ADHD

A Good Read for Behavioral Healthcare Providers

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A Good Read for Behavioral Healthcare Providers

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When I scanned over the first paragraph, I knew that Jill Sederstrom’s article “Clinicians must turn evidence into practice” in Behavioral Healthcare was going to be a good read. So, I got myself a coffee and settled down to enjoy it; I was not disappointed. I recommend you read it too.

As researcher and a clinician, I have sat on both sides of the table in the struggle to create an evidence base that is robust and valid, but also able to inform clinical care. I understand the problem and I’m very pleased to see it so eloquently acknowledged and explored by the author, including interviews with Kelly Clark, MD, President-elect of the American Society of Addiction Medicine, and Melanie Smith, Licensed Mental Health Counselor and Program & Training Manager of the Renfrew Center in Florida.

Some key messages from the article:

  • With an emphasis on quality initiatives, the importance of evidence-based practice in behavioral healthcare is growing. Payers “will be evaluating whether facilities are embracing the latest evidence that has been shown to produce optimal patient outcomes. They want the most value for their healthcare dollar.”
  • Behavioral healthcare providers must be prepared or the next few years “will become very problematic” for them. But, incorporating evidence into care is not an easy process and it takes time. Facilities need to invest to “translate what’s discovered in a research setting into everyday practice”.
  • Evidence-based approaches give clinicians a framework based on empirical data. “We don’t really have a lot of ability to know in the long-term how our patients are doing, [and]…whether or not what we’re doing is the most effective and efficient way to help someone get better”, says Smith.
  • Clark points out that evidence-based medicine (or evidence-informed medicine) “lends itself to quality metrics that are population-based and allow clinicians and facilities to see an issue from a broader population-based perspective that provides bench marking opportunities.”
  • The clinical trials that are required to bring a drug or device to market often do not represent real world scenarios. Distilling information from claims data or other big data sources can provide “actionable intelligence for clinicians”. “There’s not a lot of information that’s practical and usable for me in my office…” Smith says.

So how can we bring evidence into care? Highlights of the Renfrew Centers’ successful approach are described in the article; they are trailblazing. There is also an opportunity for large and small behavioral healthcare provider organizations to implement evidence-based care without needing to be the pioneers.

As the CEO of a health IT company, I now wrestle with the challenge of helping clinicians (including those who don’t have the band-width to be trailblazers) to deliver evidence-informed medicine to each individual patient.

Digital health solutions are enabling the findings of research to be easily applied in clinical care; incidentally they are also generating a wealth of real-world data that in itself enriches the evidence base and our understanding of optimal treatments.

We can distill the evidence base and protocols derived from it into integrated software that clinicians can use at the point-of-care. We can then capture the clinical characteristics and the symptoms of each individual patient and map them (automatically) against those best-practice guidelines. This generates personalized care recommendations which enable clinicians and patients to together make evidence-informed treatment decisions. By monitoring an individual’s status both at and between clinical consultations (using remote technologies) we can track progress and treatment like never before. We can identify early when things are going awry and come back to the “electronic” protocols to guide care.

The growing database of clinical data generated allows an organization to explore concordance with quality measures and monitor outcomes at a population level. The improved understanding of optimal treatment practices improves care and ensures the best value for each healthcare dollar. That seems like good thing!

My cup of coffee’s finished. Thanks Jill Sederstrom for a great read.

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Mehealth supports October ADHD Awareness Month

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Mehealth supports October ADHD Awareness Month

ADHDAwareness

It’s October 1st, which means that ADHD Awareness Month begins today!

More than anything, this month is a chance for us all to support what we know is true: ADHD can affect anyone, regardless of age, race, nationality, or income level. More importantly ADHD is not a debilitating issue, shouldn’t intimidate families, and can be managed successfully when parents, teachers, and pediatricians are able to work together.

