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American Academy of Child & Adolescent Psychiatry (AACAP): Psychopharmacology Update Institute
Approved Options Increase for ADHD Treatment
NEW YORK – Clinicians have more approved drugs options than ever before for treating children with attention-deficit/hyperactivity disorder, and results from two recently published meta-analyses further document the efficacy of several of these treatments.
The drug treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) now starts with prescribing a stimulant, and for refractory cases follows with an alternative stimulant, and then treatment with atomoxetine (Strattera) , followed by a long-acting alpha-2 agonist (such as guanfacine [Intuniv] or clonidine [Kapvay]), followed by a combination of a long-acting alpha-2 agonist plus a stimulant, Dr. Laurence L. Greenhill said at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“I can now cite all these treatments as approved by the FDA [Food and Drug Administration] and as standard of care. There really has been progress” in treating ADHD, said Dr. Greenhill, professor of clinical child and adolescent psychiatry at Columbia University in New York.
A meta-analysis published last year confirmed atomoxetine’s safety and efficacy as monotherapy for treating pediatric ADHD in 25 double-blind, randomized, controlled studies that enrolled a total of nearly 4,000 patients (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:174-87) The results showed a number needed to treat to achieve a clinical benefit of 4, against a number needed to harm to produce an adverse effect of 6, but with serious adverse effects occurring no more often than among patients on placebo. These numbers show both good efficacy and safety for atomoxetine when treating pediatric ADHD, Dr. Greenhill said.
A second meta-analysis published last year assessed the safety and efficacy of long-acting alpha-2 agonists in randomized studies when used either alone (in nine studies) or in combination with a stimulant (in three studies), with a total enrollment in the 12 studies of 2,276 pediatric patients with ADHD (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:153-73). The results showed an effect size for reducing hyperactivity and impulsivity of –0.59 when used as monotherapy and –0.39 when used in combination. As monotherapy the long-acting alpha-2 agonists caused increased fatigue, sedation, and somnolence, as well as more hypotension, bradycardia, and QTc prolongation than did placebo. When used in combination, these drugs caused increased somnolence, hypotension, and bradycardia. Although these results showed that treatment with these drugs require monitoring, the overall safety profile was “very reassuring,” Dr. Greenhill said.
Another notable finding reported last year came from a study of combined treatment with a stimulant and risperidone (Risperdal) for pediatric patients with ADHD and aggression in the Treatment of Severe Childhood Aggression (TOSCA) study. TOSCA randomized 168 patients 6-12 years old with ADHD and either oppositional defiant disorder or conduct disorder to treatment with a stimulant (usually controlled-release methylphenidate) plus parent training, or to the stimulant and parent training plus risperidone.
Six weeks later, patients who received risperidone along with the background treatments had on average a statistically significantly reduced score on the Nisonger Child Behavior Rating Form Disruptive–Total subscale, compared with the patients on the background treatment only, the study’s primary endpoint (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:47-60).
The results “show that this kind of combination treatment can be effective” in this “very well-thought-out study,” Dr. Greenhill said. In addition, the effects from adding risperidone “occurred quickly,” he noted.
Two other notable reports on ADHD last year documented the steadily rising prevalence of the disorder, and the ongoing value from treatment for controlling symptoms. Based on data collected by telephone interviews with randomly selected U.S. adults during 2003, 2007, and 2011, parent-reported history of a diagnosis of ADHD in children aged 4-17 years old increased from 7.8% in 2003 to 11% in 2011, which worked out to approximately 2 million more children with the diagnosis in 2011, compared with 2003 (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:34-46). In 2011, the median age of initial ADHD diagnosis occurred when children were 6 years old.
In another study, 157 patients aged 6-17 years with ADHD and well controlled on treatment with lisdexamfetamine dimesylate (Vyvanse) were randomized to continued treatment or drug withdrawal. Symptoms recurred quickly in most patients, with about 40% meeting the study’s definition of treatment failure by 2 weeks off treatment, and more than 60% having a significant resumption of symptoms by the time they had been off treatment for a month (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:647-57).
Dr. Greenhill is an adviser to BioBehavioral Diagnostics. He has received research support from Rhodes and Shire.
NEW YORK – Clinicians have more approved drugs options than ever before for treating children with attention-deficit/hyperactivity disorder, and results from two recently published meta-analyses further document the efficacy of several of these treatments.
The drug treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) now starts with prescribing a stimulant, and for refractory cases follows with an alternative stimulant, and then treatment with atomoxetine (Strattera) , followed by a long-acting alpha-2 agonist (such as guanfacine [Intuniv] or clonidine [Kapvay]), followed by a combination of a long-acting alpha-2 agonist plus a stimulant, Dr. Laurence L. Greenhill said at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“I can now cite all these treatments as approved by the FDA [Food and Drug Administration] and as standard of care. There really has been progress” in treating ADHD, said Dr. Greenhill, professor of clinical child and adolescent psychiatry at Columbia University in New York.
A meta-analysis published last year confirmed atomoxetine’s safety and efficacy as monotherapy for treating pediatric ADHD in 25 double-blind, randomized, controlled studies that enrolled a total of nearly 4,000 patients (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:174-87) The results showed a number needed to treat to achieve a clinical benefit of 4, against a number needed to harm to produce an adverse effect of 6, but with serious adverse effects occurring no more often than among patients on placebo. These numbers show both good efficacy and safety for atomoxetine when treating pediatric ADHD, Dr. Greenhill said.
A second meta-analysis published last year assessed the safety and efficacy of long-acting alpha-2 agonists in randomized studies when used either alone (in nine studies) or in combination with a stimulant (in three studies), with a total enrollment in the 12 studies of 2,276 pediatric patients with ADHD (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:153-73). The results showed an effect size for reducing hyperactivity and impulsivity of –0.59 when used as monotherapy and –0.39 when used in combination. As monotherapy the long-acting alpha-2 agonists caused increased fatigue, sedation, and somnolence, as well as more hypotension, bradycardia, and QTc prolongation than did placebo. When used in combination, these drugs caused increased somnolence, hypotension, and bradycardia. Although these results showed that treatment with these drugs require monitoring, the overall safety profile was “very reassuring,” Dr. Greenhill said.
Another notable finding reported last year came from a study of combined treatment with a stimulant and risperidone (Risperdal) for pediatric patients with ADHD and aggression in the Treatment of Severe Childhood Aggression (TOSCA) study. TOSCA randomized 168 patients 6-12 years old with ADHD and either oppositional defiant disorder or conduct disorder to treatment with a stimulant (usually controlled-release methylphenidate) plus parent training, or to the stimulant and parent training plus risperidone.
Six weeks later, patients who received risperidone along with the background treatments had on average a statistically significantly reduced score on the Nisonger Child Behavior Rating Form Disruptive–Total subscale, compared with the patients on the background treatment only, the study’s primary endpoint (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:47-60).
The results “show that this kind of combination treatment can be effective” in this “very well-thought-out study,” Dr. Greenhill said. In addition, the effects from adding risperidone “occurred quickly,” he noted.
