Thank you again to all the volunteers that made the event a success, and hopefully a useful resource for education and encouragement to the community.

Introduction

It is estimated that in any given year, ADHD affects 4.1 percent of adults, ages 18-44.  Although everyone has occasional lapses in attention and concentration, people with ADHD have symptoms that significantly affects their ability to function in school, work, home, and social settings.

Symptoms:

ADHD in adults can be conceptualize as a disorder of our brain’s “executive functions”.  The executive functions include planning, initiating and inhibiting actions, selecting relevant sensory information to focus on, etc.  Impairment of the executive functions can result in many of the following symptoms:

Inattentiveness as displayed in:

-Difficulty paying attention to details, or careless mistakes in schoolwork, work, or other activities.

-Difficulty keeping attention on tasks or activities

-Difficulty following instructions on tasks despite understanding instructions

-Difficulty focusing on the current conversation because of distracting background noises or conversations

-Difficulty organizing activities

-Difficulty focusing on tasks for a long period of time

-Often misplacing or losing belongings

-Often easily distracted

-Often forgetful in daily activities

Hyperactivity as displayed in:

-Often feeling fidgety during meetings, resulting in fidgeting with hands or feet, shifting positions in seat, or standing up from seat when remaining in the seat is expected.

-Often feeling restless, feeling “driven by a motor”, or always “on the go”

-Often talking excessively

Impulsivity as displayed in:

-Often blurting out answers before questions have been finished, interrupting others as they are speaking, or intruding on others’ conversations

-Difficulty waiting one’s turn

Diagnosis

Diagnosis of ADHD in an adult is dependent on a history of ADHD symptoms in childhood before age 7.  If ADHD-like symptoms suddenly emerge in adulthood without a childhood history, it is likely that a different disorder with overlapping symptoms is responsible.  Major depression and bipolar disorder, among others, can mimic different aspects of ADHD.

There must also be clear evidence of significant impairment of functioning from ADHD symptoms in more than one realm (e.g. home, school, work and social settings).

There are three major types of ADHD:

1.ADHD Predominantly Inattentive Type: formerly known as “Attention Deficit Disorder”, or ADD.
2.ADHD, Predominantly Hyperactive-Impulsive Type
3.ADHD, Combined Type: ADHD combined type is a combination of the symptoms of inattentive type and hyperactive-impulsive type.

Of note, many still use the term “Attention Deficit Disorder” or “ADD” to refer to ADHD – Inattentive Type.  This is because the term “ADD” was used until 1987 when it was changed to ADHD – Inattentive Type with the DSM-III-R.

ADHD is diagnosed clinically, based on history.  Oftentimes, information from parents or teachers is helpful.  Psychological testing is sometimes used to help diagnose unclear cases of ADHD.  There is no blood test or imaging test that is diagnostic for ADHD.  However, if there are clinical signs that suggest a medical problem may be contributing to ADHD symptoms, your doctor may order blood tests or brain imaging tests to see if there are any other factors contributing to the ADHD symptoms.

Treatment

Treatment can involve therapy, medications, or combined treatment, depending on patient preference and severity of symptoms.

• Therapy: Behavior therapy has been shown to be effective in children with ADHD.  In adults, elements of cognitive behavioral therapy (CBT) and cognitive rehabilitation including compensatory strategies can be helpful to cope more effectively with the disorder.
• Medications: The most commonly used medications for treating ADHD are stimulants.  These medications are controlled substances and are generally prescribed by a psychiatrist or neurologist.  There are two major classes of stimulants: amphetamine class stimulants and methylphenidate class stimulants.  There are also other types of ADHD medications that do not fall into the amphetamine or methylphenidate classes.  Click the links below for more information on the different types of ADHD medications:
  • Amphetamine class stimulants
  • Methylphenidate class stimulants
  • Other ADHD medications

Treatment with stimulants needs to be carefully monitored.  Your physician will need to know about any personal or family history of cardiac problems including heart attacks, high blood pressure, arrthymias, etc.  You may need to undergo an electrocardiogram (EKG) or further testing prior to initiating treatment if there is the possibility of cardiac problems.   Your physician will want to monitor your blood pressure and heart rate periodically, as those can be increased by stimulants.  Common side effects that will also need to be monitored is possible weight loss because of appetite suppression, and slowed growth in children.

• Combined Treatment: The combination of therapy and medications can be the most effective form of treatment for some patients.

For Further Information

See the Wikipedia entry on ADHD, or contact a qualified mental health professional.

Article written 12/19/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  Image © 2009 Bob Lin.  All rights reserved.

