A windy Chicago welcomed 314 psychiatrists and advance practice psychiatric practitioners to “Bipolar Disorder and ADHD: Solving Clinical Challenges, Improving Patient Care,” April 2-4, 2009, at the Westin Chicago River North. Presented by CURRENT PSYCHIATRY and the American Academy of Clinical Psychiatrists (AACP), the interactive continuing medical education conference offered attendees up to 19.5 CME credits.

Thursday, April 2, 2009

Moderator: Richard Balon, MD, Program Chair

Kiki Chang, MD, Associate Professor of Psychiatry at the Stanford University School of Medicine, kicked off the meeting with a discussion of diagnosis and treatment of ADHD in children and adolescents. Dr. Chang presented data on comorbidity and symptom overlap between ADHD and bipolar disorder and discussed stimulant and nonstimulant pharmacotherapy of ADHD.

Click here for video of Dr .Chang speaking about the importance of obtaining a baseline EKG in children before starting psychostimulants; how to distinguish between ADHD and bipolar disorder; and “ADHD Plus.”

Anthony L. Rostain, MD, director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania School of Medicine, discussed the challenges in diagnosing ADHD in adults and outlined how ADHD symptoms manifest differently in adults than in children. He also offered tips for making an accurate diagnosis of adult ADHD and listed screening scales that can be used in clinical practice.

After a short networking break, Dr. Rostain continued the discussion of adult ADHD with a presentation on treatment strategies. He outlined stimulant and nonstimulant options and how to manage pharmacotherapy for adults with comorbid psychiatric disorders such as anxiety, substance abuse, or depression. Dr. Rostain also addressed concerns about adverse cardiac side effects with psychostimulant treatment and how to adjust medications to maximize treatment response.

Click here for video of Dr. Rostain as he discusses getting adult patients with ADHD ready for treatment.

Kevin Murphy, PhD, president of the Adult ADHD Clinic of Central Massachusetts, presented data showing why psychotherapy and other psychosocial interventions play a vital role in adult ADHD treatment. He recommended that clinicians help patients accept that negative symptoms are caused by a neurobiological disorder—not a character flaw or willful misconduct—that requires ongoing maintenance. Adult patients often need ongoing education and support to develop compensatory skills and strategies, avoid substance abuse, and address challenges with work, school, and family.

Click here for video of Dr. Murphy discussing the importance of instilling hope during treatment of adults with ADHD

In his second presentation, Dr. Murphy emphasized that serving as a partner/advocate for the adult with ADHD is key to continued treatment over time. To convince someone who is skeptical about starting treatment, he recommends that clinicians “take the powerplay” out of the conversation. Demystify the diagnosis, and explain why the patient meets criteria for ADHD, he said. Explain how the medication works and why treatment is important—without “jamming it down their throats,” he said. Emphasize the patient’s attributes, such as intelligence, creativity, high energy, “feistiness,” or sense of humor.

S. Nassir Ghaemi, MD, Director of the Mood Disorders and Psychopharmacology Programs and professor of psychiatry at Tufts, University, described the “hierarchy of diagnosis” implicit in DSM-IV-TR in his discussion of comorbid adult ADHD and bipolar disorder. Because of overlapping symptoms, mood disorders (bipolar and unipolar) should be ruled out before a clinician considers a psychotic or anxiety disorder. Similarly, he cautioned against diagnosing ADHD while a patient is experiencing a mood episode or psychotic illness.

Early onset of bipolar disorder is common, according to Dr. Chang. One-half of adults with bipolar disorder experience onset as children (14%) or adolescents (36%). In children, the bipolar spectrum includes severe mood dysregulation, “full” bipolar disorder (types I and II), and possible prodromal states (such as ADHD or depression with a family history of bipolar disorder and bipolar disorder not otherwise specified). Children with bipolar disorder often show irritability, but this symptom is not specific to bipolar disorder. Randomized controlled trials have shown lithium and atypical antipsychotics to be effective for mood stabilization in pediatric bipolar disorder.