Two other notable reports on ADHD last year documented the steadily rising prevalence of the disorder, and the ongoing value from treatment for controlling symptoms. Based on data collected by telephone interviews with randomly selected U.S. adults during 2003, 2007, and 2011, parent-reported history of a diagnosis of ADHD in children aged 4-17 years old increased from 7.8% in 2003 to 11% in 2011, which worked out to approximately 2 million more children with the diagnosis in 2011, compared with 2003 (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:34-46). In 2011, the median age of initial ADHD diagnosis occurred when children were 6 years old.
In another study, 157 patients aged 6-17 years with ADHD and well controlled on treatment with lisdexamfetamine dimesylate (Vyvanse) were randomized to continued treatment or drug withdrawal. Symptoms recurred quickly in most patients, with about 40% meeting the study’s definition of treatment failure by 2 weeks off treatment, and more than 60% having a significant resumption of symptoms by the time they had been off treatment for a month (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:647-57).
Dr. Greenhill is an adviser to BioBehavioral Diagnostics. He has received research support from Rhodes and Shire.
NEW YORK – Clinicians have more approved drugs options than ever before for treating children with attention-deficit/hyperactivity disorder, and results from two recently published meta-analyses further document the efficacy of several of these treatments.
The drug treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) now starts with prescribing a stimulant, and for refractory cases follows with an alternative stimulant, and then treatment with atomoxetine (Strattera) , followed by a long-acting alpha-2 agonist (such as guanfacine [Intuniv] or clonidine [Kapvay]), followed by a combination of a long-acting alpha-2 agonist plus a stimulant, Dr. Laurence L. Greenhill said at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“I can now cite all these treatments as approved by the FDA [Food and Drug Administration] and as standard of care. There really has been progress” in treating ADHD, said Dr. Greenhill, professor of clinical child and adolescent psychiatry at Columbia University in New York.
A meta-analysis published last year confirmed atomoxetine’s safety and efficacy as monotherapy for treating pediatric ADHD in 25 double-blind, randomized, controlled studies that enrolled a total of nearly 4,000 patients (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:174-87) The results showed a number needed to treat to achieve a clinical benefit of 4, against a number needed to harm to produce an adverse effect of 6, but with serious adverse effects occurring no more often than among patients on placebo. These numbers show both good efficacy and safety for atomoxetine when treating pediatric ADHD, Dr. Greenhill said.
A second meta-analysis published last year assessed the safety and efficacy of long-acting alpha-2 agonists in randomized studies when used either alone (in nine studies) or in combination with a stimulant (in three studies), with a total enrollment in the 12 studies of 2,276 pediatric patients with ADHD (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:153-73). The results showed an effect size for reducing hyperactivity and impulsivity of –0.59 when used as monotherapy and –0.39 when used in combination. As monotherapy the long-acting alpha-2 agonists caused increased fatigue, sedation, and somnolence, as well as more hypotension, bradycardia, and QTc prolongation than did placebo. When used in combination, these drugs caused increased somnolence, hypotension, and bradycardia. Although these results showed that treatment with these drugs require monitoring, the overall safety profile was “very reassuring,” Dr. Greenhill said.
Another notable finding reported last year came from a study of combined treatment with a stimulant and risperidone (Risperdal) for pediatric patients with ADHD and aggression in the Treatment of Severe Childhood Aggression (TOSCA) study. TOSCA randomized 168 patients 6-12 years old with ADHD and either oppositional defiant disorder or conduct disorder to treatment with a stimulant (usually controlled-release methylphenidate) plus parent training, or to the stimulant and parent training plus risperidone.
Six weeks later, patients who received risperidone along with the background treatments had on average a statistically significantly reduced score on the Nisonger Child Behavior Rating Form Disruptive–Total subscale, compared with the patients on the background treatment only, the study’s primary endpoint (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:47-60).
The results “show that this kind of combination treatment can be effective” in this “very well-thought-out study,” Dr. Greenhill said. In addition, the effects from adding risperidone “occurred quickly,” he noted.
Two other notable reports on ADHD last year documented the steadily rising prevalence of the disorder, and the ongoing value from treatment for controlling symptoms. Based on data collected by telephone interviews with randomly selected U.S. adults during 2003, 2007, and 2011, parent-reported history of a diagnosis of ADHD in children aged 4-17 years old increased from 7.8% in 2003 to 11% in 2011, which worked out to approximately 2 million more children with the diagnosis in 2011, compared with 2003 (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:34-46). In 2011, the median age of initial ADHD diagnosis occurred when children were 6 years old.
In another study, 157 patients aged 6-17 years with ADHD and well controlled on treatment with lisdexamfetamine dimesylate (Vyvanse) were randomized to continued treatment or drug withdrawal. Symptoms recurred quickly in most patients, with about 40% meeting the study’s definition of treatment failure by 2 weeks off treatment, and more than 60% having a significant resumption of symptoms by the time they had been off treatment for a month (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:647-57).
Dr. Greenhill is an adviser to BioBehavioral Diagnostics. He has received research support from Rhodes and Shire.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Approved options increase for ADHD treatment
NEW YORK – Clinicians have more approved drugs options than ever before for treating children with attention-deficit/hyperactivity disorder, and results from two recently published meta-analyses further document the efficacy of several of these treatments.
The drug treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) now starts with prescribing a stimulant, and for refractory cases follows with an alternative stimulant, and then treatment with atomoxetine (Strattera) , followed by a long-acting alpha-2 agonist (such as guanfacine [Intuniv] or clonidine [Kapvay]), followed by a combination of a long-acting alpha-2 agonist plus a stimulant, Dr. Laurence L. Greenhill said at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“I can now cite all these treatments as approved by the FDA [Food and Drug Administration] and as standard of care. There really has been progress” in treating ADHD, said Dr. Greenhill, professor of clinical child and adolescent psychiatry at Columbia University in New York.
A meta-analysis published last year confirmed atomoxetine’s safety and efficacy as monotherapy for treating pediatric ADHD in 25 double-blind, randomized, controlled studies that enrolled a total of nearly 4,000 patients (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:174-87) The results showed a number needed to treat to achieve a clinical benefit of 4, against a number needed to harm to produce an adverse effect of 6, but with serious adverse effects occurring no more often than among patients on placebo. These numbers show both good efficacy and safety for atomoxetine when treating pediatric ADHD, Dr. Greenhill said.
A second meta-analysis published last year assessed the safety and efficacy of long-acting alpha-2 agonists in randomized studies when used either alone (in nine studies) or in combination with a stimulant (in three studies), with a total enrollment in the 12 studies of 2,276 pediatric patients with ADHD (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:153-73). The results showed an effect size for reducing hyperactivity and impulsivity of –0.59 when used as monotherapy and –0.39 when used in combination. As monotherapy the long-acting alpha-2 agonists caused increased fatigue, sedation, and somnolence, as well as more hypotension, bradycardia, and QTc prolongation than did placebo. When used in combination, these drugs caused increased somnolence, hypotension, and bradycardia. Although these results showed that treatment with these drugs require monitoring, the overall safety profile was “very reassuring,” Dr. Greenhill said.
