“Joyful Beginnings” – mixed media, January, 2004

Amy Musia – Evansville, Indiana

www.ajmusia.com

Louis B. Cady, MD – CEO & Founder – Cady Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Wellness Institute Adjunct Professor – University of

Southern IndianaAdjunct Clinical Lecturer – Indiana University School

of Medicine Department of PsychiatryChild, Adolescent, Adult & Forensic Psychiatry –

Evansville, Indiana

Lisa Seif, LCSW, CADAC, CSAMS – CWI Lisa Seif, LCSW, CADAC, CSAMS – CWI TherapistTherapist

Director: Warrick County Drunk Driving and Drug Court Program Adjunct Professor – ITT

Facilitator – Adventure Based Challenge Program for YOUTH FIRST

Zoned, Stoned and Blown: The Emotional Tsunami of Psychiatric Disorders Coupled

Chemical Dependency

ADD – inattentive, without Rx

ADD – inattentive, on Adderall

Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

Never mind the pictures. Adult ADD isn’t real, is it?

• Study of 24 ADHD adults vs. 18 controls

• Comparable on age, SE status, sex, handedness, education, IQ and achievement tests

• MRI on 1.5 T Siemens scanner; image parcellation of neocortex into 48 gyral based units

Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80

Volumetric Adult ADHD study, cont.• Relative to controls, ADHD adults had:

– Significantly smaller overall cortical gray matter– Smaller prefrontal cortex– Smaller anterior cingulate cortex

• CONCLUSIONS:– Adults with ADHD have volume difference in brain

regions in areas involved in attention and executive control.

– These data, largely consistent with studies of children, support the idea that adults with ADHD have a valid disorder with persistent biological features.

Seidman LJ, et al. Biol Psychiatry. 2006 Nov 15;60(10):1071-80

ADHD – A Family Practice Perspective Montano, B – Un. Of CT Medical School Dept of Family Practice

• Adult prevalence rate 4.5%• Most adult sufferers have not been properly

diagnosed or treated. • They have at least one comorbid psych. d.o.• This d.o. may offer the first clue of ADHD• Comorbidities may confound the diagnosis.• Use of available standardized rating scales

helpful.• Primary caregivers encouraged to dx and tx.

J Clin Psychiatry. 2004;65 Suppl 3:18-21.

Hyperactivity

—Age—

Impulsivity

Inattention

ADHD: Course of the Disorder

*

Loss of productivity Tardiness, mistakes Disorganization Disruption of work flow

Horrigan J, et al. Presented at 47th Annual AACAP Meeting: October 24-29, 2000. New York, NY.

Kids and Adults – Differences in HYPERACTIVE domain

AS A CHILD:• Squirming, fidgeting• Cannot stay seated• Cannot wait turn • Runs/climbs excessively• Cannot play quietly• On the go/driven by motor• Talks excessively• Blurts out answers• Intrudes, interrupts others

AS AN ADULT:• Work inefficiencies• Can’t sit through meetings• Cannot wait in line• Drives too fast• Self-selects very active job• Cannot tolerate frustration• Talks excessively• Makes inappropriate

comments• Interrupts others

Sources: DSM-IV (TR). APA 2000:85-93)Weiss MD, Weiss JR. J Clin Psychiatry 2004;65(Suppl 3):27-37.

Persistence of ADHD Into Adulthood• ADHD is a heterogeneous disorder associated with

considerable disability and comorbidity that, in many cases, persists into adulthood1

– Some studies have found persistence as high as 36.3%2

• Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD3

• Current prevalence of ADHD persistent into adulthood 4.4%4

• Much of the treatment of adult ADHD can be based on experience in treating children/adolescents5

1. Barkley et al. J Abnorm Psychol. 2002;111:279-289.2. Kessler RC et al. Biol Psychiatry 2005 June;57(11):1442-51. [retrospective review of 3,197 14-44 yo

respondents in NCS-R]3. Biederman et al. Am J Psychiatry. 1993;150:1792-1798. 4. Kessler et al. Am J Psychiatry. 2006;163(4):716-

23. 5. Dodson WW. J Clin Psychol. 2005;61:589-606.

