The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilities--primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self-medication hypothesis of addictive disorders. The cause-consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self-medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.

The Self-medication Hypothesis of Substance Use Disorders: A Reconsideration and Recent Applications

Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

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European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD.

This practice parameter reviews the literature on the assessment and treatment of children and adolescents with bipolar disorder. The parameter focuses primarily on bipolar 1 disorder because that is the type most often studied in juveniles. The presentation of bipolar disorder in youth, especially children, is often considered atypical compared with that of the classic adult disorder, which is characterized by distinct phases of mania and depression. Children who receive a diagnosis of bipolar disorder in community settings typically present with rapid fluctuations in mood and behavior, often associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders. Thus, at this time it is not clear whether the atypical forms of juvenile mania and the classic adult form of the disorder represent the same illness. The question of diagnostic continuity has important treatment and prognostic implications. Although more controlled trials are needed, mood stabilizers and atypical antipsychotic agents are generally considered the first line of treatment. Although patients may respond to monotherapy, combination pharmacotherapy is necessary for some youth. Behavioral and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the impact of the illness on family and community functioning.

Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.

Treatment-resistant depression (TRD) is a common clinical occurrence among patients treated for major depressive disorder. However, a clear consensus regarding the criteria defining TRD is lacking in the psychiatric community. Many patients who are considered treatment resistant are actually mis-diagnosed or inadequately treated. Clinicians need to accurately diagnose TRD by examining primary and secondary (organic) causes of depression and acknowledging paradigm failures that contribute to a misdiagnosis of TRD. A correct determination of what constitutes TRD requires consensus on criteria of treatment response (i.e., dose, duration, and compliance) and on the number of adequate trials required before a patient is determined to be nonresponsive. Additionally, clinical validation of available staging models needs to be completed. While several studies have identified predictors of non-response, clinical studies investigating the predictors of resistance following the failure of 2 or more antidepressant trials should be pursued. In managing TRD, 3 pharmacotherapy strategies are in clinical use: optimization of antidepressant dose, augmentation/combination therapies, and switching therapies. However, the optimal strategy for treating TRD has yet to be identified. Therefore, further controlled clinical trials are essential to identify the most effective treatment strategies.

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Treatment-resistant depression

Objective To review the literature of the past decade covering the epidemiology, clinical characteristics, assessment, longitudinal course, biological and psychosocial correlates, and treatment and prevention of pediatric bipolar disorder (BD). Method A computerized search for articles published during the past 10 years was made and selected studies are presented. Results Pediatric BD is increasingly recognized, and there are several prevailing views on core features of this disorder. The incidence and prevalence of the disorder and the associated comorbidities vary according to study setting and criteria used. This disorder is highly recurrent and accompanied by substantial psychiatric and psychosocial morbidity. Familial studies, including “top down” (offspring of parents with BD) and “bottom up” (relatives of youths with BD) studies indicate that pediatric BD is aggregated in families with adult or later-onset BD and suggest the existence of genetic predisposition. Greater understanding of the risk factors for early onset BD and recognition of the phenomenology of prodromal symptoms offers hope for early identification and prevention. Neuroimaging studies indicate frontotemporal and frontostriatal pathology, but none of these findings seems to be disorder specific. Combination pharmacotherapies appear promising, and the field awaits further short- and long-term randomized, placebo-controlled trials. Preliminary studies of various psychotherapies, including psychoeducation strategies tailored specifically for BD in youths, look encouraging. Conclusions Considerable advances have been made in our knowledge of pediatric BD; however, differing viewpoints on the clinical presentation of BD in children are the rule. Phenomenological and longitudinal studies and biological validation using genetic, neurochemical, neurophysiological, and neuroimaging methods may strengthen our understanding of the phenocopy. Randomized, controlled treatment studies for the acute and maintenance treatment of BD disorder are warranted.

Pediatric bipolar disorder: a review of the past 10 years.

