Prescribed stimulant use for ADHD continues to rise steadily

NIH and AHRQ study finds pace of the rise has slowed in recent years


Source: NIMH

The prescribed use of stimulant medications to treat attention deficit hyperactivity disorder (ADHD) rose slowly but steadily from 1996 to 2008, according to a study conducted by the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ). The study was published online ahead of print September 28, 2011, in the American Journal of Psychiatry continuing education for Social Workers

ADHD is one of the most common childhood disorders, and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity). The condition is frequently treated with stimulants such as methylphenidate (e.g., Ritalin), amphetamines (e.g., Adderall) or other types of medications. Behavioral therapies can also be effective.

During the 1990s, stimulant prescription use increased significantly, going from a prevalence rate among youth of 0.6 percent in 1987 to 2.7 percent in 1997, with the rate stabilizing around 2.9 percent in 2002. Recent reports, however, suggest that the prescribed use of these medications and the diagnosis of ADHD have continued to rise. Based on the Health Resources and Services Administration's National Survey of Children's Health, the percentage of children age 4-17 years diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007.

"Stimulant medications work well to control ADHD symptoms, but they are only one method of treatment for the condition. Experts estimate that about 60 percent of children with ADHD are treated with medication," said co-author Benedetto Vitiello, M.D., of NIH's National Institute of Mental Health (NIMH).

For this most recent survey, Dr. Vitiello and Samuel Zuvekas Ph.D., of AHRQ examined data from the AHRQ-sponsored Medical Expenditure Panel Survey, a nationally representative annual survey of U.S. households, to determine prescribed stimulant use among children under age 19 from 1996-2008. They found a slow but steady increase — from 2.4 percent in 1996 to 3.5 percent in 2008.The rate grew an average of 3.4 percent each year, which is substantially less than the growth rate between 1987 and 1996, which averaged about 17 percent per year.

Overall, prescription use among 6-12-year-olds was highest, going from 4.2 percent in 1996 to 5.1 percent in 2008. But the fastest growth of prescribed use occurred among 13-18-year-olds, going from 2.3 percent in 1996 to 4.9 percent in 2008. "This continuous increase among teens likely reflects a recent realization that ADHD often persists as children age. They do not always grow out of their symptoms," said Dr. Vitiello.

Prescription use among preschoolers remained very low at 0.1 percent from 2004 onward and decreased between 2002 and 2008, suggesting that stimulant use among very young children continues to be disfavored. Boys continued to be three times more likely to be prescribed a stimulant than girls, and use among white children continued to be higher than among black or Hispanic children (4.4 percent in 2008 among whites, compared to 2.9 percent in blacks and 2.1 percent in Hispanics). However, prescribed stimulant use is increasing among racial and ethnic minorities, likely suggesting more recognition of ADHD and acceptance of psychopharmacological treatment among these groups, according to the authors.

In addition, rates were substantially lower in Western states compared to other regions of the nation, with no increase in recent years, a finding consistent with other studies. In comparison, rates in the Northeast increased from 2.7 percent in 2002 to 4.6 percent in 2008.

"These persistent differences in prescribed stimulant use related to age, racial and ethnic background, and geographical location indicate substantial variability in how families and doctors approach ADHD treatment throughout the United States," said Dr. Zuvekas.

The researchers concluded that when comparing the rates of prescribed use with the estimated prevalence of ADHD diagnosis, it appears that many children with ADHD are not treated with stimulants. "The children with the most severe symptoms are more likely to be taking stimulants. Those with milder symptoms are more likely being treated with psychosocial treatments or other non-stimulant medications," they said.

Reference

Zuvekas S and Vitiello B. Stimulant medication use in children: a 12-year perspective. American Journal of Psychiatry. Online ahead of print September 28, 2011.

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The Agency for Healthcare Research and Quality (http://www.ahrq.gov) is part of the U.S. Department of Health and Human Services. AHRQ's mission is to improve the quality, safety, efficiency and effectiveness of health care for all Americans. AHRQ's research helps people make more informed decisions and improve the quality of health care services.

