or fidget tools to incorporate movement.
      • Take brief movement breaks every 20–30 minutes.

    Noise-Canceling Headphones

    • Why: Blocking environmental noise improves focus on tasks.
    • Evidence: RCTs demonstrate that noise-canceling headphones significantly reduce distractions in ADHD.
    • Implementation:
      • Use headphones during work or study sessions to minimize auditory interruptions.

    6. Diet and Lifestyle Adjustments

    Nutrition for Focus

    • Why: Stable blood sugar and adequate nutrition reduce mental fatigue and improve concentration.
    • Evidence: Studies suggest that diets high in protein and low in refined sugar reduce distractibility in ADHD.
    • Implementation:
      • Eat balanced meals with complex carbs, proteins, and healthy fats.
      • Avoid high-sugar snacks during focus-intensive tasks.

    Exercise and Movement

    • Why: Physical activity improves attention and executive function in ADHD.
    • Evidence: A 2018 RCT found that 20 minutes of moderate aerobic exercise improved focus in children with ADHD.
    • Implementation:
      • Schedule exercise breaks or mini workouts during the day.
      • Use movement as a tool to reset focus between tasks.

    7. Cognitive Behavioral Therapy (CBT) for ADHD

    Why: CBT addresses thought patterns and behaviors contributing to distractibility.

    Evidence: Multiple RCTs demonstrate the efficacy of CBT in improving attention and task persistence in ADHD.

    Implementation:Work with a therapist trained in ADHD-specific CBT.Practice CBT strategies like identifying and reframing negative thoughts about distractions.

    Conclusion

    Reducing distractions in ADHD involves a combination of environmental modifications, structured strategies, and personalized interventions. These evidence-based approaches can help individuals focus, complete tasks, and thrive in daily life. By experimenting with these methods and tailoring them to your needs, you can find a system that works best for you.

  • Give Me Stimulants—Just Don’t Make Me Come to the Office

    Give Me Stimulants—Just Don’t Make Me Come to the Office

    A JAMA study found a significant rise in stimulant prescriptions between 2019 and 2022, with a 37.5% increase in total volume. This trend was particularly noticeable through telehealth, where stimulant prescriptions soared from 1.4% to 38.1%, peaking at 51.8% in mid-2020. The shift was largely influenced by COVID-19 pandemic policies, which eased telehealth restrictions. While antidepressant prescriptions also rose, opioid prescriptions declined by 17.2%. The study emphasizes the need to balance access with monitoring for potential misuse as telehealth policies evolve​

    Link to Article: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2823646?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamanetworkopen&utm_content=wklyforyou&utm_term=091324&adv=null

  • Are Stimulants Neurotoxic?

    Are Stimulants Neurotoxic?

    Introduction:

    The diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) is well established in the field of psychiatry. Not only is it well accepted, but ADHD has dramatically increased over the past 10 years. Some would even say it’s an epidemic in its own right. The use of psychostimulants as a treatment is common practice, and today we are here to discuss the risk of neurotoxicity with ADHD medication.

    What Are Psychostimulants

    Psychostimulants include methylphenidate (MPH) and mixed amphetamine salts such as Adderall. These remain the most effective and widely used medications for the treatment of ADHD. These medications function by blocking the dopamine reuptake transporter and increase dopamine stimulation at the postsynaptic receptors. These medications work to increase attention and reduce impulsivity but the long-term implications of consistent use are largely unknown. 

    Substance Use and Stimulant Prescribing

    Most lines of evidence in the literature indicate that these medications do not promote substance use later in life and may even decrease the potential for future substance abuse. I’ve also found lines of evidence that indicate the opposite, but the general consensus in the field is that there is not increased risk for future substance abuse. We do know that drugs that function in a similar manner to these medications result in molecular and structural changes to neurons. It is unknown if this also occurs with stimulant medications used to treat ADHD. 

    Neuronal Effects of Amphetamine

    Methamphetamine is a known neurotoxin and several studies have indicated this in animal models. Recently exposure to amphetamine has been sown to cause impairments on the development of dendritic branching up to 3 months after stopping methylphenidate. In mice there is evidence that MPH use causes loss of dopamine neurons in the substantia nigra which may increase the risk of Parkinson’s disease. Other groups have shown alterations in nerve growth factors and brain derived neurotrophic factor in the frontal cortex after chronic MPH use. When neurons from the prefrontal cortex are exposed to MPH it alters their electrical activity. MPH was found to reduce electrical activity and it persists in a dose dependent fashion even 10 weeks post exposure. In rats the use of MPH is associated with decreased response to normal stimuli and increased response to adverse stimuli. We need to be careful extrapolating this information to humans as these studies were conducted in animal models.