The new issue of *Academic Psychiatry (vol. 34, #3, May-June) includesan article: "Prevalence of ADHD Diagnosis and Nonmedical PrescriptionStimulant Use in Medical Students."The authors are Jeffrey P. Tuttle, M.D., Neil E. Scheurich, M.D. andJohn Ranseen, Ph.D.Here's the
OBJECTIVE: The authors aimed to determine the prevalence of ADHDdiagnosis and the prevalence of nonmedical prescription stimulant useamong a sample of medical students.
METHODS: An anonymous survey was administered to 388 medical students(84.0% return rate) across all 4 years of education at a public medicalcollege.
RESULTS: Eighteen medical students (5.5%) reported being diagnosed withADHD and 72.2% of those students were diagnosed after the age of 18.Thirty-three medical students (10.1%) reported using prescriptionstimulants for nonmedical purposes during their lifetime. The mostcommonly reported motivation for nonmedical prescription stimulant usewas to improve academic performance. There was no significantcorrelation between an ADHD diagnosis and a history of nonmedicalprescription stimulant use (p=0.072).
CONCLUSION: This survey suggests that medical students appear to be arelatively high-risk population for nonmedical prescription stimulant use.The author note provides the following contact info: Jeffrey PaulTuttle, University of Kentucky, Department of Psychiatry, 3470 BlazerParkway, Lexington, KY 40509;
Friday, April 30, 2010
Wednesday, April 21, 2010
Brain Repair After Stroke
Stroke is the second leading cause of death worldwide. A majority of patients survive stroke, however, making this disorder a major source of human disability. Although most patients have some spontaneous behavioral improvements after a stroke, the recovery is generally incomplete. Compounding this burden of disability is the fact that one in four patients who have a stroke is under 65 years of age.
An emerging approach to reducing the degree of disability after a stroke focuses on brain repair. Repair therapies aim to restore the brain, a goal that differs from that of neuroprotection therapies, in which the aim is to limit acute stroke injury. A number of repair-related therapies have been defined in preclinical studies. Such therapies can produce enduring behavioral gains when introduced days to months after the onset of stroke. Several classes of therapy are under study for brain repair, including the use of stem cells, growth factors, small molecules, electromagnetic stimulation, and intensive physiotherapy.1 Many of these therapies, including robot-based physiotherapy,2 are already in human trials.
It is in this context that Lo et al.3 describe a multicenter, randomized, controlled trial to evaluate the effect of robotic therapy on motor status in people with long-term disability after stroke. As reported in this issue of the Journal, the primary study hypothesis was that robotic therapy, when compared with intensive comparison therapy or usual care, would lead to greater improvements in upper-limb function at 12 weeks, as measured by the change in score on the Fugl-Meyer scale. Patients were randomly assigned to one of three types of treatment: robot-assisted therapy, which consisted of high-intensity, repetitive movements of the proximal and distal arm; intensive comparison therapy, which matched the robotic therapy in schedule, form, and intensity but did so with the use of conventional rehabilitation techniques; or usual care, which may have included various types of physical and occupational therapy. Subjects in the two intensive-therapy groups received three sessions (each approximately 1 hour in duration) per week over 12 weeks. Patients in the trial varied widely in the time since the onset of stroke (6 months to 24 years), had multiple coexisting illnesses (including mental health conditions and previous strokes), and were receiving multiple medications.
The investigators' results did not support their study hypothesis. When robot-assisted therapy was compared with either intensive comparison therapy or usual care, no significant differences in the change in the Fugl-Meyer score were seen. There were no safety concerns. In secondary analyses extending to 24 weeks after treatment, robot-based therapy was better than usual care but was not better than intensive comparison therapy. However, since function had improved in patients in the two active treatment groups, these findings reaffirm the idea that motor status can be improved in patients with long-term disability after stroke.
