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2023</time></div><h1 class="text-[26px] font-medium leading-8">FDA Approves First Generics for the Treatment of ADHD, BED</h1><div class="py-3 text-gray-600 md:flex flex-col md:justify-between"><div class="flex flex-col xs:flex-row"><p class="mr-1 self-start">Author(s):</p><div class="flex flex-col xs:flex-row mb-3 md:mb-0"><div class="flex flex-wrap"><span class="text-md mr-2"><a class="text-author text-gray-500 hover:text-primary underline hover:no-underline decoration-gray-400" href="/authors/erin-o-brien">Erin O'Brien</a></span></div></div></div><div class="max-w-full"><div class="flex flex-wrap sm:flex-nowrap items-center w-fit my-2"></div><div class="w-full flex flex-col sm:flex-row justify-between mt-2"><div class="block md:hidden "><div class="mt-2 flex items-center max-w-fit"><button title="FDA Approves First Generics for the Treatment of ADHD, BED" aria-label="facebook" class="react-share__ShareButton" 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0-2-2h-1V3a2 2 0 0 0-2-2H5zM4 3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1v2H4V3zm1 5a2 2 0 0 0-2 2v1H2a1 1 0 0 1-1-1V7a1 1 0 0 1 1-1h12a1 1 0 0 1 1 1v3a1 1 0 0 1-1 1h-1v-1a2 2 0 0 0-2-2H5zm7 2v3a1 1 0 0 1-1 1H5a1 1 0 0 1-1-1v-3a1 1 0 0 1 1-1h6a1 1 0 0 1 1 1z"></path></svg></a></div><style> .print-wrap { width: 32px; height: 32px; background: #7F7F7F; border-radius: 100%; } .print { background: #7F7F7F; color: white; padding: 2px; border-radius: 100%; } </style></div></div></div></div><div class=" lg:w-full flex flex-col lg:flex-row lg:items-center lg:justify-end"></div><p class="py-2 mb-2 text-sm italic text-gray-600">Generics are now approved for adults in the treatment of BED and for individuals aged 6 years and older in the treatment of ADHD.</p><div class="py-2"><div class="blockText_blockContent__TbCXh"><div class=""><div style="width:70%;float:center;max-width:525px;margin:0 auto 1rem;clear:both;cursor:" class=" figure"><div class="flex-none relative text-center"><span style="box-sizing:border-box;display:inline-block;overflow:hidden;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;position:relative;max-width:100%"><span style="box-sizing:border-box;display:block;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0;max-width:100%"><img style="display:block;max-width:100%;width:initial;height:initial;background:none;opacity:1;border:0;margin:0;padding:0" alt="" aria-hidden="true" src="data:image/svg+xml,%3csvg%20xmlns=%27http://www.w3.org/2000/svg%27%20version=%271.1%27%20width=%276000%27%20height=%274000%27/%3e"/></span><img alt="wladimir1804_AdobeStock" title="wladimir1804_AdobeStock" src="data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain"/><noscript><img alt="wladimir1804_AdobeStock" title="wladimir1804_AdobeStock" srcSet="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fa37b75eb7a161f7ae69bf47af10cdb91422e2fbf-6000x4000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75 1x" src="/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2Fa37b75eb7a161f7ae69bf47af10cdb91422e2fbf-6000x4000.jpg%3Ffit%3Dcrop%26auto%3Dformat&w=3840&q=75" decoding="async" data-nimg="intrinsic" style="position:absolute;top:0;left:0;bottom:0;right:0;box-sizing:border-box;padding:0;border:none;margin:auto;display:block;width:0;height:0;min-width:100%;max-width:100%;min-height:100%;max-height:100%;object-fit:contain" loading="lazy"/></noscript></span></div><div id="image-caption" class="text-gray-500 italic"><div class="blockText_blockContent__TbCXh"><p class="pb-2">wladimir1804_AdobeStock</p></div></div><div class="top-[-100%] block w-[1px] transition-opacity duration-500 ease-in-out opacity-0 overflow-hidden"><img class="m-auto absolute inset-0 max-w-[0%] max-h-[0%] border-[3px] border-solid border-white shadow-[0px_0px_8px_rgba(0,0,0,0.3)] box-border transition ease-in-out duration-500" src="https://cdn.sanity.io/images/0vv8moc6/psychtimes/a37b75eb7a161f7ae69bf47af10cdb91422e2fbf-6000x4000.jpg?fit=crop&auto=format"/></div></div><style> #image-caption p{ font-size: 12px; max-width: 525px; margin: 0 auto; text-align: center; } </style></div><p class="pb-2">The US Food & Drug Administration (FDA) announced that it has approved several generics for the treatment of attention-deficit/hyperactivity disorder (<a target="_blank" href="https://www.psychiatrictimes.com/view/optimizing-treatment-for-adhd">ADHD</a>) and binge-eating disorder (<a target="_blank" href="https://www.psychiatrictimes.com/view/psychedelics-for-the-treatment-of-binge-eating-disorder-in-males">BED</a>).</p><p class="pb-2">The first generics of Vyvanse (lisdexamfetamine dimesylate) capsules and chewable tablets are now approved for the treatment of ADHD in patients aged 6 years and older and for the treatment of moderate to severe BED in adults.<sup class="text-inherit">1</sup> These approvals follow the FDA’s announcement of the shortage of an immediate-release formulation of amphetamine mixed salts (Adderall) on October 12, 2022.<sup class="text-inherit">2</sup></p><p class="pb-2">“The <a target="_blank" href="https://www.psychiatrictimes.com/view/the-rx-crisis-the-impact-of-ongoing-adhd">shortages of stimulants</a> (largely generics) have been a nightmare to children, families, and their practitioners,” Timothy Wilens, MD, chief of the Division of Child and Adolescent Psychiatry and codirector of the Center for Addiction Medicine at Massachusetts General Hospital, told <em>Psychiatric Times</em>®. “At a public health level, it is important for policy makers to understand their multifaceted nature and work together to help alleviate such severe, impactful shortages in the future.”<sup class="text-inherit">2</sup></p><p class="pb-2">With the approval of the lisdexamfetamine dimesylate generic for the treatment of ADHD, more patients with ADHD may have access to treatment. In addition to approving generics, the FDA has announced that it will continue to address the ongoing Adderall shortage by providing assistance to manufacturers, monitoring supply, and sharing updates and other information about the shortage.<sup class="text-inherit">3</sup></p><p class="pb-2"></p><p class="pb-2"><strong>References</strong></p><p class="pb-2">1. FDA approves multiple generics of ADHD and BED treatment. US Food & Drug Administration. News release. August 28, 2023. Accessed August 29, 2023. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-multiple-generics-adhd-and-bed-treatment?utm_medium=email&utm_source=govdelivery">https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-multiple-generics-adhd-and-bed-treatment?utm_medium=email&utm_source=govdelivery</a></p><p class="pb-2">2. Kunz L. The Rx crisis: the impact of ongoing ADHD medication shortages. <em>Psychiatric Times</em>. August 7, 2023. Accessed August 29, 2023. <a target="_blank" href="https://www.psychiatrictimes.com/view/the-rx-crisis-the-impact-of-ongoing-adhd">https://www.psychiatrictimes.com/view/the-rx-crisis-the-impact-of-ongoing-adhd</a></p><p class="pb-2">3. FDA announces shortage of Adderall. US Food & Drug Administration. Updated August 1, 2023. Accessed August 29, 2023. <a rel="nofollow noreferrer noopener" target="_blank" href="https://www.fda.gov/drugs/drug-safety-and-availability/fda-announces-shortage-adderall">https://www.fda.gov/drugs/drug-safety-and-availability/fda-announces-shortage-adderall</a></p><p class="pb-2"></p></div></div><div class="flex items-center lg:w-3/4 mb-4 pb-12"></div><div class="jsx-19ede9f0a5a45918 py-4 relative bg-primary md:px-8 -ml-6 xs:ml-0 w-screen xs:w-auto"><div class="jsx-19ede9f0a5a45918 px-4 sm:px-0"><div class="flex justify-between items-center py-1 space-x-4 border-0 select-none sm:border-b border-secondary"><div class="text-3xl text-white text-lg sm:text-3xl">Related Videos</div></div></div><div style="scroll-snap-type:none" class="jsx-19ede9f0a5a45918 flex items-start overflow-x-auto space-x-4 py-4 relative mx-auto w-full pl-4"><a id="" class="w-[200px] h-fit space-y-3 flex-none select-none no-underline" style="scroll-snap-align:center;text-decoration:none" 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Greenblatt, MD</a></div><div class="jsx-ad50481d5ee26850 article-summary"><a class="jsx-ad50481d5ee26850" href="/view/think-zinc-micronutrient-supplementation-for-the-treatment-of-anorexia-nervosa?utm_source=www.psychiatrictimes.com&utm_medium=relatedContent"></a></div></div></div><div style="border-bottom:1px solid #CCCCCC" class="jsx-ad50481d5ee26850"></div></div></div></div></div><div class="pb-24"></div></div><script type="application/ld+json">{"@context":"https://schema.org","@type":"NewsArticle","headline":"FDA Approves First Generics for the Treatment of ADHD, BED","datePublished":"2023-08-29T17:40:43.300Z","dateModified":"2023-08-29T17:40:46Z","inLanguage":"en-US","image":"https://cdn.sanity.io/images/0vv8moc6/psychtimes/a37b75eb7a161f7ae69bf47af10cdb91422e2fbf-6000x4000.jpg?fit=crop&auto=format","mainEntityOfPage":{"@type":"WebPage","@id":"https://www.psychiatrictimes.com/view/fda-approves-first-generics-for-the-treatment-of-adhd-bed"},"publisher":{"@type":"Organization","name":"Psychiatric Times","logo":{"@type":"ImageObject","url":"https://www.psychiatrictimes.com/PsychiatricTimesLogo.png"}},"articleBody":"\n\nThe US Food & Drug Administration (FDA) announced that it has approved several generics for the treatment of attention-deficit/hyperactivity disorder (ADHD) and binge-eating disorder (BED).