Topic Brief 1: Considering Titration and Treatment-Resistant Patients

CME/CE-Certified Internet Topic Brief

Release date: May 2009
Expiration date: August 31, 2010

Estimated Time to Complete This Activity
1.0 hour (60 minutes)

Faculty Co-Editors
James J. McGough, MD, MS
Professor, Clinical Psychiatry
UCLA Semel Institute for Neuroscience and Human Behavior
Los Angeles, California

Timothy E. Wilens, MD
Associate Professor, Psychiatry
Harvard Medical School
Director, Substance Abuse Services
Clinical and Research Programs
Pediatric Psychopharmacology
Massachusetts General Hospital
Boston, Massachusetts

Faculty Reviewer
Larry Culpepper, MD, MPH
Professor and Chairman, Family Medicine
Boston University School of Medicine
Boston Medical Center
Boston, Massachusetts

Sponsorship and Support
Sponsored by Veritas Institute for Medical Education, Inc.

Supported by an educational grant from McNeil Pediatrics, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. administered by Ortho-McNeil Janssen Scientific Affairs, LLC.

Method of Participation
Read this Topic Brief, complete the CME/CE Activity Evaluation and Request for Credit Form online, and receive your statement of credit immediately. Print your statement of credit.

This activity is provided free of charge to participants.

James J. McGough, MD, MS, is Professor of Clinical Psychiatry at the Semel Institute for Neuroscience and Human Behavior and David Geffen School of Medicine at University of California, Los Angeles (UCLA). Dr McGough graduated from Duke University School of Medicine in 1986, where he remained for his residency in psychiatry. He completed a fellowship in child and adolescent psychiatry at UCLA and has been a member of the faculty in the Division of Child and Adolescent Psychiatry since 1994. He presently serves as director of clinical teaching programs in both child and adolescent psychopharmacology and attention-deficit/hyperactivity disorder (ADHD), which are required training venues for child psychiatric residents. He is vice chief of staff of the UCLA Resnick Neuropsychiatric Hospital and chair of the UCLA Medical Institutional Review Board. Dr McGough is board certified in psychiatry, child and adolescent psychiatry, and addiction psychiatry. He received a National Institute of Mental Health (NIMH)-funded K23 Career Development Award for ADHD pharmacogenomics and an MS degree in clinical research through UCLA’s NIMH-funded K30 program. Dr McGough has been a principal or co-principal investigator for more than 50 clinical trials, including both National Institutes of Health- and industry-sponsored studies. He has authored more than 100 research publications, reviews, and book chapters, with a particular emphasis on pediatric psychopharmacology and ADHD genetics.

Timothy E. Wilens, MD, is Associate Professor of Psychiatry at Harvard Medical School in Boston, Massachusetts. In addition, he is Director of Substance Abuse Services in the Pediatric Psychopharmacology Clinic at Massachusetts General Hospital.

Dr Wilens earned his BS in literature, science, and arts at the University of Michigan Honors College, and his MD at the University of Michigan Medical School in Ann Arbor. He completed a residency in child, adolescent, and adult psychiatry at Massachusetts General Hospital under the auspices of Harvard Medical School in Boston. He is triple boarded in adult, child/adolescent, and addiction psychiatry.

Dr Wilens’ research interests include the relationship of ADHD, bipolar disorder, and substance abuse, as well as the pharmacotherapy of ADHD across the lifespan and juvenile bipolar disorder. His peer-reviewed articles concerning these and related topics number more than 190 and are published in prestigious journals such as JAMA, the American Journal of Psychiatry, Archives of General Psychiatry, and Pediatrics. Dr Wilens has also published more than 70 book chapters and 300 abstracts and presentations for national and international scientific meetings. He is a Distinguished Fellow of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry, is a scientific reviewer for 22 journals, and is active in a number of other local and national professional societies. He is named consistently among the Best of Boston—Child/Adult Psychiatry and the Top/Best Doctors in America.

Larry Culpepper, MD, MPH, is Professor of Family Medicine and the founding Chairman of the Department of Family Medicine at Boston University School of Medicine. Dr Culpepper is also Chief of Family Practice at Boston Medical Center. He received his MD degree from Baylor College of Medicine and his MPH degree from Boston University.

An active researcher, Dr Culpepper has conducted federally funded studies of depression and anxiety, otitis media, and school-based and community interventions to improve pregnancy outcomes and to prevent teen pregnancies. Recently, he served as the principal investigator of an AHRQ funded developmental center for patient safety research devoted to the study of problems affecting low income and minority vulnerable populations in ambulatory care settings. He is a co-investigator of the Primary Care Anxiety Project, a study of the course of anxiety disorders in primary care settings. Dr Culpepper’s department operates a large hospitalist inpatient service and obstetric and newborn service, and provides leadership to a network of 15 community health centers involving over one million visits annually. It is also responsible for Boston University’s Student Health Service and for the Boston University Medical Center’s Occupational Health Service.

