Symposium
S01 -​​ Attention-Deficit Hyperactivity Disorder: Are There Other Treatment Options?​​ 

Friday, 23 October​​ 
13:30 – 16:45 (3 hrs plus 15 min break
)
Michael Van Ameringen*, MD, FRCPC; Ana Paula Francisco, MD; Carolina Goldman Bergmann, MD; Lawrence Martin, MD, FRCPC​​ 

 

CanMEDS Roles:​​ 

  • Medical Expert​​ 

  • Scholar​​ 

  • Collaborator​​ 

At the end of this session, participants will be able to:​​ 1) Examine the evidence supporting next-step treatments for refractory adult attention-deficit hyperactivity disorder (ADHD) and examine the impact of borderline personality disorder comorbidity on treatment outcome; 2) Explore vitamins and minerals as treatment for ADHD symptoms; and 3) Review the literature on the use of cannabis to treat ADHD and examine possible interactions between the cannabinoid system and ADHD physiopathology.​​ 

Attention-deficit hyperactivity disorder (ADHD) is one of the most common childhood mental disorders and often continues into adolescence and adulthood. ADHD is associated with substantial functional impairments, such as educational attainment, occupational difficulties, relationship problems, and delinquency. ADHD is also associated with high rates of psychiatric comorbidity, which can have significant effects on treatment outcome. First-line treatments for ADHD include psychostimulants; however, there is also evidence to support the use of non-stimulants and cognitive-behavioural therapy. Despite reports in the literature of high efficacy associated with standard ADHD treatments, many patients remain symptomatic; furthermore, there is often a reluctance to use standard treatments for reasons including side effects, stigma, a desire for natural treatments, and distrust of pharmaceuticals. Therefore, a need for alternative treatment approaches is warranted. This symposium aims to explore multiple avenues of treatment alternatives. The phenomena of treatment resistance in ADHD with next-step pharmacological approaches will be explored. The impact of nutritional supplements and dietary changes on ADHD symptoms will also be presented. Another presentation will review the evidence examining the use of cannabis for ADHD symptoms. Finally, the impact of comorbid borderline personality disorder on ADHD treatment outcome will be presented.

S01a - The Effect of Cannabis and Cannabinoids on Attention-Deficit Hyperactivity Disorder Symptoms. What Do We Know So Far?
Ana Paula Francisco, MD​​ 

At the end of this session, participants will be able to:​​ 1) Examine the prevalence of cannabis use in attention-deficit hyperactivity disorder (ADHD); 2) Review the current literature about the effect of cannabis use and ADHD symptoms; and 3) Explore possible interactions between the cannabinoid system and the ADHD physiopathology.​​ 

Treatment options for attention-deficit hyperactivity disorder (ADHD) include stimulant and non-stimulant medications, as well as cognitive-behavioural therapy. Unfortunately, these agents are associated with side effects that can sometimes lead to poor treatment adherence. In clinical practice and in online discussion forums, individuals with ADHD have stated that cannabis has helped improve their ADHD symptoms. Cannabis is one of the most commonly used psychoactive substances in the world and is used at high rates among people with ADHD. In treatment-seeking patients who use cannabis, the prevalence of ADHD is around 34% to 46%. Although it remains illegal in many countries, cannabis legislation has changed in several countries and jurisdictions. In Ontario, Canada, 28.8% of cannabis users reported that they used cannabis for therapeutic purposes in the year prior to legalization. Since there is a likelihood of an increase in cannabis use, it is important to understand what the literature says about the effects of cannabis on ADHD symptoms.

There are equivocal findings as to whether cannabis improves ADHD symptoms in humans, with age and sex arising as influential factors. There are also some animal experiments showing inconsistent effects of cannabinoids on ADHD symptoms. This presentation will explore the evidence-based literature about the effects of cannabis on people with ADHD, as well as the possible role of the endocannabinoid system in ADHD physiopathology, making it a potential novel target for ADHD treatment.

References:

  • Mitchell JT, Sweitzer MM, Tunno AM, et al. “I use weed for my ADHD”: A qualitative analysis of online forum discussions on cannabis use and ADHD. PLoS One 2016;11:e0156614.