\n\nThe first generics of Vyvanse (lisdexamfetamine dimesylate) capsules and chewable tablets are now approved for the treatment of ADHD in patients aged 6 years and older and for the treatment of moderate to severe BED in adults.1 These approvals follow the FDA’s announcement of the shortage of an immediate-release formulation of amphetamine mixed salts (Adderall) on October 12, 2022.2\n\n“The shortages of stimulants (largely generics) have been a nightmare to children, families, and their practitioners,” Timothy Wilens, MD, chief of the Division of Child and Adolescent Psychiatry and codirector of the Center for Addiction Medicine at Massachusetts General Hospital, told Psychiatric Times®. “At a public health level, it is important for policy makers to understand their multifaceted nature and work together to help alleviate such severe, impactful shortages in the future.”2\n\nWith the approval of the lisdexamfetamine dimesylate generic for the treatment of ADHD, more patients with ADHD may have access to treatment. In addition to approving generics, the FDA has announced that it will continue to address the ongoing Adderall shortage by providing assistance to manufacturers, monitoring supply, and sharing updates and other information about the shortage.3\n\n\n\nReferences\n\n1. FDA approves multiple generics of ADHD and BED treatment. US Food & Drug Administration. News release. August 28, 2023. Accessed August 29, 2023. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-multiple-generics-adhd-and-bed-treatment?utm_medium=email&utm_source=govdelivery\n\n2. Kunz L. The Rx crisis: the impact of ongoing ADHD medication shortages. Psychiatric Times. August 7, 2023. Accessed August 29, 2023. https://www.psychiatrictimes.com/view/the-rx-crisis-the-impact-of-ongoing-adhd\n\n3. FDA announces shortage of Adderall. US Food & Drug Administration. Updated August 1, 2023. Accessed August 29, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fda-announces-shortage-adderall\n\n","description":"Generics are now approved for adults in the treatment of BED and for individuals aged 6 years and older in the treatment of ADHD.","author":[{"@type":"Person","name":"Erin O'Brien"}]}</script></div></div><div class="flex-none w-[300px] z-[9999] relative hidden md:block"><div style="top:5rem" class="sticky custom-spacing"><div class="collapse-container " style="overflow:hidden;max-height:900px;transition:max-height .4s ease-in-out"></div></div></div></div><div id="div-gpt-ad-pixel" style="width:1px;height:1px" class=""></div><noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-5V9L5PL" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><div id="footerOuterWrap" class="w-full bg-primary flex flex-col items-center justify-center"><div class="container w-[1340px]"><div id="footerInnerWrap" class="bg-primary 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If you do not already have an account with Physicians’ Education Resource, LLC, you will be prompted to create one. You must have an account to evaluate and request credit for this activity.","_key":"038de917ff11"}],"_type":"block","style":"normal","_key":"dee93a0f8815"},{"_type":"brtag","_key":"4ef192764e6a"},{"markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/eating-disorders","_key":"e45352746d85","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"With the onset of the COVID-19 pandemic, rates of medical hospitalization for severe malnutrition in the context of ","_key":"511d50fbcc5d0"},{"marks":["e45352746d85"],"text":"eating disorders","_key":"30036e586128","_type":"span"},{"_type":"span","marks":[],"text":" increased dramatically among children and adolescents.","_key":"c989d409afc5"},{"_type":"span","marks":["superscript"],"text":"1","_key":"b6dec395dc7c"},{"_type":"span","marks":[],"text":" First-time presentations rose, average age at admission fell, and overall acuity heightened, as evidenced by higher rates of in-hospital psychotropic use, longer lengths of stay, and greater need for intensive services like inpatient psychiatric or residential care upon discharge.","_key":"34e696b573b2"},{"_type":"span","marks":["superscript"],"text":"2","_key":"1bdbddc04b54"},{"_key":"a397781e7668","_type":"span","marks":[],"text":" Hospitalization rates have shown a downward trend over the last year, but total and first-time admissions to pediatric medical units for eating disorder care remain significantly higher than prepandemic levels."},{"_type":"span","marks":["superscript"],"text":"3","_key":"e45a9935255e"}],"_type":"block","style":"normal","_key":"abba94df99a6"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"For pediatric hospitalists and consultation-liaison (CL) psychiatry teams, caring for severely malnourished children and adolescents in the acute medical setting poses unique challenges, both for in-hospital management and longer-term care planning. We present a multidisciplinary approach and clinical practice guideline (CPG) for providing evidence-based standardized treatment to this special population. The CPG was developed by an interdisciplinary workgroup at the University of Michigan, C.S. Mott Children’s Hospital, based on our own clinical experience and modeled on standard practices within the field of adolescent medicine, as outlined in a similar protocol by Sylvester and Forman at Boston Children’s Hospital.","_key":"9839bab2e0bc0"},{"_key":"b6bbfd6a30aa","_type":"span","marks":["superscript"],"text":"4"},{"text":" Additionally, we share access to internally developed psychoeducation materials for patients and families in hopes that these resources might aid in practice efforts at other institutions. Even with a formalized protocol, we highlight ongoing treatment challenges relating to acute behavior management, capacity concerns, ethics around compelling care, and common barriers to discharge planning.","_key":"87d34d64329c","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"a6722b12c287"},{"children":[{"_type":"span","marks":["strong"],"text":"A Multidisciplinary Approach","_key":"7b0ac63cd5690"}],"_type":"block","style":"normal","_key":"9b53583ed214","markDefs":[]},{"_type":"block","style":"normal","_key":"b18f8ef07e4a","markDefs":[],"children":[{"text":"At our hospital, patients who are admitted for medically monitored nutrition restoration are cared for by a primary general pediatrics team, made up of an attending pediatric hospitalist, pediatric residents, and medical students. Our protocol requires consultation to adolescent medicine (AM), pediatric CL psychiatry, and a registered dietitian nutritionist (RDN). Additional team members have varied levels of involvement based on each patient’s needs, and might include psychiatry social workers, a behavioral support nurse, child life specialists, art and music therapists, spiritual care, learning specialists, and any other relevant medical subspecialty consultants (eg, pediatric endocrinology, pediatric cardiology). Bedside nurses play a crucial role in each patient’s care and are vital members of the multidisciplinary team. A patient care attendant (a 1:1 bedside observer) is assigned to each patient upon admission and is continued for at least the first 24 hours, at which point the team and family discuss the benefit of maintaining that resource for the duration of the stay. Indication for the patient care attendant include increased supervision and monitoring of eating disorder behaviors in the hospital