Whereas medications in the methylphenidate and amphetamine classes all act by increasing the release of norepinephrine and dopamine and blocking their reuptake, the following ADHD medications act in different ways.

Other ADHD Medications:

Bupropion (generic) – Inhibits norepinephrine and dopamine reuptake.  Also used as an antidepressant and smoking cessation aid.  Available as generic or as brand-name Wellbutrin.

Strattera (atomoxetine) – Inhibits norepinephrine reuptake. Unique in that it does not become therapeutic until 4-8 weeks after initiation.

Intuniv (guanfacine) – Stimulates alpha2-adrenergic receptors.  Not to be confused with guaifenesin (an over the counter cough medicine).

Provigil (modafinil) – exact mechanism of action unknown, but affects the dopamine system.  Used in the military to prolong alertness.  Not officially FDA approved for the treatment of ADHD, but at times prescribed “off-label”.

Article written 12/19/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  All rights reserved.

Amphetamines act by increasing the release of norepinephrine and dopamine and blocking their reuptake.

Amphetamine Class Stimulants:

Dextroamphetamine (generic) – Duration 3-5 hours for immediate release version, duration 4-8 hours for extended release version

Dexedrine (dextroamphetamine) – Discontinued in the U.S.

Procentra (dextroamphetamine) – Duration 3-5 hours

Amphetamine/Dextroamphetamine (generic) – Duration 3-5 hours for immediate release version, duration 4-8 hours for extended release version

Adderall (amphetamine/dextroamphetamine) – Duration 3-5 hours

Adderall XR (amphetamine/dextroamphetamine) – Duration 8-12 hours

Vyvanse (lisdexamfetamine) – a pro-drug that is converted to dextroamphetamine by the liver, duration 9-13 hours

Article written 12/19/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  All rights reserved.

Methylphenidate class stimulants act by increasing the release of norepinephrine and dopamine and blocking their reuptake.

Methylphenidate Class Stimulants:

Methylphenidate (generic) – Duration 3-5 hours for immediate release version, duration 4-8 hours for extended release version

Ritalin (methylphenidate) – Duration 3-5 hours

Ritalin SR (methylphenidate) – Duration 4-8 hours

Ritalin LA (methylphenidate) – Duration 8-12 hours

Methylin (methylphenidate) – Duration 3-5 hours

Methylin ER (methylphenidate) – Duration 4-8 hours

Metadate ER (methylphenidate) – Duration 4-8 hours

Metadate CD (methylphenidate) – Duration 8-12 hours

Concerta (methylphenidate) – Duration 8-12 hours

Daytrana (methylphenidate transdermal) – Duration 2 hours after application until up to 5 hours after removal

Focalin (dexmethylphenidate) – Duration 3-5 hours

Focalin XR (dexmethylphenidate) – Duration 8-12 hours

Article written 12/19/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  All rights reserved.

Introduction

It is estimated that in any given year, 6.7 percent of the U.S. population has Major Depressive Disorder (MDD), the clinical name for what people generally refer to as depression.  A medication used to treat depression is the third most prescribed medication in the U.S., behind only cholesterol-lowering medication and asthma medication.  Although everyone has ups and downs in their moods, people with MDD have such severe downs that it significantly affects their daily function.

Symptoms

The main symptom of MDD is depressed mood, plus additional common symptoms as described by the mnemonic SIGECAPS:

S: Sleep (decreased or increased)
I: Interest (decreased, also known as anhedonia)
G: Guilt (feeling worthless, hopeless, helpless)
E: Energy (decreased)
C: Concentration (decreased)
A: Appetite (decreased or increased)
P: Psychomotor retardation or activation (feeling slowed or feeling restless)
S: Suicidal thoughts

Diagnosis

As with most mood disorders, MDD is diagnosed clinically, based on history.  There is no blood test or imaging test that is diagnostic for MDD.  However, if there are clinical signs that suggest a medical problem may be contributing to your depression, your doctor may order blood tests to check for infections and check your thyroid, liver, kidneys, and vitamin B12 and folate levels to see if there are any other factors contributing to your depression.  At times, brain imaging may be helpful to make sure there are not any underlying brain abnormalities that are contributing to your depression.  Before initiating medication treatment of MDD, it is important that your doctor screen you for Bipolar Affective Disorder (BPAD), as many anti-depressant medications that can help people with MDD can actually make people with BPAD much more unstable.

Treatment

Treatment can involve psychotherapy, medications, or combined treatment, depending on patient preference and severity of symptoms.

