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Spring 2012, Volume 15 no 3

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Research Updates

 

Mark de la Hey

 

People with ADHD fall through the cracks as they enter adult life

Attention-deficit/hyperactivity disorder (ADHD) is generally thought of as a childhood disorder, but it often continues into adulthood. New research from King’s College London indicates that in the United Kingdom there is a gap in care for people with ADHD making the transition from child services to adult services. Surveying the available literature, the researchers found that although about two thirds of children with ADHD continue to experience some degree of impairment at age 25, most completely disengage from services by age 21. This is partly because there has traditionally been poor co-ordination between child and adult services in treating ADHD. Transition services are generally lacking or poorly thought out, and child services for ADHD often end early in adolescence. More recently, however, British child services have begun continuing care until age 18 and older due to the difficulty of transferring to adult services. Many mental health professionals are sceptical about the validity of ADHD as an adult disorder, and adult mental health services often do not see ADHD as falling within their mandate. The authors conclude with a set of 19 recommendations, including recommendations that health care providers recognize that ADHD often continues into adulthood and that they work together to develop clear protocols for transitioning people with ADHD from child services to adult services.

BMC Psychiatry, November 3, 2011, 11: 174, doi: 10.1186/1471-244X-11-174. Susan Young et al., Institute of Psychiatry, King’s College London, United Kingdom.

 

Beliefs may be more important than medication in treating depression

In depression treatment, the beliefs of patients and clients regarding their treatment may have a bigger impact on the outcome than the treatment itself, according to new research from Massachusetts General Hospital in Boston. The results were based on the responses of 207 adults with major depressive disorder to treatment with St. John’s wort, sertraline (Zoloft) or placebo. After eight weeks of treatment, participants were asked to guess which treatment they were receiving. It turned out that the actual treatment to which participants were assigned had no significant effect on outcome. However, those who guessed that they were being treated with either St. John’s wort or sertraline did show significant improvement, with a slight advantage for those who guessed St. John’s wort. Those who guessed placebo reported limited improvement in symptoms. Sixty-eight per cent of participants who guessed St. John’s wort were considered treatment responders, meaning they showed at least a 50 per cent reduction in depression symptoms at the study’s completion. Fifty-six per cent of those who guessed sertraline were responders, but this was true of only 24 per cent of those who guessed placebo. Given that the original study on which these findings are based was advertised as a clinical trial of St. John’s wort, participants may have been more enthusiastic than the general public about the herb, and this may have influenced their responses. The authors conclude that further research is needed to explain the power of belief in influencing treatment outcomes.

Journal of Clinical Psychiatry, October 4, 2011, published online, doi: 10.4088/JCP.10m06453. Justin A. Chen et al., Department of Psychiatry, Massachusetts General Hospital, Boston.

 

Potentially harmful painkiller use found among people on methadone

People in methadone maintenance therapy often obtain prescriptions for other opioid medications which could lead to overdose, according to research from the Centre for Addiction and Mental Health in Toronto. The study’s authors used data from the Ontario Drug Benefit database on 18,759 individuals who had received at least 30 days of methadone maintenance therapy. They found that 18 per cent of these individuals had received at least one prescription of more than seven days’ duration for an opioid medication other than methadone. Within this group, the average number of non-methadone opioid prescriptions was 12 a year, the most frequently prescribed being codeine and oxycodone (OxyContin). Almost half of the non-methadone opioid prescriptions were from a physician or a pharmacy not involved in the individual’s methadone therapy. This suggests to the study’s authors that “many such prescriptions reflect duplicitous drug-seeking behavior, either for personal use or for diversion and financial gain.” They note that the prescription of other opioids in addition to methadone maintenance is unsafe, and are particularly concerned that the large quantities of long-acting oxycodone they found being prescribed to participants in their study could lead to fatal overdoses. The authors suggest that “[this] problem could be largely mitigated by real-time access to prescription data for both physicians and pharmacists prior to writing and filling prescriptions, which presently exists in only a few jurisdictions in Canada, the United States, and elsewhere.”

Addiction, November 2, 2011, published online, doi: 10.1111/j.1360-0443.2011.03707.x. Paul Kurdyak et al., Centre for Addiction and Mental Health, Toronto, Ontario.

 

Brain chemical similar to marijuana could lead to new painkillers

Researchers at the University of California, Irvine, have found a way to increase the potency of anandamide, a naturally occurring chemical in the body that has a painkilling effect similar to marijuana. Anandamide, like the active ingredient in marijuana, is a neurotransmitter that acts on cannabinoid receptors in the body, thus providing an analgesic effect. However, anandamide is short-lived because it is ordinarily transported to areas within neurons where it is broken down by an enzyme called fatty acid amide hydrolase (FAAH). The researchers identified a protein that they dubbed FLAT (FAAH-like anandamide transporter), which transports anandamide to the areas where it is rendered inactive. They then discovered a compound called ARN272, which prevents anandamide from binding with FLAT. Administration of ARN272 increased blood levels of anandamide and reduced pain-related behaviour in mice that had been injected with a chemical irritant to induce pain. The authors suggest that since these results demonstrate the importance of FLAT in transporting anandamide in neurons, drugs that target FLAT could be developed as painkillers, and ARN272 would appear to be a promising candidate for such a drug.