To help do our part, mehealth has a full month of activities planned meant to raise awareness for this important cause:

  • The 31 days of ADHD Awareness: Follow our @mehealthADHD Twitter handle as we tweet out one ADHD fact per day. Be sure to RT and comment on our Tweets to help spread the message to as many people as possible!
  • Share your ADHD child’s artwork: Starting this week, we’ll be accepting artwork from children with ADHD to share on our Facebook Page. We will be posting your child’s drawings, paintings, sketches, etc. at the end of each week, so stay tuned for further instructions on how to submit!
  • Add an ADHD “Twibbon” to your profile: Make sure your Social Media profile is on board with ADHD Awareness month as well! Click the following link to add an official Twitter ribbon i.e. “Twibbon” showing your support for ADHD Awareness: Add a Twibbon here.
  • Succeeding with ADHD: On both our Facebook and Twitter Pages we will be sharing success stories of people who have not only overcome their ADHD symptoms, but thrived thanks to the unique characteristics common with the condition.
  • Friday Feedback: We want to hear your voice! Each Friday we’ll be asking questions on Facebook asking your opinion on important ADHD topics. Share your input on everything from parenting advice to proven tips and strategies for handling the everyday challenges of ADHD.

 

Most importantly…. Talk about ADHD! Parents, teachers and pediatricians can use Social Media to support and help reduce the stress and unknown. Share your successes not just on Social Media, but also in person and with your peers. This month is a chance to break down stigmas that still exist and make sure each of us doing our part to help, whether that means ensuring that pediatricians have the tools to properly assess ADHD, or simply being more open about discussing how the disorder affects individuals on a daily basis. We all must contribute to make a difference.

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A Panacea for the ADHD Epidemic?

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A Panacea for the ADHD Epidemic?

Psychiatry Advisor published a great article by Sanford Newmark MD, of the Osher Center for Integrative Medicine at the University of California, San Francisco.

A True ADHD Epidemic or an Epidemic of Overdiagnosis? reminds us of the stats about ADHD in US children. It doesn’t matter how often I see the numbers, they never fail to shock me.

  • 6.4 million children aged 4 to 17 years have received a diagnosis of attention-deficit/hyperactivity disorder – that’s 11% of children1
  • 4.2 million children are taking psychostimulants1
  • Between 2003 and 2011 there was a 35% increase in diagnosis
  • There is no indication that this increase leveling out

 

While I think we need to be mindful of the possibility that environmental factors, such as toxins, may be causing behavioral symptoms that mimic those of ADHD (see our insecticides blog of June 12), I concur with Dr Newmark in believing that there is a diagnostic epidemic.

He says:

“I believe that this dramatic increase in ADHD diagnoses is caused by two factors:

  1. Overdiagnosis through inadequate evaluation and societal pressure for treatment; and
  2. A significant increase in the demands being made on our children, schools, and families.”

 
Without wanting to seem overly pessimistic, I don’t fancy our chances of finding a quick cure for number 2, so let’s turn our attention to factor number 1. This nut we can crack!

The problem is that although guidelines for diagnosing ADHD have been written by the American Academy of Pediatrics physicians aren’t great at following them2.

We can curb the diagnostic frenzy by educating physicians about the requirements for a correct diagnosis and then providing them with the tools to do it right.

The diagnostic requirements.
The AAP supports the DSM-5 criteria for ADHD. The child must have at least six inattention symptoms or six hyperactive/impulsive symptoms present for 6 months or longer. Symptoms should began before twelve years of age, be present in two settings (for example home and school) and cause meaningful impairment. The symptoms and impairment should not be better explained by some other diagnosis, psychiatric or otherwise.

The tools to apply them.
Dr Newmark asks “how many of our frontline providers have the time and resources to conduct an adequate evaluation?” In this era of modern medicine I think the answer is every single one of them.

mehealth for ADHD is an online software system, underpinned by the AAP guidelines and DSM-5, that enables physicians to have all the information they need to make a proper assessment and diagnosis when they see the child, including assessments from home and school.

It is cost effective, saves time and improves diagnosis and care practices. This recent TV coverage makes the point.

We went into medicine to provide the best treatment we could to our patients. That includes making the right diagnosis. Let’s do it.

