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Case opinion for the experts

Discussion in 'Psychiatry' started by ghost dog, 04.11.12.

  1. ghost dog

    ghost dog

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    Hey folks,

    I saw a chronic pain pt in consult recently, and was wondering if I could get your expert opinion in regards to management of his ADHD condition.

    During psychiatric review of symptoms:

    He filled out a PHQ-9 questionnaire for depression and scored 11 points, which fell into the self-rated category of " moderately depressed." Didn't satisfy the DSM-IV criteria for a major depressive episode.

    He also filled out a GAD-7 questionnaire for anxiety and scored 15 points, falling into the self-rated category of " severe anxiety " , likely fulfilling the DSM-IV criteria for a generalized anxiety disorder. He denied panic attacks.

    He was taking : Percocet " 3 tabs / day" Ativan " 1 mg QHS " , and Ritalin sustained release unspecified dose.

    I performed an on-site urine drug screen, which was negative for : both oxycodone and benzos. He then informed me that he had run out early on both the Percocet and Ativan. Of significant note, the pt has a history of crack cocaine and alcohol dependence in remission x 4 years.

    He was recently started on Ritalin for a diagnosis of ADHD 2 months ago by Psychiatry. I should note that he was initially tried on an unspecified anti-depressant , " that made
    me worse."



    He hasn't worked in 2 years.

    My question here is: given the above significant risk factors, and the fact that the patient isn't working, what would the rationale be for continuing this medication ?

    What is your opinion on taking both a stimulant and a benzo ? In this case, the patient was using Ativan for insomnia.
    Last edited: 04.11.12
  2. mgdsh

    mgdsh

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    forgive me for being cynical, but given that his UDS is completely negative and he's on 3 medications with decent street value I'd explore the fact that he might be selling

    - How's his sleep & pain been since he's ran out?
    - Possibly recommend psychological testing for further evaluation of the ADHD?
  3. F0nzie

    F0nzie

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    Why does he need Ritalin? Is he studying for the boards?
  4. kugel

    kugel

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    1) What is the rationale for continuing these meds even without the risk factors?
    If he has chronic pain, let's address it as a chronic problem rather than using meds generally intended for acute use. If he has chronic anxiety, let's address it as a......you get the idea.

    2) As far as diagnosis, let's start at the top. Is there evidence he has sufficient dysfunction due to psychiatric/psychologic symptoms to warrant ANY psychiatric diagnosis at all? In other words, before we decide what DSM dx to apply, are we convinced there is one at all?

    3) If he does have enough dysfunction to warrant a psychiatric diagnosis, let's find out what he wants. Does he want to get better? Does he want to get back to work? What if he could get better without Percoset or Ativan or Ritalin, would he do it? What if it took 40 hrs per week of appt's and homework and exercise and support groups, etc.? All of which amounts to no more than a normal work week.

    As for taking amphetamine plus an opiate plus a BZD...generally I don't like it.
    If I was going to treat this patient, I would likely start with a clear statement that we're Not going to go on like this. We are going to remove one of the 3 (perhaps give him that choice), and then plan to taper and discontinue the others over time. During the taper, and for months after, there will be drug testing, and no early refills.
  5. ELOVL4

    ELOVL4 FinallyLeaving East Coast

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    I recently had a patient in Inpatient rotation with almost similar presentation. Heavy Alcohol user, Shelter resident, Borderline traits, Expressing all the symptoms of Anxiety D/O, Panic Attack, Depression. But when I clinically evaluated her symptoms, it did not corroborate the diagnosis. A clear drug seeking behavior. In Fact the pt was begging to give her IM medications and was intentionally getting agitated or showing behavior , so that the resident will medicate with IM medications.
    This type of patients are very smart. They do their homework before coming to clinic or fast Track, ER. Sometime these type of patients study all the features of Anxiety disorders and depressive d/o with the help of internet, and try to mimic those symptoms.