Friday, April 3, 2009

Moderator: Sanjay Gupta, MD, AACP President

Anticipate unplanned pregnancies when choosing medications for women of reproductive age with bipolar disorder, advised Marlene P. Freeman, MD, Massachusetts General Hospital perinatal and reproductive psychiatry program. A patient may deny plans to become pregnant, but two-thirds of U.S. women have at least one unintended pregnancy, and 50% to 60% of pregnancies are unintended or mistimed. Because relapse rates for bipolar women who discontinue medication during pregnancy are high, it is recommended that patients consider the serious risks of untreated bipolar disorder as well as medication exposure. Valproate appears to be the mood stabilizer associated with the greatest teratogenic potential. Among the anticonvulsants, lamotrigine appears to have the most favorable reproductive safety profile, and lithium appears to have a much lower risk of teratogenicity than was thought years ago, with a very low absolute risk of malformations with first-trimester exposure. More data are needed to inform the use of atypical antipsychotics across pregnancy and breastfeeding.

Click here for video of Dr. Freeman discussing why it is important to consider unplanned pregnancy when prescribing medication to women of reproductive age.

In his second presentation at the conference, Dr. Ghaemi reviewed the use of stimulants in bipolar disorder treatment and the risk of mood destabilization. Because patients with bipolar disorder often also experience cognitive dysfunction, he reviewed nonstimulant strategies for preserving brain function and enhancing cognition.

Click here for video of Dr. Ghaemi discussing how to preserve brain function in patients with bipolar disorder; how to identify early signs of brain dysfunction; and if it is appropriate to use stimulants in patients with bipolar disorder.

Next, Dr. Freeman returned to the podium to summarize of the latest evidence on subsyndromal depression in bipolar I disorder. She discussed the functional toll of subsyndromal depression, the risk of switching to mania with antidepressant therapy, effective use of mood stabilizers, and evidence supporting other therapies. These include psychotherapy, complementary and alternative medicine, omega-3 fatty acids, exercise, and light therapy.

Suicidal behavior in patients with bipolar disorder was the topic of the session presented by Frederick Goodwin, MD, Research Professor of Psychiatry at George Washington University Medical Center. Dr. Goodwin covered suicide risk factors, mood stabilizers’ efficacy in reducing suicide risk, and the importance of ongoing communication with patients and families about suicide and the underlying bipolar disorder.

Dr. Ghaemi served as moderator at a luncheon symposium on “Maintaining wellness in patients with bipolar disorder.” Claudia Baldassano, MD, assistant professor of psychiatry at the University of Pennsylvania, discussed how to promote wellness in patients with bipolar disorder. Robert Hirschfeld, MD, professor and chairperson, cepartment of psychiatry and behavioral sciences, University of Texas Medical Branch, spoke on integrating pharmacotherapy and nonpharmacologic treatments for bipolar disorder.
Friday afternoon’s sessions began with a presentation of the evidence on rapid and ultradian cycling in bipolar disorder patients by Steven Dubovsky, MD, professor and chair, department of psychiatry, University at Buffalo. Dr. Goodwin then described how to use lithium in the acute treatment of mania, treatment of bipolar depression, and maintenance treatment bipolar disorder.

In a “Psychopharmacology Jam Session,” audience members stepped to the microphones to comment on clinical case reports presented by AACP members Sanjay Gupta, MD, president; Gregory Teas, MD, and Nagy Youssef, MD.

The day ended with a session by Dr. Chang, who discussed strategies for promoting treatment adherence in patients with bipolar disorder. Dr. Chang’s presentation covered patient, clinician, and system factors that contribution to nonadherence and included video from a patient interview that helped illustrate these issues.

Saturday, April 4, 2009

Moderator: Donald W. Black, MD, Program Co-Chair

The day’s sessions began with Dr. Ghaemi reviewing the latest evidence related to alcohol abuse in patients with bipolar disorder and ADHD. He covered the effect on alcohol use and dependence of medications used to treat bipolar disorder and ADHD.

Charles Bowden, MD, professor of Psychiatry and Pharmacology at University of Texas Health Science Center, continued the program with a session on antidepressant use in bipolar disorder. In his extensive evidence review, Dr. Bowden discussed implications for assessment, and how sample selection procedures can optimize the generalizability of a study’s findings.

After a break for networking and visiting the exhibitors, Dr. Ghaemi returned to discuss the use of antipsychotics for treating phases of bipolar disorder. He reviewed evidence from multiple studies of multiple drugs and suggested that clinicians balance the differential efficacy across agents against the risks and potential for using alternate medications.

Finally, the conference concluded with Dr. Bowden, who presented a session titled How to use mood stabilizers other than lithium for bipolar disorder. His presentation included guidelines for and caveats regarding using combination drug therapy for treatment of mania and evidence supporting the use of specific medications for preventing relapse.