References:

  1. Centers for Disease Control and Prevention. Attention-deficit/hyperactivity disorder (ADHD): data & statistics. New data: medication and behavior treatment. Accessed July 28 2015.
  2. Epstein, et al. (2014). Variability in ADHD care in community-based pediatric practices. Pediatrics; originally published online November 3, 2014; DOI: 10.1542/peds.2014-1500.

 

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“What’s yours is mine… and what’s mine is mine too”

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“What’s yours is mine… and what’s mine is mine too”

Is this really physicians’ approach to their patient’s health data?

Dan Munro (no relation!) wrote a fantastic article for Forbes earlier this month about doctors’ reluctance to share health data with patients, commenting on a poll of Sermo members.

SERMO is the #1 social network of physicians. Verified members discuss practice management, collaborate on cases, and vote on the latest polls.

 
Over 2300 physicians responded to the question
“Should patients have access to their entire medical record ‒ including MD notes, any audio recordings, etc…?”
49% ‒ Access to all records should only be given on a case-by-case basis
34% ‒ Yes, Always
17% ‒ No, Never
 

Dan Munro summarizes “In effect, a full two-thirds (66%) [of physicians] were clearly reluctant to share health data with their patients. A significant 17% were completely opposed to the idea outright ‒ ever.

So, from the opposite viewpoint, how willing are patients to share their health data with providers?

The recent Office of the National Coordinator for Health IT (ONC) survey of over 2000 respondents reported that fewer than one patient in 10 withholds information from their providers, and seven in 10 were willing to share their medical records electronically with other providers treating them even if they had security concerns.

I like the mind-set of Peter Elias, MD (Family Medicine and SERMO member) who shares all his patient data, including clinical notes, and makes the following case:

“It profoundly changes the nature of the relationship. If the record (or visit note) is written explicitly as a shared document, it is no longer possible to maintain a relationship based on asymmetric power. I can no longer keep secrets. If there is an issue or potential issue impacting care, I have to address it with the patients. This is often what clinicians find objectionable. The thinking is ‘how can I document that I think the patient is being unreasonable or that depression is contributing to their pain or that their report of symptoms is exaggerated if they will see it?’ This is exactly why I think it is so important. Hiding these issues and using them to alter care without involving the patient is manipulative and paternalistic and keeps the patient from being fully autonomous.”
Clinician at computer screen

In 2015, isn’t this the best way forward?

I think we can go a step further: Turn the computer screen round and share it with patients. That’s our approach at mehealth.

Janet

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Concerta generics: Can the FDA emerge without egg on its face?

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Concerta generics: Can the FDA emerge without egg on its face?

The story so far…

The red flag was raised following reports that patients with ADHD were not responding as expected to the generic versions of Concerta (methylphenidate hydrochloride extended-release tablets) manufactured by Mallinckrodt Pharmaceuticals and Kudco Ireland Ltd.

The FDA began an analysis of the products and data against Janssen’s brand-name drug and its generic, marketed by Actavis. The drugs all share the same active ingredient, but the non-Janssen manufactured products have a different extended release mechanism.

In a statement in November last year, the FDA concluded that “In some individuals, the Mallinckrodt and Kudco products may deliver drug in the body at a slower rate during the 7- to 12-hour range. The diminished release rate may result in patients not having the desired effect.” No “serious safety concerns” were identified.

broken egg

As a result of the findings, the FDA changed the ratings of these two generics so that they could no longer be automatically substituted for Concerta at the pharmacy. The agency also gave the manufacturers six months to provide data showing bio-equivalency to Concerta or withdraw their drugs from the market.

Fast-forward to June… The FDA deadline has expired.

Kudco has reportedly now submitted information to the agency to meet its requirements. Mallinckrodt, however, has opted for attack as the best line of defence and filed a lawsuit challenging the FDA’s authority to reclassify its generic.

Both drugs are still on the market.

Put another way, seven months later people with ADHD are still, every day, being prescribed, paying for, and taking drugs which we (and the FDA) know “may not have the desired effect.”

Is that really okay?

There was a great article about this in May in the Wall Street Journal.