Occupational functioning of ADHD children followed into adulthood

• most are employed full time• lower occupational status and SES• change jobs more frequently • more firings and layoffs• more conflict with supervisors and coworkers• employer ratings of ADHD adults lower in

– completing work– independence– need for supervision

• great probability of being self-employed (Mannuzza)

Weiss & Hechtman, 1993; Mannuzza et al, 1993, Barkley et al, 1990

Unemployment, underemployment are also problems…

What happens if ADHD isn’t treated?What happens if ADHD isn’t treated?

Psychiatric disorders (lifetime) in adults with ADHD [multiple sources, % is estimated; N.B. – this is WITHOUT TREATMENT GROWING UP]

• Substance use disorders (all) 50%• Anxiety disorders 40%

• Major depression 35%

• Learning disabilities 20%

• Bipolar disorder 10%

• Antisocial disorder 10%

% of patients with ADHD presenting with OTHER psychiatric disorders

[“Reverse comorbidity”]

• Major depression: 20% have ADHD• Bipolar disorder: 15% have ADHD• Generalized anxiety disorders: 20% have ADHD

• Substance abuse: 25% have ADHD

– Sources: Alpert, et al. Psychiatry Res. 1996;62:213. Nierenberg et al. Presented at the 157th Annual Meeting of the APA 2002. Faraone S et al. J . Affect Disorder 2000; 58:99. Wilens. Psych Clinic N. Am 2004.

Earlier Initiation of Smoking with ADHD

237 6 to 17-year-old boys

0.6

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0.2

0.1

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0 2 4 6 8 10 12 14 16 18 20 22 24P<0.003

ADHD n=128Control n=109

Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44.4 year follow-up

SUD’s in Adolescents with ADHD

• 75% - non medicated ADHD (n=19) [p<.001]

• 25% - medicated ADHD (n=56)

• 18% - Non-ADHD control (n=137)

Biederman et al Pediatrics 1998; 104:e20

Biederman J, et al. Pediatrics. 1999;104:e20-e25.

40

30

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UnmedicatedADHD

MedicatedADHD

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32

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P<0.001

Pharmacotherapy Significantly Reduces Substance Abuse in Adults

with ADHD

(N=56)(N=19)(N=137)

3-fold!

Biederman, et al. Biol Psychiatry. 1998;44:269-273.

Lif

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10

20

30

40

50

60

Increased Lifetime Substance Abuse in Untreated Adults with ADHD

Control (n=268)ADHD (n=239)

27%

P<0.001

55%

The 3 Big Reasons for substance abuse – Louis B. Cady, M.D.

• Looking for help– Something to make their minds work

better– Looking for something to CALM DOWN with

• Looking for Mr. Good-Drug– Something to take AWAY the pain of failure

and lack of performance• Hanging with the WRONG CROWD

– “like attracts like”; “losers attract losers”

ADHD vs. Bipolar Disorder

• Mood lability• Bursts of energy• Restlessness• Talkativeness• “Racing thoughts”• Impatience

• Impulsivity• Impaired judgment• Irritability• Chronic course• Lifelong impairment• Genetic clustering

American Psychiatric Association. DSM-IV; 1994:78-84, 350-363.

12 Features in Common:12 Features in Common:

ADHD vs. BPD in Adults

ADHD• Constant• Lifelong• Moods triggered• Moods congruent• Instantaneous shifts• Thoughts “jump”• Family Hx of ADHD

Bipolar• Cyclical• Later onset (mean, 26 yrs)• Moods untriggered• Moods incongruent• Gradual shifts• Thoughts “race”• Family Hx of bipolar

STEP-BD reports at least 19% comorbidity of bipolar disorder and ADHD.

STEP-BD = Systematic Treatment Enhancement Program for Bipolar Disorder.

American Psychiatric Association. DSM-IV; 1994:78-85, 350-363.