• Psychotherapy: Cognitive Behavioral Therapy (CBT) has been shown to be effective for Major Depressive Disorder. I recommend a CBT workbook to my depressed patients -  The Feeling Good Handbook by David D. Burns.   Many patients find it helpful to go through the workbook and suggested exercises with the guidance of a mental health professional, though the workbook is made to be self-guided.  Some patients find insight-oriented psychotherapy or supportive therapy to be more helpful types of therapy than CBT.
• Medications: The most commonly used medications for treating Major Depressive Disorder are selective serotonin reuptake inhibitors (SSRI’s).  These medications can be prescribed by your primary care doctor, or by your psychiatrist.  If SSRI’s are not effective, serotoinin-norepinephrine reuptake inhibitors (SNRI’s), other anti-depressants such as bupropion (Wellbutrin), atypical antipsychotics, and other adjunctive medications can be effective.  Older medications such as monoamine oxidase inhibitors (MAOI’s) and tricyclic antidepressants (TCA’s) can also be alternatives if newer, safer medications are not effective.  The best predictor of your response to medications is how you have responded to medications in the past.   How blood-relatives have  responded to medications in the past can also help your doctor choose the best medication for you.
• Combined Treatment: For many patients, the combination of psychotherapy and medications is the most effective form of treatment.

For Further Information

See the Wikipedia entry on MDD, a handout from the National Institute for Mental Health (NIMH), or contact a qualified mental health professional.

Article written 12/1/09 by Minyang Mao, M.D.  Revised 12/1/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  Image © 2009 Bob Lin.  All rights reserved.

Introduction

Seasonal Affective Disorder, or SAD, is a mood disorder related to the shortening of sunlight hours during winter.  It is more common in northern latitudes, in Finland for example.  It is difficult to have an accurate estimate of actual prevalence in the U.S., but estimates range from 0 to 9.7%.

Symptoms

Symptoms of SAD are the same as those of depression, with the main symptom of depressed mood, plus additional common symptoms as described by the mnemonic SIGECAPS:

S: Sleep (decreased or increased)
I: Interest (decreased, also known as anhedonia)
G: Guilt (feeling worthless, hopeless, helpless)
E: Energy (decreased)
C: Concentration (decreased)
A: Appetite (decreased or increased)
P: Psychomotor retardation or activation (feeling slowed or feeling restless)
S: Suicidal thoughts

The unique aspect of SAD versus non-seasonal depression is that SAD regularly appears in the fall or winter, and SAD tends to disappear during spring and summer months, whereas non-seasonal depression has no correlation to the changing of seasons.

Diagnosis

There is not currently a distinct diagnosis of “Seasonal Affective Disorder” in the DSM-IV.  Psychiatrists diagnose SAD by adding a “Seasonal Pattern Specifier” to a Major Depressive Episode that appears as part of Major Depressive Disorder or Bipolar Type I or Type II Disorder.  As with most mood disorders, SAD is diagnosed clinically, based on history.  There is no blood test or imaging test that is diagnostic for SAD.

Treatment

Treatment can involve psychotherapy, medications, light therapy, or combined treatment, depending on patient preference and severity of symptoms.

• Psychotherapy: Cognitive Behavioral Therapy (CBT) has been shown to be effective for Seasonal Affective Disorder.  Because SAD is a subtype of depression, I recommend the same workbook to my SAD patients that I recommend for my depressed patients -  The Feeling Good Handbook by David D. Burns.   Many patients find it helpful to go through the workbook and suggested exercises with the guidance of a mental health professional, though the workbook is made to be self-guided.
• Medications: The most commonly used medications for treating Seasonal Affective Disorder are the same medications for non-seasonal depression: selective serotonin reuptake inhibitors (SSRI’s).  These medications can be prescribed by your primary care doctor, or by your psychiatrist.
• Light Therapy: Because the cause of Seasonal Affective Disorder appears related to the lack of sunlight exposure during fall/winter months, light therapy treatments have been developed.  Most studies have focused on 10,000 lux light therapy for 30 minutes per day, given early in the morning.  There are commercially available lightboxes and light visors that deliver this light in various forms.  The key factors for effectiveness are intensity (lux) and duration.  It is important to keep in mind that as you get farther from the light, the lux drops significantly.  Most lightboxes require that you are within 12 inches of the light to deliver the recommended 10,000 lux.  Important safety considerations are to make sure that you are not being exposed to UV light which can predispose you to skin cancer.  Some boxes use special UV-free bulbs, others use a UV light filter to screen out UV rays.  There is investigation into whether blue-light can be more effective than full-spectrum light.  Another safety issue is that light therapy can cause patients with Bipolar Disorder to become manic or hypomanic.  Thus, I recommend that light therapy be initiated and conducted under the supervision of a psychiatrist.
• Combined Treatment: For some patients, the combination of psychotherapy, medications, and light therapy is the most effective form of treatment.