Most recently, an article by Katie Thomas in the New York Times included an interview with Dr. Louis Kraus MD, a chief of child psychiatry practicing in Chicago. He reported receiving regular calls from pharmacies and some insurers asking him to change his prescriptions so they could dispense the cheaper ADHD generics “— drugs that he considers inferior. “I’m enraged about it,” Dr. Kraus said.”

I looked online for the FDA’s Charter.

What is the agency’s obligation to the American public? I abandoned my search when the first page included a pledge to “Provide comfortable waiting areas”.

Really!

So as the court takes over, can the FDA maintain integrity and retain public confidence? It seems to me that something has gone badly wrong when patient safety is determined by a judge and not the FDA.

Janet

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Providing quality care despite a shortage of doctors

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Providing quality care despite a shortage of doctors

There is a steady flow of academic articles and press coverage about how the shortage of physicians is impacting US healthcare. Many of the media stories recount personal tragedies; too little care, too late.

Patients are suffering from a lack of primary care physicians and specialists in towns that are medically underserved because of their remote location, or simply because there are insufficient numbers of medical practitioners covering the local population.

Nationwide Shortage and Surplus of Primary Care Physicians

This map from the American Action Forum colors the physician shortage or surplus in each county, where “shortage” and “surplus” are defined as the total number of physicians above or below the population-adjusted national average.

By way of example, some worrying statistics:

 

  • Nearly 20 percent of Americans live in areas with an insufficient number of primary care doctors (U.S. Department of Health and Human Services)
  • Almost 91 million adults live in areas where shortages of mental-health professionals make obtaining treatment difficult (U.S. Department of Health and Human Services)
  • The nation will face a shortage of between 46,000-90,000 physicians by 2025 (Association of American Medical Colleges)

 

It’s easy to rant in a blog about how bad it is that people have to wait to get the care they need. It’s much harder and slower to find appropriately qualified healthcare professionals and the funds to employ them. So is there a solution? Yes. It’s digital health.

Health informatics technologies can ensure that scarce resources are used most effectively to meet the needs of the population. These examples focus on the care of children with ADHD, but they apply to other domains also.

Improved efficiency is definitely a benefit of health IT. Automated electronic communication shortens the time it takes to gather the necessary information to assess and treat children with ADHD. A clinician using mehealth for ADHD tells us it reduces his assessment and diagnosis time by 75 percent. Replacing paper ratings with online assessments dramatically reduces the administrative burden and frees up clinical time.

Delivering the best, evidence-based care for all patients that come to the clinic isn’t easy; it’s hard for pediatricians to be experts in everything. There’s some controversy around the diagnosis and treatment of ADHD, so referring all suspected cases to a child psychiatrist has become standard practice for some pediatricians. With 11% of US children receiving a diagnosis of ADHD, the idea that child psychiatrists could, or should, see them all is clearly untenable. Software is empowering pediatricians to manage routine cases and triage those that need a referral. mehealth for ADHD maps symptoms (automatically collected, scored and analyzed) against DSM-5 criteria and AAP ADHD guidelines, and it provides assessment and treatment reports. It doesn’t remove the need for good clinical judgment, but it supports pediatricians in delivering optimal care… themselves.

Telehealth consultations and e-consults are revolutionizing healthcare and providing under-served communities with essential pediatric and psychiatric medical expertise. But using an expert’s on-line time effectively is essential. A psychiatric expert 200 miles from the patient wants to have a succinct, standardized summary of what’s been happening since the last consultation, ideally viewable before the on-line session. ADHD monitoring software does just that; automatically rated scores of symptoms, impairments and side effects, from home and school, are plotted longitudinally against pharmacological and behavioral interventions. What’s more, from January this year The Centers for Medicare & Medicaid Services (CMS) expanded reimbursement for telehealth services provided to Medicare beneficiaries; more motivation for going digital. Details here.

So that’s it. It’s not rocket science.

