Some patients with Adult ADHD

Some patients with Adult ADHD • Dr Rigo Van Meer • 9/10/2013 • Thanks to: • Catherine Flanagan • Innisfail Team • Tully Team

Goal • Make doctors and mental health workers more aware of adult adhd • Make them consider adhd as a possibility • Sharpen clinical acumen in diagnosing adhd • Especially in complicated cases

ADHD in adults can be from trivial to very severe • Severe cases can be compounded by depression, anxiety, angriness and aggression, social deterioration, loss of meaning in life, illegal drug use and incarceration. • Treatment of severe cases often gives spectacularly positive results that are life changing. These successful treatments are in my experience one of the very rewarding things a psychiatrist can do in his profession.

Adult ADHD lessons learned 1 • I found reading about adult adhd treatment particularly unhelpful. Much general statements and warnings, little practical guidance. I learned from experience in around 150 adult adhd patients that: • Dose of Ritalin 10mg or Dexamphetamine 5mg is between 2 and 12 tablets daily, with an average of 6. • Under-dosing gives many problems, as patients will use the dose they need, and run out of their tablets too soon. Once the right dose is found, patients do not want to increase the dose. • Dexamphetamine has fewer side effects and is felt as “softer” than Ritalin. Dexamphetamine is therefore in general the better medication • Stimulant treatment: • As a rule reduces the urge to drink alcohol or to smoke dope. • Often will improve sleep dramatically. • Often has a general improvement in mood -> anti depressants can be stopped.

Adult ADHD lessons learned 2 • Patients with adhd who seek treatment are often treated negatively and condescending by doctors and pharmacists. Patient with adhd who seek treatment are sometimes branded as “drug seeking”. When they try another doctor they are “doctor shopping”. • Many patients with adhd use marijuana or alcohol to dampen their constant feeling of stress and unrest. • Dexamphetamine and methylphenidate are not addictive. Patients who do not have adhd find these drugs in general unpleasant. • Illegal use of amphetamines is often self medication for adhd. Proper treatment of adhd decreases crime and keeps people out of jail.

Qualitatively different effect • From my experience with successful and unsuccessful treatments I have the strong impression that patients with adhd have a qualitatively different reaction to stimulants than most other people. • Patients with adhd become relaxed and their sleep improves • Others become stressed and can't sleep very well • Some illegal amphetamine users seem to know this, as one of my patients was made fun of when he became relaxed on speed in stead of high."Ha ha, you have adhd," another user told him • I am not aware of research in this phenomenon, but I would love to read about it 6

Common adhd problems • Mood swings: • aggressive outbursts • Depressive feelings (not reacting to anti depressants) • Bad sleep (restless, waking up often) • Feeling stressed, restless, on edge much of the time • Use of marijuana and alcohol (calms me down)

Questions for ADHD screening • Have you ever been diagnosed with ADHD or has the diagnosis been considered? • Did you have trouble concentrating most of your life? • (E.g. being easily distracted, not finishing things, getting easily bored, being forgetful, acting chaotic) • Do you feel restless much of the time? • (E.g. feeling pressured, not relaxed, difficulty sitting still, fidgeting, moving all the time) • If you ever used ritalin, amphetamines or speed, how did you react to it?

Minimal training • Registrars should be trained to be confident in diagnosing and treating adhd in adults. • During their training they should diagnose and treat at least ten patients with adult adhd, simple cases and cases with psychiatric co morbidity • Does this sounds reasonable?

ADHD • Attention problems • Can’t stay focused • Easily bored • Starts a lot, finishes little • Can’t plan • Can’t listen to instructions

But also… • Often feels stressed or on edge • Easily irritated or angry • Emotionally more up and down • Feels out of control (and often is)

And socially… • Misses out on education • Runs with the wrong crowd • Problems heap up: can’t solve them • Drug use, alcohol • Offences (drugs, aggression) • “Depression”, anxiety • Life goes nowhere

Presentation to psychiatrist • Young patient treated for adhd turns 18 • Adhd patient from other state seeks continuation of treatment • GP/psychologist/patient thinks of ADHD • Depression/anxiety/social stress • Schizophrenia/BPAD + adhd