setting to ensure integration of these concerns into the treatment plan.","_key":"71012045b6e40","_type":"span","marks":[]}]},{"children":[{"_type":"span","marks":[],"text":"In many cases, complexities in the clinical presentation or psychosocial situation are so impactful for treatment planning that it is beneficial for the primary and consultant teams to round jointly each day. We also regularly convene multidisciplinary care team meetings, generally once toward the beginning of the admission and again closer to discharge. These meetings typically include the family (and sometimes the patient) and, if needed, step-down treatment centers, to optimize treatment progress and to plan for next steps in care.","_key":"aafc703267200"}],"_type":"block","style":"normal","_key":"49d48242bdac","markDefs":[]},{"markDefs":[],"children":[{"text":"Approaching the medical admission with this multidisciplinary team model from start to finish helps signal to patients and families that eating disorders are complex illnesses requiring not only medical stabilization and treatment but also comprehensive mental health, family, and social support interventions. Furthermore, we find that the multidisciplinary approach is vital for the well-being of our care teams, providing reinforcement and reassurance to individual team members as they navigate complex family dynamics and high expressed-emotion interactions.","_key":"7c7e51a172f80","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"5fe64c3b474d"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Patient Characteristics","_key":"801ff04e13980"}],"_type":"block","style":"normal","_key":"d266949fddb2"},{"children":[{"_key":"7082161184120","_type":"span","marks":[],"text":"C.S. Mott Children’s Hospital admits patients through aged 24 years though most are younger than 21 years. Most patients who are admitted for malnutrition related to disordered eating are in their mid- to late teens, but we have seen increasingly younger patients over the last few years, especially in the 10- to 12-year-old range. Patients 25 years and older are admitted to our University Hospital, where they are treated under a similar protocol, modified for that age population."}],"_type":"block","style":"normal","_key":"4cd7089aed59","markDefs":[]},{"_key":"03170a85ee66","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/topics/emergency-psychiatry","_key":"588605806bf8","nofollow":true,"blank":true}],"children":[{"_type":"span","marks":[],"text":"Some patients self-present to the ","_key":"58bf5dd9ca830"},{"_type":"span","marks":["588605806bf8"],"text":"emergency department","_key":"f127921226f4"},{"_key":"c5c0edccb54d","_type":"span","marks":[],"text":" (ED) due to significant weight loss or concerning symptoms, such as fainting or fatigue. Many patients are referred to the ED by primary care physicians or our own outpatient AM clinic upon detecting abnormal vitals, labs, physical exam signs, or failure to respond to outpatient management in the context of weight loss or reported food restriction. Often, patients carry an existing diagnosis of an eating disorder and are being followed longitudinally for that condition by AM or outside eating disorder specialists. Some patients, however, are presenting for first-time evaluation in the acute care setting and have never discussed the notion of an eating disorder diagnosis with a medical or mental health clinician. Unfortunately, there is a cohort of patients who have had multiple medical admissions to our hospital for malnutrition and are well known to the inpatient pediatric and consultation teams; this can be both helpful and challenging in treatment planning."}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"3f5fb6fccdf4","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/schizophrenia","_key":"cf67a9076898"}],"children":[{"text":"The overwhelming majority of patients fit the picture of anorexia nervosa (AN) but we do occasionally admit patients with bulimia nervosa or other disordered eating behaviors. When patients are admitted for malnutrition in the context of avoidant/restrictive food intake disorder (ARFID), we alter the protocol to better align with the unique needs of those patients. We currently have a multidisciplinary work group collaborating to formalize a separate protocol for ARFID admissions. When the diagnosis remains unclear or points toward a non–eating-disordered psychiatric reason for malnutrition, such as severe depression, ","_key":"ae4905dc5b1e0","_type":"span","marks":[]},{"marks":["cf67a9076898"],"text":"psychosis","_key":"f958acc1c77d","_type":"span"},{"text":", obsessive-compulsive disorder, or catatonia, the CL team collaborates with the medical providers to devise a treatment plan that is best suited for the presentation.","_key":"412ef9100869","_type":"span","marks":[]}]},{"_type":"block","style":"normal","_key":"6307078c9431","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The Protocol","_key":"ac0c5523d9050"}]},{"children":[{"text":"The CPG outlines specific admission criteria to aid the ED clinicians who first assess these patients. Any questions or uncertainty regarding the appropriateness of admission can be discussed in real time with the on-call AM consultant. Admission criteria include any of the following: acute food refusal for 24 hours with failure to demonstrate 100% completion of a standard meal in the ED; concerning physical signs or symptoms of malnutrition; body mass index (BMI) less than or equal to 75% of the median for age and sex; bradycardia (\u003c 50 beats per minute while awake), hypotension (\u003c 90/45 mm Hg), or hypothermia (\u003c 96 °F, \u003c 36 °C); intractable vomiting or uncontrolled bingeing/purging; or failure of outpatient treatment.","_key":"e10398a067090","_type":"span","marks":[]},{"marks":["superscript"],"text":"5","_key":"1ad9c1b24a06","_type":"span"}],"_type":"block","style":"normal","_key":"17af79dd6893","markDefs":[]},{"markDefs":[],"children":[{"_key":"c13462ddf97a0","_type":"span","marks":[],"text":"Once the decision is made to admit the patient, the primary team places a standardized order set, which triggers a specific meal plan, sets up regular laboratory monitoring, and prompts consultation to AM, CL, and the RDN. Efforts are made to transition the patient out of the ED space as soon as possible, as that environment is not ideally suited for following a strict meal plan and supervision protocol. Ultimately, hospital census and acuity guide bed placement. For situations in which prolonged ED boarding is unavoidable, the CPG contains a section outlining adaptations of the protocol for the ED setting."}],"_type":"block","style":"normal","_key":"9d181c7e57a9"},{"_type":"figure","_key":"04a9096a3066","asset":{"_ref":"image-452fd7b2757bc5bc6b877fe55fc0cc2831188c4f-1676x590-png","_type":"reference"},"widthP":70,"blank":true,"disableLightBox":true,"imgcaption":[{"_key":"3b5e25e5fce7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Table. ","_key":"04057562ae040"},{"_type":"span","marks":[],"text":"Medical Monitoring and Diagnostic Testing","_key":"95546b63afc3"}],"_type":"block","style":"normal"}],"alignment":"right","disableTextWrap":false,"alt":"TABLE. Medical Monitoring and Diagnostic Testing"},{"_key":"86e858a42a56","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F452fd7b2757bc5bc6b877fe55fc0cc2831188c4f-1676x590.