Psych Update v7n1 2015 - MC7900-0215 - Mayo Clinic

PsychUpdate

Psychiatry and Psychology News From Mayo Clinic Vol. 7, No. 1, 2015

INSIDE THIS ISSUE Family-Based Therapy Highly
Effective for Most Anorexia Patients
2 Adult ADHD
Presents Anorexia nervosa, which affects about 2 outpatient program that seeks to avoid
Diagnostic percent of young women and 1 percent of hospitalization and instead actively engages
and Therapeutic adolescent males, has challenged clinicians parents in the process of restoring their
Challenges for decades. The disorder profoundly alters child to a healthy weight at home. FBT treats
the lives of patients, interfering with growth, anorexia first and foremost as a medical ill-
3 Expanding the development and fertility and commonly ness and uses food as a therapeutic agent.
Collaborative co-occurs with substance use and mood and
Care Model anxiety disorders. The mortality rate — an “Children and teens with anorexia aren’t
estimated 20 percent — is the highest of any capable of making good choices about their
Leslie A. Sim, Ph.D., L.P. psychiatric illness. health. Their brains are hijacked by starva-
tion, so the parents have to step in and make
Yet traditional psychodynamic mod- those choices for them,” Dr. Sim explains.
els such as adolescent-focused individual “The choice they make is that kids have to
therapy (AFT), which stresses autonomy, eat. We don’t have any good pharmacology
self-efficacy and individuation, have met for anorexia; food is the medicine, and we
with little success. Less than half of patients know that it works.”
treated with AFT recover physically and
psychologically over the long term; the rest Results of the first randomized controlled
continue to experience symptoms of varying trial to demonstrate the effectiveness of FBT
severity throughout life. appeared in JAMA Psychiatry (formerly
Archives of General Psychiatry) in 2010. In
Several factors account for these poor that study, researchers found that FBT was
outcomes, according to Leslie A. Sim, Ph.D., superior to AFT on most clinically signifi-
L.P., a psychologist specializing in eating cant measures, including relapse rate from
disorders at Mayo Clinic’s campus in Roches- full remission — 10 percent and 40 percent,
ter, Minnesota. “Many of these kids are very respectively. Subsequent studies and clinical
ill; they’re not thinking clearly or flexibly and experience have confirmed those findings.

aren’t capable of engaging in traditional Feast or famine
psychotherapy,” she says. “Then, too, as
clinicians, we’re trying to reduce their FBT is a challenging and labor-intensive
control over weight and eating, which process that requires loving support and
in many cases they have incorporated remarkable patience and persistence from
into their identity as a moral value. So parents, one of whom must be present to
in essence, we are asking a child to stop monitor each meal and snack, no matter how
the behavior that in her eyes makes her long a child takes to eat it.
a good person.”
“There is no one right way to do it,
Family-based therapy (FBT) also but the key is not to let children out of the
known as the Maudsley approach, was demand that they consume a certain amount
developed as an alternative to tradi- of food at every meal,” Dr. Sim says, adding
tional interventions. It is an intensive that the goal is to regain weight quickly and

aggressively — an outpatient rate of 2 pounds have been derailed by anorexia and establish-
a week — so high-fat, calorie-dense foods are ing a healthy parent-adolescent relationship,
encouraged. where illness is no longer the focus of life.”

Once parents see the physical and psycho- Mayo Clinic has one of the few FBT pro-
logical changes in their children — which can grams in the country. At least 80 percent of
occur quite quickly — they feel much more treated patients make a full recovery — defined
empowered, Dr. Sim says. “There is nothing as achieving normal or near-normal weight —
worse than seeing your child starve and not be though younger patients with a shorter history
able to do anything about it,” she points out. of the disorder have a better chance of success.
“Parents are our allies; we couldn’t do it with-
Children’s reactions vary. Some, especially out them,” Dr. Sim says.
older teens, are angry and aversive. Others
are relieved to be able to relinquish control For more information
over food to their parents. And many adjust Lock J, et al. Randomized clinical trial compar-
to the regimen once they start feeling better. ing family-based treatment with adolescent-
A relatively brief hospital stay may be needed focused individual therapy for adolescents
for the small subset of patients for whom the with anorexia nervosa. JAMA Psychiatry.
outpatient program isn’t working. 2010;67:1025.