  • Implement technology to improve efficiency so that primary care physicians can spend their time solving clinical problems, not administrative ones.
  • Use clinical decision support tools to help primary care physicians deliver the highest quality of care in their practice, themselves; that’s best for patients and for over-stretched specialists.
  • Exploit telehealth and remote monitoring tools, providing specialists with all the information they need to consult effectively with primary care physicians and patients, however far away they are.

 
It would be over zealous to say, “problem solved”, but it’s a great step in the right direction!

Janet

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Pyrethrum: The flower with a dark side

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Pyrethrum: The flower with a dark side

Picture of pyrethrum flowers

Chrysanthemum cinerariaefolium

This cheerful little flower has a dark side.

Pyrethrum (Chrysanthemum cinerariaefolium) is a natural source of insecticide. The flowers are pulverized and the active components, pyrethrins, are extracted and used in insecticides. Pyrethroids are industrially produced chemicals that simulate the natural pyrethrins.

Pyrethroid and pyrethyrin insecticides are now the most commonly used pesticides in private homes and for public health purposes. They are also increasingly popular in agriculture. We apply them to our pets, our gardens, our food crops, the world around us (such as large-scale mosquito fumigation) and our children (in anti-lice shampoos and mosquito repellents). The US Environmental Protection Agency (EPA) found pyrethroids and pyrethrins in more than 3,500 registered commercial products. They are everywhere… and their use is escalating. It is no surprise that US bio-monitoring studies report widespread exposure of the population to one or more pyrethroids.

So does that matter?

Pyrethroids and pyrethrins are believed to be safer to humans than banned DDT and organophosphates. I think that’s a bit like saying “it’s safer to be hit by a car than by a truck”. It may be true, but it’s still really bad for you.

In 2013, a Canadian study of nearly 800 children found at least one urinary metabolite for pyrethroids present in 97% of the children, and a 10-fold risk of behavioral problems associated with some metabolites.

Numerous animal studies had already reported that rodents exposed to pyrethroids during brain development showed increased activity in later life, so some impact in humans was not altogether unexpected. Interestingly, in mice the observed hyperactivity and impulsivity-like behavior is heightened in males.

Consider these facts about ADHD:

 

  • ADHD is a heritable disorder, known also to be influenced by environmental and other modifiable risk factors.
  • The symptoms include inattention, hyperactivity, and impulsivity and different subtypes are recognized.
  • The rates of diagnosis and presentation differ between boys and girls.

 

A research study undertaken at Cincinnati Children’s Hospital Medical Center, published online in the journal Environmental Health, explored pyrethroid pesticides as a risk factor for ADHD.

The study cohort comprised 687 children aged 8–15 years. Urinary levels of the pyrethroid metabolite 3-phenoxybenzoic acid (3-PBA) were measured. ADHD was defined by either meeting DSM IV criteria on the Diagnostic Interview Schedule for Children (DISC) or a positive caregiver report of diagnosis. Children with detectable urinary 3-PBA were twice as likely to have ADHD, and hyperactive-impulsive symptoms increased by 50% for every 10-fold increase in levels. The effects were observed in boys, not girls. The effects on inattention were not significant.

Of course, all research findings need to be replicated, but the results are alarmingly consistent with previous evidence.

The authors comment, “Should the link between pyrethroid exposure and hyperactivity-impulsivity in children be replicated, these findings might represent a potential pyrethroid-specific ADHD phenotype. Efforts to characterize etiologic-specific ADHD phenotypes are paramount not only to elucidating the biologic basis of ADHD: they may ultimately prove useful in defining subgroups of children with ADHD with a distinct course, comorbidity profile, and intervention response, and thus form the basis for targeted clinical and treatment efforts”.

So sadly, like other insecticides, the pyrethroid pesticides don’t just stick to killing those bugs that what we want them to kill. Now it seems that they may be toxic to our children as well as to honeybees. President Obama’s action earlier this year to save the nation’s bees was widely publicized. Will he now campaign to save our children? I hope so.