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"a5b8fa72cbcf","nofollow":true,"blank":true}],"children":[{"_type":"span","marks":[],"text":"Because of the potential development of refeeding syndrome in severely malnourished patients undergoing nutrition repletion, close medical monitoring is paramount. A standard panel of labs and diagnostic testing is collected upon admission and throughout the hospital stay, as outlined in the ","_key":"dfb5e06d5a170"},{"_type":"span","marks":["strong","a5b8fa72cbcf"],"text":"Table","_key":"c6152116fec8"},{"_type":"span","marks":[],"text":". Fluid balance is closely monitored and a daily fluid goal and free water limit are set. Intravenous (IV) fluids are avoided in favor of enteral nutrition and hydration, but dextrose-containing IV fluids are occasionally necessary to maintain appropriate blood glucose levels or address clinical dehydration or ketonuria. Phosphorus and thiamine supplementation are initiated reflexively for patients with BMI less than 70% of the median for age and sex at the time of admission. Other electrolyte replacement and supplementation is instituted as needed throughout the hospitalization, based on lab monitoring.","_key":"897df64eda8d"},{"_type":"span","marks":["superscript"],"text":"5","_key":"dc291d90e0b4"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"Nutrition is initiated at a level of 1500 kcal per day unless otherwise directed by AM. Calorie level is advanced by 300 kcal/day to until the patient is reliably gaining at least 0.3 kg to 0.4 kg every 2 days. The patient is not told calorie content or goals, and all information labels are removed from food items. The RDN meets with the patient and family upon admission to obtain the dietary history and to allow the patient to select 3 “no” foods for the duration of the hospitalization (these are limited to specific food items and cannot represent an entire food group). Subsequently, the RDN manages the patient’s meal plan entirely, selecting the menu and ordering the trays in accordance with the given kcal level, rate of advancement, known allergies or intolerances, and specified “no” foods.","_key":"e141966bf1920","_type":"span"}],"_type":"block","style":"normal","_key":"b563863d5359"},{"markDefs":[],"children":[{"_key":"6f951682c49f0","_type":"span","marks":[],"text":"In the case of vegetarianism or veganism, the context of this preference is critical. If the family has been vegetarian/vegan for years and/or adheres to religious or culturally specified dietary restrictions, efforts are made to accommodate as able. If vegetarianism/veganism arose in the context of disordered eating behaviors, animal sources of food are gradually reintroduced alongside explanatory and supportive discussions with the patient and family. No outside food is permitted throughout the hospitalization to ensure accurate evaluation and monitoring of nutritional and fluid intake and to limit opportunities for negotiation or counterproductive behaviors."}],"_type":"block","style":"normal","_key":"efb8cef8eeb9"},{"markDefs":[],"children":[{"marks":[],"text":"Calorie needs are provided as 3 meals and 3 snacks daily, following a set schedule and adhering to firm time limits to allow for proper digestion and prevent behavioral tactics to prolong meals or avoid food. Meals and snacks are to be completed in 30 min and 15 min, respectively. Food or beverages that are not completed within the time frame are replaced with a commercially available nutritional supplement drink at a concentration of 1.5 kcal/mL. Nursing follows an algorithm in which the proportion of food remaining on the tray at the end of the time limit is estimated, either 1% to 50% or 51% to 99% of total calories, and then cross-referenced to the calorie level for the day to determine the milliliter amount. The patient is allotted 10 to 15 minutes to complete the supplement, depending on the volume. If the patient is unable to take in the necessary dose of nutrition via food and oral supplement within the given time frame, a nasogastric (NG) tube is placed to ensure nutrition delivery. We help patients and families to understand that in the context of an eating disorder, “food is medicine.” The tube is not meant to be a threat or a punishment but rather a tool to provide the medical intervention the patient needs when oral intake has been too difficult to achieve on their own. When an NG tube is needed, it is left in place until the patient has been able to take in 100% of their nutrition orally (food or supplement) for at least 24 hours.","_key":"dd993212d48c0","_type":"span"}],"_type":"block","style":"normal","_key":"907e173108dc"},{"children":[{"_type":"span","marks":[],"text":"To ensure that energy intake is directed toward organ recovery and weight restoration, energy expenditure is limited as much as possible via activity restriction. For the first 24 hours, the patient is placed on bed rest with assistance to the bathroom. This measure also helps to prevent falls related to syncope or cardiovascular compromise, which are more commonly encountered near the start of admission. Activity is gradually reintroduced with time spent in a bedside chair, seated showers, 30-minute wheelchair rides, and attendance at child life or music therapy events, all based on the clinical assessment of stability for each activity. Exercise of any kind is prohibited and patients are monitored for subtle exercise attempts such as pacing, squatting, or leg lifts in bed. Bathroom use is supervised with the door cracked open, with direct visualization expected for hygiene activities like teeth brushing and hair care but listening only for toileting and showering. These measures allow staff to monitor for purging, exercise, or fluid loading and to observe for signs of distress or syncope. Patients are encouraged to use the bathroom before meals or snacks, and bathroom use is discouraged for 1 hour after.","_key":"3fc0375df0d60"}],"_type":"block","style":"normal","_key":"9fd7e518dcee","markDefs":[]},{"markDefs":[],"children":[{"text":"Throughout hospitalization, the CL team provides psychoeducation and psychotherapeutic support to the patient and family as they navigate the protocol. Because of the high comorbidity of eating disorders with other psychiatric conditions, a thorough diagnostic evaluation is conducted upon admission, with a special focus on safety assessment.","_key":"f73109a698fa0","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"6,7","_key":"bc134f7c67a8"},{"_type":"span","marks":[],"text":" In cases where active suicidal ideation raises imminent safety concerns, we institute our hospital’s suicide precautions protocol and reassess daily the need for maintaining that level of care. Suicide risk management also becomes a specific part of the treatment plan, including potential need for a higher level of care after medical stabilization or formal safety planning and lethal means restriction in the discharge planning process.","_key":"6ef9889b29d2"}],"_type":"block","style":"normal","_key":"e0b38d39b8f1"},{"_type":"block","style":"normal","_key":"c90e4f8a1134","markDefs":[{"_key":"c1e7cacbb995","nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/psychopharmacology"}],"children":[{"_type":"span","marks":[],"text":"Many patients experience high levels of anxiety around mealtimes, especially as food volume increases or as patients detect changes in how their body looks or feels upon gaining weight. When anxiety and distress become so overwhelming as to affect the patient’s ability to eat or otherwise engage in necessary cares, or when distress manifests in severe behavioral dysregulation or aggression, psychotropic medication support can be helpful, either on an as-needed basis or scheduled. When medications are initiated, it is understood that this intervention is likely time limited during this high-acuity period. Medication targets symptom management and psychiatric comorbidities rather than serving as a primary intervention for the eating disorder itself, recognizing the lack of support in the literature for the efficacy of ","_key":"dea5677b3bd60"},{"_type":"span","marks":["c1e7cacbb995"],"text":"psychopharmacology","_key":"f7ef40e48615"},{"text":" in longer-term eating disorder treatment.","_key":"a6032cb972d2","_type":"span","marks":[]},{"_key":"eeb49ac767cc","_type":"span","marks":["superscript"],"text":"8"},{"_type":"span","marks":[],"text":" The goal is to enable the patient to restore nutrition enough to engage in evidence-based therapies post discharge. Hydroxyzine and olanzapine are the most frequently utilized medications, with aripiprazole used occasionally and selective serotonin reuptake inhibitors sometimes initiated to address comorbid depression or anxiety.","_key":"915a9aad932e"}]},{"children":[{"_type":"span","marks":[],"text":"The CL team typically provides patients with psychotherapeutic worksheets relating to insight, self-reflection, and coping, and uses those worksheets as platforms for deeper discussion. For many patients, however, malnutrition is so profound that their ability to engage with executive function–related tasks and higher-order thinking around emotion regulation are significantly impaired, with limited insight into the need for treatment. We advise patients and families that the primary goal during medical hospitalization is to restore nutrition and that mental health interventions at this acute point are purposely focused on psychoeducation and broad emotional support; these are