Another notable finding reported last year came from a study of combined treatment with a stimulant and risperidone (Risperdal) for pediatric patients with ADHD and aggression in the Treatment of Severe Childhood Aggression (TOSCA) study. TOSCA randomized 168 patients 6-12 years old with ADHD and either oppositional defiant disorder or conduct disorder to treatment with a stimulant (usually controlled-release methylphenidate) plus parent training, or to the stimulant and parent training plus risperidone.
Six weeks later, patients who received risperidone along with the background treatments had on average a statistically significantly reduced score on the Nisonger Child Behavior Rating Form Disruptive–Total subscale, compared with the patients on the background treatment only, the study’s primary endpoint (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:47-60).
The results “show that this kind of combination treatment can be effective” in this “very well-thought-out study,” Dr. Greenhill said. In addition, the effects from adding risperidone “occurred quickly,” he noted.
Two other notable reports on ADHD last year documented the steadily rising prevalence of the disorder, and the ongoing value from treatment for controlling symptoms. Based on data collected by telephone interviews with randomly selected U.S. adults during 2003, 2007, and 2011, parent-reported history of a diagnosis of ADHD in children aged 4-17 years old increased from 7.8% in 2003 to 11% in 2011, which worked out to approximately 2 million more children with the diagnosis in 2011, compared with 2003 (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:34-46). In 2011, the median age of initial ADHD diagnosis occurred when children were 6 years old.
In another study, 157 patients aged 6-17 years with ADHD and well controlled on treatment with lisdexamfetamine dimesylate (Vyvanse) were randomized to continued treatment or drug withdrawal. Symptoms recurred quickly in most patients, with about 40% meeting the study’s definition of treatment failure by 2 weeks off treatment, and more than 60% having a significant resumption of symptoms by the time they had been off treatment for a month (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:647-57).
Dr. Greenhill is an adviser to BioBehavioral Diagnostics. He has received research support from Rhodes and Shire.
On Twitter @mitchelzoler
NEW YORK – Clinicians have more approved drugs options than ever before for treating children with attention-deficit/hyperactivity disorder, and results from two recently published meta-analyses further document the efficacy of several of these treatments.
The drug treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) now starts with prescribing a stimulant, and for refractory cases follows with an alternative stimulant, and then treatment with atomoxetine (Strattera) , followed by a long-acting alpha-2 agonist (such as guanfacine [Intuniv] or clonidine [Kapvay]), followed by a combination of a long-acting alpha-2 agonist plus a stimulant, Dr. Laurence L. Greenhill said at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“I can now cite all these treatments as approved by the FDA [Food and Drug Administration] and as standard of care. There really has been progress” in treating ADHD, said Dr. Greenhill, professor of clinical child and adolescent psychiatry at Columbia University in New York.
A meta-analysis published last year confirmed atomoxetine’s safety and efficacy as monotherapy for treating pediatric ADHD in 25 double-blind, randomized, controlled studies that enrolled a total of nearly 4,000 patients (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:174-87) The results showed a number needed to treat to achieve a clinical benefit of 4, against a number needed to harm to produce an adverse effect of 6, but with serious adverse effects occurring no more often than among patients on placebo. These numbers show both good efficacy and safety for atomoxetine when treating pediatric ADHD, Dr. Greenhill said.
A second meta-analysis published last year assessed the safety and efficacy of long-acting alpha-2 agonists in randomized studies when used either alone (in nine studies) or in combination with a stimulant (in three studies), with a total enrollment in the 12 studies of 2,276 pediatric patients with ADHD (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:153-73). The results showed an effect size for reducing hyperactivity and impulsivity of –0.59 when used as monotherapy and –0.39 when used in combination. As monotherapy the long-acting alpha-2 agonists caused increased fatigue, sedation, and somnolence, as well as more hypotension, bradycardia, and QTc prolongation than did placebo. When used in combination, these drugs caused increased somnolence, hypotension, and bradycardia. Although these results showed that treatment with these drugs require monitoring, the overall safety profile was “very reassuring,” Dr. Greenhill said.
Another notable finding reported last year came from a study of combined treatment with a stimulant and risperidone (Risperdal) for pediatric patients with ADHD and aggression in the Treatment of Severe Childhood Aggression (TOSCA) study. TOSCA randomized 168 patients 6-12 years old with ADHD and either oppositional defiant disorder or conduct disorder to treatment with a stimulant (usually controlled-release methylphenidate) plus parent training, or to the stimulant and parent training plus risperidone.
Six weeks later, patients who received risperidone along with the background treatments had on average a statistically significantly reduced score on the Nisonger Child Behavior Rating Form Disruptive–Total subscale, compared with the patients on the background treatment only, the study’s primary endpoint (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:47-60).
The results “show that this kind of combination treatment can be effective” in this “very well-thought-out study,” Dr. Greenhill said. In addition, the effects from adding risperidone “occurred quickly,” he noted.
Two other notable reports on ADHD last year documented the steadily rising prevalence of the disorder, and the ongoing value from treatment for controlling symptoms. Based on data collected by telephone interviews with randomly selected U.S. adults during 2003, 2007, and 2011, parent-reported history of a diagnosis of ADHD in children aged 4-17 years old increased from 7.8% in 2003 to 11% in 2011, which worked out to approximately 2 million more children with the diagnosis in 2011, compared with 2003 (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:34-46). In 2011, the median age of initial ADHD diagnosis occurred when children were 6 years old.
In another study, 157 patients aged 6-17 years with ADHD and well controlled on treatment with lisdexamfetamine dimesylate (Vyvanse) were randomized to continued treatment or drug withdrawal. Symptoms recurred quickly in most patients, with about 40% meeting the study’s definition of treatment failure by 2 weeks off treatment, and more than 60% having a significant resumption of symptoms by the time they had been off treatment for a month (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:647-57).
Dr. Greenhill is an adviser to BioBehavioral Diagnostics. He has received research support from Rhodes and Shire.
On Twitter @mitchelzoler
NEW YORK – Clinicians have more approved drugs options than ever before for treating children with attention-deficit/hyperactivity disorder, and results from two recently published meta-analyses further document the efficacy of several of these treatments.
The drug treatment algorithm for attention-deficit/hyperactivity disorder (ADHD) now starts with prescribing a stimulant, and for refractory cases follows with an alternative stimulant, and then treatment with atomoxetine (Strattera) , followed by a long-acting alpha-2 agonist (such as guanfacine [Intuniv] or clonidine [Kapvay]), followed by a combination of a long-acting alpha-2 agonist plus a stimulant, Dr. Laurence L. Greenhill said at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“I can now cite all these treatments as approved by the FDA [Food and Drug Administration] and as standard of care. There really has been progress” in treating ADHD, said Dr. Greenhill, professor of clinical child and adolescent psychiatry at Columbia University in New York.
