Mental Health Lecture Part B - ADHD, Substance Abuse Disorders
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A cluster of characteristics or behaviors that are related to several heterogeneous biopsychosocial behaviors and neurodevelopmental processes, which ultimately negatively influence one's social, occupational, or academic function (Feifel & MacDonald, 2008; Goodman et al., 2012).

Genetic
Perinatal stress
Low birth weight
Traumatic brain injury
Maternal smoking during pregnancy
Early deprivation
Dietary intake of certain chemicals and sugar

Behavioral
Hyperactivity, impulsivity, disinhibition, novelty seeking, risk behaviors, and reward dependence
Cognitive
Organizational issues, poor planning and execution skills, slower or impaired information processing, and deficits in time management

Social-emotional
Emotional impulsivity, dysphoria, anger, anxiety, emotional lability, trouble reading social cues, and issues with making or keeping friends
Deficits in executive function
Problems with self-regulation, sequencing behaviors, planning and organization, working memory, and internalized speech

Interrupting conversations
Frequent job changes
Irritability
Quick to anger
Relationship discord
Dangerous driving habits
Low frustration tolerance

Behavior modification
Parent training
Family therapy
Social and academic skills training
Individual psychotherapy
Cognitive-behavior modification
Therapeutic recreation

Upon initiation of drug therapy with or without nondrug therapy, the expectation is that the core symptoms of attention deficit hyperactivity disorder (ADHD) will abate, and the patient will no longer experience functional deficits in social, occupational, or academic domains.
This result tends to emerge relatively quickly, particularly after the initiation of medication therapy.

First line: stimulants
Methylphenidate or amphetamine
Second line: nonstimulants
Atomoxetine
Guanfacine or clonidine
Third line: bupropion

A practitioner is prescribing a second-line drug for a patient with ADHD who failed to respond to the first-line therapy. What drug is recommended?
A. Methylphenidate
B. Amphetamine
C. Bupropion
D. Atomoxetine

D. Atomexetine
Rationale: Atomoxetine should be the next drug utilized in patients who have failed stimulants; this is also appropriate for patients who have contraindications to stimulants. Methylphenidate and amphetamine are first-line therapies, and burpopion is a third-line therapy.

A practitioner is prescribing Wellbutrin for an adult diagnosed with ADHD. What is the recommended dosage?
A. 100 mg BID, then 100 mg TID; max. 450 mg/d
B. 45 kg: 0.1 mg HS, then titrate in 0.1 mg
C. 0.1 mg BID; maximum 2 to 4 mg/d
D. 10 mg/d; maximum 30 mg/d

A. 100 mg BID, then 100 mg TID; max. 450 mg/d
Rationale: The recommended dosage of Wellbutrin for an adult is 100 mg BID, then 100 mg TID; maximum 450 mg/d.

A practitioner is monitoring a patient placed on stimulant medication for ADHD with weekly assessments. The patient is not improving but has no side effects. What is the next recommended step in this therapy?
A. Decrease dosage of medication prescribed.
B. Change type of medication prescribed.
C. Increase dosage of medication prescribed.
D. Add a second medication.

C. Increase dosage of medication prescribed.
Rationale: With weekly assessments showing no improvement, but no side effects, the medication dosage should be increased.

Drug information
Patient-oriented information sources
Nutrition/lifestyle changes
Complementary and alternative medications

In 2011, it was estimated that approximately 11% of children 4-17 years of age (6.4 million) in the United States are diagnosed with ADHD, with a CDC-estimated prevalence of 5.6% to 15.9% of children.
In 2013, the worldwide prevalence of ADHD in children was estimated at 5.6%, a contrast to our domestic statistics (American Psychiatric Association, 2013).
Clinically meaningful symptoms persist into adulthood in 60%-80% of patients, which suggests that ADHD is not exclusively a condition of childhood that resolves spontaneously but rather is a chronic illness.

Substance Use Disorders (SUD) occur when the recurrent use of alcohol and/or drugs causes "clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home" (SAMHSAa).
The range of substance use/misuse can be considered on a continuum from abstinence to full blown addiction.

