Implementation of an Adult ADHD Toolkit in Primary Care: A Prospective Cohort Survey.

OBJECTIVE: Attention-deficit/hyperactivity disorder (ADHD) in adulthood presents unique challenges for primary care providers, and many lack confidence addressing it. To support them, a workgroup of volunteer primary care and mental health providers created an Adult ADHD Toolkit containing information about the disorder and treatment advice. The objective of this study was to establish the impact of implementing the toolkit in primary care. METHODS: Providers completed a survey immediately before and 5 months after the toolkit was implemented. Participation was voluntary and anonymous. Also, prescriptions for stimulant and nonstimulant adult ADHD medications were tracked 6 months before and 6 months after the toolkit was introduced. RESULTS: The response rate was 77.4% (n=24) at baseline and 64.5% (n=20) at follow-up. At follow-up compared to baseline, participants reported significantly higher comfort for assessment of adult ADHD (P=.039). Participants also reported higher comfort for nonmedication management (P=.10). There was no difference for comfort with medication management or prescribing practices pre versus post toolkit rollout, although participants were more comfortable with and prescribed a greater number of stimulants than nonstimulants. CONCLUSIONS: Given the complexities of addressing adult ADHD, the results of this study are encouraging. Our findings highlight ways primary care providers can be supported, as well as areas that require greater attention. Still, more research is needed with a larger sample size to further explore and validate the efficacy of the toolkit.

Integrating psychosocial concepts into psychopharmacology training: a survey study of program directors and chief residents.

A growing body of evidence suggests that psychiatric medication outcomes are shaped significantly by psychological and social factors surrounding the prescribing process. Little, however, is known about the extent to which psychiatry programs integrate this evidence base into residency training or the methods by which this is accomplished. Psychiatry residency program directors and chief residents participated in an exploratory online survey to establish how psychosocial factors known to impact medication outcomes are integrated into psychopharmacology education. While participants highly valued the importance of psychosocial factors in the prescribing process, there was limited emphasis of these factors in psychopharmacology training. Additionally, some teaching methods that could advance understanding of complex interactions in the psychopharmacology relationship were found to be underutilized. Given that medication outcomes are significantly influenced by psychosocial factors, psychiatric educators have a responsibility to teach residents about the evidence base available. Residents exposed to this evidence base will be better equipped to manage the complexities of the psychopharmacology role. The results of this study offer clues as to how psychosocial factors may be more fully integrated into residency psychopharmacology training.

Teaching all the evidence bases: reintegrating psychodynamic aspects of prescribing into psychopharmacology training.

The discipline of psychiatry appears poised at the edge of a paradigm shift. Enthusiasm about psychopharmacological treatments and neuroscientific understandings is giving way to a sobering recognition of the limitations of current biologically oriented approaches. Psychiatry training programs have both an opportunity and a responsibility to address the challenges presented by the evidence. Although the average psychiatrist would profess a biopsychosocial ideal, an examination of our practice, journals, and training curricula suggests that we still have a long way to go before we employ a truly integrated model. There is a compelling, though oft-neglected evidence base demonstrating that pharmacologic treatment outcomes are as dependent on psychological and interpersonal factors as on medical ones. In order to maximize our usefulness to patients, psychiatry must embrace more complex and integrated understandings, transcending reductionistic models that promote mind-body splits. This article explores some of the costs of a model that places disproportionate emphasis on a biological framework. Relevant evidence bases are reviewed that demonstrate the utility of emphasizing the psychology of psychopharmacology. Implications for psychiatric training are considered, and suggestions are made for better integrating meaning factors into psychopharmacology education.

Nocturnal plasma melatonin profile and melatonin kinetics during infusion in status migrainosus.

The plasma melatonin profile was significantly disturbed (phase-shift of the maximum melatonin level) in four out of six female sufferers from status migrainosus, compared with nine healthy controls. The number of secretion peaks was similar in both groups. A nocturnal 20 micrograms melatonin infusion (from 21.00 to 01.00 h) evoked plasma melatonin levels slightly higher than a physiological secretion peak. During infusion, the episodes of secretion were reinforced and the endogenous plasma profile was phase-advanced in two patients displaying a phase-delay. These data suggest impaired pineal function in migraine. In the absence of side effects of melatonin infusion, the relief of certain migraine symptoms described by our patients might support a controlled trial of melatonin in migraine.

Flutamide versus orchidectomy in the treatment of metastatic prostate carcinoma.

