neuropsychiatry

April 2022

greg@neuropsychiatry.co.nz (Greg Finucane) — Fri, 21 Apr 2023 01:13:33 GMT

Autumnal musings.

Good news, it now looks as though lisdexamfetamine/ Vyvanse will be available within months. It was previously registered though not funded by Pharmac, but it practical terms obtaining it was very difficult. It will be imported by Takeda Pharmaceuticals and Jo and I will meet with their advisor in a few weeks time. The multiple daily dosing necessary for people taking dexamphetamine has been a real disadvantage compared with methylphenidate.

Last month, I enjoyed attending the American Neuropsychiatric Association conference virtually. There were some great presentations and one of the more interesting was by Dr Tamara Pringsheim regarding the phenomenon of “TikTok tics” which has been an issue for the past few years amongst movement disorder experts. I have seen several cases myself. These are now being labelled Functional Tic Like Behaviours to help align their treatment with functional neurological disorders in general, and diagnostic criteria have been developed. The good news is that people do recover over time.

There was also some useful discussion around the use of stimulants for ADHD when a comorbidity of a tic disorder such as Tourettes Disorder. It’s clear from the literature and expert opinion that there is no simple correlation between commencing a stimulant and an exacerbation of the tic disorder, and none of the discussants indicated they would avoid trials of appropriate treatment. There are of course cases in which methylphenidate etc. does increase tic frequency and severity, but equally atomoxetine can and tics can improve if the individual is less stressed. Of course other treatments such as clonidine run minimal risk of exacerbating tics but are also less effective.

January 2022

greg@neuropsychiatry.co.nz (Greg Finucane) — Mon, 02 Jan 2023 22:45:43 GMT

Happy New Year // Nga mihi o te tau hou pakeha.

I hope 2023 brings you some of that which you are seeking/ needing/ growing towards. I am optimistic it will be a year of growth and development of helpful knowledge, including from lived-experience, encouraging professional skill development and service development.

As a mea culpa, I was interested in the Parkinson’s Secrets by Michael Okun in November 2022 outlining in detail, with the family’s consent, why Muhammad Ali actually had young onset idiopathic Parkinson’s Disease rather than chronic traumatic encephalopathy (time course, clinical features, medication response, FDG-PET imaging etc.) as many of us, from afar, will have assumed. There’s no substitute for careful clinical evaluation and being in possession of all the relevant facts.

In this respect, the polarised argument discussed by Johann Hari in his book Stolen Focus about ADHD either as a “real” biological disorder or alternatively as trauma/ anxiety/ environmental-related concentration difficulties remains topical and is unlikely to be resolved soon. Some aspects are canvassed in the Science vs blog in December 2022 on the “evils” of Adderall, in the context of the recent shortage in the US. A recent book by Casey Schwartz, Attention: a Personal History of Finding Focus (or Trying To), is a case in point. Her story, to me, illustrates problems with poor quality diagnosis but also stimulant abuse, rather than the non-existence of ADHD; thus also “Addicted to Perfect” by Vitale Buford. And Johann Hari thinks we need an Attention Rebellion to overcome the environmental drivers of the collective fall off in attentional capabilities. Undoubtedly there are some people with attentional difficulties consequent on stress, depression and other issues who think they have ADHD when this is not the case, though also of course ADHD causes stress, depression etc. so reality is complicated, like the Muhammad Ali scenario.

I am looking forward to Gloria Mark’s book Attention Span: Finding focus for a Fulfilling Life, due out in the next few days; she appears to have a different take on the environmental drivers of (non-ADHD) attentional complaints, including the importance of matching attentional demanding workflows to your chronotype.

One area where ADHD has a substantial biological basis is in epilepsy; perhaps 30-40% of children with epilepsy having comorbid ADHD in some studies, and perhaps 20% of adults. This is clearly an under-served population, especially given the results of a 2019 Swedish study of 995 youth (Brickell et al. Epilepsia 2019 Feb; 60(2): 284–293) in which the use of stimulants reduced seizures by approximately 27%. The untreated ADHD may have a greater impact on functioning than the seizures.