Patient J, male, 48 • Male, born 1955, Diesel fitter, Married. Four adult children. • Referral by GP July 2013 • From letter of GP • Stopped Effexor-XR a week ago as he did not think they were helping his depression • Drove to Mt Carbine with his rifle yesterday >> drove home again • Police were called >> mate has now his rifle • No other firearms at home • Things seem a lot better with Dianne (wife) now • No benefit from Lexapro or Cymbalta in past

Assessment by CW of J • L was referred to MH services by his GP after he presented feeling depressed, experiencing suicidal ideations, had a plan to shoot himself and had access to means (gun). He also recently ceased his medication as he felt they were ineffective. He has been treated with Lexapro, Effexor and Cymbalta in the past with little improvement. • L believes he may have been experiencing depression for the past 30 years, however, symptoms became worse after he had a heart attack in 2010. • Symptoms include low motivation, anhedonia, irritability, poor memory and concentration, feelings of emptiness, poor sleep and suicidal ideations. Denies any current suicidal ideations and is willing to seek treatment. • Ongoing relationship problems and financial stressors. • Drinks socially. • Identified a small group of friends and his boss as sources of support.

Medical review J • Casually dressed, well kempt • Friendly, cooperative • Comes across as nervous, is fidgety • Lifelong Hx of low mood, worsened since a heart attack. • Sleep: variable. Often not well rested in the morning. Tired during the day. • Appetite: not much of an appetite • He can't enjoy too much in his life. Has "thoughts" very often. Negative ruminations, sometimes about suicide. • Not suicidal now. • Since his interview with CW, he feels better. • This is the first time he has really sought help.

Medical review cont’d J • He hates being in busy places with many people. But he can go. No panic attacks (no clear agoraphobia) • He wants to quit his current job as a diesel fitter and wants to work on a station. He has applied for a job on a station. • He has used amphetamines in the past (at a party) Effect: made me feel normal (!)

Medical review cont’d L • Probed adhd. • Always bad concentration, in school already. • Difficulty listening to instruction or reading them (when I put the paper down I have forgotten them already). • Does not plan, but does prepare for things, as he does not want to do everything the last minute. • Difficulty finishing things at home. On the job he finishes his tasks. • Procrastinates a lot. • Feels often stressed without a reason (butterflies in his belly) • Can't stop ongoing thoughts. • No drug use. • No problematic alcohol use

Medical review cont’d J • Conclusion • Very likely adult ADHD with co-morbidity (depression) • Plan • Start trial on Dex • Meds • Dexamphetamine 5mg 6 daily (on average) • Script dex #200 • DDU OK • re 4 to 6 wk

S, male 40, amphetamine abuse and jail • From the referral letter GP: • PROBLEM: Anxiety, depression, OCD, recent release from prison • (convicted for manufacturing methamphetamine, 2 year in jail) • Tumultuous history:ADHD as a child • Anxiety, depression, OCD since late teens • Previous drug abuse mainly amphetamines including IVDU • Hepatitis C successfully cleared with interferon • He was on large doses of Aropax, Seroquel and benzodiazepines while in prison but was keen to cease medications prior to his release. He has tried to cope without medications as he does not want to get into drugs again. Is engaged with ATODS. • I started him on Lexapro 10mg, today increased to 20mg.

S, male, amphetamine use and jail • Past diagnoses • Drug addiction • 2010 (in Jail) • High anxiety and depression • Some antisocial traits evident • 2012 (Community Health) • generalised anxiety • axis 2 : deferred • meds: Quetiapine started

Medical review S, male • Presents as very stressed, almost tortured. • Is tearful at moments. • Can’t sit still, fidgety • Has all the symptoms of adhd. • Used amphetamines for over 20 year. • Says they made him feel “normal”. • emotionally labile, desperate • Conclusion • Adult ADHD with co morbidity in crisis

Medications S, male • Past Medications • Lexapro 20mg mane • Aropax 20mg • Xanax • Present Medication • Dexamphetamine 5mg6 daily

Current Situation S, male, amphetamine use and jail • Report from CW • I talked to S and daughter on the 04/10/2013 and they reported that S has now been living in Cairns with his daughter for the past 8 months. He has been working fulltime as a scaffolder for past 8 months. He states he is happy, feels normal and has no legal or illicit drug issues. • He believes that the treatment “saved his life”.