PURPOSE: To compare in a randomized clinical trial the therapeutic efficacy of the nonsteroidal antiandrogen flutamide 250 mg tid to testicular androgen suppression by orchidectomy in patients with metastatic prostate cancer. PATIENTS AND METHODS: Between 1989 and 1991, 104 patients aged 74 +/- 8 years with newly diagnosed metastatic prostate cancer, an ECOG performance status 0-2 and no prior hormone manipulation or chemotherapy, were randomized to receive flutamide 250 mg tid (54 patients) or orchidectomy (50 patients). Patients were evaluated at entry and at months 3, 6, 12, 18 and 24. The primary endpoint was duration of progression-free survival, progression being defined as an increase in PSA> 50% over the nadir value at 2 consecutive months or a single PSA rise > 50% over the nadir value with another objective parameter. At progression, the treatment was left to the discretion of the attending urologist. RESULTS: 16 patients (10 flutamide, 6 orchidectomy) are not evaluable. 86 had a minimum follow-up of 36 months, 36/42 and 41/44 have progressed in the orchidectomy and flutamide group with a time of failure of 419 and 496 days (p = 0.32); median time to progression was almost identical in both groups (370 vs. 396 days p = 0.9); overall survival at 69 months irrespective of treatment at relapse was identical in both groups. Side effects were dominated by gynecomastia, hot flushes in both groups, breast tenderness and diarrhea in the flutamide group. Overall, 4 (10%) of the patients in the flutamide group withdrew from therapy because of side effects. The impact of flutamide on sexual potency was not assessed because of the advanced age of the patients. Serum testosterone rose by 50% over baseline level at month 3 to plateau at 25% over baseline level at month 12. CONCLUSION: Although affected by the lack of a clear statistical power due to the small number of patients in each arm, this study shows that in spite of a constant elevation of serum testosterone (25% over baseline) flutamide 250 mg tid may be a reasonable alternative to castration in highly selected patients with well to moderately differentiated low volume metastatic prostate cancer and wishing to avoid the side effects of androgen deprivation, provided they are closely monitored and ready to switch to standard androgen deprivation in the presence of untolerable side effects or suboptimal treatment efficacy as assessed by the inability to achieve a low PSA nadir.

[Hemodynamic study of intravenous milrinone in 26 patients with NYHA class III or IV cardiac failure]. / Etude hémodynamique de la milrinone par voie intraveineuse chez 26 patients en insuffisance cardiaque de classe III ou IV de la NYHA.

The hemodynamic effects of milrinone (WIN 47203) were studied in 26 NYHA Class III or IV patients. The compound was administered intravenously using a protocol including an initial push dose of 50 micrograms/kg in 10 min, followed by a 24 hour infusion at the dose of 0.5 microgram/kg/min. Maximal response was obtained after 15 min and persisted during the infusion: cardiac index increased from 2.08 +/- 0.36 l/min/m2 to 3.09 +/- 0.68 l/min/m2, while capillary pressure fell from 25 mmHg to 16-17 mmHg. These variations were significant (p = 0.01). Heart rate was stable. Mean peripheral blood pressure fell modestly (6%). Systemic vascular resistance fell by 30% and pulmonary vascular resistance by 20%. All these results confirmed the beneficial effect of this inotropic agent administered intravenously. The increase in ventricular premature contractions noted by many justifies the careful surveillance of these patients by monitoring.

Pharmacokinetics of melatonin in man after intravenous infusion and bolus injection.

The pharmacokinetics of melatonin during the day-time has been studied in 4 healthy subjects after a bolus i.v. injection of 5 or 10 micrograms/person and after a 5 h infusion of 20 micrograms per person in 6 healthy subjects. In addition, a pinealomectomized patient whose nocturnal plasma melatonin had been abolished was investigated after the i.v. infusion--once during the night and once during the day. The clearance of melatonin from blood showed a biexponential decay. The pharmacokinetic parameters in the two studies were similar, except for the disappearance rate constant beta and the apparent volume of distribution at steady-state (Vss). Supplementary peaks or troughs were superimposed on the plateau and the falling part of the profile. They were not due to stimulation of endogenous secretion, because they were also seen in the pinealomectomized patient. During the melatonin infusion, the plasma hormone level reached a steady-state after 60 and 120 min, and when it was equal to the nocturnal level. The infusion regime may be valuable in replacing blunted hormonal secretion in disease states.

Effects of a four-day nocturnal melatonin treatment on the 24 h plasma melatonin, cortisol and prolactin profiles in humans.

An oral preparation of melatonin was administered daily at 22.00 h to 6 healthy volunteers during summer on 4 consecutive days (days 1-4). The daily dose was 8 mg of melatonin as a single. Three 24-h melatonin, cortisol and prolactin profiles were determined in plasma by radioimmunological methods: 1) before treatment (day 0); 2) the first day after the 4-day treatment had been stopped (day 5), 3) the third day after withdrawal of this treatment (day 7). For the melatonin rhythm, an advanced phase was observed at day 7 vs day 0, whereas the amplitude and the mesor were not modified, whatever the day. For the prolactin profile, a significant increase as compared with the control day (day 0) was detected only at day 7 between 19.00 and 21.00 h. No modification was recorded for the plasma cortisol secretion. These results suggest that melatonin, when administered at a high dose over a short period, can influence the endocrine rhythms, and especially its own endogenous secretion. This effect must be investigated over several days after the treatment has ended.