The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

Support Program Can Help Caregivers Cope with Relative’s Mental Illness

A free, nationally available program can significantly improve a family's ability to cope with an ill relative's mental disorder, according to an NIMH-funded study published June 2011 in Psychiatric Services, a journal of the American Psychiatric Association.

Background
The Family-to-Family (FTF) education and support program is a free, 12-week course offered by the National Alliance on Mental Illness (NAMI). FTF is offered throughout the United States, in two Canadian provinces and in three regions in Mexico. With more than 3,500 volunteer teachers, it is supported by local donations or municipal funds. Since 1991, 250,000 family members have participated in the program. It is the most widely available education and support program for family members of individuals with mental illnesses.

Two previous studies suggested that FTF reduces caregivers' stress and helps them gain a sense of empowerment over their situation. For this most recent evaluation of the program, Lisa Dixon, M.D., M.P.H., of the University of Maryland, and colleagues aimed to determine its effectiveness using a randomized controlled trial. Half of the 318 participants were assigned to the program immediately after enrolling in the study, while the other half were waitlisted for the program for at least three months (control condition). Those who were waitlisted were free to seek assistance from other sources.

Participants were interviewed at the beginning of the three-month program and again three months later. They were asked about their problem-solving and coping skills, their overall distress level and worries about their ill relative's situation. They were also asked about their sense of empowerment to manage challenges within the family, the mental health system, and the community. They were also tested regarding their factual knowledge about mental illness.

Results of the Study
Compared to the waitlisted control group, FTF participants showed significantly greater improvements in coping with their ill relative's condition by learning more about the illness and gaining a sense of empowerment in the family, service system and community. FTF participants also showed increased acceptance of their family member's illness as well as improved problem-solving skills, compared to those who were waitlisted. Results also suggested that FTF participants' overall sense of emotional distress eased.

Significance
The researchers concluded that FTF effectively enhances coping skills among families of people with mental illness. These results echo those found in the previous qualitative studies. The researchers suggest the program can positively influence how family members solve problems and "navigate emotional difficulties" surrounding their loved one's illness.

What's Next
Additional research is needed to conclusively determine if the positive effects of FTF can improve the outcomes of the individuals with mental illness for whom the family members were taking the class.

Citation
Dixon LB, Lucksted A, Medoff DR, Burland J, Stewart B, Lehman AF, Fang LJ, Sturm V, Brown C, Murray-Swank A. Outcomes of a randomized study of a peer-taught family-to-family education program for mental illness. Psychiatric Services. 2011 June. 62(6):591-597.

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Light Switches Brain Pathway On-and-Off to Dissect How Anxiety Works

Turns Cowering Mice into Instant Adventurers
Scientists, for the first time, have switched anxiety on-and-off in active animals by shining light at a brain pathway. Instinctively reclusive mice suddenly began exploring normally forbidding open spaces when a blue laser activated the pathway – and retreated into a protected area when it dimmed. By contrast, anxiety-like behaviors increased when an amber laser inhibited the same pathway. Researchers, supported in part by NIMH, used a virus, genetic engineering and fiber-optics to control the pathway in the brain's fear center with millisecond precision. CEUs for Social Workers

"Our findings reveal how balanced antagonistic brain pathways are continuously regulating anxiety," explained Karl Deisseroth, M.D., Ph.D., of Stanford University, a practicing psychiatrist as well as a neuroscientist. "We have pinpointed an anxiety-quelling pathway and demonstrated a way to control it that may hold promise for new types of anti-anxiety treatments."

NIMH grantees Deisseroth, Kay M. Tye, Ph.D., and colleagues, report on their findings March 17, 2011 in the journal Nature.

Optogenetic alchemy
Anxiety disorders are the most common type of psychiatric illness, affecting more than 1 in 4 people at some time during their lives. To understand the neural basis of these disorders, researchers are studying the workings of circuitry in the fear center, called the amygdala, in rodents.