Lo et al. successfully completed a difficult study and achieved a high rate of compliance, a low dropout rate, an extended follow-up period, and careful matching of therapy details across the two active treatment groups. But some basic facts of the chronic phase of stroke can frustrate hypothesis testing in clinical trials. Behavioral gains in the active-treatment groups were smaller than anticipated in power calculations, possibly because the average baseline motor deficits in patients were severe, and severe deficits are harder to improve. Finding a treatment difference between groups also might have been hampered by recruitment of highly motivated patients in all three study groups, since patients who had had a stroke sometimes many years earlier had to agree to leave home for 36 visits to a research laboratory.
Other features of the patients also may have influenced study outcomes. Patients had a substantial number of coexisting illnesses in multiple domains. For example, depression might have influenced results, given that 38% of patients were taking antidepressants. In addition, 73% of all study enrollees were receiving some form of rehabilitation therapy at baseline — a very high rate for patients with long-term disability after stroke4 — and this proportion changed little throughout the study. The high rate of rehabilitation therapy outside study protocol but concomitant with study interventions, as observed by Lo et al., is similar to previous experience in patients months or years after stroke5 and complicates hypothesis testing. What else did subjects practice during the other 165 hours per week? The experience of Lo et al. reminds us that many factors can have a substantial effect on studies involving patients after stroke and prompts conservative power calculations for future repair-based trials.
In the bigger picture, the potential for robotic therapy after stroke remains enormous. Robotic devices can provide therapy in different functional modes, a point that was not examined by Lo et al. Robots work in a consistent and precise manner and over long periods without fatigue.6 They can modulate timing, content, and intensity of training in reproducible ways, with a reduced need for human oversight.2 Robotic devices can also measure the performance of patients during therapy. In addition, robot-based therapy can interface with computers in brain-stimulation treatment or to provide simultaneous cognitive training.
The findings of Lo et al. are of broad value to planning repair-based trials. Movement training, at the heart of the current study, stands on its own as a means of improving behavior in the stroke-injured brain, as shown by Wolf et al. in a phase 3 trial.7 But movement training will also be of critical value as an adjunctive therapy to other treatments that target brain repair, such as the use of growth factors or stimulants. Repair-based therapies drive maximum brain plasticity and achieve best behavioral gains when they are shaped by training and experience.8 Thus, the findings in the active treatment groups in the study by Lo et al. will be instructive in future trials.
These results challenge us to better stratify patients with long-term disabilities after stroke. Such patients are generally selected on the basis of behavioral status. Functional neuroimaging studies have clearly shown that a single behavioral phenotype can arise on the basis of many different brain states. Anatomical and physiological testing might assist in the identification of patients whose brains have sufficient biologic substrate to improve in response to therapy. Toward this end, recent studies suggest that measures of injury to the central nervous system9 or of brain function10 can help predict a patient's capacity for treatment gains after stroke. Many different neurobiologic states can produce a particular behavioral picture, but only some of these states are likely to yield improved behavior in response to a repair-based therapy.
Studies such as that by Lo et al. reinforce the theory that the adult brain has the capacity for clinically relevant plasticity even in the chronic phase after a stroke. The future holds great hope for the development of brain-repair protocols to greatly reduce the degree of disability after stroke.
Source Information
From the Departments of Neurology and Anatomy and Neurobiology, University of California, Irvine. This article (10.1056/NEJMe1003399) was published on April 16, 2010, at NEJM.org.
An emerging approach to reducing the degree of disability after a stroke focuses on brain repair. Repair therapies aim to restore the brain, a goal that differs from that of neuroprotection therapies, in which the aim is to limit acute stroke injury. A number of repair-related therapies have been defined in preclinical studies. Such therapies can produce enduring behavioral gains when introduced days to months after the onset of stroke. Several classes of therapy are under study for brain repair, including the use of stem cells, growth factors, small molecules, electromagnetic stimulation, and intensive physiotherapy.1 Many of these therapies, including robot-based physiotherapy,2 are already in human trials.