the aims that malnourished brains are best able to target. Therapeutic interventions integrate aspects of family-based treatment (FBT) related to externalizing the eating disorder and promoting parental management of meals and nutrition. When patients do demonstrate insight and interest in processing the emotional and cognitive side of their illness, we do our best to engage in brief and focused psychotherapy as often as possible within the constraints of a busy consultation service. Ultimately, helping to coordinate longer-term mental health supports at the appropriate level of care upon discharge is the most impactful mental health intervention.","_key":"f74242d3d3640"}],"_type":"block","style":"normal","_key":"2ba445d1d1d3","markDefs":[]},{"_type":"block","style":"normal","_key":"6acef4e13a62","markDefs":[],"children":[{"_key":"9d07f76dde550","_type":"span","marks":[],"text":"Readiness for discharge is determined on a case-by-case basis, but generally is considered when vital signs have improved; short-term labs have normalized; the patient is eating adequately at goal calories (taking oral supplement is occasionally acceptable, depending on percentage of intake coming from supplement alone and the anticipated next level of care); a clear weight-gain trend is noted (if needed); and a follow-up plan is in place. Families meet with the RDN prior to discharge to ensure they understand the caloric needs of the patient and how best to meet these needs with an at-home meal plan. The treatment team coordinates with schools and universities, with permission of the patient and family, to provide guidance on safely acclimating back to typical routines or to request accommodations or temporary academic deferrals."}]},{"_type":"block","style":"normal","_key":"c25a6113db56","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Most patients discharge to outpatient care, a partial hospitalization program (PHP), or an intensive outpatient program (IOP), sometimes in person and sometimes virtually. We are fortunate to have access to an excellent multidisciplinary care center at our own institution, the Comprehensive Eating Disorders Program, which offers an FBT approach at the PHP, IOP, and outpatient levels. For more acute needs, patients might transfer to an inpatient psychiatric unit or discharge to a residential treatment center.","_key":"60ccf03cb5ce0"}]},{"style":"normal","_key":"b0bc8c32c84f","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Psychoeducation and Family Communication","_key":"4c45c83f8dd50"}],"_type":"block"},{"markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F6acf7d5ddd45d1336d7986854fc7e45a0fcf5263-276x658.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=640\u0026q=75","_key":"1105bf236c8d","nofollow":true,"blank":true}],"children":[{"marks":[],"text":"Immediately upon admission, the primary team provides the family with our internally developed guidebook, Inpatient Nutrition Recovery for Children. This 40-page booklet relays information about the multidisciplinary care team, what is happening medically and psychologically relating to the eating disorder, what nutrition recovery entails and why it is important to monitor closely throughout, how the protocol works and why limitations are set, helpful things for parents to say and do, pitfalls to avoid, general information about planning for discharge, and a list of external resources for families to access. The book was written and edited by a multidisciplinary work group and was processed through our institution’s Plain Language Review Board to ensure broad accessibility. With a small internal grant for patient education, we funded professional graphic design and binding for the book and obtained 300 hard copies to distribute. Future goals include translation of the guidebook into additional languages. Families have provided positive feedback about the value of the book in addressing their questions and alleviating their distress about hospitalization. We welcome others to freely access and distribute the digital booklet (see ","_key":"505bb11433010","_type":"span"},{"text":"Figure 1","_key":"4aab48ff9061","_type":"span","marks":["strong","1105bf236c8d"]},{"text":" ","_key":"700e3769e196","_type":"span","marks":["strong"]},{"_key":"28b3313dd1c5","_type":"span","marks":[],"text":"for QR code)."}],"_type":"block","style":"normal","_key":"72d8385dc8ce"},{"alt":"FIGURE 1. QR Code for Inpatient Nutrition Recovery for Children Guidebook","disableTextWrap":false,"imgcaption":[{"_type":"block","style":"normal","_key":"8abb8889ad5e","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure 1. ","_key":"8854d1b525f10"},{"_type":"span","marks":[],"text":"QR Code for Inpatient Nutrition Recovery for Children Guidebook","_key":"4d65f2f7ebac"}]}],"widthP":40,"disableLightBox":true,"_type":"figure","blank":true,"_key":"b4ff643a20d0","alignment":"right","asset":{"_ref":"image-6acf7d5ddd45d1336d7986854fc7e45a0fcf5263-276x658-png","_type":"reference"}},{"children":[{"_type":"span","marks":[],"text":"Alongside the guidebook, the grant funded the creation of a professionally produced a 12-minute video, Managing Eating Disorder Behaviors, that addresses helpful ways for families to manage common eating disorder behaviors. The video features actors portraying a mother and daughter sitting through a meal and outlines strategies for handling negotiation attempts, food diversion, and emotional outbursts. For hospitalized patients, the video is preloaded onto an internal network that offers informational videos pertinent to each patient’s presenting concerns on the television in their hospital room. Caregivers are also provided with a QR code linking directly to the video so they can watch it on a personal device away from their child (see ","_key":"0e09dd9dc5f90"},{"_type":"span","marks":["strong","985a6fe02ef5"],"text":"Figure 2","_key":"cf051c897361"},{"_type":"span","marks":[],"text":" for QR code).","_key":"18707cb6d5d5"}],"_type":"block","style":"normal","_key":"4da1d2bc51a9","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F43ac29c2955c9bc8eddececcb805d51633558b3c-318x528.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=640\u0026q=75","_key":"985a6fe02ef5"}]},{"_type":"figure","asset":{"_ref":"image-43ac29c2955c9bc8eddececcb805d51633558b3c-318x528-png","_type":"reference"},"widthP":40,"disableLightBox":true,"imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure 2. ","_key":"941772eec0370"},{"_type":"span","marks":[],"text":"QR Code for Managing Eating Disorder Behaviors Video","_key":"621f1512d709"}],"_type":"block","style":"normal","_key":"5ef466099ce3"}],"alignment":"right","alt":"FIGURE 2. QR Code for Managing Eating Disorder Behaviors Video","_key":"7d5d01d7e5a1","blank":true,"disableTextWrap":false},{"_type":"block","style":"normal","_key":"9a1a2d811a15","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Acute Behavior Dysregulation","_key":"9596bdb9b0ac0"}]},{"_key":"99f821294841","markDefs":[],"children":[{"text":"It is not uncommon for patients to demonstrate significant behavioral dysregulation during the refeeding process, manifesting as emotional or verbal outbursts, throwing food or other objects, physical aggression toward others, self-harm attempts, or tampering with or removing the NG tube, and this remains an important challenge for care. When verbal de-escalation measures and environmental interventions alone are insufficient, our care team works together with the patient and family to devise a structured behavioral plan (eg, access to electronics or other preferred activities contingent on maintaining safe behaviors and engaging in cares). We are fortunate to have a skilled behavioral support nurse on the CL team who can sit with patients and families during meals and help with coaching and distress tolerance. Oral medications can be helpful for addressing anxiety and agitation. Intramuscular medication is occasionally necessary to ensure the safety of the patient and others around them.","_key":"1a988888f9e90","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"8910d773e06b","markDefs":[],"children":[{"marks":[],"text":"On rare occasions, patients refuse NG tube placement or go to great lengths to disrupt or remove the tube once it is placed. We have seen patients try to cut or chew through the tubing or pull it out completely, even when bridled. If these behaviors are not manageable with the previously mentioned interventions, and