Treating ADHD in pts with a psychotic d/o

[medstudent234]

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This seems like a very tricky thing to do as antipsychotics and stimulants have opposing effects and you’d be at risk of causing a relapse with increasing dopamine. I saw a pt today with well controlled schizoaffective d/o, bipolar type as well as an ADHD history who was presently bothered by ADHD symptoms. Assuming poor concentration wasn’t due to depression, curious how people would approach this.

 

[clausewitz2]

This seems like a very tricky thing to do as antipsychotics and stimulants have opposing effects and you’d be at risk of causing a relapse with increasing dopamine. I saw a pt today with well controlled schizoaffective d/o, bipolar type as well as an ADHD history who was presently bothered by ADHD symptoms. Assuming poor concentration wasn’t due to depression, curious how people would approach this.

Deficits in working memory and processing speed are often found in folks with psychotic disorders. These cognitive deficits often predate the onset of frank psychosis. How confident are you that this is ADHD as such?

 

[DisorderedDoc417]

Intuniv.

 

[NJWxMan]

It's called bipolar disorder. I almost always get rid of stimulants in adult mood disorders to help clarify diagnosis.

 

[splik]

The data shows for patients with bipolar I disorder who are being treated appropriately, it is safe to use psychostimulants (methylphenidate at least). The data is less good for primary psychotic disorders, but you can safely treat comorbid ADHD with stimulants in patients who are stable on neuroleptics for psychosis. As mentioned above, diagnostic clarification is important, and a risk-benefit analysis must consider the severity of the psychotic illness and risk of relapse/decompensation versus the level of impairment for ADHD symptoms. Also, remember that subjective cognitive dysfunction and neuropsychological impairments are found in patients with bipolar disorder and psychotic illness even in the absence of significant mood/psychotic symptoms, and can be hard to tease apart from ADHD. ADHD is supposed to be a neurodevelopmental disorder, so childhood diagnosis, collateral, school records (where available), a good history from pt and other source (using something like the DIVA, Wender Utah) and your own observations of the patient. And of course there is the effects of psychotropic drugs (anticonvulsants, antipsychotics), which are obviously not good for your brain. You also want to consider level of functioning. If the pt is on disability and not doing anything and has no interest in doing so, I would question the need to treat ADHD. However if this was someone who is working/studying and these ADHD symptoms are significantly impairing and their bipolar/psychotic illness is well controlled, their could be enormous benefit to treating ADHD.

 

[thoffen]

There are certainly studies on use of modafanil for negative symptoms, for example, with benefit and without exacerbating psychosis. Generally speaking the risk of causing psychosis with these drugs is in significantly supratherapeutic use. Less clear with people who have existing psychosis. However, saying that their mechanisms of action are cross purposes is simplistic and essentially inaccurate. This is not to say that there is no risk and you should hand out stimulants regularly. For people with only ADHD, stimulant prescription often requires careful risk-benefit analysis and setting up of external controls. Obviously there are non-stimulant and therapeutic options to consider. But by no means are stimulants expressly prohibited.

 

[Georgit]

It's called bipolar disorder. I almost always get rid of stimulants in adult mood disorders to help clarify diagnosis.

I've seen a bipolar whose most striking syntomp was a huge attention deficit. The mood was fair, no sign of psychosis . But she can not stand still,jumping from a subject to another etc
I'd be curious to see what a stimulant could do. Theoretically a switch to full mania, but who knows for sure.
Shortly afterwards she took her life, also from outside I could see that her internal "anxiety" was unbearable, a torture.
I argue if in a desperate case like this something can be tried to quell the internal fire that is devouring the person to death

 

[whopper]

It's okay to give stimulants in truly ADHD patients with Bipolar or Schizophrenia-assuming they're taking the meds for the Bipolar or Schizophrenia consistently, and I'd rather try non-stimulants such as Atomoxetine or Bupropion first.

 

[FlowRate]

For my own education, how do you differentiate ADHD from the cognitive--including attentional--deficits expected of the quiescent and symptomatic phases of those illnesses?

Thinking about it more--it seems to me that this is another example of a place where our categorical diagnostic system is less useful than a dimensional one or an RDOC type symptom/sign system. If methylphenidate helps with deficits of attention generally then it wouldn't matter whether the deficits of attention were from the BPAD/Schiz spectrum or an independent "ADHD."

 

[whopper]

Disorder/disease course and history.

E.g. someone with a history of psychomotor hyperactivity with anxiety that's constant and going on for years since childhood is different from someone who just got it in the last few days after starting an antipsychotic are very different things.

 

[FlowRate]

Disorder/disease course and history.

E.g. someone with a history of psychomotor hyperactivity with anxiety that's constant and going on for years since childhood is different from someone who just got it in the last few days after starting an antipsychotic are very different things.

Thanks. I have a bad habit of editing my posts a couple of times after I initially post so that's why there's more stuff above. I guess what I'm wondering is whether "ADHD" in this population is "ADHD" discretely or a deficit related to parts of the BPAD/Schizophrenia spectrum. Those cognitive deficits also start in school years, before onset of psychotic symptoms. (But TBH I'm not sure whether those deficits include inattention, will have to do more reading.)

 

[thoffen]

Disorder/disease course and history.

E.g. someone with a history of psychomotor hyperactivity with anxiety that's constant and going on for years since childhood is different from someone who just got it in the last few days after starting an antipsychotic are very different things.

This is of course the right answer, but also there can be a lot of bias or inaccuracy in historical accounts or lack of available data. Sure, psychometric testing can aid the evaluation, but I have a big distaste for colleagues who send patients to psychologists for testing as if their evaluation is 100% sensitive and specific. It's a clinical diagnosis either way. They just have more tools to aid the assessment. In many cases it's an unnecessary and expensive hurdle. In others it is taken as truth (positive or negative eval) and never rethought when the clinical results of whatever treatment approach aren't meeting expectations.

This is where understanding risks and benefits and whatever external controls there are to mitigate risks is helpful. Punting when you are uncertain is not always the best action.

 

[WisNeuro]

This is of course the right answer, but also there can be a lot of bias or inaccuracy in historical accounts or lack of available data. Sure, psychometric testing can aid the evaluation, but I have a big distaste for colleagues who send patients to psychologists for testing as if their evaluation is 100% sensitive and specific.

I would personally love if I didn't have to cancel several consults a week from psychiatry for "ADHD Testing" before they'll start a stimulant. Would save my assistant and myself some time here and there.

 

[clausewitz2]

The SPMI arm of my shop has a very deep bench of people experienced with psychotic disorders and very occasionally we do use small doses of stimulants with people with an SCZ diagnosis who are stable from a positive symptom standpoint but who are extremely negative. This has been very successful in some cases. This is to say that it is not insane to do this; remember the animal models of psychosis based on stimulants and the psychosis experienced by meth users are all based on much larger doses of these medications than anyone would ever intentionally prescribe.

Here is an attempt at rounding up literature on giving stimulants for negative sx:

ScienceDirect

 

[whopper]

This is of course the right answer, but also there can be a lot of bias or inaccuracy in historical accounts or lack of available data.

True and some patients are horrific with not describing very needed important details.

The typical schizophrenic you see in an inpatient unit several times, I'd likely never give them a stimulant if they had ADHD.

The type of schizophrenic who can work full time (yes they're out there, just you usually don't see these types in residency) who has ADHD, this type of person can be considered for stimulants for their ADHD, cause this person likely is taking their schizophrenia meds consistently.