A meta-analysis published last year confirmed atomoxetine’s safety and efficacy as monotherapy for treating pediatric ADHD in 25 double-blind, randomized, controlled studies that enrolled a total of nearly 4,000 patients (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:174-87) The results showed a number needed to treat to achieve a clinical benefit of 4, against a number needed to harm to produce an adverse effect of 6, but with serious adverse effects occurring no more often than among patients on placebo. These numbers show both good efficacy and safety for atomoxetine when treating pediatric ADHD, Dr. Greenhill said.
A second meta-analysis published last year assessed the safety and efficacy of long-acting alpha-2 agonists in randomized studies when used either alone (in nine studies) or in combination with a stimulant (in three studies), with a total enrollment in the 12 studies of 2,276 pediatric patients with ADHD (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:153-73). The results showed an effect size for reducing hyperactivity and impulsivity of –0.59 when used as monotherapy and –0.39 when used in combination. As monotherapy the long-acting alpha-2 agonists caused increased fatigue, sedation, and somnolence, as well as more hypotension, bradycardia, and QTc prolongation than did placebo. When used in combination, these drugs caused increased somnolence, hypotension, and bradycardia. Although these results showed that treatment with these drugs require monitoring, the overall safety profile was “very reassuring,” Dr. Greenhill said.
Another notable finding reported last year came from a study of combined treatment with a stimulant and risperidone (Risperdal) for pediatric patients with ADHD and aggression in the Treatment of Severe Childhood Aggression (TOSCA) study. TOSCA randomized 168 patients 6-12 years old with ADHD and either oppositional defiant disorder or conduct disorder to treatment with a stimulant (usually controlled-release methylphenidate) plus parent training, or to the stimulant and parent training plus risperidone.
Six weeks later, patients who received risperidone along with the background treatments had on average a statistically significantly reduced score on the Nisonger Child Behavior Rating Form Disruptive–Total subscale, compared with the patients on the background treatment only, the study’s primary endpoint (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:47-60).
The results “show that this kind of combination treatment can be effective” in this “very well-thought-out study,” Dr. Greenhill said. In addition, the effects from adding risperidone “occurred quickly,” he noted.
Two other notable reports on ADHD last year documented the steadily rising prevalence of the disorder, and the ongoing value from treatment for controlling symptoms. Based on data collected by telephone interviews with randomly selected U.S. adults during 2003, 2007, and 2011, parent-reported history of a diagnosis of ADHD in children aged 4-17 years old increased from 7.8% in 2003 to 11% in 2011, which worked out to approximately 2 million more children with the diagnosis in 2011, compared with 2003 (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:34-46). In 2011, the median age of initial ADHD diagnosis occurred when children were 6 years old.
In another study, 157 patients aged 6-17 years with ADHD and well controlled on treatment with lisdexamfetamine dimesylate (Vyvanse) were randomized to continued treatment or drug withdrawal. Symptoms recurred quickly in most patients, with about 40% meeting the study’s definition of treatment failure by 2 weeks off treatment, and more than 60% having a significant resumption of symptoms by the time they had been off treatment for a month (J. Am. Acad. Child Adolesc. Psychiatry 2014;53:647-57).
Dr. Greenhill is an adviser to BioBehavioral Diagnostics. He has received research support from Rhodes and Shire.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
New pediatric OCD syndrome features abrupt onset
BROOKLYN, N.Y.– Children who develop an obsessive-compulsive disorder with a dramatically acute onset might have a newly described condition known as Pediatric Acute-Onset Neuropsychiatric Syndrome.
The syndrome is so new that a U.S.-based expert panel, the Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) Consensus Conference, met in May 2013 to devise the first recommendations for the clinical assessment of children with suspected PANS. A report was released last October (J. Child Adolesc. Psycharmacol. 2014 [doi:1089/cap.2014.0084]).
“The key issue is the acute onset,” Dr. Barbara J. Coffey said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “Typical obsessive-compulsive disorder (OCD) is not dramatic in onset in kids, but with PANS, which will probably involve 10% or less of all children with OCD, these kids are perfectly fine and developing normally and then one day they suddenly won’t go to school, won’t touch anything, won’t eat, and look terror stricken,” said Dr. Coffey, professor of psychiatry and chief of the Tics and Tourette’s Clinical and Research Program at Mount Sinai Hospital in New York.
PANS as a diagnostic entity traces its roots back to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), first described in 1998 by Dr. Susan E. Swedo and her associates at the National Institute of Mental Health (Am. J. Psychiatry 1998;155:264-71). PANDAS more recently “morphed” into PANS as research identified potential infectious triggers beyond group A streptococcus as well as noninfectious environmental or metabolic factors that could trigger an acute-onset OCD similar to PANDAS, Dr. Coffey said.
The new PANS diagnostic criteria recommended by the 2013 consensus panel defined the syndrome as an “abrupt, dramatic onset of OCD or severely restricted food intake with at least two additional, concurrent neuropsychiatric symptoms, also with acute onset, from this list: anxiety; emotional lability, depression, or both; irritability, aggression, or severe oppositional behavior or some combination of these; behavioral regression; deterioration in school performance; sensory or motor abnormalities; and somatic signs or symptoms, including sleep disturbance, enuresis, or urinary frequency.
Another key diagnostic touchstone is that the symptoms cannot be explained by another neurologic or medical disorder, which means workup of a child with suspected PANS must be comprehensive and must rule out other plausible causes. “PANS is a disorder of exclusion; you need to rule out everything else,” Dr. Coffey said. The differential diagnosis includes OCD, anorexia nervosa, avoidant /restrictive food intake disorder, Tourette syndrome, transient tic disorder, bipolar disorder, Sydenham’s chorea, autoimmune encephalitis, systemic autoimmune disease, and Wilson’s disease.
A recent report from researchers at the University of South Florida in Tampa presented findings from a study of 43 children aged 4-14 years, diagnosed with PANS, who presented with more than 40 clinical symptoms ranging from anxiety and mood and behavioral symptoms in all patients to features such as sleep disturbance, tics, urinary problems, and attention-deficit/hyperactivity disorder (J. Child Adolesc. Psychopharmacol. 2014 [doi:10.1089/cap.2014.0062]). “What is remarkable to me is that literally every psychiatric symptoms known is listed,” Dr. Coffey said. “It is a challenge to work your way through these.”
The consensus group recommended that workup of a child with suspected PANS should include a family history, medical history, physical examination, psychiatric evaluation, infectious diseases evaluation, neurological assessment, assessment of symptoms and history to gauge possible immune dysfunction, assessment of somatic symptoms, and genetic evaluation.
The Tampa study of 43 PANS cases documented a long list of apparent triggers, including several types of infection as well as immune disorders such as Kawasaki’s disease, allergies, and asthma. Among the infections implicated as triggers, group A streptococcus remained the most frequent, in 58% of cases, but other apparent triggers included Mycoplasma pneumoniae, in 12%, and an upper respiratory infection in 37%.
When an infection is the suspected trigger, management includes antibiotic treatment to eradicate the pathogen, usually with a penicillin or a cephalosporin, but azithromycin can be helpful because of its efficacy against Mycoplasma. Treatment usually needs to continue for 4-6 weeks, and in many cases much longer. Management also should include clinical treatments for psychiatric manifestations, such as for OCD, Dr. Coffey said.