    For your patient.. I would not give him Ativan for insomnia...I may give him Ambien.
    In adult ADHD with comorbid Anxiety D/O and depression,

    Better approach would be... Sertraline+ Methylphenidate (Ritalin)
  6. nitemagi

    nitemagi Senior Member

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    Stop all 3 meds. Start an SSRI or SNRI, plus maybe guanfacine.
  7. IAmAUser

    IAmAUser Member

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    .
    Last edited: 06.20.12
  8. TexasPhysician

    TexasPhysician Moderator

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    Some patients are so ADHD that they can't properly fill out a job application without meds.

    On another note: The psychological tests given to this patient do not replace a good exam and do not necessarily provide any psychiatric diagnosis.

    I think it is impossible to provide much advice here without seeing the patient or at least getting a better feel about what the OP observed to be clinically wrong.
  9. billypilgrim37

    billypilgrim37 Unstuck in Time

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    The benzo seems like the most inappropriate (alc dependence), and easiest to find a replacement for if the indication is truly insomnia. Starting there makes sense. And then everything other folks said.
  10. BobA

    BobA Member

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    Completely agree. One of the criteria for ADHD is:
    C. Some impairment from the symptoms is present in at least two settings (e.g., at school [or work] and at home).

    Does he work? Is he in school?

    How impaired is he? Just being disorganized and inattentive doesn't count (especially if he's on opioids and benzo's).
  11. BobA

    BobA Member

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    Completely agree. Easiest one to get rid of is the benzo.
  12. whopper

    whopper Former jolly good fellow

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    Some people with ADHD experience it to the degree where if not treated., they experience extreme anxiety secondary to their ADHD problems.

    Those people usually need their ADHD controlled. If it is controlled, their substance abuse likelihood drops.

    This situation, like so many others in psychiatry can be like holding the wolf by the ears. Many psychiatrist don't want to give someone abusing drugs another substance of possible abuse.

    The way I handled this was if a TOVA test was (+), I'd be open to giving a stimulant only if UDSs were clean and they tried an failed at least one non-stimulant treatment for ADHD. I used to make it two meds, but I had so many ADHD patients appear to be sincere, do well on a stimulant, and had several clean UDSs after stimulants were started. (Well clean except for a stimulant).

    The TOVA test is the only one I'm aware of with a symptom exaggeration (malingering) index. It's also a test where if someone researches ways to fake ADHD on an interview, it's sure not going to help them figure how to fake their way through that test.
  13. ghost dog

    ghost dog

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    Nice to hear the experts agree with what I'm thinking.

    This is what I recommended to the family doc:

    1. Tapering and stop the Ativan, as he is not obtaining benefit from this medication ( he was getting about 4-6 hrs / sleep per night). Honestly, do any pts really get long term sleep benefit from chronic benzo use ?

    2. Considering his pain was moderate - and his disability score fell into the " moderate disability " category on the oswestry index - and he indicated he was getting dramatic relief from percocet - and he was taking ritalin for his ADHD - there is no reason on earth why this pt shouldn't be working. I would not be scripting this pt narcs.

    I provided the recommendations that if the family MD wished to continue scripting Percocet she should be using UDS, an opioid contract and the expectation the pt will be returning to the work force if he wishes to remain on opioids (i.e. opioids = increase in functionality or off ya go).

    3. I also recommended low dose Trazadone + Cymbalta, and some non-opioid based Tx strategies for his LBP.

    Will see if he returns.
    Last edited: 04.12.12
  14. whopper

    whopper Former jolly good fellow

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    The thought crossed my mind on doing a study where a large sample of patients on Suboxone are given a TOVA test because so many of my Suboxone patients, when doing one are (+) on it for ADHD.

    I never ever treated anxiety (in a literal sense, not a DSM sense) with a stimulant until I saw a TOVA test showing they had it, and then surprisingly it lowered their anxiety. Several of these patients had classic sx of an anxiety disorder including several that fit a perfect criteria of panic disorder or generalized anxiety disorder, but after SSRIs, and SNRIs didn't work, grasping for straws, I had them take a TOVA test. After it was (+) and after a failed trial of Wellbutrin, I tried a stimulant and many of these patients appeared much more calm and said their anxiety was gone or greatly reduced.