they prevent us from delivering necessary nutrition in the context of severe medical compromise, we sometimes employ physical restraint to ensure that the patient receives the imperative medical care. In these instances, we first consult the Pediatric Ethics Committee and convene with the multidisciplinary team and family to discuss the safest and most appropriate approach to the intervention. Even for minors, whose parents ultimately make medical decisions, we are thoughtful about valuing patient autonomy and the importance of assenting to care. Acknowledging the effects of malnutrition and the eating disorder itself on the patient’s ability to recognize the need for treatment, we work to balance self-determination against the imminent risk of serious medical complications or death. Furthermore, we consider the psychological effects of physical restraint, especially in the context of the patient’s past mental health history and any previous experiences with restraint or forced care. We aim to make the most compassionate and medically safe decision possible in each context.","_key":"74919c4d69790","_type":"span"}]},{"_type":"block","style":"normal","_key":"867bb0081832","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Modifications to the protocol or changes to the level of staffing are often instituted before proceeding to forced use of an NG tube, and we have had several cases in which these alterations have successfully allowed us to restore nutrition safely without using physical restraint. When implemented, restraint is used only for the duration of the time needed to place the tube and safely administer nutrition; a patient would not be left in restraints between meals for the sake of maintaining the integrity of the tube. If needed, formula administration is consolidated and clustered as is safely possible given the volume to reduce the number of tube administrations or time needed in restraints.","_key":"db7b021442fb0"}]},{"style":"normal","_key":"315c76df6201","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Typically, this level of behavioral dysregulation occurs in the context of the most severe cases of malnutrition, and we see significant and rapid improvement as the brain is refed. After extreme behavioral exacerbations requiring intensive interventions, we prioritize debriefing and processing with staff across disciplines, acknowledging the moral distress that can come with providing care in these difficult situations.","_key":"4ff1bee323e80"}],"_type":"block"},{"children":[{"_type":"span","marks":["strong"],"text":"Decisional Capacity","_key":"e693b250a6f10"}],"_type":"block","style":"normal","_key":"7aa5e47e5e7e","markDefs":[]},{"_key":"dde19e5dbf19","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Implementing the protocol and eliciting patient engagement can be especially challenging for 18- to 24-year-olds, as these patients typically have legal decision-making rights over their care (unless under guardianship/conservatorship). Questions regularly arise regarding the decisional capacity to decline an NG tube or dispositional capacity to leave the hospital before it is medically safe to do so. We can divide these patient types conceptually into 2 groups: those who live at home with their parents (and may still be in high school) or are otherwise dependent on their caregivers, and those who live independently as working adults or college/university students who do not rely on family support for daily living.","_key":"36ca830acf8c0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"For the first group, parents who align with the treatment team in recognizing the need for care can support their child’s recovery by declining to take them home if the child wants to leave the hospital or enacting firm limits and other forms of “tough love” to encourage their child’s participation in care. In the context of an eating disorder, this may include not paying for cellular telephone service, removing access to preferred activities, or withdrawing tuition support for college/university. We try to help parents and patients understand that these measures are not meant to be punitive but to guide the patient toward sound decision-making when the eating disorder and malnutrition are clouding their judgment. In fact, when parents take these steps to help their child’s recovery, they are actively working toward enabling the young adult to regain autonomy, not just with respect to food but also in other aspects of their life that may have been commandeered by the eating disorder.","_key":"0085d53c6c770","_type":"span"}],"_type":"block","style":"normal","_key":"e1de0f9e4b09"},{"children":[{"_key":"3ea5263da6560","_type":"span","marks":[],"text":"For young adults who live independently, or for situations in which the parental intervention approach is not possible or is ineffective, questions related to compelling care are more difficult. Comprehensive psychiatric assessment of capacity is required in each case and for each decision point as it cannot be generalized that the presence of a severe eating disorder (or severe malnutrition) necessarily compromises decision-making capacity. Additionally, the risk level for each decision is crucial, especially as it pertains to leaving the hospital before reaching medical stability. Discharging to an apartment with roommates, a sedentary job, established provider connections, and a grocery delivery service is very different from transitioning to a solo apartment with out-of-state parents, a limited friend base, no established care providers, and an on-your-feet job or full academic course load. For students, support through their college/university may also be activated to enhance their support network, including academic accommodations, school-based health programs, and residential advisers. To the extent that patients are willing to engage, we partner with them to mitigate the risks as best as possible before we consider discharging against medical advice."}],"_type":"block","style":"normal","_key":"7175dcb04cee","markDefs":[]},{"_type":"block","style":"normal","_key":"55b2b1391b8f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Sometimes, we send patients out with the expectation that we will see them again in the ED very soon, hoping that we can be more effectual with our help the next time. For cases in which patients truly do not demonstrate capacity or willingness to collaborate to mitigate risk, and medical compromise is so severe that the only medically safe decision is to continue treatment in the hospital, we again consult with our Ethics Committee, Clinical Risk and Patient Relations, and our Office of the General Counsel as pursuit of emergency medical guardianship (either by family or a third party) may be necessary.","_key":"4cc3b0b000fe0"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Notably, significant debate continues around the concept of involuntary or compulsory treatment for AN, with varied opinions from medical, ethical, legal, philosophical, psychological, and societal perspectives.","_key":"3e0ce70367720"},{"_key":"f40d07817d8d","_type":"span","marks":["superscript"],"text":"9"},{"_key":"2c307b89b33f","_type":"span","marks":[],"text":" As providers, our goal is to care for the patient before us. We do our best to act responsibly, compassionately, transparently, and within the bounds of our professional ethics. We learn from every case and we always strive to improve."}],"_type":"block","style":"normal","_key":"882177001103"},{"_key":"11c339287e5f","markDefs":[],"children":[{"_key":"f8be0bf2f9cf0","_type":"span","marks":["strong"],"text":"Barriers to Discharge Planning"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"marks":[],"text":"Unfortunately, resources for eating disorder care are limited and wait lists are long. When transitioning to outpatient-level care, we typically can arrange for weekly weigh-ins and vitals checks at the primary care office, but mental health supports are more challenging to align quickly. Sometimes, the inability to arrange for appropriate outpatient therapy within a reasonable time frame pushes us toward PHP or IOP as the best discharge plan.","_key":"e9ad235b5d8c0","_type":"span"}],"_type":"block","style":"normal","_key":"ee80ce35c438"},{"_type":"block","style":"normal","_key":"e6c30f7490e1","markDefs":[],"children":[{"_key":"72f5836e62370","_type":"span","marks":[],"text":"In Southeast Michigan, we are fortunate to have several options for PHPs focused on eating disorder care, though only 1 of them (our own) operates under an in-person, family-based treatment model. There are a number of common barriers to accessing any of these programs, including insurance coverage, patient age, and geographic limitations; driving more than an hour each way—twice daily—is often not feasible for working families. Additionally, BMI/weight at discharge can be a limiting factor, as many programs will not accept patients below a BMI of 15 or weight less than 80% of estimated goal. Our own program can be more flexible around this metric as we have ready access to AM, specialized nursing, and the hospital itself. When weight or BMI affect placement options, we must consider prolonging hospitalization to achieve the necessary weight gain vs discharging home for weight restoration, which can be onerous on families and often results in readmission."