Patient L, 33, bipolar disorder 2003 Studies at Uni engineering Taken to hospital by mother due to deterioration of mental state developing gradually over several weeks and then rapidly in ten days Somewhat dishevelled, guarded, elevated mood: he is confident, fatuous, FTD, rhyming & punning, is undercover agent, mother involved with Osama Bin Laden, he knows the Kennedy’s, etc. etc. Does not hear voices. Presented during admission superficially well, but delusional when longer engaged. No insight. ITO Has used marijuana which is seen as the cause of his deterioration

L, male 33, bipolar disorder Brother: depressive episodes Two maternal cousins: psychotic episodes Grandmother: Hx BPAD 2004 To Innisfail Team after admission in Brisbane for hypomania. Settled on Lithium. ITO Schizoaffective disorder DDx: BPAD From then on: Hx of relapses, ITO, non compliance with medication, admissions and good periods. He is often obnoxious, but friendly at other times.

L, male 33, bipolar disorder 2013 Stabilised on Lithium SR 450mg 3 daily Aripiperazole 30mg He works as a diesel fitter for 24 months now. Full time, completing mechanical engineering apprenticeship. He wants to study again He is remarkably insightful and compliant Discharged from mental health service, but still in occasional contact

L, 33, male, bipolar disorder Then .... His former caseworker talks with him about how his life and apprenticeship is going. He picks up on a raft of adhd symptoms. He completes a full questionnaire and Luke “ticks all the boxes” He asks me to review Luke I agree. Clear ADHD. Start trial with dexamphetamine. Dose finding: 8 tablets daily (40mg)

L, male, 33, bipolar disorder Very good effect: Feels calmer. Thoughts are clearer Can organize his day now He watched a full movie. Never could do that before Completes one task at a time Generally feels better. Mood improved No craving for alcohol, dope or cigarettes any more. Uses much less Finds other people react much more positive towards him He has still grandiose ideas at times, but he says with the dexamphetamine he can put them in a much more realistic light. He feels the dex works as an anti-psychotic (!!) He is very happy with the changes He says it is late in his life, but he feels he can now go on with his life

Reflection on L, 33, male, bipolar disorder A very difficult patient with whom I worked for many years. The thought that he (also) might have adhd never occurred to me. It is very good to have an attentive and well trained team. Treatment of his adhd has improved L’s quality of life significantly Conclusion BPAD ADHD Both well managed now

B, female, 50+, drugs and depression • Patient has been long known to the service with multiple problems: • Drug addiction (on Suboxone, seen by ATODS) • Depression • HepC • Anne developed Parasitosis delusion, needing a lengthy hospitalization. • Probably induced by drugs, possibly bad methamphetamine. She had never been psychotic before. • She lived with a drug addicted and dealing partner.

B, female, 50+, drugs and depression 2 • She was stabilized on: • Suboxone 32mg • Amisulpiride 600mg • Quetiapine 300mg • Venlafaxine 300mg • Diazepam 5mg tds • And ready for discharge from the service, although she felt stil depressed and generally unhappy. • On presentation she had symptoms and a history of untreated adhd. I found her unfocused and disorganized, emotionally unstable and unable to manage her life • Trial with stimulants indicated but: • Had developed severe psychotic symptoms likely induced by drugs • Lived with an amphetamine using & dealing partner • Has a history of drug abuse herself

B, female, 50+, drugs and depression 3 • Decided to trial dexamphetamine anyway because: • Could give her a big improvement in mental state • She was convinced she could keep the dex away from her partner • She was motivated to try • I have not seen any adhd patient developing psychotic symptoms under dex • (but I have seen a patient with acquired brain damage developing psychotic symptoms, that stopped as soon as the dex was stopped)

B, female, 50+, drugs and depression 4 • Result turned out to be very good (pfew!) • General concentration improved. Feels more in control of her life. Much more settled and happier. Nil recurrence of psychosis. Amisulpiride and Quetiapine stopped. Still on Venlafaxine, suboxone and prn valium, and Dexamphetamine 5mg 6 daily. • Report by CW on current Situation • Talked to B on the 04/10/2013 and she reported that she continues to work 2 days per week at Endeavour. She is no longer in a relationship with her abusive drug dealer partner Shane. B is a new relationship with J who is not a user, nor physical abuser. He is very supportive of B. Since commencing on Dexamphetamine B has repaired her relationship with her parents. She is presently attempting to reduce the Suboxone with the help of ATODS and receiving counselling for people who were IV users.