Dr Culpepper has served as President of the North American Primary Care Research Group (NAPCRG) and Chairman of the Research Committee of the Society of Teachers of Family Medicine (STFM). He is a Primary Care Fellow of the federal Health Resources and Services Administration, and has chaired or served as a member of research grant review committees for 5 NIH and other federal agencies, as well as on 6 federal expert panels for consensus committees or evidence-based centers. He founded and is the Chairman of the Board of the Rhode Island Public Health Foundation. He is a member of The Depression and Bipolar Support Alliance and the Anxiety Disorders Association of America Scientific Advisory Boards. He is the editor of the Primary Care Companion to the Journal of Clinical Psychiatry. In 1997, Dr Culpepper received the NAPCRG-STFM Career Research Award, and in 1998, he was elected to the Institute of Medicine.

Statement of Need
Attention-deficit/hyperactivity disorder (ADHD) is associated with significant impact for the individual patient as well as for society. Older adolescent and adult patients experience a spectrum of disorder-related functional impairments that are associated with considerable educational and occupational underachievement. In the United States, the loss of workforce productivity associated with ADHD has been estimated at $67 billion to $116 billion.

Overall, ADHD remains underrecognized and undertreated. According to the National Comorbidity Survey Replication, of the 4.4% of adults who have ADHD, only 11% were treated within the past year. These data reinforce the ongoing need to educate clinicians concerning core clinical information pertinent to recognizing, diagnosing, treating, and managing ADHD in late adolescence and adulthood.

This activity will focus on dose titration and other strategies pertinent to managing adolescent and adult patients with ADHD, which may be resistant to pharmacotherapy.

Intended Audience
Psychiatrists, primary care physicians, pediatricians, physician assistants (PAs), and nurse practitioners (NPs) who care for patients with ADHD.

Learning Objective
You will be able to select and titrate pharmacologic treatments that affect symptomatic behavior and improve the functioning of your patients with ADHD, and to employ strategies for encouraging patient adherence to treatment.

Accreditation/Designation of Credit
Veritas Institute for Medical Education, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Physicians
Veritas Institute for Medical Education, Inc. designates this educational activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Family Physicians
This activity has been reviewed and is acceptable for up to 1.0 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 5/15/09. Term of approval is for one year from this date, with option for yearly renewal.

Nurse Practitioners
Veritas Institute for Medical Education, Inc. approved as a provider for nurse practitioner continuing education by the American Academy of Nurse Practitioners: AANP Provider Number 040309. This program has been approved for 1.0 contact hour of continuing education (which includes 1.0 hour of pharmacology).

Financial Disclosure
In accordance with the ACCME’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Disclosures are as follows:

Larry Culpepper, MD, MPH—AstraZeneca (speakers bureau and/or consultant); Blue Cross Foundation of Massachusetts (grant/research support); Forest Laboratories; Eli Lilly and Company; Pfizer Inc; Somaxon; Takeda; Wyeth (speakers bureau and/or consultant),

James J. McGough, MD, MS—Eli Lilly and Company (grant/research support); Shire (consultant).

Timothy E. Wilens, MD―Abbott Laboratories (grant/research support, consultant); Eli Lilly and Company (grant/research support, speakers bureau, consultant); McNeil Pediatrics, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. administered by Ortho-McNeil Janssen Scientific Affairs, LLC (grant/research support, speakers bureau, consultant); Merck & Co, Inc (grant/research support, consultant); National Institutes of Health (National Institute on Drug Abuse) (grant/research support, consultant); Novartis Pharmaceuticals Corporation (speakers bureau, consultant); Shire (grant/research support, speakers bureau, consultant).

The staff of Veritas Institute for Medical Education, Inc. has nothing to disclose.

Off-Label/Investigational Uses of Drugs/Medical Devices Disclosure
Participants are advised that this CME/CE activity will contain references to unlabeled/unapproved/investigational uses of drugs to treat patients with ADHD.

Disclaimer
The opinions expressed in this activity are those of the presenters and do not necessarily reflect those of Veritas Institute for Medical Education, Inc. or McNeil Pediatrics, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc. administered by Ortho-McNeil Janssen Scientific Affairs, LLC. Please consult the appropriate package insert for full prescribing information on all drug therapies discussed.