It is in this context that Lo et al.3 describe a multicenter, randomized, controlled trial to evaluate the effect of robotic therapy on motor status in people with long-term disability after stroke. As reported in this issue of the Journal, the primary study hypothesis was that robotic therapy, when compared with intensive comparison therapy or usual care, would lead to greater improvements in upper-limb function at 12 weeks, as measured by the change in score on the Fugl-Meyer scale. Patients were randomly assigned to one of three types of treatment: robot-assisted therapy, which consisted of high-intensity, repetitive movements of the proximal and distal arm; intensive comparison therapy, which matched the robotic therapy in schedule, form, and intensity but did so with the use of conventional rehabilitation techniques; or usual care, which may have included various types of physical and occupational therapy. Subjects in the two intensive-therapy groups received three sessions (each approximately 1 hour in duration) per week over 12 weeks. Patients in the trial varied widely in the time since the onset of stroke (6 months to 24 years), had multiple coexisting illnesses (including mental health conditions and previous strokes), and were receiving multiple medications.
The investigators' results did not support their study hypothesis. When robot-assisted therapy was compared with either intensive comparison therapy or usual care, no significant differences in the change in the Fugl-Meyer score were seen. There were no safety concerns. In secondary analyses extending to 24 weeks after treatment, robot-based therapy was better than usual care but was not better than intensive comparison therapy. However, since function had improved in patients in the two active treatment groups, these findings reaffirm the idea that motor status can be improved in patients with long-term disability after stroke.
Lo et al. successfully completed a difficult study and achieved a high rate of compliance, a low dropout rate, an extended follow-up period, and careful matching of therapy details across the two active treatment groups. But some basic facts of the chronic phase of stroke can frustrate hypothesis testing in clinical trials. Behavioral gains in the active-treatment groups were smaller than anticipated in power calculations, possibly because the average baseline motor deficits in patients were severe, and severe deficits are harder to improve. Finding a treatment difference between groups also might have been hampered by recruitment of highly motivated patients in all three study groups, since patients who had had a stroke sometimes many years earlier had to agree to leave home for 36 visits to a research laboratory.
Other features of the patients also may have influenced study outcomes. Patients had a substantial number of coexisting illnesses in multiple domains. For example, depression might have influenced results, given that 38% of patients were taking antidepressants. In addition, 73% of all study enrollees were receiving some form of rehabilitation therapy at baseline — a very high rate for patients with long-term disability after stroke4 — and this proportion changed little throughout the study. The high rate of rehabilitation therapy outside study protocol but concomitant with study interventions, as observed by Lo et al., is similar to previous experience in patients months or years after stroke5 and complicates hypothesis testing. What else did subjects practice during the other 165 hours per week? The experience of Lo et al. reminds us that many factors can have a substantial effect on studies involving patients after stroke and prompts conservative power calculations for future repair-based trials.
In the bigger picture, the potential for robotic therapy after stroke remains enormous. Robotic devices can provide therapy in different functional modes, a point that was not examined by Lo et al. Robots work in a consistent and precise manner and over long periods without fatigue.6 They can modulate timing, content, and intensity of training in reproducible ways, with a reduced need for human oversight.2 Robotic devices can also measure the performance of patients during therapy. In addition, robot-based therapy can interface with computers in brain-stimulation treatment or to provide simultaneous cognitive training.
The findings of Lo et al. are of broad value to planning repair-based trials. Movement training, at the heart of the current study, stands on its own as a means of improving behavior in the stroke-injured brain, as shown by Wolf et al. in a phase 3 trial.7 But movement training will also be of critical value as an adjunctive therapy to other treatments that target brain repair, such as the use of growth factors or stimulants. Repair-based therapies drive maximum brain plasticity and achieve best behavioral gains when they are shaped by training and experience.8 Thus, the findings in the active treatment groups in the study by Lo et al. will be instructive in future trials.
These results challenge us to better stratify patients with long-term disabilities after stroke. Such patients are generally selected on the basis of behavioral status. Functional neuroimaging studies have clearly shown that a single behavioral phenotype can arise on the basis of many different brain states. Anatomical and physiological testing might assist in the identification of patients whose brains have sufficient biologic substrate to improve in response to therapy. Toward this end, recent studies suggest that measures of injury to the central nervous system9 or of brain function10 can help predict a patient's capacity for treatment gains after stroke. Many different neurobiologic states can produce a particular behavioral picture, but only some of these states are likely to yield improved behavior in response to a repair-based therapy.