}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"When psychiatric hospitalization is needed, either due to comorbid safety concerns, comorbid psychiatric illnesses, or psychological factors impeding the patient from progressing past tube dependence, our options are significantly limited. Only 2 psychiatric units in our state (ours included) can accommodate NG tubes or will consider admitting patients with an active eating disorder diagnosis. Payer coverage is also challenging, especially if there is not a clear suicide risk. Payers will often authorize only 1 or 2 days of treatment in the context of an eating disorder, which offers little value in helping the patient to progress. If the psychiatric inpatient team cannot successfully advocate for additional covered days, then the options amount to hastening the discharge, billing the family, or (more commonly) positioning the hospital to absorb the cost. Ultimately, clinical need guides decision-making around inpatient psychiatric admission, but the coverage constraints can certainly burden families in an already stressful situation, and they highlight a clear inequity in the provision of care for this population.","_key":"8259ecb54f6f0"}],"_type":"block","style":"normal","_key":"878dbd1ce009"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"For patients who need residential care, there are no eating disorder–specific facilities that accept children in our state. Medicaid will not cover out-of-state residential care, leaving publicly insured patients without any options. For those with private insurance coverage or who can self-pay, we look regionally or nationally, which involves significant care coordination and supplemental cost to the family for transportation and local lodging. Once again, equitable access to care is a clear problem. Another significant barrier is that the patient must agree to enter the residential program voluntarily, even in cases when the parents are the legal guardians and decision- makers. We have seen many patients 18 years and older refuse residential treatment entirely or check themselves out prematurely, leaving their families with little recourse and often prompting repeat medical admission.","_key":"3540d0600a6b0"}],"_type":"block","style":"normal","_key":"cba38e065558"},{"children":[{"_type":"span","marks":["strong"],"text":"Concluding Thoughts","_key":"e34ec70ec1920"}],"_type":"block","style":"normal","_key":"a52aa0ae62cf","markDefs":[]},{"style":"normal","_key":"2de5f439f0b7","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Caring for patients with malnutrition due to eating disorders presents significant challenges related to patient insight and buy-in, behavior management, and longer-term care planning. Despite these challenges, inpatient medical admission often serves as the first step in recovery and may be perceived as a wake-up call by both patients and families.","_key":"5ab27b6211f30"},{"_type":"span","marks":["superscript"],"text":"10","_key":"022991598829"},{"_type":"span","marks":[],"text":" Implementing a formalized CPG and disseminating standardized psychoeducation materials to patients and families has unquestionably improved the process at our institution. Still, we continue to face challenges in this space. We are hopeful that the resources needed to support patients with this illness can grow and develop at a rate commensurate with the clear increase in disease burden we are all experiencing across the country. We welcome questions, discussion, and open distribution of our materials.","_key":"aac115a2102b"}],"_type":"block"},{"_key":"959fde07bec3","markDefs":[],"children":[{"_key":"762f53b0c0090","_type":"span","marks":["strong"],"text":"Dr Pierce"},{"_type":"span","marks":[],"text":" ","_key":"6837ddd46529"},{"_key":"2c3873f0cc66","_type":"span","marks":["em"],"text":"is the medical director of the Pediatric Consultation-Liaison Psychiatry Service and the child and adolescent psychiatry hospital education lead at the C.S. Mott Children’s Hospital, University of Michigan Hospital Systems. She is also a clinical assistant professor in the Department of Psychiatry, Division of Child and Adolescent Psychiatry. "},{"_type":"span","marks":["strong"],"text":"Dr Stoody","_key":"2c1e0db87dd3"},{"_key":"05736f0dfb8d","_type":"span","marks":["strong","em"],"text":" "},{"_type":"span","marks":["em"],"text":"is an assistant professor at the C.S. Mott Children’s Hospital, University of Michigan Hospital Systems.","_key":"55980a6dfb4e"},{"marks":[],"text":" ","_key":"83cb6e4185e7","_type":"span"},{"marks":["strong"],"text":"Dr Cwynar","_key":"08903a069197","_type":"span"},{"_type":"span","marks":["em"],"text":" is a dual-certified pediatric and psychiatric mental health nurse practitioner. She has worked on the Child and Adolescent Consult and Liaison Service at C.S. Mott Children’s Hospital, University of Michigan Hospital Systems, since 2016.","_key":"e6d2cda9461b"},{"_type":"span","marks":[],"text":" ","_key":"8e85bc664366"},{"_type":"span","marks":["strong"],"text":"Ms Khan ","_key":"360fef3070d1"},{"text":"is the lead social worker for the child psychiatry hospital section and a clinical social worker on the Pediatric Consultation-Liaison Psychiatry Service in the University of Michigan Hospital Systems. ","_key":"4161c0b52386","_type":"span","marks":["em"]},{"_type":"span","marks":["strong"],"text":"Dr Bravender","_key":"10be47035966"},{"marks":[],"text":" ","_key":"67a6e2bf13a7","_type":"span"},{"_key":"ada4ed79e064","_type":"span","marks":["em"],"text":"is the David S. Rosen Collegiate Professor of Adolescent Medicine and clinical professor of pediatrics and psychiatry at the University of Michigan. He also serves as associate chair for faculty affairs in the Department of Pediatrics, Division of Adolescent Medicine director, executive director of the Mott Comprehensive Eating Disorders Program, and comedical director of the University of Michigan Adolescent Health Initiative."}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"5355f9277e9d0"}],"_type":"block","style":"normal","_key":"273de78cbef0"},{"markDefs":[{"_key":"4efdbe5ae105","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/34244452/"}],"children":[{"_key":"fbb09b2a8c860","_type":"span","marks":[],"text":"1. Otto AK, Jary JM, Sturza J, et al. "},{"_type":"span","marks":["4efdbe5ae105"],"text":"Medical admissions among adolescents with eating disorders during the COVID-19 pandemic.","_key":"fbb09b2a8c861"},{"text":" ","_key":"ae6f8f96635e","_type":"span","marks":[]},{"_key":"fbb09b2a8c862","_type":"span","marks":["em"],"text":"Pediatrics"},{"text":". 2021;148(4):e2021052201.","_key":"fbb09b2a8c863","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"f683db49ae87"},{"_type":"block","style":"normal","_key":"aeeace80d63b","markDefs":[{"href":"https://pubmed.ncbi.nlm.nih.gov/35815415/","_key":"ed9d9f285517","blank":true,"_type":"link"}],"children":[{"_type":"span","marks":[],"text":"2. Shum M, Moreno C, Kamody R, et al. ","_key":"3166dc2d1b600"},{"_type":"span","marks":["ed9d9f285517"],"text":"The evolving needs of children hospitalized for eating disorders during the COVID-19 pandemic.","_key":"3166dc2d1b601"},{"_type":"span","marks":[],"text":" ","_key":"f4c4245f2f9d"},{"_type":"span","marks":["em"],"text":"Hosp Pediatr","_key":"3166dc2d1b602"},{"_type":"span","marks":[],"text":". 