ADHD Comorbidity with bipolar disorder – how to tell’em apart

• Adults with ADHD– Lack severe mood lability symptoms– Moderate impairment in functions

• Adults with ADHD + BPD– Prominent mood lability (think “rage-aholic”)– High rates of hyperactive/impulsive symptom– Episodicity of mood and overall symptoms– Severe impairment in function

– Wilens et al. Biol Psychiatry 2003;54:1

How to Commit Malpractice

• Send a bipolar/ADHD patient into orbit with stimulants!

• Potential errors:– Failure to take a good

enough history• Failure to ask “the

question”

– Failure to start REALLY LOW on ADD medication

“Strattera [coupled with Prozac or Paxil] has been great for our admissions.”

-Dr. William Beute, MDPine Rest Campus ClinicGrand Rapids, MIApril 21, 2004[quoted with permission]

The “Take Home” – don’t prescribe a 2D6 drug-drug interaction.

OTHER DIAGNOSTIC STUFF…..

LOW ENERGY – frequently occurring with depression. A “no duh,” KNOWN finding.

• People with depression have LOW ENERGY….

So you….

Depression & Anxiety Dx in 1 Easy Lesson

DEPRESSIONSIG: E- CAPS!

• Sleep• Sadness • Interest loss• Guilt• Energy• Concentration• Appetite• Psychomotor Sx• Suicidal thinking

• Gen. ANXIETY D.O.• Somatic Sx (“energy”,etc.)• WORRY• Irritability• Concentration• Keyed up• Insomnia (“sleep”)• Restlessness

SWICKIR is Quicker:

Worry + 3 = GAD (Baughman)5of 9 with 1 of 2 x 2 weeks

Depression & LOW ENERGY in One Easy Lesson

DEPRESSIONSIG: E- CAPS!

• Sleep• Sadness • Interest loss• Guilt• Energy• Concentration• Appetite• Psychomotor Sx• Suicidal thinking

OTHER FREQUENT CAUSES:• Hypothyroidism

• Sub-syndromal or other

• Low DHEA• Exhausted adrenals

– (can check with 4 cortisol levels)

• Low testosterone• Low micronutrients and

vitamins• (low growth hormone)

5 of 9 with 1 of 2 x 2 weeks w/o other causes!!!

MUST EXCLUDE OTHER CAUSES, as well as treat for presumptive diagnosis.

Anxietydisorders

Stahl SM. J Clin Psychiatry. 1993;54(1 suppl):33-38.

Majordepressive

disorder

Comorbiddepressionand

anxiety

Continuum of Depression and Anxiety

Depression & Anxiety By the Numbers:

Depression• 2 – 4 % of US

population/year

• Lifetime:– 21% of women

– 13& of men

ANXIETY

• 4-8% of US population/year

• 60% with anxiety disorder come in with somatic symptoms!

Adapted from Katon, W. Jounrl Clin Pysch, 1990, Depression & Chronic Mental Illness; and - Kessler, R et al. Lifetime & 12 Month Prevalence of DSM-IIIR Psychiatric Disorders in the U.S. (Ntl Comorb. Study). Arch Gen Psych, Jan 1994, 8-19. Myers, Weissman, Tischler. Six month prevalence of psychiatric disorders in three communities. Arch Gen Psych 1984; 41:959-967. Goldberg, Bridges. The diagnosis of anixety in primary care settings. Br J Clin Pract Symp, 1985; 38 (suppl):28-33

Major Depressive Disorder (MDD)

Generalized Anxiety Disorder (GAD)

Depressed mood

Anhedonia

Appetite disturbance

Worthlessness

Suicidal ideation

DSM-IV-TR. Washington, DC: American Psychiatric Association. 2000.

Sleep disturbance

Psychomotor agitation

Concentration difficulty

Irritability

Fatigue

Worry

Anxiety

Muscle tension

Palpitations

Sweating

Dry mouth

Nausea

Overlapping Symptoms of Depression and GAD

Adrenal Burnout

Diagnostic Pearls - Cady• How’s work?

– How has your employment history been?