“Weight restoration and normalizing eating Mayo Clinic Child and Adolescent Eating
are the first and most important instruments Disorders Clinic. http://www.mayoclinic.org/
of change,” Dr. Sim says. “Later we work on diseases-conditions/eating-disorders/care-at-
handing control back to the child, and we help mayo-clinic/why-choose-mayo-clinic/CON-
parents with that process. The third and final 20033575.
phase involves handling normal adolescent
issues such as independence and sexuality that

Adult ADHD Presents Diagnostic
and Therapeutic Challenges

J. Michael Bostwick, M.D. Current evidence suggests that attention- These important distinctions are not
deficit/hyperactivity disorder (ADHD), the reflected in the Diagnostic and Statistical Man-
most common neurodevelopmental disorder ual of Mental Disorders, Fifth Edition (DSM-5).
of childhood, often persists throughout life The revised criteria for adult ADHD remain
and may affect 4 to 5 percent of U.S. adults. Yet child-focused, and only about one-third of
adult ADHD remains controversial — a clini- adults meet them. Furthermore, many patients
cally heterogenous, multifactorial syndrome continue to have problems with executive
with no set of consistent findings to support its functioning — the neurologically based skills
diagnosis and no single etiology to explain its involving mental control and self-regulation
pathology. This complexity may make providers — even when the core symptoms outlined in
reluctant to assess for ADHD, potentially lead- DSM-5 are effectively treated.
ing to underdiagnosis and undertreatment.
For adults, the consequences of lifelong
Inattention symptoms predominate functional difficulties can be devastating, says
Several studies, including a 2009 study in The J. Michael Bostwick, M.D., a psychiatrist at
Journal of Clinical Psychiatry, have demon- Mayo Clinic’s campus in Rochester, Minnesota.
strated that ADHD symptoms in adults differ “Little people, little problems; big people, big
considerably from those in children. More than problems,” he observes.
90 percent of adults with ADHD have atten-
tion issues, including difficulty with planning, Diagnosis is also complicated when behav-
follow-through, organization and time manage- ioral, mood and medical disorders, including
ment. Hyperactivity may decline or disappear in depression, anxiety, substance use, thyroid
adulthood, but impulsivity remains a significant problems and sleep apnea are present. Medical
problem. In adults, manifestations can be subtle, conditions can mask symptoms of adult ADHD,
including symptoms as diverse as restless, driven and psychiatric comorbidities make treatment
activity, an inability to relax or sexual impulsivity. more difficult. By some estimates, more than
half of adults who had childhood ADHD have
one or more psychiatric disorders.

2 MAYO CLINIC | PsychUpdate

Diagnostic criteria Figure. Adult ADHD Self-Report Scale-V1.1 Screener.

ADHD is a clinical diagnosis, so a detailed his- when core symptoms of ADHD are successfully
tory and exam are critical. Adult ADHD should managed, functional improvements may be
be suspected when: relatively modest.
• Core symptoms are present but don’t meet full
In addition to medications, an integrated
ADHD criteria treatment plan should include identifying a
• Residual symptoms cause serious functional patient’s strengths and weaknesses, assessing
for residual symptoms, and employing psycho-
difficulties social interventions such as time management
• Substance use or mood and anxiety disorders and cognitive behavioral therapy. “We try to
tailor medications to a patient’s needs and miti-
combine with core symptoms gate abuse potential,” Dr. Bostwick says. “Then
• A long history of psychosocial dysfunction we work very hard to build skills that will bring
order to a disordered life.”
exits, including disrupted education, employ-
ment and relationships For more information
• A discrepancy exists between intelligence and Wilens TE, et al. Presenting ADHD symptoms,
achievement subtypes and comorbid disorders in clinically
referred adults with ADHD. The Journal of Clini-
“When ADHD hasn’t been previously diag- cal Psychiatry. 2009;70:1557.
nosed, it’s usually possible to trace behavioral
and attentional difficulties back to preschool,”
Dr. Bostwick says. “When people mature,
ADHD manifests as underachievement. Many
adult patients are failing in life; they may have
a history of work and relationship issues and
an inability to function at a level equal to their
intelligence. They may recognize that they are as
intelligent as their friends but may be painfully
aware they have not had the same success.”