Some caution around atomoxetine in this context would be prudent as a 2020 Korean study (Park et al. Psychiatry Investig. 2020 May; 17(5): 412–416) suggested 8% may have had an increase in seizure frequency (though atomoxetine was only one discontinued in one case), but there is a reassuring 2018 ten year retrospective cohort study (Liu et al. J Child Adolesc Psychopharmacol. 2018 Mar 1; 28(2): 111–116) in which hospitalisations for seizures were not increased in children taking stimulants.

It is hard to know why the prevalence is high—I fantasise it has something to do with interictal EEG spikes though common causal factors are often blamed and it is important to check attentional issues are not due to the anti-epileptic medication. Some authors consider stimulants may be less effective than in “normal” developmental ADHD, though my clinical experience is that they are beneficial in most cases.

Obviously, Autism Spectrum Disorder is sometimes in the mix as well, either as part of an underlying syndrome (birth anoxia, severe paediatric TBI, velocardiofacial syndrome / 22q11.2 deletion….) or as a common neurodevelopmental comorbidity.

Anyways, very best wishes for the year ahead.

October 2022

greg@neuropsychiatry.co.nz (Greg Finucane) — Sat, 15 Oct 2022 04:20:43 GMT

Another eventful month

Its been a week for ADHD news with a GP who specialises in ADHD being defended at a disciplinary tribunal hearing for allegedly breaking the rules on prescribing, and Dr David Hughes, the medical practitioner who is the Pharmac Chief Medical Officer and not a psychiatrist as such, stating it is time to change access criteria to stimulants.

One of the key problems here is that of the accuracy of ADHD diagnoses as discussed in my last blog. It’s not appropriate to treat poor concentration due to anxiety with stimulants; I ' m also thinking here of the Variable Attention Stimulus Trait discussed by Ed Hallowell and John Rate in their book ADHD 2.0 released early last year, which I thoroughly recommend.

I t's clear that increasing access to stimulants is appropriate. I recall Pharmac changing criteria around 20 years ago to make it much more difficult to prescribe stimulants to support recovery from traumatic brain injury, or other forms of acquired bring injury e.g. for amotivation post stroke, and those working in the field weren’t consulted. These applications should be for a rehab ilitation specialist or neuropsychiatrist though rather than at primary care level.

Methamphetamine is pretty widely available in NZ, unfortunately , so the need to tightly control stimulant access to prevent harm is less justifiable now, when symptomatic individuals would benefit from their use. And its not a time to be overcautious about diagnosis as individuals with undiagnosed A D HD by and large found the Covid lockdowns very difficult. However, each year there are people admitted to mental health units who have abused prescribed stimulants and have become psychotic. Also, unlike other controlled substances such as opiates and benzodiazepines which should mostly be for short to medium term use only, stimulants are appropriately prescribed long term. This implies both that the diagnosis should be robust, and adverse effects should be monitored for, both rare adverse effects (such as peptic oesophagitis with dexamphetamine) or more common problematic effects (unmasking psychosis, exacerbating arrhythmia).

On another topic the new research showing a 15 fold increase in Motor Neurone Disease in Scottish former rugby players at autopsy in the Journal of Neurology, Neurosurgery and Psychiatry two weeks ago is both quite compelling and very concerning; this needs more research of course. The open access article can be accessed here: https://jnnp.bmj.com/content/jnnp/early/2022/09/07/jnnp-2022-329675.full.pdf