Deisseroth's team has pioneered a method, called optogenetics, of experimentally activating brain activity with light. They incorporate a protein borrowed from light-reactive organisms to make brain tissue similarly light-responsive. Previously, they used this tool to activate particular types of neurons. The new study is the first to use it to reversibly manipulate a specific projection of a neuron (see picture below). It's also the first time the technique has been used to study anxiety as opposed to fear – a generalized state versus a transient reaction to an immediate threat.

The researchers borrowed a gene that codes for a light-sensitive protein from algae and delivered it to the amygdala pathway via a virus. In the algae, the protein's function is to activate a pathway that causes the organism to swim toward blue spectrum light. Hence a blue light now activated the amygdala pathway. When they wanted to inhibit the pathway in response to light, they similarly borrowed a gene from a light-responsive bacterium that codes for a protein that inhibits a pathway in response to a particular spectrum of light — in this case amber — and infected the amygdala pathway with that gene.

When the researchers optogenetically activated whole neuronal cell bodies in the amygdala, it increased anxiety-like behavior: mice hunkered down in a protected corner of a maze and wouldn't venture into more exposed areas. These and related findings led the researchers to hypothesize that they would get the same effect if they narrowed the focus of the activation to just a specific neuronal projection (see picture below).

A post-doc's eureka! moment
But it turned out that the opposite was true.

When they activated the projection with the blue laser, the engineered mice suddenly seemed to summon the courage to explore the more exposed parts of the maze that they would normally avoid (see video below).

"I was quite surprised. We did not see aversion. We did not see fear. We did not see any of these things I expected to see," said Tye, whose post-doctoral study is supported by a NIMH-funded training grant. "I suddenly got this huge, dramatic effect of reduction in anxiety-related behaviors and I had to follow it up. So I pretty much dropped my original ideas of what I was going to study during my fellowship and started pursuing this."

When the researchers blocked activity in the projection with the amber laser, the animals showed even more anxiety-like behavior than they usually do. The experiments hint at how the brain is able to regulate anxiety levels — on a millisecond timescale — by dialing activity up and down in such antagonistic amygdala pathways.

Futuristic anxiety treatment?
Tye said she and Deisseroth plan to follow up with further dissection of anxiety pathways. She also hopes to examine whether such optogenetic manipulations, sustained over hours or days, might induce long-lasting adaptations — perhaps for weeks –– in the set-points of anxiety pathways.

A future anxiety disorder treatment that might similarly target such specific pathways could, theoretically, quell anxiety instantly without producing unwanted side effects, such as drowsiness, often experienced with current anti-anxiety medications. For patients with severely debilitating anxiety, a treatment something like deep brain stimulation for depression, but more precisely targeted at a specific pathway, might someday be feasible, she suggested."Everything else in your brain should be unperturbed, because the manipulation would be so specific," explained Tye.

Video shows a mouse under "optogenetic" control while in an anxiety-producing situation. Being in elevated, open spaces makes mice anxious. So, in this "elevated-plus maze," the mouse normally stays in the arms with high walls; it normally won't venture into arms with low walls. However, this mouse has been genetically engineered to have an anxiety-quelling pathway in its fear hub activate when a blue laser shines on it via the fiber-optic cable. At those times (when the blue text appears), the animal gains courage and ventures into the normally scary places. Video speeds up a 15 minute session 10-fold.

Researchers were surprised to discover that activating the whole cell body of an amygdala neuron increased anxiety in mice, while activating just one of its projections had the opposite effect. So unraveling the secrets of how anxiety works might require dissecting the action of each such pathway individually, say the researchers.