For Further Information

See the Wikipedia entry on SAD, a Mayo Clinic article on SAD, an article from the American Academy of Family Physicians, or contact a qualified mental health professional.

Article written 11/10/09 by Minyang Mao, M.D.  Revised 11/10/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  Image © 2009 Bob Lin.  All rights reserved.

Although the odds ratio would seem very alarming, the actual rate of babies getting septal heart defects remains low:  9 out of 1000 children born to mothers on one SSRI, or 21 children out of 1000 children born to mothers on multiple SSRIs would be expected to have heart defects.  In comparison, 4.5 out of 1000 children NOT on SSRIs get septal heart defects.

The take home for this study is this: the recent ACOG/APA recommendations on SSRIs in pregnancy remain applicable.  See more details on the recommendations on my previous blog post.  The addition to this is that generally women should NOT be on multiple SSRIs during pregnancy as that contributes a more significant risk as noted in the Denmark study.  However, women with severe depression stable on SSRIs should generally stay on their SSRIs during pregnancy as the overall risk of septal heart defect remains low on one SSRI (9 out of 1000 children on SSRI, versus 4.5 out of 1000 without SSRI).   In those with severe depression who are stable on SSRIs, the risk of relapse of depression with the discontinuation of SSRI, and the subsequent effect on the mother and child (mothers may eat poorly, miss prenatal visits, not follow medical instructions, use substances like tobacco, alcohol, recreational drugs to cope with depression, have difficulty meeting needs of child once she is born, and many more – see more details at womenshealth.gov) is significant and generally outweighs the risk of septal heart defect.  Of note, each individual case needs to be assessed by a psychiatrist and OB/Gyne to weigh the risks in the individual case.

Article written 9/29/09 by Minyang Mao, M.D.

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content © 2009 Minyang Mao, M.D.  Image © 2009 Bob Lin.  All rights reserved.

Article Abstract

APA Press Release

WebMD Article

L.A. Times Article

One of my special clinical interests is panic disorder.  Panic disorder is an example of the link between mind and body and how they can have a strong impact on each other.  About 6 million American adults ages 18 and older, or about 2.7 percent of people in this age group struggle with this disorder. (NIMH)

Symptoms

Patients generally report repeated, generally unpredictable episodes of extreme fear and discomfort starting suddenly and peaking within 10 minutes.  Common symptoms during these episodes called “panic attacks” are:

• hyperventilation or shortness of breath
• fast heart rate or palpitations
• chest pain
• trembling or shaking
• numbness or tingling in fingers and other extremities
• feelings of choking
• nausea
• dizziness or lightheadedness
• chills or hot flashes
• feelings that the world is unreal (derealization)
• feelings that the patient is observing herself from the outside (depersonalization)
• fears of losing control or going crazy
• fears of dying

Diagnosis

Panic disorder is diagnosed clinically, based on history.  There is no blood test or imaging test that is diagnostic for panic disorder.  That being said, the symptoms of panic disorder mimic many medical illnesses, including potentially life-threatening conditions like heart attack or stroke.  It is critical for the patient to be medically cleared before arriving at the diagnosis of panic disorder.

Treatment

Treatment can involve psychotherapy, medications, or combined treatment, depending on patient preference and severity of symptoms.

• Psychotherapy: Cognitive Behavioral Therapy (CBT) has been proven to be very effective for panic disorder.  The CBT workbook my patients have found to be most helpful for panic disorder is Mastery of Your Panic and Anxiety Workbook by Craske and Barlow.  Many patients find it helpful to go through the workbook and suggested exercises with the guidance of a mental health professional, though the workbook is made to be self-guided.
• Medications: The most commonly used medications for treating panic disorder are the selective serotonin reuptake inhibitors (SSRI’s) and benzodiazepenes. These medications can be prescribed by your primary care doctor, or by your psychiatrist.
• Combined Treatment: For some patients, the combination of psychotherapy and medications is the most effective form of treatment.  If CBT is successful, patients are often able to eventually decrease or even stop their medications.

For Further Information

See the Anxiety Disorders Association of American (ADAA) website, or contact a qualified mental health professional.

Article written 8/29/09 by Minyang Mao, M.D. and updated 8/30/09

Disclaimer: This article is intended as an educational resource only, and is not intended to be a replacement for treatment. For evaluation and treatment, please contact a qualified mental health professional.

Content and images are © 2009 Minyang Mao, M.D. All rights reserved.