Dr. Coffey has served on advisory boards for Eli Lilly, Jazz, and Novartis, has been a speaker on behalf of Quintiles, and has received research grants from Boehringer Ingelheim, Bristol-Myers Squibb, Catalyst, Eli Lilly, Otsuka, and Shire.
On Twitter @mitchelzoler
BROOKLYN, N.Y.– Children who develop an obsessive-compulsive disorder with a dramatically acute onset might have a newly described condition known as Pediatric Acute-Onset Neuropsychiatric Syndrome.
The syndrome is so new that a U.S.-based expert panel, the Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) Consensus Conference, met in May 2013 to devise the first recommendations for the clinical assessment of children with suspected PANS. A report was released last October (J. Child Adolesc. Psycharmacol. 2014 [doi:1089/cap.2014.0084]).
“The key issue is the acute onset,” Dr. Barbara J. Coffey said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “Typical obsessive-compulsive disorder (OCD) is not dramatic in onset in kids, but with PANS, which will probably involve 10% or less of all children with OCD, these kids are perfectly fine and developing normally and then one day they suddenly won’t go to school, won’t touch anything, won’t eat, and look terror stricken,” said Dr. Coffey, professor of psychiatry and chief of the Tics and Tourette’s Clinical and Research Program at Mount Sinai Hospital in New York.
PANS as a diagnostic entity traces its roots back to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), first described in 1998 by Dr. Susan E. Swedo and her associates at the National Institute of Mental Health (Am. J. Psychiatry 1998;155:264-71). PANDAS more recently “morphed” into PANS as research identified potential infectious triggers beyond group A streptococcus as well as noninfectious environmental or metabolic factors that could trigger an acute-onset OCD similar to PANDAS, Dr. Coffey said.
The new PANS diagnostic criteria recommended by the 2013 consensus panel defined the syndrome as an “abrupt, dramatic onset of OCD or severely restricted food intake with at least two additional, concurrent neuropsychiatric symptoms, also with acute onset, from this list: anxiety; emotional lability, depression, or both; irritability, aggression, or severe oppositional behavior or some combination of these; behavioral regression; deterioration in school performance; sensory or motor abnormalities; and somatic signs or symptoms, including sleep disturbance, enuresis, or urinary frequency.
Another key diagnostic touchstone is that the symptoms cannot be explained by another neurologic or medical disorder, which means workup of a child with suspected PANS must be comprehensive and must rule out other plausible causes. “PANS is a disorder of exclusion; you need to rule out everything else,” Dr. Coffey said. The differential diagnosis includes OCD, anorexia nervosa, avoidant /restrictive food intake disorder, Tourette syndrome, transient tic disorder, bipolar disorder, Sydenham’s chorea, autoimmune encephalitis, systemic autoimmune disease, and Wilson’s disease.
A recent report from researchers at the University of South Florida in Tampa presented findings from a study of 43 children aged 4-14 years, diagnosed with PANS, who presented with more than 40 clinical symptoms ranging from anxiety and mood and behavioral symptoms in all patients to features such as sleep disturbance, tics, urinary problems, and attention-deficit/hyperactivity disorder (J. Child Adolesc. Psychopharmacol. 2014 [doi:10.1089/cap.2014.0062]). “What is remarkable to me is that literally every psychiatric symptoms known is listed,” Dr. Coffey said. “It is a challenge to work your way through these.”
The consensus group recommended that workup of a child with suspected PANS should include a family history, medical history, physical examination, psychiatric evaluation, infectious diseases evaluation, neurological assessment, assessment of symptoms and history to gauge possible immune dysfunction, assessment of somatic symptoms, and genetic evaluation.
The Tampa study of 43 PANS cases documented a long list of apparent triggers, including several types of infection as well as immune disorders such as Kawasaki’s disease, allergies, and asthma. Among the infections implicated as triggers, group A streptococcus remained the most frequent, in 58% of cases, but other apparent triggers included Mycoplasma pneumoniae, in 12%, and an upper respiratory infection in 37%.
When an infection is the suspected trigger, management includes antibiotic treatment to eradicate the pathogen, usually with a penicillin or a cephalosporin, but azithromycin can be helpful because of its efficacy against Mycoplasma. Treatment usually needs to continue for 4-6 weeks, and in many cases much longer. Management also should include clinical treatments for psychiatric manifestations, such as for OCD, Dr. Coffey said.
Dr. Coffey has served on advisory boards for Eli Lilly, Jazz, and Novartis, has been a speaker on behalf of Quintiles, and has received research grants from Boehringer Ingelheim, Bristol-Myers Squibb, Catalyst, Eli Lilly, Otsuka, and Shire.
On Twitter @mitchelzoler
BROOKLYN, N.Y.– Children who develop an obsessive-compulsive disorder with a dramatically acute onset might have a newly described condition known as Pediatric Acute-Onset Neuropsychiatric Syndrome.
The syndrome is so new that a U.S.-based expert panel, the Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) Consensus Conference, met in May 2013 to devise the first recommendations for the clinical assessment of children with suspected PANS. A report was released last October (J. Child Adolesc. Psycharmacol. 2014 [doi:1089/cap.2014.0084]).
“The key issue is the acute onset,” Dr. Barbara J. Coffey said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “Typical obsessive-compulsive disorder (OCD) is not dramatic in onset in kids, but with PANS, which will probably involve 10% or less of all children with OCD, these kids are perfectly fine and developing normally and then one day they suddenly won’t go to school, won’t touch anything, won’t eat, and look terror stricken,” said Dr. Coffey, professor of psychiatry and chief of the Tics and Tourette’s Clinical and Research Program at Mount Sinai Hospital in New York.
PANS as a diagnostic entity traces its roots back to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), first described in 1998 by Dr. Susan E. Swedo and her associates at the National Institute of Mental Health (Am. J. Psychiatry 1998;155:264-71). PANDAS more recently “morphed” into PANS as research identified potential infectious triggers beyond group A streptococcus as well as noninfectious environmental or metabolic factors that could trigger an acute-onset OCD similar to PANDAS, Dr. Coffey said.
The new PANS diagnostic criteria recommended by the 2013 consensus panel defined the syndrome as an “abrupt, dramatic onset of OCD or severely restricted food intake with at least two additional, concurrent neuropsychiatric symptoms, also with acute onset, from this list: anxiety; emotional lability, depression, or both; irritability, aggression, or severe oppositional behavior or some combination of these; behavioral regression; deterioration in school performance; sensory or motor abnormalities; and somatic signs or symptoms, including sleep disturbance, enuresis, or urinary frequency.
Another key diagnostic touchstone is that the symptoms cannot be explained by another neurologic or medical disorder, which means workup of a child with suspected PANS must be comprehensive and must rule out other plausible causes. “PANS is a disorder of exclusion; you need to rule out everything else,” Dr. Coffey said. The differential diagnosis includes OCD, anorexia nervosa, avoidant /restrictive food intake disorder, Tourette syndrome, transient tic disorder, bipolar disorder, Sydenham’s chorea, autoimmune encephalitis, systemic autoimmune disease, and Wilson’s disease.