    I never saw this occur in training because no one in my residency program even knew what a TOVA test was. But given that the math behind the test showed it was accurate and patients were getting better (e.g. a guy who couldn't sit still in the chair and is now very calm and sitting still), I personally believe my theory is accurate.
  15. BobA

    BobA Member

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    Sort of an aside ,but Whopper do you know how good the TOVA is for picking up malingering?
  16. nitemagi

    nitemagi Senior Member

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    Y'know I fall more into the skeptic group for ADHD. Largely because so much of the literature is based on Biedermann's group, and he has had so many pharma scandals which obviously puts the validity of his work into question.

    Further, I have to wonder phenomenologically how the history of PTSD or trauma can create sx's of inattention. I've seen dissociation (mild level but persistent) in relatively functional individuals, as well as a function of avoidance in not paying attention to thinks (allowing someone to function better by not focusing on their overwhelming feelings). Finally, I think there's a role to conditioning or training to inattention as well. I don't buy that the condition can be solely explained as a genetic or congenital condition. Maybe a pre-dispositional factor.
  17. whopper

    whopper Former jolly good fellow

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    The TOVA like any other test is not perfect but what makes it different from other tests of ADHD is it's not a simply self-report test. Further, people trying to fake ADHD by researching it's diagnostic criteria will not be able to use this to fake it on the TOVA.

    The TOVA's symptom exaggeration index is scored on a 0 to 4, with the higher the number the more likelihood of malingering, with the test recommending that a 0-1 being strong evidence for not malingering. A 2-3 is a grey zone with 3 being more likely but still in the grey, and a 4 being strong reason.

    Per data the sensitivity and specificity are both over 80% if the score is above a 3

    Getting back to the original topic. there's so many ways this could be handled but here's food for thought.

    Gabapentin: likelihood of it being abused is low, it reduces pain, and per studies does reduce relapse in those with an alcohol use disorder.
    Norepinephrine reuptake-inhibitors: reduce pain, in several these have ADHD benefits

    Do one med at a time, have the patient document the effect of each med. Go through med trials and only keep the meds that seem to work, drop the ones that don't.

    If you're afraid of the patient abusing, drug screens, and use of meds that prevent abuse (e.g. naltrexone) could be considered.

    As I mentioned, I would be open to a stimulant, but only if there's testing for it (not a self-report scale), a non-stimulant was tried and failed, and urine drug screens are done given his history. I really hate cases where the person truly appears to have ADHD but has a history of substance abuse because it puts the clinician in a damned if you do, damned if you don't (holding the wolf by the ears) situation. If you give with a stimulant it could actually help his substance use problems but you could be enabling the person, don't, and you might not help someone needing it but you won't be possibly enabling a drug user.
    Last edited: 04.14.12
  18. billypilgrim37

    billypilgrim37 Unstuck in Time

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    .
    Last edited: 04.14.12
  19. billypilgrim37

    billypilgrim37 Unstuck in Time

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    I don't think there's really a lot of question about the quality or validity of the MGH psychopharm group's ADHD work, and other very good groups generally come to the same conclusions. It's the fact that they count non-episodic ADHD symptoms towards mania that has been the real controversy.
  20. curiositykat

    curiositykat

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    How can people suggest med changes without hearing an HPI, a MSE, and some sort of formulation? Checklists are not, btw, an hpi. Sorry to be churlish, but is the above considered adequate information to make ANY recommendations?
  21. splik

    splik

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    yes checklists are no replacement for history, and the PHQ-9 is quite frankly worse than useless (too many false positives due to low specificitity high sensitivity), but you don't need to know anything about the patient to know that is just bad prescribing to give someone ritalin, ativan and percocet, unless they were dying and even then it would be highly questionable. ativan is not a good treatment for insomnia even if you are using benzos, i have never even prescribed oxycodone outside of my palliative patients and would certainly never start percocet in any patient.
  22. nitemagi

    nitemagi Senior Member

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    Partially agree. Now this only shows ethical violations, and doesn't speak to the data or their analysis, but is a good place to start--

    http://www.alternet.org/health/88333:

