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Shuhainie Nadia Yusof Nurulraini Mohd Ramli. 24-weeks treatment with extended release methylphenidate improves emotional symptoms in adult ADHD. Introduction. What is ADHD? A chronic disorder Begin during early childhood and continues to adolescence

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24-weeks treatment with extended release methylphenidate improves emotional symptoms in adult ADHD


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shuhainie nadia yusof nurulraini mohd ramli
Shuhainie Nadia Yusof

NurulrainiMohdRamli

24-weeks treatment with extended release methylphenidate improves emotional symptoms in adult ADHD

introduction
Introduction
  • What is ADHD?
    • A chronic disorder
    • Begin during early childhood and continues to adolescence
    • Can be full or partial clinical picture in 60% of patients during adulthood
definition
Definition
  • Major syndromes defines by DSM IV:
    • Attention disorder
    • Hyperactivity
    • Impulsivity
  • Different concepts was defined by:
    • CAARS(Conners Adult ADHD Rating Scales, Conners et al. 1999)
    • BAADS (Brown Adult Attention Disorder Scales, Brown 1996)
    • Utah criteria of adult ADHD (P. Wender, 1995)
definition1
Definition
    • Hypothesis: co-occuring emotional symptoms accompany those 3 major syndromes can be detected
  • Inattention, hyperactivity and impulsivity are lifelong and chronic dimension, while others emotional symptoms (eg: poor temper control, affective lability, emotional overreactivity)are episodic phenomena
medications
Medications
  • 1st line therapy: MPH (methylphenidate)
  • Altenative drugs:
    • Amphetamine
    • Atomoxetine (ATX) in case of non-response to stimulant medication or high abuse potential
  • Limited knowledge of MPH effect to adult ADHD
    • Reimherr et al. (2007) :
      • positive response of MPH
      • a short 2x4-week not achieve robustness of the treatment over time
investigation
Investigation
  • Objective:
    • to access the medium- to long-term effects of extended release MPH on emotional symptom and other psychopathology frequently seen in ADHD patients
  • Subjects:
    • Outpatients with ADHD aged > 18 years, fulfill DSM-IV criteria for ADHD
  • Design:
    • MPH-ER (50% immediate release, 50% extended release)
study intervention
Study intervention
  • 1st five weeks:
    • Flexible dose schedule (10mg/day – 60mg/day)
    • Lower daily dose if :
      • Intolerable adverse event
      • Higher dose not increase improvement
    • Interval between two doses : 6-8 hours
  • After 5 weeks:
    • Min. maintenance dose : 20mg/day
slide8

Assessments

  • General assessments:
    • Medical history
    • Physical examination
    • Vital parameters, etc…
    • EEG, ECG, complete blood count
  • Emotional symptoms assessments:
    • EMS (Emotional Dysregulation Scale) :
      • 10 items : 0-2 score per item, max score = 20
    • ELS (Emotional Lability Scale) :
      • 6 items : 0-3 score per item, max score = 18
    • SCL-90-R (Symptom Checklist 90-Revised)
result
Result
  • ITT (intend-to-treat) population:
    • total:
      • 363 - 4 (bad data quality/non-compliance)
      • = 359 patients
    • MPH ER: 241 patients
    • placebo: 118 individuals
    • Drop-out: 110 subjects (lower rate in MPH ER)
      • MPH ER : 13% adverse effect
      • Placebo : 25% lack of efficacy
  • PP (per protocol) population : 249 (183/66)
d iscussions
Discussions
  • Overall effect sizes of investigation, 0.37 by comparison study by Reimherr et al. (2007), 0.70
    • Use of low dose (0.55mg/kg/day) in comparison to Reimherr et al. (0.7mg/kg/day)
    • Concern of long term safety and tolerability of MPH
    • To find out whether low doses of MPH ER lead to positive response
    • Conclusion: differences of effect sizes is a consequence of low dose regimen
discussions
Discussions
  • Improvement of emotional psychopathology (affective lability, temper dyscontrol, and emotional overreactivity) with MPH treatment
    • Hypothesis : Emotional symptoms are part of ADHD psychopathology rather than comorbid condition
  • Robust decline of problems with self-concept and of obsessive-compulsive disorder
    • MPH treatment reduces classical ADHD psychopathology causing also decline of their coping strategy
discussions1
Discussions
  • No improvement of anxiety and depression with MPH treatment
    • Anxiety and depression are only comorbid to ADHD, not part of ADHD emotional psychopathology
conclusion
Conclusion
  • Treatment with low doses of MPH-ER in adult patient with ADHD over a period of nearly 6 months leads to a small to medium but robust improvement of emotional symptoms.
acknowledgements
Acknowledgements
  • The World Journal of Biological Psychiatry, 2010; 11: 709-718
  • Michael Rosler, Wolfgang Retz, Roland Fischer, Claudia Ose, Barbara Alm, JurgenDeckert, Alexandra Philipsen, Sabine Herpertz& Richard Ammer