A recent report from researchers at the University of South Florida in Tampa presented findings from a study of 43 children aged 4-14 years, diagnosed with PANS, who presented with more than 40 clinical symptoms ranging from anxiety and mood and behavioral symptoms in all patients to features such as sleep disturbance, tics, urinary problems, and attention-deficit/hyperactivity disorder (J. Child Adolesc. Psychopharmacol. 2014 [doi:10.1089/cap.2014.0062]). “What is remarkable to me is that literally every psychiatric symptoms known is listed,” Dr. Coffey said. “It is a challenge to work your way through these.”
The consensus group recommended that workup of a child with suspected PANS should include a family history, medical history, physical examination, psychiatric evaluation, infectious diseases evaluation, neurological assessment, assessment of symptoms and history to gauge possible immune dysfunction, assessment of somatic symptoms, and genetic evaluation.
The Tampa study of 43 PANS cases documented a long list of apparent triggers, including several types of infection as well as immune disorders such as Kawasaki’s disease, allergies, and asthma. Among the infections implicated as triggers, group A streptococcus remained the most frequent, in 58% of cases, but other apparent triggers included Mycoplasma pneumoniae, in 12%, and an upper respiratory infection in 37%.
When an infection is the suspected trigger, management includes antibiotic treatment to eradicate the pathogen, usually with a penicillin or a cephalosporin, but azithromycin can be helpful because of its efficacy against Mycoplasma. Treatment usually needs to continue for 4-6 weeks, and in many cases much longer. Management also should include clinical treatments for psychiatric manifestations, such as for OCD, Dr. Coffey said.
Dr. Coffey has served on advisory boards for Eli Lilly, Jazz, and Novartis, has been a speaker on behalf of Quintiles, and has received research grants from Boehringer Ingelheim, Bristol-Myers Squibb, Catalyst, Eli Lilly, Otsuka, and Shire.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Psychopharmacology in primary care faces challenges
NEW YORK – Incorporating psychiatric assessment and treatment into a busy primary care practice is not easy, but it is doable.
“Every time I start a patient on a [psychiatric] medication I have a moment of trepidation, even though I have now done this for about 4 years,” Dr. Diane E. Bloomfield said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “It still does not come easily to me,” said Dr. Bloomfield, a general-practice pediatrician at the family care center of Montefiore Medical Center in New York.
Inclusion of mental health as part of routine pediatric practice is a new concept. “Until recently, we pediatricians did not think of mental health as part of daily practice,” she said.
Dr. Bloomfield cited three factors that pose the greatest challenges to integrating psychiatry into her practice: time constraints, reimbursement, and knowledge gaps.
Reimbursement limitations contribute to the time issue. Most of Dr. Bloomfield’s patients are covered by Medicaid, which allows for a 15-minute session with each patient and family. That’s barely enough time to assess a child’s social and emotional development, in addition to all the other bases she must cover during an appointment, but she tries to carve out time for more challenging cases by scheduling them near the end of her day.
Dr. Bloomfield said that she routinely administers the Pediatric Symptom Checklist to all her patients who are 4-18 years old. She recommended that pediatricians take advantage of all the screening tools that the American Academy of Pediatrics (AAP) includes with its practice guidelines, along with the other mental health resources on the AAP website. Using improved coding on her billings also allowed her to arrange reimbursement for more of the time she spends on mental health conditions.
Reducing the knowledge gap can be more complicated. Many pediatricians, Dr. Bloomfield included, did not prescribe methylphenidate or selective serotonin reuptake inhibitors (SSRIs) during training. The boxed warning that the Food and Drug Administration put on antidepressants starting in 2004 has been another factor dampening drug psychotherapy by pediatricians, dissuading them from treating depression, she said.
Some of these dilemmas decreased when the AAP released in 2010 two algorithms that provided a framework for identifying and managing mental health and substance abuse concerns in primary care (Pediatrics 2010;125:S109-25). Neither algorithm, however, dealt with psychopharmacology.
Survey results have shown that many pediatricians become more willing to prescribe SSRIs if they can consult with a psychiatrist about the diagnosis and treatment. Pediatricians are generally more comfortable prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD). “We see a lot of kids with ADHD, so we think we need to do something for them. In addition, medications for ADHD either work or don’t work, but they don’t cause suicidality,” Dr. Bloomfield said.
An AAP working group that included Dr. Bloomfield recently introduced a pilot program for a revised residency curriculum that includes a mental health module as well as a second module that focuses on anxiety diagnosis and management. In addition, certain states, including Massachusetts and New York, have introduced postresidency education programs that deal with child and adolescent psychiatry, including drug treatment.
Dr. Bloomfield said that she had taken training courses in the New York program. “It gave me the tools for evaluating patients and it taught me how to start medications in a safe way.” The midcareer training she received through New York’s Child and Adolescent Psychiatry for Primary Care program “made me much more confident that I could address my patients’ psychosocial needs.” Today, Dr. Bloomfield said she tries to manage children and adolescents with mild depression herself and not refer them to a specialist.
“Pediatricians are quite willing” to include psychiatric interventions in their practice, but we need support from psychiatrists to receive the necessary education and adequate reimbursement,” Dr. Bloomfield said.
On Twitter @mitchelzoler
NEW YORK – Incorporating psychiatric assessment and treatment into a busy primary care practice is not easy, but it is doable.
“Every time I start a patient on a [psychiatric] medication I have a moment of trepidation, even though I have now done this for about 4 years,” Dr. Diane E. Bloomfield said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “It still does not come easily to me,” said Dr. Bloomfield, a general-practice pediatrician at the family care center of Montefiore Medical Center in New York.
Inclusion of mental health as part of routine pediatric practice is a new concept. “Until recently, we pediatricians did not think of mental health as part of daily practice,” she said.
Dr. Bloomfield cited three factors that pose the greatest challenges to integrating psychiatry into her practice: time constraints, reimbursement, and knowledge gaps.
Reimbursement limitations contribute to the time issue. Most of Dr. Bloomfield’s patients are covered by Medicaid, which allows for a 15-minute session with each patient and family. That’s barely enough time to assess a child’s social and emotional development, in addition to all the other bases she must cover during an appointment, but she tries to carve out time for more challenging cases by scheduling them near the end of her day.
Dr. Bloomfield said that she routinely administers the Pediatric Symptom Checklist to all her patients who are 4-18 years old. She recommended that pediatricians take advantage of all the screening tools that the American Academy of Pediatrics (AAP) includes with its practice guidelines, along with the other mental health resources on the AAP website. Using improved coding on her billings also allowed her to arrange reimbursement for more of the time she spends on mental health conditions.
Reducing the knowledge gap can be more complicated. Many pediatricians, Dr. Bloomfield included, did not prescribe methylphenidate or selective serotonin reuptake inhibitors (SSRIs) during training. The boxed warning that the Food and Drug Administration put on antidepressants starting in 2004 has been another factor dampening drug psychotherapy by pediatricians, dissuading them from treating depression, she said.