  23. nitemagi

    nitemagi Senior Member

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    A nice critique on the literature behind the "genetics" of ADHD.

    http://www.jayjoseph.net/files/ADHD_Reply.pdf

    Given it's by a psychologist that critiques the overuse of genetics as explanatory models of anything, but it's a good paper to open up thinking outside of the paradigm that everything that comes out of MGH is truth.
  24. Ibid

    Ibid

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    Overall top bombing by Jay Joseph.
    http://www.jayjoseph.net/publications


    Leo, J., & Joseph, J. (2002). Schizophrenia: Medical Students are Taught It's All in the Genes, But Are They Hearing the Whole Story? Ethical Human Sciences and Services, 4, 17-30.
  25. splik

    splik

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    Not that I am a proponent of genetics, but anyone who compares psychiatric geneticists with Nazis and Eugenecists undermines they argument as Jay Joseph does. I think it is reasonable to suggest that traits like inattentiveness and hyperactivity may be heritable and certain SNPs or CNVs may increase the risk for such traits. That doesn't mean there are 'genes for' ADHD, in the same way there aren't genes for any other 'mental disorders', it would be remarkable if there were.
  26. splik

    splik

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    also what medical students are taught that schizophrenia is all in the genes? I know I went to an unusual medical school, but we were taught some of what is diagnosed as schizophrenia is probably genetic, and some of it is probably due to chronic social stress. Even in less enlightened places, it would, I think be unusual for students to be taught it was 'all in the genes' as even the most ardent geneticists would not agree with that most of what is diagnosed as schizophrenia is not purely genetic.
  27. billypilgrim37

    billypilgrim37 Unstuck in Time

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    Eh, just like you get tired of hearing the same anti-psychiatry arguments, this article presents some of the same kinds of anti-child arguments that just get old. They get old because, while they have some truth in them, the truth is pretty distorted.

    I have plenty of issues with MGH and Biederman's work. But I have more issues with this guy firebombing child psychiatry with no precision.

    Any time you read an article that says there has been a 40x increase in diagnoses of pediatric bipolar disorder, you should stop reading. It's not true. It's based on one study using insurance claims about # of visits, nothing to do with the number of kids diagnoses. In the time period studied, others find that the rate of diagnosis increased by more of a factor of 2-5x, with the bigger increases being in younger kids. There are 4 relevant articles on the rates of diagnoses from the late 90s to mid 2000s, I should dig up the references tonight. I might have then on my jump drive if I get a no-show. Pediatric bipolar diagnoses have increased to be sure, and for some bad reasons (many of which Biederman is personally responsible for), but also because we have learned phenomenologically more about what BP really does look like in kids, and we acknowledge (Mostly from STEP-BD) that BP symptoms start regularly in childhood and adolescence.

    And as big as the MGH psychopharm group has been for ADHD as well, it's by no means the biggest group doing the same work, and the NIMH-funded MTA study has much more influence than anything else nowadays. Russ Barkley's group would be a better place to look for "blaming" about how we treat ADHD, but I'm not sure there's any huge systematic complaints about his work.

    Having issues with the Biederman's work is a perfectly valid position. It's just better to have the right issues. The right issues being that he promoted non-episodic bipolar disorder in children without good scientific rationale, and that they think they are above rules of disclosure and management of conflict of interest. Those are terrible, damning things. There's no reason to look for other things that aren't really there.

    Later edit: I should clarify that I honestly do not believe that the MGH group promoted non-episodic BP because they wanted to sell more Risperdal. I honestly believe they felt that these non-episodic symptoms of mania were really a child variant of BP, and the fact that mood stabilizing medications were beneficial for explosive, chronically irritable children with ADHD bolstered the fact. So, while I think their conclusions were incorrect, and that their conclusions have been misused, I want it clear I think they were "wrong" but not "evil" in intent. Being arrogant and being malevolent are very different things, and the former has its consequences, but should not be confused with the latter.