The CBD for epilepsy story has not become any less confusing. There does seem benefit especially for certain epilepsy syndromes such as Tuberous Sclerosis complex, Dravet syndrome and Lennox-Gastaut syndrome (Epidiolex is approved for these indications in the US). However, research last year showed the naturally occurring endocannabinoid 2-arachidonoylglycerol (2-AG) is released early and helps damp down seizures but then its breakdown produces prostaglandins causing vasoconstriction and so reduced oxygen supply to the vulnerable area, potentially causing some of the post ictal confusion and fatigue. Some preparations of CBD, possibly those with some THC, may increase seizures in some people, though on the other hand a case series of 10 children with epilepsy taking a whole plant cannabis preparation had an 86% reduction in seizures with no major adverse effects (BMJ Paediatrics Open, 2021). One paper in Epilepsy and Behaviour last July indicated CBD oil may improve tolerability of some anticonvulsant medications. On the other hand, CBD oil can cause sleepiness, diarrhoea, fatigue, decreased appetite and impaired liver function, and may interact with other anti-epilepsy drugs. People taking valproate may develop increased liver function tests, while people taking Clobazam may feel especially tired. Though, another paper suggests clobazam is more effective alongside CBD oil.

In practice, many families do try CBD oil for those with refractory seizures. Unfortunately the NZ Medical Cannabis Agency approved medicinal cannabis products remain too expensive for most families and so “artisanal” CBD products with unclear quality control are accessed. Sometimes the CBD oil seems to contribute to fatigue, poor concentration, loss of motivation, “suppression of personality” in neurodivergent individuals etc. and so it seems that whilst CBD oil is worth trying, there needs to be an individualised titration and detailed cost benefit analysis for each case .

Mauri ora, Greg

Spring 2022

greg@neuropsychiatry.co.nz (Greg Finucane) — Tue, 13 Sep 2022 23:28:19 GMT

This is the first in a series of, hopefully, regular blogs about neuropsychiatric and related themes, intended to be commentary and musings about current topics, trends or developments, rather than tentative book chapters for some future publication. The author is entirely to blame for the opinions expressed herein.

ADHD remains in the news, and as always provokes controversy. Is it a condition manufactured by Big Pharma to push products (probably not, given the key medications in question are really quite elderly now), is it a medicalisation of developmentally age appropriate behaviours (that wouldn’t explain why it runs in families), does it simply result from poor parenting (some of the parents I know are very switched on, loving, and work with the best advice from professionals)?

There are some current issues for 2022. Will Vyvanse (lisdexamfetamine) get through the Pharmac process? I don’t know why the Pharmac specialist advisory committees don’t invite discussion with or submissions from individuals with the relevant conditions, their families, or clinicians who actually manage the relevant clinical problems. Only one of the (worthy) clinicians on the relevant committee seems in a position to routinely diagnose or manage ADHD. Their deliberations can be viewed on the Pharmac website.

How are we doing on defining the parameters of ADHD to improve diagnosis? Not so well - there is ongoing debate about the need for demonstration of objective attentional or other cognitive changes, yet ADHD professionals who do not think such is required continue to speak of it as a neurodevelopmental condition when well defined neurodevelopmental conditions have objective findings to support the diagnosis such as the facial dysmorphia in Fetal Alcohol Spectrum Disorder or cognitive impairment following paediatric acquired brain injury. Of course, ADHD is a somewhat complex and diverse condition and we know that just as the genetics is complex, so individuals present with a variety of attentional and other changes. Gaining clarity on these, though is worth attempting - rather than leaving this as a condition in which ticking off a number of possible symptoms justifies commencing medication which should be continued for decades.

On another topic, it was good to see that Prof Sir Richard Faull and Prof Maurice Curtis from the Auckland Brain Bank had contributed to the recently published paper in Frontiers in Neurology on Chronic Traumatic Encephalopathy (and free to download) on 22 July. This is a very thorough discussion of the topic and makes a good case that a link between repeat TBI and CTE is now beyond reasonable doubt. Sports bodies globally are struggling to modify practices to reduce risk and media attention needs to remain on this area, but clinicians also need to work towards establishing consensus criteria for diagnosis and finding effective treatments.