Reference
Amygdala circuitry mediating reversible and bidirectional control of anxiety. Tye KM, Prakash R, Kim SY, Fenno LE, Grosenick L, Zarabi H, Thompson KR, Gradinaru V, Ramakrishnan C, Deisseroth K. Nature. 2011 Mar 17;471(7338):358-62. Epub 2011 Mar 9. PMID: 21389985

Depression and Mood Disorders

Depression and Mood Disorders
The Prevalence of Major Depression and Mood Disorders in Suicide

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Depression and Mood Disorders CEUs for MFTs, LCSWs, LPCs, and Social Workers
Mental Health: A Report of the Surgeon General, states that "major depressive disorders account for about 20 to 35 percent of all deaths by suicide" (p. 244). This estimate is based on a review of psychological autopsies conducted by Angst, Angst, and Stassen (1999). This brief review is intended to address this prevalence estimate. It is important to note that this estimate refers only to the prevalence of major depressive disorder among those who commit suicide, not any other mood disorders (e.g., bipolar I & II, dysthymia, adjustment disorder with depressed mood). Prevalence estimates that include other mood disorders in addition to major depression are much higher.

Major depression in suicide
The lower bound of the 20-35% estimate of the prevalence of major depression in suicide is loosely based on one psychological autopsy study; a study where the reliability of the diagnoses are somewhat questionable. This study (Rich, Young & Fowler, 1986) of 204 subjects identified 15% of suicides as having major depressive disorder. However, an additional 30% were reported as having "atypical depression," defined in this study as having a depressive syndrome that followed the onset of substance use. If this ambiguously defined group were to be considered major depression, the estimate climbs to 45%. A number of other studies suggest that the prevalence of major depression in suicide is somewhat over 30%. The four other available psychological autopsy studies that include samples of suicides from the full age range and reliable diagnoses based on structured interviews (Arato, Demeter, Rihmer & Somogyi, 1988; Dorpat & Ripley, 1960; Foster, Gillespie, McClelland & Patterson, 1999; Henriksson et al., 1993) obtained prevalence estimates of major depression ranging from 30-34% of suicides. In addition, several psychological autopsy studies examining more specific subsamples (e.g., the elderly, adolescents, women) find even higher prevalence estimates. In three psychological autopsy studies of adolescents (Brent et al. 1988; Brent et al., 1999; Shaffer et al., 1996) 41%, 43%, and 32% of adolescent suicides were determined to have had major depression prior to death. Two studies of young adults (Lesage et al. 1994; Runeson, 1989) found a prevalence of 40% and 41%, respectively. A study of 104 women by Asgard (1990) found a 35% rate of major depression. One study of 54 older adults over age 65 found a prevalence of 54%. In summary, the available data suggest that the 20-35% estimate for the prevalence of major depressive disorder in completed suicide is probably somewhat conservative and that a 30-40% prevalence estimate is probably more accurate. This estimate includes both secondary and primary depression. Many of these individuals would also be comorbid with other disorders, especially substance abuse.

Mood disorders in suicide
Prevalence estimates for all mood disorders in suicide (including MDD, Bipolar I & II, dysthymia, and adjustment disorder with depressed mood) are much higher than for major depression alone. These rates are probably closer to 60%, although as noted below, this estimate varies because of inconsistency of the criteria used to define a "mood disorder" across investigations. Four studies examining the full age range of suicides estimate that 36%, 48%, and 66%, and 70% of suicides have some sort of "depressive disorder" or "depression" (Foster et al., 1999; Rich et al., 1986, Henriksson et al., 1993, Barraclough, Bunch, Nelson, & Sainsbury, 1974). Three studies of adolescents found prevalence estimates for "mood disorders" or "affective disorders" of 61%, 63%, and 67% respectively (Shaffer et al., 1996; Brent et al. 1988; Marttunen et al., 1992). Two studies of young adults (Lesage et al., 1994; Runeson, 1989) found estimates of 60% and 64%. A study of 104 women by Asgard (1990) found a 59% rate of "mood disorders." In a review of psychological autopsy studies that examined patterns of psychiatric diagnosis across age groups, Conwell and Brent (1995) concluded that depressive disorders increased with age. Overall estimates for the rates of mood disorders range from 36% to 70% with great interstudy variability. This variability is probably partly a combination of unreliable methods of diagnosis and different definitions of what constitutes a "mood disorder." Despite this variability, a number of studies have found a pattern for increasing mood disorders with aging.