    References Edit:
    Harpaz-Rotem I, Rosenheck RA: Changes in outpatient psychiatric diagnosis in privately insured children and adolescents from 1995 to 2000. Child Psychiatry Hum Dev 2004 34:329–40.

    Harpaz-Rotem I, Leslie DL, Martin A et al.: Changes in child and adolescent inpatient psychiatric admission diagnoses between 1995 and 2000. Soc Psychiatry Psychiatr Epidemiol 2005; 40: 642–7.

    Blader JC, Carlson GA: Increased rates of bipolar disorder diagnoses among U.S.child, adolescent, and adult inpatients, 1996–2004. Biol Psychiatry 2007; 62: 107–14.

    Moreno C, Laje G, Blanco C et al.: National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry 2007; 64: 1032–9.

    The Moreno paper is usually the one folks cite, since it's the most alarming, but there are these 3 (plus a few more, when I looked back) that tell some more of the story. It's a complicated question of diagnoses, but the answer "there was a 40x increase" is so simplistic as to not be all that useful, and at worse, it's used maliciously to paint child psychiatrists in as negative a light as possible.
    Last edited: 04.16.12
  28. Ibid

    Ibid

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  29. billypilgrim37

    billypilgrim37 Unstuck in Time

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    Has he written anything more recently on the topic? 12 years is an opportunity for quite a sea change in discussion, and many of us weren't doing psychiatry then. I feel like most people rail against "other psychiatrists" who say things like "schizophrenia is all genetic," but they never figure out who these fictional "other psychiatrists" really are. We are not above creating our own fictional bad guys. And if we don't, some psychologist who likes getting paid to write magazine articles will do it for us. ;)
  30. Ibid

    Ibid

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    He seems to have taken a ten year rest and started railing again in 2011. I've become quite disillusioned with the critical psychiatry movement recently. As you have alluded recently it is the collateral damage these firefights cause that should be the locus of at least some concern above and beyond "being right".
    Last edited: 04.16.12
  31. ghost dog

    ghost dog

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    I think you'll find you are incorrect in regards to the low specificity of the PHQ-9.

    I agree that, in and of itself the PHQ-9 is just a tool. However, I find it quite a useful tool for monitoring an interval response to pharmacological management of depression.

    In conjunction with a proper psych hx, it's useful.

    Please find attached the following parameters:


    http://www.depression-primarycare.org/images/pdf/ce_manual.pdf



    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/




    Operating Characteristics of VariousPHQ-9 Cut points for Diagnosing Major Depression

    PHQ-9 Score

    Sensitivity (%)


    Specificity (%)


    + Likelihood Ratio

    ≥9

    95


    84


    6.0

    ≥10

    88


    88


    7.1

    ≥11

    83


    89


    7.8

    ≥12

    83


    92


    10.2

    ≥13

    78


    93


    11.1

    ≥14

    73


    94


    12.0

    ≥15

    68


    95


    13.6
    Last edited: 04.17.12
  32. BobA

    BobA Member

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    The PHQ9 is a very helpful instrument in the outpatient psych world. Of course, it's a screening test for depression as everyone has mentioned. Someone with Sleep Apnea would have a moderate score on it as well. However, once the diagnosis of depression is made in an outpatient, the PHQ-9 has been very helpful for me in tracking how my outpatients respond to their med changes, or life stressors, etc. I get a PHQ9 on all my depressed patients like checking a vital sign, and I'm able to graph it over time in the medical record.

    It saves a huge amount of time, and also provides some quality control by ensuring that those important questions are addressed in a short med visit. This allows time for the patient to tell me how their REALLY doing, and for me to provide some brief psychoeducation or (ideally) some brief CBT. When you only have 15min you could spend the entire appointment assessing what the PHQ9 does quickly in the waiting room.

    I use a GAD-7, Beck Anxiety Inventory, PCL-C or PCL-M, etc the same way.

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