• How’s your mood? Your marriage (relationship)?• How was school for you?• Are people nervous driving with you?• Are there periods of time when you have too much

energy for no particular reason?• Do you ever have to have a beer at the end of the day to

relax?– [gently lead in to other substances, especially stimulants that

may have a CALMING effect]– “Have you ever taken any of your child’s ADD Rx?”

An Higelian Dialectical blend of therapeutic alternatives - Cady

• Thesis: “you can’t be treated if you are using.”• Anti-thesis: “Doc, I can’t stop using unless you can do

something for me.” • Synthesis: “Let’s see if we can work something out.”

• “crossover titration” or replacement of illicit substance with RATIONAL alternative (e.g. – cocaine with Bupropion or atomoxetine; marijuana with clonazepam or Oxycarbazepine (Trileptal ®). Must be willing to ‘GET SOBER.’

– REFINEMENT of pharmacotherapy as case unfolds• Willingness to get into AA/NA and GET A SPONSOR, and

WORK STEPS – if appropriate.

• If you don’t want to fool with it, REFER, don’t just brand them as “hopeless” or untreatable.

Methylphenidate Efficacy in Adult ADHDControlled Comparison of MPH in Adult ADHD

*P <.0001.Adapted with permission from Spencer et al. Arch Gen Psychiatry. 1995;52:434-443.

42

36

0

6

12

18

24

30

Baseline Week 1 Week 2 Week 3`

ADH

D R

ating

Sca

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core Placebo

Subthreshold ADHDMPH

*

**

N=23

Efficacy of a Mixed Amphetamine Salts Compound in Adult ADHD

Adapted with permission from Spencer et al. Spencer et al. Arch Gen PsychiatryArch Gen Psychiatry. 2001;58:775-782.. 2001;58:775-782.

40

30

20

10

Baseline Week 1 Week 2 Week 3

ADH

D R

ating

Sca

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P <.001P <.001

Placebo

Mixed amphetaminesalts compound

N=27

DSM-IV ADHD Symptom Checklist

Atomoxetine Efficacy in Adult ADHD

CAARS-Inv ADHD = Investigator-rated Conners Adult ADHD Rating Scale.

Adapted from Michelson et al. Biol Psychiatry. 2003;53:112-120.

CAAR

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Tot

al

32

30

28

26

24

22

Baseline Week 2 Week 4 Week 8Week 6 Week 10

Placebo Atomoxetine

***

††

†

*P <.05; **P <.003; †P ≤.001.

Current medications available for Adult ADHD

• Atomoxetine Nov. 2002• Mixed amphetamine salts XR August 2004• D-methylphenidate XR June 2005• Methylphenidate OROS June 2008• Lisdexamfetamine June 2008

Response to Psychostimulants - Arnold et al. J Attention Dis. 2000;3:200.

Best Response(Percent)

AMP MPHEqual response to either stimulant

Meta-analysis of Within-Subject Comparative Trials Evaluating Response to Stimulant Medications

28%28%

16%16%

41%41%

AMP=Amphetamine (Adderall®, Dexedrine®, Dextrostat®); MPH=methylphenidate (Ritalin®, others).

Treatment Pearls• Don’t be afraid to treat/refer. You can actually be

sued if you DON’T (and you have obtained the history, and then a catastrophe occurs).

• RX: Pick the one best agent in each stimulant class– Sustained effect throughout the day best

• RX: Start with the LOWEST PILL STRENGTH IT COMES IN (or DILUTE IT (Vyvanse).– Go up from there.

• Push as high as needed, within PI.• If in doubt, refer.

LISA

People at Risk

PSYCHIATRIC• ADHD• Depression• Anxiety disorders• Bipolar d.o.• Self-described usage• FAMILY HISTORY

– (parent OR grandparent = 4 X the risk!!)

LEGAL• High risk/high need• Low risk/no need

PSYCHOSOCIAL

PERSONALITY TRAITS

William Duncan Silkworth, MD

“The phenomenon of craving”

David L. Ohlms, MD

• “Few other major primary diseases produce the range of emotional and physical complications caused by addiction to the drug, ALCOHOL.”