Objective: To evaluate the effects of medications used in the treatment of adults with attention-deficit/hyperactivity disorder (ADHD) on blood pressure and pulse. Method: Subjects were those with DSM-III-R-/DSM-IV-diagnosed ADHD enrolled in placebo-controlled studies of 5 different medications for ADHD. Cardiovascular data from these studies of both stimulants (methylphenidate, amphetamine compounds, pemoline) and nonstimulants (bupropion, desipramine) were reanalyzed for baseline-to-endpoint active-treatment or placebo effects on blood pressure and heart rate. Results: There were 125 subjects with a mean ′ SD age of 39 ′ 9 years. In general, active drug treatment for ADHD compared to baseline was associated with several statistically significant changes in systolic blood pressure (bupropion: +5.9 mm Hg, p <.05 by paired t test; amphetamine: +5.4 mm Hg, p <.05), diastolic blood pressure (desipramine: +7.1 mm Hg, p <.05), and heart rate (bupropion: +6.9 mm Hg, p <.05; amphetamine: +7.3 mm Hg, p <.05; methylpheni-date: +4.5 mm Hg, p <.05). New-onset cases of systolic or diastolic hypertension (blood pressure ≥ 140/90) were recorded in 8% (7/89) of placebo-treated subjects and 10% (9/89) of subjects receiving active medication, regardless of the class (stimulant, nonstimulant). Conclusion: Both stimulant and nonstimulant catecholaminergic medications used in adults with ADHD are associated with minor, but statistically significant, changes in heart rate and blood pressure that were often observed in those receiving placebo. Given the minor pressor and chronotropic effect of these medications, adults with ADHD should have their blood pressure and heart rate checked at baseline and periodically during treatment.

Blood Pressure Changes Associated With Medication Treatment of Adults With Attention-Deficit/Hyperactivity Disorder

Objective: Previous work in adults and youths has suggested that juvenile onset bipolar disorder (BPD) is associated with an elevated risk of substance use disorders (SUD). Considering the public health importance of this issue, the authors now report on a controlled study of adolescents with and without BPD to evaluate the risk of SUD. Method: Probands with DSM-IV BPD ( n = 57, mean age ± SD = 13.3 ± 2.4 years) and without DSM-IV BPD ( n = 46, 13.6 ± 2.2 years) were studied. Structured psychiatric interviews and multiple measures of SUD were collected. Results: Bipolar disorder was associated with a highly significant risk factor for SUD (32% versus 7%, Z = 2.9, p = .004) that was not accounted for by conduct disorder (adjusted odds ratio = 5.4, p = .018). Adolescent-onset BPD (≥13 years) was associated with a higher risk of SUD compared with those with child-onset BPD (χ 2 1 = 9.3, p = .002). Conclusions: These findings strongly indicate that BPD, especially adolescent onset, is a significant risk factor for SUD independently of conduct disorder.

Risk of Substance Use Disorders in Adolescents With Bipolar Disorder

Objective: Despite its common onset in preschool years, few studies have examined the characteristics of bipolar disorder (BPD) in preschoolers. This study reports on the clinical characteristics, psychiatric comorbidity, and functioning of preschoolers identified with BPD who were referred to a pediatric psychiatric clinic. Methods: Structured psychiatric interviews assessing lifetime psychopathology by Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria were completed with parents about their children and confirmed by clinical interview of the child. Family, social, and overall functioning were also assessed at intake. Findings from preschoolers ages 4 to 6 years were compared with a group of children ages 7 to 9 years (school age). Results: We identified 44 preschoolers and 29 consecutively ascertained school-age youth with BPD. Preschoolers had similar rates of comorbid psychopathology compared to school-age youth with BPD. Preschoolers and school-age children with ...

Patterns of comorbidity and dysfunction in clinically referred preschool and school-age children with bipolar disorder.

Objective: Adolescents and adults with attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUD) are increasingly recognized in clinical practice. The role of pharmacological treatment for ADHD in these comorbid individuals remains unclear. Methods: A systematic review of the medical literature was conducted through PubMed, supplemented with data from scientific presentations, to evaluate the role of medication treatment of ADHD in substance abusing individuals with ADHD. Meta-analysis was used to evaluate the effects of medication therapy on ADHD and SUD outcomes in general, while specifically addressing trial design, trial duration, retention, class of medication, age group, concurrent psychotherapy, and outcome in both SUD and ADHD domains. Results: Four studies in adolescents and five studies in adults with ADHD plus SUD were identified (two controlled and seven open studies; n = 222 subjects). The standard mean difference (SMD) indicated statistically significant improvements ...

The clinical dilemma of using medications in substance-abusing adolescents and adults with attention-deficit/hyperactivity disorder: what does the literature tell us?

Hadley Moore

Papers

Blood Pressure Changes Associated With Medication Treatment of Adults With Attention-Deficit/Hyperactivity Disorder

Risk of Substance Use Disorders in Adolescents With Bipolar Disorder

Patterns of comorbidity and dysfunction in clinically referred preschool and school-age children with bipolar disorder.

The clinical dilemma of using medications in substance-abusing adolescents and adults with attention-deficit/hyperactivity disorder: what does the literature tell us?