Issue 90, Oct 2019
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ADHD and safe driving: expert recommendations for teens and adult drivers

Auden PA. et al. ADHD Rep. 2019; June 19 27(4):8-14. doi:10.1521/adhd.2019.27.4.8. NIMHSID:NIMHS1037253

PMID 31331797

Background

Driving is an essential life skill that promotes independence, facilitates mobility, and also is necessary for employment. The skill of driving remains a complex task involving the coordination of cognitive and motor skills in a constantly changing environment. Drivers with ADHD experience more frequent motor vehicle accidents and a higher number of traffic violations which do not decline into adulthood as they do for drivers without ADHD. The focus of this review is to provide concrete, evidence-based information for parents of teens as well as adult drivers with ADHD.

Methods

A panel of researchers and clinicians with expertise in ADHD and driving safety was set up. Based on their research and clinical experience, the individuals provided evidence-based information for families about driving safely with ADHD. The panel provided increased awareness of different aspects of driving. The panel commented on issues such as the timing of stimulant medication, stick shift, turning off cruise control, alcohol use, phone use, technological tools, automated driving systems, obtaining permits, and questions related to delaying licensure.

Results

The results of the recommendations can be summarized under appropriate headings.

Stimulant medication timing and vehicular crashes: There is clear evidence that medication increases driving safety and reduces vehicular crashes. Driving without medication, taking a lower dose, or driving after the effects of the medication has worn off all negate the medication effects. Individuals may drive worse after the medication has worn off compared to when they do not take the medication. This is called the “rebound effect”. No suggestions can be made about nonstimulant medications as there is a lack of data.

Drive stick and turn off cruise control: This keeps the driver engaged. If the driver loses attention, there is immediate feedback of grinding gears/stalled car. Cruise control is more likely to let attention drift in people with ADHD. They should avoid cruise control.

Don’t drink and drive: While this is true for all drivers, it is even more important for those with ADHD. This group is less likely to notice they had too much to drink as well as lower levels of alcohol cause greater dysfunction, impaired attention and judgement than those without ADHD.  The “no questions asked” policy of picking up the teen anywhere or setting up a rideshare account is important.

Devices and technological tools: This group should not use the cell phone while driving as attentional impairment may be greater. Technological tools such as a video camera can help monitor the sudden changes in care movement and are useful in providing behavioral feedback. 

Peers and Parents matter: The relationship with the teen is key. Greater the relationship, more likely the teen is bound to listen to the parent. Parents may consider a driving contract with the teen. Many states have “graduated driver’s licensing laws,” which limit the number of teens in the car as this had a relationship to traffic accidents. Parents may consider the teen having a checklist. Often teens with ADHD lack the motivation to learn driving mostly due to the ADHD as it is to complete school tasks. The task can be broken down to simplify.

Obtaining a permit/driver’s license: Parents need to work with the teen and also consider using a third party such as a driving school. Teens with ADHD may need more support and accountability than those without. Teens with ADHD also need to practice more, and a driving log should be maintained.

It’s not just ADHD: Often, these individuals have other comorbid conditions such as depression, autism spectrum disorder, oppositional defiant disorder which are also associated with negative driving outcomes.

Should Licensure be delayed?

Drivers with ADHD earn their permit later at age 20-21 while those without ADHD are typically licensed by age 17-18. The delay may be due to parental concerns. The experts in the field disagreed on this point. Those in favor of delaying suggest that there are greater practice opportunities and that individuals with ADHD are behind in development. Those not in favor of delaying licensure suggest that teens with ADHD are more likely to drive without a license, and this is backed up by research.

Conclusions

There is agreement that ADHD is associated with increased risk of motor vehicle crashes and other negative outcomes. Additionally, the panel agreed that ADHD is not a sentence to become a “bad driver.” Parents should understand the risk is real but not fate. These recommendations would help parents of teenagers with ADHD as well as adult drivers with ADHD weigh the risks and rewards and take appropriate steps thus enhancing driving safety.

Clinical Commentary

As a clinician who treats patients with ADHD, these recommendations were spot on. Many of the points addressed in the article I did not think of but make complete sense, and the recommendations are practical. These are the recommendations of experts on ADHD with regard to driving to improve safety.