Some of these dilemmas decreased when the AAP released in 2010 two algorithms that provided a framework for identifying and managing mental health and substance abuse concerns in primary care (Pediatrics 2010;125:S109-25). Neither algorithm, however, dealt with psychopharmacology.
Survey results have shown that many pediatricians become more willing to prescribe SSRIs if they can consult with a psychiatrist about the diagnosis and treatment. Pediatricians are generally more comfortable prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD). “We see a lot of kids with ADHD, so we think we need to do something for them. In addition, medications for ADHD either work or don’t work, but they don’t cause suicidality,” Dr. Bloomfield said.
An AAP working group that included Dr. Bloomfield recently introduced a pilot program for a revised residency curriculum that includes a mental health module as well as a second module that focuses on anxiety diagnosis and management. In addition, certain states, including Massachusetts and New York, have introduced postresidency education programs that deal with child and adolescent psychiatry, including drug treatment.
Dr. Bloomfield said that she had taken training courses in the New York program. “It gave me the tools for evaluating patients and it taught me how to start medications in a safe way.” The midcareer training she received through New York’s Child and Adolescent Psychiatry for Primary Care program “made me much more confident that I could address my patients’ psychosocial needs.” Today, Dr. Bloomfield said she tries to manage children and adolescents with mild depression herself and not refer them to a specialist.
“Pediatricians are quite willing” to include psychiatric interventions in their practice, but we need support from psychiatrists to receive the necessary education and adequate reimbursement,” Dr. Bloomfield said.
On Twitter @mitchelzoler
NEW YORK – Incorporating psychiatric assessment and treatment into a busy primary care practice is not easy, but it is doable.
“Every time I start a patient on a [psychiatric] medication I have a moment of trepidation, even though I have now done this for about 4 years,” Dr. Diane E. Bloomfield said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. “It still does not come easily to me,” said Dr. Bloomfield, a general-practice pediatrician at the family care center of Montefiore Medical Center in New York.
Inclusion of mental health as part of routine pediatric practice is a new concept. “Until recently, we pediatricians did not think of mental health as part of daily practice,” she said.
Dr. Bloomfield cited three factors that pose the greatest challenges to integrating psychiatry into her practice: time constraints, reimbursement, and knowledge gaps.
Reimbursement limitations contribute to the time issue. Most of Dr. Bloomfield’s patients are covered by Medicaid, which allows for a 15-minute session with each patient and family. That’s barely enough time to assess a child’s social and emotional development, in addition to all the other bases she must cover during an appointment, but she tries to carve out time for more challenging cases by scheduling them near the end of her day.
Dr. Bloomfield said that she routinely administers the Pediatric Symptom Checklist to all her patients who are 4-18 years old. She recommended that pediatricians take advantage of all the screening tools that the American Academy of Pediatrics (AAP) includes with its practice guidelines, along with the other mental health resources on the AAP website. Using improved coding on her billings also allowed her to arrange reimbursement for more of the time she spends on mental health conditions.
Reducing the knowledge gap can be more complicated. Many pediatricians, Dr. Bloomfield included, did not prescribe methylphenidate or selective serotonin reuptake inhibitors (SSRIs) during training. The boxed warning that the Food and Drug Administration put on antidepressants starting in 2004 has been another factor dampening drug psychotherapy by pediatricians, dissuading them from treating depression, she said.
Some of these dilemmas decreased when the AAP released in 2010 two algorithms that provided a framework for identifying and managing mental health and substance abuse concerns in primary care (Pediatrics 2010;125:S109-25). Neither algorithm, however, dealt with psychopharmacology.
Survey results have shown that many pediatricians become more willing to prescribe SSRIs if they can consult with a psychiatrist about the diagnosis and treatment. Pediatricians are generally more comfortable prescribing stimulants for attention-deficit/hyperactivity disorder (ADHD). “We see a lot of kids with ADHD, so we think we need to do something for them. In addition, medications for ADHD either work or don’t work, but they don’t cause suicidality,” Dr. Bloomfield said.
An AAP working group that included Dr. Bloomfield recently introduced a pilot program for a revised residency curriculum that includes a mental health module as well as a second module that focuses on anxiety diagnosis and management. In addition, certain states, including Massachusetts and New York, have introduced postresidency education programs that deal with child and adolescent psychiatry, including drug treatment.
Dr. Bloomfield said that she had taken training courses in the New York program. “It gave me the tools for evaluating patients and it taught me how to start medications in a safe way.” The midcareer training she received through New York’s Child and Adolescent Psychiatry for Primary Care program “made me much more confident that I could address my patients’ psychosocial needs.” Today, Dr. Bloomfield said she tries to manage children and adolescents with mild depression herself and not refer them to a specialist.
“Pediatricians are quite willing” to include psychiatric interventions in their practice, but we need support from psychiatrists to receive the necessary education and adequate reimbursement,” Dr. Bloomfield said.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
AUDIO: Training broadens psychotherapy in primary care
NEW YORK– The REACH Institute trains primary care clinicians to include more mental health assessment and management in their practices, Dr. Lawrence V. Amsel said during an interview at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Many primary care clinicians don’t feel adequately trained to interview patients, guage their mental status, and then act on the findings by treatment or referral. But over the past decade, psychiatrists have developed and validated several tools that are appropriate for a primary care practice, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York, and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. The program also tries to make clinicians comfortable prescribing psychiatric medications and links them with psychiatrists who can provide consultations when needed.
“It’s kind of like a psychiatrist extender,” when a psychiatrist consults with several primary care clinicians, which allows for improved psychiatric care of many more patients, he said.
Dr. Amsel is on the faculty of the REACH Institute.
On Twitter@mitchelzoler
NEW YORK– The REACH Institute trains primary care clinicians to include more mental health assessment and management in their practices, Dr. Lawrence V. Amsel said during an interview at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Many primary care clinicians don’t feel adequately trained to interview patients, guage their mental status, and then act on the findings by treatment or referral. But over the past decade, psychiatrists have developed and validated several tools that are appropriate for a primary care practice, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York, and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. The program also tries to make clinicians comfortable prescribing psychiatric medications and links them with psychiatrists who can provide consultations when needed.
“It’s kind of like a psychiatrist extender,” when a psychiatrist consults with several primary care clinicians, which allows for improved psychiatric care of many more patients, he said.
Dr. Amsel is on the faculty of the REACH Institute.
On Twitter@mitchelzoler
NEW YORK– The REACH Institute trains primary care clinicians to include more mental health assessment and management in their practices, Dr. Lawrence V. Amsel said during an interview at the psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
Many primary care clinicians don’t feel adequately trained to interview patients, guage their mental status, and then act on the findings by treatment or referral. But over the past decade, psychiatrists have developed and validated several tools that are appropriate for a primary care practice, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York, and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. The program also tries to make clinicians comfortable prescribing psychiatric medications and links them with psychiatrists who can provide consultations when needed.
“It’s kind of like a psychiatrist extender,” when a psychiatrist consults with several primary care clinicians, which allows for improved psychiatric care of many more patients, he said.
Dr. Amsel is on the faculty of the REACH Institute.