  • Katzman MA, Furtado M, Anand L. Targeting the endocannabinoid system in psychiatric illness. J Clin Psychopharmacol 2016;36:691–703.​​ 

S01b - Can Vitamins and Minerals Be Used to Improve Attention-Deficit Hyperactivity Disorder Symptoms? What the Evidence Says
Carolina Goldman Bergmann, MD​​ 

At the end of this session, participants will be able to:​​ 1) Review the prevalence of using vitamins and minerals as an attention-deficit hyperactivity disorder (ADHD) treatment; 2) Review the affect of dietary changes on ADHD symptoms; and 3) Review the efficacy of vitamins and minerals as an ADHD treatment.​​ 

Treatment with stimulants, non-stimulants, and behavioural changes are well established for attention-deficit hyperactivity disorder (ADHD). Nevertheless, although current treatments reduce symptoms, they may not be entirely satisfactory due to side effects, cost, or lack of response. In addition, many patients often ask about alternative treatments to treat or improve symptoms of ADHD. Nutritional supplementation and dietary changes have been well studied and shown to be effective in different areas of medicine, for example, the prevention of heart disease with omega-3 supplementation. In the field of psychiatry, studies examining vitamins,​​ nutrients, and dietary changes are emerging that have enhanced our limited understanding of their effects on ADHD symptoms. Recent preliminary research has indicated that vitamins and minerals, such as vitamin D, iron, zinc, magnesium, omega-3, and iodine could potentially improve ADHD symptoms. There has also been an increasing interest in the impact of the Mediterranean Diet, artificial food colours, and probiotic intake on ADHD symptoms. This presentation will explore and evaluate the current use of ADHD treatment with vitamins, minerals, and other dietary changes.

References:

  • Rytter MJH, Andersen LBB, Houmann T, et al. Diet in the treatment of ADHD in children—a systematic review of the literature. Nord J Psychiatry 2015;69:1–18.

  • Yang R, Li R. Complementary and alternative medicine in ADHD treatment: more soundly designed clinical trials needed. World J Pediatr 2019;15:516–19.

S01c - Treatment of Refractory Adult Attention-Deficit Hyperactivity Disorder: What Are the Next Steps?
Michael Van Ameringen, MD, FRCPC​​ 

At the end of this session, participants will be able to:​​ 1) Review the adult attention-deficit hyperactivity disorder (ADHD) treatment literature; 2) Explore predictors of response to first-line ADHD treatment; and 3) Examine the evidence supporting next-step treatments for refractory adult ADHD.​​ 

Stimulants are considered first-line pharmacotherapy for adult attention-deficit hyperactivity disorder (ADHD) and their use is supported by a wide body of literature. Effect sizes for stimulants range between 0.42 and 0.9 and the number needed to treat (NNT) from 2 to 3 for long-acting stimulants and 2 to 4 for short-acting stimulants. Given these moderate to large effect sizes demonstrated in multiple meta-analyses, it would appear that most individuals with ADHD respond well to this intervention; however, in clinical practice, treatment resistance can be problematic in this population and many adult ADHD patients require further treatment trials with non-stimulants or adjunctive treatments. Although the stimulant literature reports similarly large effect sizes for children and adolescents with ADHD, it has also been reported that 45% to 50% do not attain an adequate response to stimulant treatment. This clinical issue has not been adequately explored or characterized in the literature. There are no reliable neurobiological markers that might predict adult treatment response to stimulants. However, there is evidence to suggest that psychiatric comorbidity may have a significant impact on treatment course and outcome. This presentation will explore evidence-based next-step strategies for adult ADHD patients who are refractory to first-line treatment.

References:

  • Retz W, Retz-Junginger P. Prediction of methylphenidate treatment outcome in adults with attention deficit/hyperactivity disorder (ADHD). Eur Arch Psychiatry 2014;264(Suppl 1):S35–S43.​​ 

  • Shim S-H, Yoon H-J, Bak J, et al. Clinical and neurobiological factors in the management of treatment refractory attention-deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry 2016;70:237–44.

S01d - Attention-Deficit Hyperactivity Disorder, Borderline, or Both? Sorting Out a Diagnostic Challenge
Lawrence Martin, MD, FRCPC​​ 

At the end of this session, participants will be able to:​​ 1) Appreciate the prevalence and significance of emotion dysregulation in attention-deficit hyperactivity disorder (ADHD); 2) Understand the common or overlapping features of ADHD and borderline personality disorder presentations; and 3) Learn a strategy for distinguishing between disorders and implementing appropriate treatments.​​ 

Attention-deficit hyperactivity disorder (ADHD) and borderline personality disorder share multiple common symptoms and functional impairments. Both involve significant problems with emotion regulation and impulsivity. The current diagnostic default is to a personality disorder, in part because the DSM V does not represent the emotion dysregulation often seen in ADHD. It is important to distinguish between these disorders because treatments are markedly different for each. This session will articulate the common and unique features for each and outline a possible strategy for reaching diagnostic clarity in patients with often similar presentations.

References:

  • Shaw P, Stringaris A, Nigg J, et al. Emotional dysregulation and attention-deficit/hyperactivity disorder. Am J Psychiatry 2014;171:276–93.

  • Weibel S, Nicastro R, Prada P, et al. Screening for attention-deficit/hyperactivity disorder in borderline personality disorder. J Affect Disord 2018;226:85–91.

/ Virtual Conference 2020