  • In my opinion, this article or its summary may be a good handout for adult patients or the parents of teens learning driving.
  • I particularly think some worthwhile practical tips such as medication timing, avoiding alcohol, not using cruise control, and the use of technology was key.
  • The need for more practice is key as well as outsourcing the driver education to a professional.
  • In summary: These recommendations should be provided to the parents of teens as well as adults with ADHD and documented in the chart. The parents can process the information and apply it to their unique situation after weighing the pros and cons.
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Psychotic depression: should the antipsychotic be continued in addition to the antidepressant once symptoms are in remission?

Flint AJ et al. JAMA. 2019 Aug 20; 332 (7):622-631. Doi: 10.1001/jama.2019.10517. [Epub ahead of print]

PMID: 31429896

Background

Psychotic depression is a severely disabling and potentially lethal psychiatric illness. There is currently limited information about the efficacy and tolerability of antipsychotic medication for patients whose symptoms are in remission. The aim of this study was to determine the clinical effects of antipsychotic medication once an episode of psychotic depression has responded to a combination treatment with an antidepressant and antipsychotic medication.

Methods

This 36-week randomized clinical trial was conducted at four academic medical centers. The patients were 18 years and older who had an acute episode of psychotic depression treated with sertraline and olanzapine for up to 12 weeks and met criteria for remission of psychosis and remission of depressive symptoms for eight weeks before entering the clinical trial. The study duration was from November 2011 to June 2017. All patients continued sertraline. The patients were randomized to switch from olanzapine to placebo (N=62) or continue olanzapine (N=64).

The primary outcome was risk of relapse, and the secondary outcome measures were a change in weight, waist circumference, lipids, serum glucose, hemoglobin AIC.

Results

This study had a high completion rate of 90.5%.  20% of the patients randomized to olanzapine and 55% of those randomized to placebo experienced a relapse. Relapse is more than twice as likely in the sertraline-placebo group compared to the sertraline-olanzapine group. The anthropometric and metabolic measures were higher in the olanzapine group.

Conclusions

The continuation of sertraline and olanzapine over 36 weeks reduced the risk of relapse compared to sertraline and placebo. The benefits need to be balanced against the adverse effects of antipsychotics, such as olanzapine.   

Clinical Commentary

 This rigorous long-term study over six years provides important findings for the clinician. Psychotic depression is characterized by delusions of guilt and persecution in the context of a major depressive episode. This group of individuals have a higher symptom burden and morbidity over time compared to those with nonpsychotic major depression. Patients with psychotic depression are 10 times more likely to have psychosis in their recurrent depressive episodes. This translates into a higher number of hospital admissions and twice the likelihood of going on disability. Please note that the diagnosis is at times difficult to make as the psychotic symptoms cause dysfunction but may be subtle.

This study answers the question “Once a patient with psychotic depression is in remission can they be off the antipsychotic and only on the antidepressant?” The antipsychotic used in the trial was olanzapine.

  • It is important to note that even those patients continuing on sertraline-olanzapine combination 1 in 5 relapsed over 36 weeks.
  • The benefits of combined treatment are at a cost, which includes weight gain, metabolic issues, and tardive dyskinesia, as well as other extrapyramidal side-effects.
  • Nearly all relapses occurred within two months of randomization, indicates that combined treatment should be continued for at least four months after remission and is highly effective for the prevention of recurrence of psychotic depression. It is still unclear how much longer does combined treatment offer protection? Should it be a lifetime?
  • We can extrapolate from this study that an antipsychotic with a low metabolic burden can be tried in combination with an antidepressant in place of olanzapine at the start or substituted after four months after remission, but there is no supporting data.
  • Limitations: Findings limited to sertraline-olanzapine combination. Patients were not assessed for comorbid personality disorders. The olanzapine was tapered over four weeks. A slower taper could result in a possible lower relapse rate.
  • In summary, this study clearly suggests that the sertraline-olanzapine combination is effective for preventing relapse and should be continued for four months after remission. At this point, a very slow taper should be done of the antipsychotic and at any hints of recurrence of symptoms the antipsychotic restarted. The equation needs to factor in psychological stability versus metabolic effects and tardive dyskinesia related to the antipsychotic medication. Please note this study was done in an era when there was no FDA approved treatments for TD. The burden of a relapse of psychotic depression is substantial, and in some cases, a long-term antidepressant-antipsychotic combination is clinically indicated. It makes the case for shared decision making.
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Mental disorders and suicide: the association!