• “It is destructive to practically every major organ system in the human body compared to other drugs.”

• “The fact that the majority of people can drink without losing control reinforces the [erroneous] opinion that there is something very wrong with the basic character of those who do lose control.”

- Cady & Seif

People at Risk

High Risk/High Need• Middle stages of CD• Unemployment• UnEMPLOYABLE• Undereducated• Few law-abiding

friends• No stable relationship• Hopelessness,

homelessness

Low risk/low need• Early stages• Employed• Good support system• Has a vision of the

future• Spiritual foundation• Able to conceptualize

recovery concepts• Motivation to change

People at risk – legal woes

• Legal– Repeat drunk driving– Repeat drug offenses– “Petition to revoke”– Failed urine drug screens– Antisocial behaviors (driving on suspended

license, etc.)

Psychosocial:

– History of “ODD”, conduct problems as child– “terminally unique”– Impatient (low impulse control – ADHD?!)– Resistant to change– No life purpose– no family support– No goals– No purpose – No pleasure

Risky behaviors

• “people places and things”

• “lying, cheating, and stealing”

• Failure to follow through on recovery maintenance activities• Never grasping “step #1” in AA• Not dealing with dual diagnosis issues (medication noncompliance)

Patients at risk

• Family biology/genetics– (psychiatric AND/or addictive disorders)

• Unenlightened, “un-shrunk” state:– “euphoric recall” never dealt with– “Dry” but not “Sober.” (Not in recovery.)

• “Hard wired” issues - Learning disabilities

• Isolation – social, psychological, emotional

RELAPSE PREVENTION STRATEGIES

“Alcoholism doesn’t go away, like diabetes heart disease, cancer, blindness, paralysis… sooner or later you have to accept that you have no control over the PHYSICAL abnormalities. Counseling and support groups can’t change the way our bodies metabolize drugs, alcohol, and substances.”

- Cady and Seif

Step ONE!!

• “We admitted that we were [are?] powerless over alcohol – and that our lives had become unmanageable.”

What happens when you slip?

Key concepts of relapse prevention

• Alcoholism/ CD don’t go away

• Ongoing recovery is great but a drink can undo it.

• Need to ACCEPT no control over this “physical allergy” (Silkworth)

Medication/Meditation• MEDICATION:

– INITATION:• Axiom: “Treat the problem, not the symptom.” (Cady)• “Jump on it; don’t just look at it.” (Cady)

– MAINTENANCE:• Drug screen- “Trust, but verify.” (Reagan)

• MEDITATION:– “the principle of mindfulness” – Time alone for “reprogramming” – retrain the brain

into a “sober brain”– Learn social and relaxation skills

MedicationCONDITION CONFOUNDS APPROPRIATE INAPPROPRIATE

ADHD Prev. Meth, Cocaine

Strattera, Intuniv, Bupoprion

Ritalin, Adderall, Stimulants

ADHD EtOH, MJ – to calm down

Stimulant? sedatives

Anxiety, Depression, ADHD

Alcohol, MJ TREAT THE PROBLEM, NOT THE SX – eg., SSRI’s, focused Rx for ADHD which can cause anxiety, detc.

“brain dead benzo’s” (Xanax, Klonopin)

Bipolar Mood stabilizers “downers”(BZD’s)

Chemically dependent

Uppers/downers: Red Bull, etc.

Know When to Fold’Em

Team Approach• COMMUNICATION between members:

– Physician (frequently not a psychiatrist)– Social worker/therapist– Probation/parole officer (judge)– School or supervisor, if appropriate

• Cross training:– MD’s should know about recovery issues– CD workers – should know about Rx

• TIPS:– Release of information’s need to be signed– Maintenance of collegiality

Personal collection Louis B. Cady,

M.D.

“For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room opening into another hallway, again lined with doors. Medicine is always wonderful and never will be finished.”- Charles H. Mayo, M.D.

Thanks for coming! Please fill out evaluations! Contact info: Dr. Cady and Lisa Seif, LCSW – 812-429-0772 (frontdesk@cadywellness.com )