ADHD Highlights From APA 2010
Richard H. Weisler, MD: My name is Rick Weisler. I'm a practicing psychiatrist in North Carolina and an Adjunct Professor of Psychiatry at the University of North Carolina in Chapel Hill, and Adjunct Associate Professor of Psychiatry at Duke University Medical Center [Durham, North Carolina]. I want to thank you for tuning in today. I am at the APA [American Psychiatric Association] Annual Meeting and looking at what's being covered in ADHD [attention-deficit/hyperactivity disorder], but also thinking about what the needs are for the field.
There are obviously huge gaps in our knowledge base. We need effective treatments; we need to know how they work and their side effects. We also need to know something about the underlying structures in the brain and how the brain works in ADHD. One of the posters[1] here at the APA meeting that looked interesting was a study in progress. It's being done by Amy Shah, Melissa Delbello, and colleagues in Cincinnati [Ohio]. They are looking at what happens with projections from the cerebellum into the limbic brain, and how these connections might modulate mood. Previously, neuroimaging studies showed cerebellar abnormalities in patients with either bipolar disorder or ADHD, but what isn't known is what happens in people who have both. Maybe as many as 1 in 4 people will actually have comorbid bipolar disorder in ADHD. Their prediction is that comorbid ADHD and bipolar disorder will have the greatest structural abnormalities in the cerebellar vermis when examined with structural MRI. This illness used to be thought of as being associated with minimal brain dysfunction, but we clearly have evolved away from that. Other affective disorders, like depression, may also be associated with changes in the brain; this should also be explored in the future. I'm encouraged that investigators are beginning to look at this; even though this is a small study, it may be a step in the right direction and could give us guidance in this area.
Another thing that we need to look at is what happens if one drug does not work. If there's not an adequate response to treatment, what should clinicians do? What can guide us? In essence we need a study like STAR*D [Sequenced Treatment Alternatives to Relieve Depression] for ADHD. For example, you've started somebody on a stimulant and they're partially better but not really well: Are you better off switching to a different stimulant, or are you better off augmenting with another agent? Or do you add metacognitive therapy in a 12-session program, like Mary Solanto has explored recently, or cognitive-behavioral therapy, which Dr. Safren has explored recently. There are a lot of different areas such as these that are important for us to look at moving forward.
Another poster[2] here at the APA meeting looked at long-term open-label coadministration of guanfacine extended release added to stimulants on the core symptoms of ADHD. This is a study being done by Dr. Rubin and many other researchers; even though it's an open-label design, making it harder to interpret, the study authors concluded that combination therapy may offer some advantage in folks who have a suboptimal response to psychostimulants alone. It is interesting to think about issues, [including] adjusting the dose and the potential side effects when you start mixing drugs together. Hopefully [we will have] drugs in addition to guanfacine extended release. We'll need to look at broader areas and find new mechanisms of action. What happens when you use drugs like bupropion or atomoxetine in combination with a stimulant, which some doctors do? Wouldn't it be great if we had really good data, ie, sizeable studies that could guide us in those cases because we know that untreated ADHD carries a huge risk? There's a performance risk both at work and at home and in relationships; also driving accidents clearly increase, as does substance abuse, when ADHD is untreated.
In the area of substance use disorders, be aware that you have to be vigilant when prescribing stimulants, and that they may be abused or diverted. It's important to pay attention to these patients and educate them and their families about the need to control the medication and not share it with other people. It's important to take ADHD medications properly and be aware of other medications that patients are taking. ADHD is really an exciting area of medicine, and research on the condition is truly blossoming, which is great to see after being totally unrecognized for many, many decades.
I want to thank you for listening. Hopefully next year we'll have more news, more excitement to share, and even more to come because it's a great illness to study; it's very rewarding to treat both for providers and patients and their families.
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Cite this: Richard H. Weisler. APA 2010 Expert Video: ADHD Highlights - Medscape - Jun 10, 2010.
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