Tool LS et al. J Affect Disord. 2019 Aug 19; 138 (3):259-302. Doi: 10.1016/j.jad.2019.08.054[ Epub ahead of print].

PMID:31450139

Background

debate as to the extent of association with mental health disorders. This study aimed to examine the evidence on the contribution of mental health disorders to suicide among record-linkage studies.  

Methods

The design was a meta-analysis using English language studies from eight major databases between January 2000 and June 2018.  Studies were chosen that linked collected data on mental disorders and suicide.

Results

There were 20 articles representing 13 unique studies. The pooled rate ratio (RR) was 13.2 for psychotic disorders, 12.3 for mood disorders, 8.1 for personality disorders, 4.4 for substance use disorders, and 4.1 for anxiety disorders in the general population. The overall pooled RR for these mental disorders was 7.5. The population attributable risk of mental disorders was up to 21%.

Conclusions

The findings underscore the important role of mental disorders in suicide. There is still an unmet need to increase the access to people for quality mental health care to prevent suicide by people with mental disorders.

Clinical Commentary
  • The evidence from this and other studies is clear of the increased association of suicide with mental disorders. This study suggests an eight-fold higher risk of suicide in those associated with a mental disorder than those without.
  • The rate is highest in those associated with psychotic, mood, and personality disorders. One study suggested a 45-fold higher risk with borderline personality disorder.
  • I would say primary prevention is key. This is extremely difficult considering the breakdown of family structure, stressors of modern-day life, and social media. In such cases, screening and early interventions are the key.
  • Mishara and Chagnon (2016) have suggested six models that may explain the underpinnings of the relationship with suicide. Model 1 contends that suicide and mental disorders have a common etiology, such that biogenetic vulnerability and degenerative life events can lead to both. Model 2 suggests that some mental disorders such as substance abuse may develop as an alternative to suicide as people try to avoid suicidal thoughts and impulses. Model 3 views suicide as a result of direct distortion of the mental disorders such as command hallucinations in psychotic illness and extreme hopelessness in depression. Model 4 indicates that suicide is a result of negative experiences due to mental illness such as exclusion. Model 5 suggests that suicide is iatrogenic such as suboptimal treatment of mental disorders or wrong diagnosis and treatment (treating bipolar disorder as major depression as a result of missed diagnosis not using mood stabilizers). Model 6 combines the previous 5 factors with the addition of a crisis situation.
  • In Summary: we should screen for mental disorders, work towards reducing stigma, and treat optimally. Increased access to services and dealing with noncompliance would be helpful. Suicide may finally be an emotional arrest akin to cardiac arrest that despite all of the above may not always be preventable.
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Complementary therapies for clinical depression: an overview of systematic reviews.

Haller H. et al. BMJ Open. 2019; Aug 5;9(8):e028527. doi: 10.1136/bmjopen-2018.028527.

PMID:31383703

Background

Patients with mental illness, including depression, want to try complementary and alternative medicine (CAM) treatments. This summary aimed at summarizing the level 1 evidence on CAM for a patient with a diagnosis of major depression.  

Methods

The major databases were searched for meta-analyses of randomized controlled clinical trials (RCTs) until June 2018. The outcomes included depression severity, response, remission, relapse, and adverse events. The quality of evidence was assessed according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considering the methodology of the studies, inconsistency, indirectness, imprecision, of evidence and the potential risk of publication bias.

Results

The search revealed 26 meta-analyses conducted between 2002 and 2018. Two CAM treatments were found to have moderate evidence. This included St. John’s Wort which had comparative efficacy with standard antidepressants for mild to moderate depression and less adverse events. Mindfulness-based cognitive therapy (MBCT) was superior to standard antidepressant drug treatment for prevention of depression relapse. Other CAM treatments had low or very low quality.

Conclusions

All but two CAM treatments had a low or very low quality of evidence. This was due to avoidable methodological flaws of the original RCTs and meta-analyses not following the Consolidated Standards of Reporting Trials and Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines. There is a need for further research.

Clinical Commentary

CAM treatments are very popular as they are deemed to be “not strong” however, good evidence is to the contrary. We can also add medical cannabis to the list explored for which there is no evidence either.