Picture of President Obama with some honeybees

 

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Environmental Factors Impacting ADHD: What We Found Through Google

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Environmental Factors Impacting ADHD: What We Found Through Google

google screenshot

We recently typed ‘ADHD Research’ in the Google news search bar. Based on the top headlines, it was great to see that there is no shortage of organizations willing to dedicate funds to finding the causes of the disorder. According to Google, recent studies show that ADHD is impacted by artificial food coloring, living at high altitudes, living near the ocean, and second hand smoke. This all from the first two pages of the search results!

So, how does this research help the 1 in 11 kids in the US living with ADHD… and those destined to develop it?

Once an environmental factor is proven (not by just one study, but by robust validated research) to increase the risk of developing ADHD, then what can we do about it? Identifying risk factors can open up new avenues for scientific research into the molecular mechanisms underlying medical conditions, but that’s a long-term benefit. Additionally, some risk factors can be reduced, such as dietary factors or smoke exposure. These are, at least, positive health measures and perhaps they also help with symptom control or can work to reduce the risk of siblings developing the condition too. Other environmental factors are more tricky to moderate … and potentially set people up for a guilt trip if they choose to live in a high place near the sea and their child then develops ADHD.

With increasing numbers of children being treated for ADHD, we also need to make sure that sure the diagnosis is being made correctly.

One media article that did catch our attention featured a Connecticut thought leader who suggested that girls have been under-diagnosed due to the unique ways ADHD presents itself when compared to boys of the same age. Check it out.

Digital technologies, like the solutions mehealth provides, help to accurately diagnose the disorder and pinpoint factors which influence the development or outcome of the condition… implementing research findings and making things better for those living with ADHD.

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Could Workplace Exercise Stations Be Effectively Used in the Classroom?

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Could Workplace Exercise Stations Be Effectively Used in the Classroom?

Recently, Jimmy Kimmell had a bit of fun with the latest fad in helping professionals who are too busy to exercise. As much as this might look like a silly idea, there are thousands of workstations across the country designed with set-ups just like this. At some point we might ask: Do you work in a gym as a professional, or as a professional with gym benefits?

jimmykimmel

All humor aside, this idea could feasibly be part of tomorrow’s classroom based on recent findings from the University of Central Florida. Last week, their researchers published a paper in The Journal of Abnormal Child Psychology which concluded that students with ADHD are far more successful when in motion.

These findings do not suggest that children should be running around the room to the detriment of the others, but rather that sitting on an exercise ball or even utilizing an exer-cycle could be beneficial for improving memory.

Last year, our blog referenced the importance of recess and clearly the connection between movement and improving the academic success of ADHD students continues to gain clinical validation.

On another note, perhaps the treadmill desk could also help address major public health issues such as obesity and juvenile diabetes.

Click the following link to read the original article covering the Universal of Central Florida’s study: “Study: Why Kids with ADHD need to squirm

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Is a Summertime Drug Holiday Right for Your Child with ADHD?

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Is a Summertime Drug Holiday Right for Your Child with ADHD?

kids on bench

This is the second post in a two part series focusing on important conversations that parents, MDs and teachers are having about kids with ADHD ahead of summer vacation. Read last week’s post to learn more about why more kids are assessed for ADHD in the spring.

As we head into summer, many parents will work with their physicians to evaluate whether giving their child a “drug holiday,” or what pediatricians call a structured treatment interruption, is appropriate for their child. There are (at least!) two schools of thought when it comes to this course of action. The first being that a treatment routine is important for kids with ADHD and going off medication could exacerbate symptoms and make it difficult for a child to interact with peers or adults. The second is that taking a break from medications… and side effects… is a good thing.

There’s no answer that’s right or wrong for everyone; decisions need to be taken considering each individual child’s medication regimen and circumstances. The important thing to remember about a drug holiday is that it’s a break from medication NOT from working with your pediatrician; families can’t abandon treatment altogether. Thankfully the evolution of digital health is helping extend the reach of the physician and changing the way patients connect, and remain connected, with doctors. When treating ADHD, access to real-time information about how a patient is doing allows doctors to respond quickly to change and optimize care… during school-time and during the vacation.

The goal is the entire family enjoying the summer months together and being prepared to welcome the new school year in September. Stay connected over the summer with mehealth for adhd!

 

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