Nature Neuroscience, November 20, 2011, published online, doi: 10.1038/nn.2986. Jin Fu et al., Department of Pharmacology, University of California at Irvine, Irvine.

 

Heavy methamphetamine use linked to schizophrenia risk

Heavy methamphetamine users appear to have an elevated risk of developing schizophrenia, according to new research from the Centre for Addiction and Mental Health in Toronto. Researchers examined California hospital discharge records from 1990 through 2000 on patients with a diagnosis of either abuse or dependence of methamphetamine, cannabis, alcohol, cocaine or opioids, as well as a control group of patients with appendicitis and no history of drug abuse or dependence. They found that patients in the methamphetamine group were 1.5 to 2.8 times more likely than those in the cocaine, opioid or alcohol groups to subsequently develop schizophrenia, and 9.4 times more likely than those in the appendicitis group to develop schizophrenia. However, the likelihood of developing schizophrenia among those in the methamphetamine group was not significantly higher than the rate for those in the cannabis group. The risk of schizophrenia was higher for all forms of drug dependence and abuse compared with appendicitis. The authors speculate that significant use of any drug of abuse could elevate the risk of persistent psychosis, given that all drugs of abuse are stressors, most of which act on the dopamine system. They recommend that “clinicians need to be vigilant in monitoring their substance-abusing patients for signs of a developing persistent psychotic reaction.”

American Journal of Psychiatry, published online November 8, 2011, doi: 10.1176/appi.ajp.2011.10070937. Russell C. Callaghan et al., Centre for Addiction and Mental Health, Toronto, Ontario.

 

Doctors can learn from Shakespeare’s mind–body connection

Shakespeare has long been admired for the depth of his insight into the human mind. Now, research from the University of Bristol in the United Kingdom shows that he was much more perceptive than other writers of his time in portraying mental states through bodily sensations. The study compared 42 of Shakespeare’s major works with 46 works by his contemporaries, looking for depictions of sensory sensations other than those involving vision, taste, the heart and the stomach and intestines. Vertigo in response to emotional distress is experienced by five of Shakespeare’s characters, but was mentioned by only one of Shakespeare’s contemporaries. Breathlessness, which the study’s author interprets as hyperventilation, shows up 11 times in Shakespeare but only twice in the works of other writers. Fatigue, as an expression of grief, shows up at least nine times in Shakespeare’s works, and only four times among his contemporaries. Deafness at a time of high emotion is mentioned three times by Shakespeare, but is never mentioned by another writer. Numbness in reaction to distress and enhanced sensation resulting from excitation are experienced by four Shakespearian characters, but are never mentioned by other writers. The author concludes that Shakespeare was “an exceptionally body-conscious writer” who may have used bodily sensations to make his characters seem more human or to heighten the emotional intensity of his plays and poems. The author suggests that doctors could become better at their work by studying Shakespeare to remind them that physical symptoms can have psychological causes.

Medical Humanities, 2011, 37: 97-102, published online first June 4, 2011, doi: 10.1136/jmh.2010.006643. Kenneth W. Heaton, Department of Medicine, University of Bristol, Bristol, United Kingdom.

Social skills deficits from prenatal alcohol exposure persist

Individuals exposed to alcohol during gestation show social skills deficits that persist into adulthood and may even worsen with age, according to a study from the University of Alberta in Edmonton. Researchers reviewed research on social skill deficits in people with prenatal alcohol exposure, including those who did and did not develop fetal alcohol spectrum disorders (FASD). They found that children and adolescents with FASD and prenatal alcohol exposure have trouble being accepted socially and find it difficult to establish and maintain relationships. Children with FASD tend to exhibit social skills deficits, including socially inappropriate behaviour; excessive friendliness; and lack of inhibition, involving a tendency to make inappropriate statements and poor-quality social advances and responses. They may also experience teasing as a consequence of these deficits. Well into adulthood, people with FASD can lag years behind others their age in terms of social development and communication skills. This lack of social skills and resultant social rejection can lead to antisocial behaviour, dropping out of school, trouble with the law and mental health problems. However, the authors note that there is some evidence that social skills interventions for children with FASD can mitigate some of the problems associated with social skills deficits.

Alcoholism: Clinical and Experimental Research, October 21, 2011, published online, doi: 10.1111/j.1530-0277.2011.01661.x. Katrina Kully-Martens et al., Department of Pediatrics, University of Alberta, Edmonton.