  • I like suggesting MBCT and am glad there is good quality evidence to support this treatment. It certainly can be suggested to the patient not wanting to take medications once symptoms are in remission.
  • St. John’s Wort is available without a prescription and may be used for mild to moderate depression. The problem is it is not regulated and there may not be standardization of dosage.  In my opinion, drug interaction with other medications may not be well known, and safety data are limited.  
  • Finally, we know that the placebo response in depression can be as high as upwards of 40% and inadequately treated psychiatric illness such as depression / bipolar disorder has significant complications such as cycling of mood refractoriness of response and even suicide.
  • In summary: The good quality evidence is lacking for most CAM treatments except St. John’s Wort and MBCT. Patients insisting on trying CAM should know that they are taking these treatments at their own risk, and we should instruct them about the complications of untreated /inadequately treated depression.
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Nondisclosure of imminent threats by patients: assessment of the reasons.

Levy AG et al. JAMA Network Open. 2019; Aug 2;2(8):e199277. doi: 10.1001/jamanetworkopen.2019.9277

PMID 31411716

Background

The patient disclosure of an imminent threat to their clinician is a key step for them towards receiving support. This study aimed at examining the frequency of patients not disclosing imminent threats to their clinicians and their reasons for doing so.

Methods

 The study incorporated results from two national nonprobability samples of 2011 US adults recruited from Amazon’s Mechanical Turk (MTurk) from March 16th to 30th, 2015, and 2499 recruited from Survey Sampling International (SSI) from November 6th to 17th, 2015. Data analysis was conducted from December 20 to 28, 2018. The main outcomes included nondisclosure of four types of imminent threats to their clinician (depression, suicidality, abuse, and sexual assault) and the reasons for nondisclosure.

Results

There were 2011 participants in the MTurk sample, which included 60% females and 60% caucasian with a mean age of 36 years old (age range 18-79). There were 2499 participants in the SSI sample, 51% female and 75% Caucasian, with a mean age of 61 years (age range 50-91 years). 48% of the MTurk sample and 40% of the SSI sample reported withholding information from their clinician with regard to at least one of the four imminent threats. The most commonly endorsed reason for withholding information includes; being embarrassed (MTurk: 73%; SSI: 71%), not wanting to be judged or lectured (Mturk: 66%; SSI: 53%), and not wanting to engage in a difficult follow-up behavior (MTurk: 63%; SSI: 51%). Participants who experienced at least one of the four imminent threats had a significantly higher odds of nondisclosure if they were female and those who were younger. 

Conclusions

 This study suggests that patients withhold important information from their clinicians about imminent health threats that they have faced. A better understanding of how to increase the patients’ comfort with reporting this information is critical to allowing clinicians to help patients mitigate these potentially life-threatening risks.

Clinical Commentary

This is an extremely thoughtful and important study. Patients withholding important information from clinicians who are supposed to help them are indirectly shooting themselves in the foot, not realizing the fact.

  • The patient’s comfort level with their clinician is key. If the patient feels they can open up, they may be more willing to not withhold important personal information.
  • This underscores the importance of building a solid therapeutic alliance with the patient, part of which includes trust from day one.
  • Being upfront with your patients could alleviate some distrust some patients may feel. If a patient is embarrassed, potentially reassuring them regarding the confidential nature of the relationship would be helpful.
  • If the patient is concerned about being judged, then the clinician should work on incorporating an emotional portfolio, to deal with the patient at his/her emotional level, e.g. a younger individual may feel as though they are being talked down to.
  • If a patient is concerned about a rigorous or difficult follow-up, then potentially working and negotiating with the patient on the future plan can achieve a collaborative approach.
  • In Summary: It is important to build trust to ensure a good therapeutic alliance. In my opinion, in mental health, it is important to get collateral information from other sources after getting the patients’ consent. We may not get all the information in one attempt, and hence, several visits may be needed to get a good understanding of the entire issue.
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Sanjay Gupta, MD
Clinical Professor of Psychiatry, SUNY Buffalo

GME Research Review is a monthly newsletter edited by Sanjay Gupta, MD, Clinical Professor of Psychiatry, SUNY Buffalo. Dr. Gupta selects, summarizes, and provides a clinical commentary on the latest published research in psychiatry. 

We are always carefully evaluating which research papers to discuss in GME Research Review. Have come across a research paper published in the last 6 months that you thought is clinically relevant? Do you want me to analyze it for you and for the benefit of others? Please email Dr. Gupta the citation at [email protected]