Challenges of treating adult ADHD

Therapy for adult ADHD can be challenging
and is a matter of some debate. As in pediatric
ADHD, stimulants are considered a first line
treatment, but they tend to be less effective in
adults, are associated with a slight cardiovas-
cular risk, and are more likely to be abused or
diverted, especially among adolescents and
college students. Although medications can
improve social and behavioral function, they
rarely normalize behavior completely. Even

Expanding the Collaborative Care Model

Most adults in the United States receive mental approach is a collaborative model that integrates
health care from nonspecialist providers, mental health professionals and care managers
mainly in the primary care setting. Yet primary into primary care. More than 70 robust, random-
care physicians have limited time, and access ized controlled trials, including the pivotal 2002
to evidence-based psychotherapy is especially Improving Mood-Promoting Access to Collabora-
challenging in primary care practices. Not only tive Treatment (IMPACT) study, which appeared
is referral to mental health specialists much in the Journal of the American Medical Associa-
more complex than to other providers, but tion, have demonstrated that collaborative care for
patients often choose not to see them. In one depression is far more effective than usual care in
small Mayo Clinic study, just half of patients a variety of treatment settings.
referred to the Department of Psychiatry and
Psychology kept their appointments. In Minnesota, the Depression Improvement
Across Minnesota, Offering a New Direction
An evidence-based alternative to this (DIAMOND) program for adults with diagnosed

MAYO CLINIC | PsychUpdate 3

Mayo Clinic depression is based on the IMPACT model. to expand it across
Psych Update Like IMPACT, DIAMOND adds a care
manager and consulting psychiatrist to the Mayo’s primary care
Medical Editor: health care team and uses the Patient Health
Matthew M. Clark, Ph.D., L.P. Questionnaire (PHQ-9) for assessment at departments. “By
the first primary care visit. Other program
Mayo Clinic Psych Update is written for physicians components include systematic monitoring treating medical and
and should be relied upon for medical education using repeat PHQ-9 measurements and a
purposes only. It does not provide a complete patient registry, a stepped-care approach to psychiatric issues
overview of the topics covered and should not treatment, and a relapse prevention plan.
replace the independent judgment of a physician Patients who don’t respond to treatment or in primary care, we
about the appropriateness or risks of a procedure have an acute crisis can receive same-day
for a given patient. specialty mental health care but are referred can look at the whole
back to primary care when stable.
Contact Us person and have
Data from Mayo show that many more
Mayo Clinic welcomes inquiries and referrals, people reach remission in DIAMOND than real potential to help David J. Katzelnick, M.D.
and a request to a specific physician is not those not in DIAMOND do — 26 percent of
required to refer a patient. patients at DIAMOND sites compared with people by catching
5.8 percent of patients at primary care and
Phoenix/ behavioral health clinics combined. Mayo problems early on,” Dr. Katzelnick says.
Scottsdale, Arizona Clinic and other DIAMOND sites consis-
866-629-6362 (toll-free) tently report the best depression outcomes Reaching more patients
Jacksonville, Florida in the state.
800-634-1417 (toll-free) The next challenge, Dr. Katzelnick adds, is
Rochester, David J. Katzelnick, M.D., chair of the extending collaborative care to patients with
Minnesota Division of Integrated Behavioral Health anxiety disorders and mental health problems
800-533-1564 (toll-free) at Mayo Clinic’s campus in Rochester, other than depression. One such evidence-
Minnesota, notes the significant effect of based program, the Coordinated Anxiety
Resources collaborative care on adherence. “In the Learning and Management (CALM) Tools
DIAMOND program, care coordinators for Living Program, was piloted at Mayo and
MayoClinic.org/medicalprofs have weekly follow-up contact with patients aims to treat four common anxiety disorders
where they address adherence and barriers including generalized anxiety disorder, social
Clinical trials, CME, Grand Rounds, to treatment. Frequent contact — virtually anxiety disorder, panic disorder and posttrau-
scientific videos and online referrals impossible in usual primary care — keeps matic stress.
patients engaged and improves the likeli-
hood of remission,” he says. Dr. Katzelnick is also interested in the
development of primary care programs for
In 2011, based on the success of DIA- patients with early substance abuse and
MOND, Mayo Clinic initiated a pilot pro- chronic pain issues and is currently developing
gram for adolescent depression called Early a program for Olmsted County, Minnesota,
Management and Evidence-Based Recogni- that would provide integrated care to patients
tion of Adolescents Living With Depression with borderline personality disorder. “We
(EMERALD). The program has received need to think not only about the person sitting
excellent results on all standard patient- in front of us but also about all those who
reported outcomes, and there are plans aren’t receiving treatment and extend care to
everybody,” he says. “To do that, we have to
work together.”

For more information

Unutzer J, et al. Collaborative care manage-
ment of late-life depression in the primary
care setting: A randomized controlled trial.
Journal of the American Medical Association.
2002;288:2836.

Education Opportunities

For more information or to register for courses, visit https://ce.Mayo.edu/psychiatry-and-psychology,
call 800-323-2688 (toll-free) or email [email protected].

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MC7900-0215