B, female, 50+, drugs and depression 5 • But…. • Around a year later B developed again symptoms of parasitosis and was shortly hospitalised • She admitted that she had used some Methamphetamine incidentally. Not clear wether this was before or after the parasitosis started again insidiously. • She was restarted on anti psychotic medication • The dexamphetamine was stopped • Lessons? • Unclear. In hindsight it had been better to stay on anti-psychotics. But after a first psychotic episode later in life, lifelong anti psychotics are not indicated. • Did the dexamphetamine play a role? • Further follow up will maybe learn us more.

P, male, 40+, stress Building designer, works from home. Married, 4 children April 2011 Self referral: “On the rocks” Anger problems, no physical violence Yelling at family Financial stresses, wife threatens to leave him Hx of drug addiction (pain killers after broken leg, 2003), stopped in 2004 Hx of depression after accident. Treated with antidepressant (which ?) ATODS for 18 months for pain killer addiction (Oxycontin, Endone, Panadeine forte, Voltaren, etc)

P, male, 40+, in 2011, stress Assessed by psychiatrist (myself): • No evidence of depression • No psychiatric diagnosis • Social stresses • Patient declined tranquilizers Referred to Tully support Centre for anger management counseling CLOSED

P, male, 40+, in 2012, stress • April 2012 • Self referred • Marital issues: fears for marriage break up • Kids (15, 13, 9, 7) not talking to me • Unemployed now, but that is not the issue • Keen to seek help • Does not see himself as depressed • Not suicidal • NOT ACCEPTED

P, male, 40+, in 2013, stress February 2013, Self referral Relationship troubles “always feeling angry” feels like he is “constantly in trouble” mood up & down all the time major sleep problems: wakes ever ½ hour. Wakes up with headache Feels tired/ exhausted Reports a signifiant decline in mood Flat, tearful during interview Ruminating negative thoughts Suicidal thoughts, no intent or plan Consumed by self blame, fearful of marriage break down

P, male, 40+ in 2013, stress Has been tried on different anti depressants in the past. Ceased to use THC recently and recently reduced cigarettes No practical issues: has full time job again (sugar mill), no financial problems, stable accommodation Scores high on Adult ADHD scale: disorganized, lacks ability to complete tasks, lack of concentration Provisional formulation: ADHD, depression?, sleep disturbance, marital problems

P, male, 40+, stress in 2013 Treatment Started on Quetiapine for sleep 75mg (telephone consultation with consultant) Encouraged to seek counseling Full assessment & medical review planned Med review ADHD Has reacted well to Quetiapine: sleeps again, calmer plan Continue Quetiapine Trial on Dexamphetamine

P, male, 40+, stress, in 2013 First follow up P does very well on the dexamphetamine Concentration improved, work going well. He is been promoted! Sleeps (too) well. Quetiapine stopped. Feels more relaxed, not stressed or despondent anymore Side effects: Excess transpiration On first day: felt “racing”.

P, male, 40+, stress, in 2013 • Further follow up • Still goes very well • On 6 tablets (found 8 too much) • Not moody anymore, thoughts “not so untidy” any more. • Improved focus and concentration, even for boring tasks • Eating breakfast for the first time • Quetiapine stopped: after some initial problems with sleep now no sleeping problems • Wife is happy with the changes. She notices when he forgets to take his dex. • Not angry anymore • Relationship is going well

P, male, 40+, stress in 2013 Collateral from family: Massive change. Kids, wife and in-laws say he is very different now. Things go well at home. Conclusion Adult ADHD reacting well to psycho stimulant treatment CLOSE

Some patients with Adult ADHD