On Twitter@mitchelzoler
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Program fosters psychotherapy in primary care practices
NEW YORK – Making primary care clinicians comfortable performing basic mental health diagnoses and management is vital for adequately treating U.S. patients with psychiatric disorders, Dr. Lawrence V. Amsel said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
In many parts of the United States there are “far fewer mental health practitioners than are needed.” Training primary care clinicians so that they are willing to do more mental health work can help address this issue, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. “It’s like producing psychiatric extenders.” By consulting with a broad range of primary care clinicians, a psychiatrist can take care of a lot more kids than usual in a single psychiatric practice,” Dr. Amsel said.
But encouraging primary care providers to become more active in mental health diagnosis and management is not easy. “Most prescriptions for mental health indications are now written by primary care clinicians, but they often describe themselves as uncomfortable prescribing these medications and not adequately trained,” Dr. Amsel said in an interview.
“Their main anxiety comes from making the wrong diagnosis and then doing harm” as a consequence of their error, he explained during his talk at the meeting. Training by the REACH curriculum highlights the role of well-validated tools now available for refining assessment of a patient and boosting confidence in the diagnosis. This includes instruments like the Pediatric Symptom Checklist and the Mental Status Exam. “Reliable and validated tools are available to improve identification and assessment of mental health problems that can be used efficiently in clinical practice,” Dr. Amsel said.
Another aspect to mental health management that often troubles primary care clinicians is doubt about their knowledge and ability to safely and effectively prescribe psychiatric medications. The REACH Institute curriculum tells clinicians to focus on each patient’s primary diagnosis and treat that first, and whenever possible to use medications that are evidence based, with good supporting documentation from double-blind, randomized, controlled trials.
“We recommend that clinicians get a summary slide of the evidence that they can show to patients or family members if necessary to make clear that there is a scientific basis for the treatment and that it is based on facts and data rather than on opinion,” he said.
Training for primary care clinicians also emphasizes that management goes beyond drug treatment and also must include a psychosocial plan for each patient.
Members of the health care system have begun to “recognize that mental health is responsible for much if not most disability. Until now, this importance had not been recognized. Now that it is being recognized, I think people will develop systems that increase the capacity for identifying children with mental health issues and provide them with improved care,” Dr. Amsel said.
Dr. Amsel had no disclosures aside from his work for the REACH Institute.
On Twitter @mitchelzoler
NEW YORK – Making primary care clinicians comfortable performing basic mental health diagnoses and management is vital for adequately treating U.S. patients with psychiatric disorders, Dr. Lawrence V. Amsel said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
In many parts of the United States there are “far fewer mental health practitioners than are needed.” Training primary care clinicians so that they are willing to do more mental health work can help address this issue, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. “It’s like producing psychiatric extenders.” By consulting with a broad range of primary care clinicians, a psychiatrist can take care of a lot more kids than usual in a single psychiatric practice,” Dr. Amsel said.
But encouraging primary care providers to become more active in mental health diagnosis and management is not easy. “Most prescriptions for mental health indications are now written by primary care clinicians, but they often describe themselves as uncomfortable prescribing these medications and not adequately trained,” Dr. Amsel said in an interview.
“Their main anxiety comes from making the wrong diagnosis and then doing harm” as a consequence of their error, he explained during his talk at the meeting. Training by the REACH curriculum highlights the role of well-validated tools now available for refining assessment of a patient and boosting confidence in the diagnosis. This includes instruments like the Pediatric Symptom Checklist and the Mental Status Exam. “Reliable and validated tools are available to improve identification and assessment of mental health problems that can be used efficiently in clinical practice,” Dr. Amsel said.
Another aspect to mental health management that often troubles primary care clinicians is doubt about their knowledge and ability to safely and effectively prescribe psychiatric medications. The REACH Institute curriculum tells clinicians to focus on each patient’s primary diagnosis and treat that first, and whenever possible to use medications that are evidence based, with good supporting documentation from double-blind, randomized, controlled trials.
“We recommend that clinicians get a summary slide of the evidence that they can show to patients or family members if necessary to make clear that there is a scientific basis for the treatment and that it is based on facts and data rather than on opinion,” he said.
Training for primary care clinicians also emphasizes that management goes beyond drug treatment and also must include a psychosocial plan for each patient.
Members of the health care system have begun to “recognize that mental health is responsible for much if not most disability. Until now, this importance had not been recognized. Now that it is being recognized, I think people will develop systems that increase the capacity for identifying children with mental health issues and provide them with improved care,” Dr. Amsel said.
Dr. Amsel had no disclosures aside from his work for the REACH Institute.
On Twitter @mitchelzoler
NEW YORK – Making primary care clinicians comfortable performing basic mental health diagnoses and management is vital for adequately treating U.S. patients with psychiatric disorders, Dr. Lawrence V. Amsel said at a psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
In many parts of the United States there are “far fewer mental health practitioners than are needed.” Training primary care clinicians so that they are willing to do more mental health work can help address this issue, said Dr. Amsel, a clinical psychiatrist at Columbia University in New York and a faculty member of the REACH Institute, a New York–based nonprofit focused on disseminating mental health skills to primary care clinicians, teachers, parents, and others. “It’s like producing psychiatric extenders.” By consulting with a broad range of primary care clinicians, a psychiatrist can take care of a lot more kids than usual in a single psychiatric practice,” Dr. Amsel said.
But encouraging primary care providers to become more active in mental health diagnosis and management is not easy. “Most prescriptions for mental health indications are now written by primary care clinicians, but they often describe themselves as uncomfortable prescribing these medications and not adequately trained,” Dr. Amsel said in an interview.
“Their main anxiety comes from making the wrong diagnosis and then doing harm” as a consequence of their error, he explained during his talk at the meeting. Training by the REACH curriculum highlights the role of well-validated tools now available for refining assessment of a patient and boosting confidence in the diagnosis. This includes instruments like the Pediatric Symptom Checklist and the Mental Status Exam. “Reliable and validated tools are available to improve identification and assessment of mental health problems that can be used efficiently in clinical practice,” Dr. Amsel said.
Another aspect to mental health management that often troubles primary care clinicians is doubt about their knowledge and ability to safely and effectively prescribe psychiatric medications. The REACH Institute curriculum tells clinicians to focus on each patient’s primary diagnosis and treat that first, and whenever possible to use medications that are evidence based, with good supporting documentation from double-blind, randomized, controlled trials.
“We recommend that clinicians get a summary slide of the evidence that they can show to patients or family members if necessary to make clear that there is a scientific basis for the treatment and that it is based on facts and data rather than on opinion,” he said.
Training for primary care clinicians also emphasizes that management goes beyond drug treatment and also must include a psychosocial plan for each patient.
Members of the health care system have begun to “recognize that mental health is responsible for much if not most disability. Until now, this importance had not been recognized. Now that it is being recognized, I think people will develop systems that increase the capacity for identifying children with mental health issues and provide them with improved care,” Dr. Amsel said.
Dr. Amsel had no disclosures aside from his work for the REACH Institute.
On Twitter @mitchelzoler
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