The cause of SUD is still unknown, but it is thought that genetics play a significant role.
Age at first exposure may also play a role

SUD is a brain disease, based on the principle of neurophysiologic reinforcement (NIDA, 2003). The "reward pathway" most commonly invoked to describe the use-addiction cycle is in the mesolimbic system in the brain where dopaminergic neurons lead to the nucleus accumbens (NAc).
These neurons originate in the ventral tegmental area (VTA) and are typically controlled by gamma-amino butyric acid (GABA). Once the GABA control is removed, dopamine is released and provides a pleasure response to the NAc.

There are 11 criteria, and a diagnosis requires at least two of these criteria to be present, with mild SUD represented by the patient exhibiting two to three criteria, moderate severity being four to five criteria, and severe disorder in patients exhibiting six or more. Many substances cause a SUD and a diagnosis will follow the same pattern. That is, to diagnose an alcohol or other SUD, the same criteria would apply.

There are 11 criteria for SUD. What is the minimum number of criteria that must be present for this disorder?
A. 1
B. 2
C. 3
4. 4

B. 2
Rationale: There are 11 criteria, and a diagnosis requires at least two of these criteria to be present, with mild SUD represented by the patient exhibiting two to three criteria, moderate severity being four to five criteria, and severe disorder in patients exhibiting six or more.

Screening(S) helps assess the severity of substance use and aids to objectively identify a level of treatment for each patient.
Brief Intervention (BI) centers on behavioral changes by increasing awareness to the problem at hand.
Referral to Treatment (RT) provides patients the opportunity for an evaluation by trained personnel and referral to appropriate level of treatment.

Treatment programs for all substance abuse have three generalized goals:
Reducing substance abuse or achieving a substance-free life
Maximizing multiple aspects of life functioning
Preventing or reducing the frequency and severity of relapse

Alcohol is the most common substance that Americans use to alter their state of mind, with more than half of Americans reporting alcohol use in the past month.
Too much alcohol may increase the risk of certain conditions: heavy drinkers see an increase in stroke, hypertension, depression, esophageal cancer, and of course, cirrhosis of the liver.

Withdrawal symptoms may appear 6 to 12 hours after discontinuation of alcohol but can start 1 to 3 days later and may last up to a week
Mild symptoms include anxiety, sweating, restlessness, and insomnia, while moderate symptoms include the mild symptoms plus increased blood pressure or heart rate, confusion, and mild hyperthermia. Severe symptoms include moderate symptoms plus hallucinations, impaired attention, seizures, and delirium tremors.

Symptoms of withdrawal from alcohol range from mild to life threatening. How many hours after discontinuation of alcohol can withdrawal symptoms appear?
A. 1 to 3 hours
B. 4 to 10 hours
C. 6 to 12 hours
D. 12 to 24 hours

C. 6 to 12 hours
Rationale: Withdrawal symptoms may appear 6 to 12 hours after discontinuation of alcohol but can start 1 to 3 days later and may last up to a week

Acamprosate
Disulfiram
Naltrexone

Opioids are a specific type of drug that include prescription medications (morphine, Percocet(R)) typically used to treat pain as well as illicit substances like heroin.
The treatment of opioid use disorder (OUD) requires both acute management of withdrawal as well as long-term, chronic care.
Buprenorphine is the first medication approved by the FDA to treat OUD outside of an opioid treatment program (OTP).
Lofexidine is a new, non-opioid adrenergic agonist medication indicated for the mitigation of opioid withdrawal symptoms in adults.
Methadone, a Schedule II controlled substance, is effective in treating OUD by reducing cravings and minimizing the euphoric effects of other opioid agonists.

Naltrexone blocks the effects of opioids by competitive binding at opioid receptors. Long-acting injectable is administered once monthly and has shown evidence to decrease heroin use compared to placebo.

Pediatric
Geriatric
Women

Patient education
Drug information
Patient oriented information sources
Complementary and alternative medications