Studies such as that by Lo et al. reinforce the theory that the adult brain has the capacity for clinically relevant plasticity even in the chronic phase after a stroke. The future holds great hope for the development of brain-repair protocols to greatly reduce the degree of disability after stroke.
Source Information
From the Departments of Neurology and Anatomy and Neurobiology, University of California, Irvine. This article (10.1056/NEJMe1003399) was published on April 16, 2010, at NEJM.org.
Psychotropic Medications Overprescribed to Children: Study Suggests
ScienceDaily (Apr. 20, 2010) — A new study from the Journal of Marital & Family Therapy warns of the dramatic rise in the use of psychotropic medications for children. One in every fifty Americans is now considered permanently disabled by mental illness, and up to eight million children take one or more psychotropic drugs.
The authors, James P. Morris, Ph.D. and George Stone, LCSW, state that there is little evidence available to warrant the widespread use of psychotropic drugs for children, and little long term data regarding its long term impact on development.
According to the authors the mental health field is currently designed to treat adults with psychotropic medications, but they are often misused in the case of children and adolescents, "This presents an ethical challenge to marriage and family therapists, who should be very cautious about these medications as an option for children. The long-term research on their safety for children is uncertain."
As an example, the diagnosis of early onset bipolar disorder and attention deficit hyperactivity disorder has climbed drastically in the past decade. Drugs designed to treat the above two disorders show a fair short term risk-benefit ratio, but a poor long-term benefit. Morris and Stone indicate, "If the psychiatric community has been misled by pharmaceutical companies in thinking that these drugs are safe for their children, the parents of these children have been in turn deluded into putting their children in harm's way."
The authors continue that the pharmaceutical industry is largely influenced by the desire for economic profit, and the marketing muscle behind the industry, and leniency of institutions such as the FDA, tout benefits that are not yet properly evaluated for pediatric use. Between 1994 and 2001, psychotropic prescriptions for adolescents rose more than sixty percent; the rise post-1999 was connected to the development and marketing of several new psychotropic drugs and the rebranding of several older ones.
Morris and Stone claim that family health professionals are put in the line of fire when children begin to experience the negative consequences of long-term use of these medications. They are left with the challenge of evaluating the quality of evidence-based care offered to their pediatric clients by the psychiatric community, and the negative effects of the medications without sufficient empirical evidence or information
The authors, James P. Morris, Ph.D. and George Stone, LCSW, state that there is little evidence available to warrant the widespread use of psychotropic drugs for children, and little long term data regarding its long term impact on development.
According to the authors the mental health field is currently designed to treat adults with psychotropic medications, but they are often misused in the case of children and adolescents, "This presents an ethical challenge to marriage and family therapists, who should be very cautious about these medications as an option for children. The long-term research on their safety for children is uncertain."
As an example, the diagnosis of early onset bipolar disorder and attention deficit hyperactivity disorder has climbed drastically in the past decade. Drugs designed to treat the above two disorders show a fair short term risk-benefit ratio, but a poor long-term benefit. Morris and Stone indicate, "If the psychiatric community has been misled by pharmaceutical companies in thinking that these drugs are safe for their children, the parents of these children have been in turn deluded into putting their children in harm's way."
The authors continue that the pharmaceutical industry is largely influenced by the desire for economic profit, and the marketing muscle behind the industry, and leniency of institutions such as the FDA, tout benefits that are not yet properly evaluated for pediatric use. Between 1994 and 2001, psychotropic prescriptions for adolescents rose more than sixty percent; the rise post-1999 was connected to the development and marketing of several new psychotropic drugs and the rebranding of several older ones.
Morris and Stone claim that family health professionals are put in the line of fire when children begin to experience the negative consequences of long-term use of these medications. They are left with the challenge of evaluating the quality of evidence-based care offered to their pediatric clients by the psychiatric community, and the negative effects of the medications without sufficient empirical evidence or information
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