2022;12(8):696-702.","_key":"3166dc2d1b603"}]},{"markDefs":[{"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/38167164/","_key":"e1a0761533be","blank":true}],"children":[{"text":"3. Toigo S, Katzman DK, Vyver E, et al. ","_key":"1402dd6803860","_type":"span","marks":[]},{"marks":["e1a0761533be"],"text":"Eating disorder hospitalizations among children and youth in Canada from 2010 to 2022: a population-based surveillance study using administrative data. ","_key":"1402dd6803861","_type":"span"},{"text":"J Eat Disord","_key":"1402dd6803862","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 2024;12(1):3.","_key":"1402dd6803863"}],"_type":"block","style":"normal","_key":"6d457b0a2121"},{"children":[{"_type":"span","marks":[],"text":"4. Sylvester CJ, Forman SF. 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I can’t stop scrolling through Instagram during my Zoom team meeting!” or someone else say “My mood is all over the place! I’m probably bipolar or something.” Many individuals have intermittent, waxing, and waning symptomatology, which does not cause any distress or decline in functionality. The truth is, all of us have times during which we experience inattentiveness. In fact, during this podcast, our listeners may have already lost their focus, or we may lose our train of thought, but this is simply normal human tendency, and it does not mean we have a clinical diagnosis such as ADHD. In training, it is important to learn and understand normal human behaviors and tendencies to avoid pathologizing normal human behavior or medicating unnecessarily. ","_key":"3c3de410752e1"}],"_type":"block","style":"normal","_key":"3c3de410752e"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: How often do you see patients who don’t necessarily meet the diagnostic criteria of ADHD? Do they have other diagnoses, and if so what are these? How do you counsel these parents and patients and address these concerns?","_key":"2a16805e6a460"}],"_type":"block","style":"normal","_key":"2a16805e6a46"},{"style":"normal","_key":"3d443d9f8d46","markDefs":[],"children":[{"marks":["strong"],"text":"Leela Magavi, MD:","_key":"3d443d9f8d460","_type":"span"},{"_type":"span","marks":[],"text":" I enjoy evaluating and treating individuals with various psychiatric diagnoses, but particularly enjoy working with children and adults with autism, ADHD, mood and anxiety disorders. Many children present with a chief complaint of ADHD. Quite a few children and adolescents who carry a diagnosis of ADHD from prior assessments or appear to have symptoms of ADHD do not, in fact, have ADHD. ","_key":"3d443d9f8d461"}],"_type":"block"},{"children":[{"text":"I have encountered many situations in which parents have unrealistic expectations. However, this is a product of systemic changes that have promoted a very competitive schooling atmosphere. It is no longer enough to earn straight A’s or ace the SATs. Let me give you an example. Mary comes home from school and needs to complete a few hours of homework and studying followed by swim practice followed by piano practice followed by a few more homework assignments. Mary repeats this schedule on a daily basis, and becomes demoralized and frustrated. She begins to avoid her friends and family. Her inattentiveness becomes evident to her parents and teachers, and her grades begin to plummet, and her school refers her family to me. In situations like these, I discuss expectations and counsel the family to support the child or teen’s wellness. Mary may be demoralized or depressed. Providing a stimulant may only exacerbate her anxiety, and thereby, worsen her depression. The treatment would involve therapy and possibly an SSRI if warranted. This may even involve redistributing tasks, taking a break from an extracurricular activity, and prioritizing sleep and wellness activities.","_key":"3dbcc7cfd48d0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"3dbcc7cfd48d","markDefs":[]},{"style":"normal","_key":"1f3e29a86035","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: What are some other prevalent disorders you often see?","_key":"1f3e29a860350"}],"_type":"block"},{"markDefs":[],"children":[{"text":"Leela Magavi, MD:","_key":"ec0e6f5f57c60","_type":"span","marks":["strong"]},{"_type":"span","marks":[],"text":" Oppositional defiant disorder is a prevalent condition. For example, Charlie, presents with verbal aggression and sometimes physical aggression when his father asks him to turn the television off or when his baseball coach gives him feedback. Charlie fares well in school, but is very oppositional toward multiple authority figures. Charlie would benefit from behavioral therapy or parent management training for oppositional defiant disorder. Charlie does not have ADHD, and a medicine would not be helpful. In such cases, when I have shared this information with patients, they have sometimes expressed sadness or frustration about the diagnosis. ","_key":"ec0e6f5f57c61"}],"_type":"block","style":"normal","_key":"ec0e6f5f57c6"},{"markDefs":[],"children":[{"marks":[],"text":"Many parents present to me hoping their children have ADHD when they do not. You may wonder why they would hope this were the case. Parents, understandably, can experience burnout and fatigue, and look to us physicians to expedite change and provide help. Therapy can take time to work, and medicine sometimes seems like a quick fix. I have open and candid discussions with parents to set expectations and reiterate that there is no magic pill or instant solution.","_key":"d2e32606db8d0","_type":"span"}],"_type":"block","style":"normal","_key":"d2e32606db8d"},{"_type":"block","style":"normal","_key":"acd556d0a498","markDefs":[],"children":[{"text":"What I explain to parents is that medicines do not change behavior. Likewise, medicines do not make homework seem more interesting than Fortnite or Call of Duty. Medicine does not simply result in improved grades. Overall, it is pivotal that we have open conversations, and answer questions about the avenues of treatment and the risk of medicating when medication is not warranted.","_key":"acd556d0a4980","_type":"span","marks":[]}]},{"children":[{"marks":["strong"],"text":"LEM: What can you say about anxiety in children?","_key":"1375beb4d98c0","_type":"span"}],"_type":"block","style":"normal","_key":"1375beb4d98c","markDefs":[]},{"_key":"5adf36c7ecad","markDefs":[],"children":[{"_key":"5adf36c7ecad0","_type":"span","marks":["strong"],"text":"Leela Magavi, MD:"},{"_type":"span","marks":[],"text":" Anxiety is often misdiagnosed as ADHD as the features overlap. In fact, anxiety is what child and adult psychiatrists see the most in clinic. I evaluate individuals of all ages, and most of my patients see me for anxiety. Anxiety can present as inattentiveness, restlessness, impulsivity and irritability. For example, Sheila presents with restlessness and perfectionistic tendencies. She procrastinates and puts off tasks due to fear of failure. She appears fidgety and nervous in class, and asks her teachers and parents to repeat themselves. ","_key":"5adf36c7ecad1"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"50177eac1453","markDefs":[],"children":[{"text":"Sheila has generalized anxiety disorder. Once her anxiety is treated, these symptoms resolve, and her school performance improves. Other kids like Sheila may present with concerns about ADHD, but actually are experiencing symptoms of depression, which can cause increased processing speed and impaired working memory, and thus, affect cognition and academic performance. Similarly, after treating depression, inattentiveness and what appeared to be ADHD symptoms, improve.","_key":"50177eac14530","_type":"span","marks":[]}]},{"style":"normal","_key":"221670c2894c","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: What are some common comorbidities, and how would you tackle these concerns in the clinic?","_key":"221670c2894c0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"2e33d01eacf00"},{"marks":[],"text":" ADHD often presents with various comorbid disorders inclusive of anxiety, depression and bipolar disorder. In these cases, once the mood and anxiety disorder is stabilized, and if ADHD symptoms continue to impair functionality, a medication for ADHD can be started. In cases where kids have ADHD and ODD, kids would benefit from a combination of therapy and stimulants. In cases where kids have ADHD and tic disorder, they may benefit from habit reversal therapy, an alpha agonist for tics, impulsivity and hyperactivity, and possibly a stimulant as well. ","_key":"2e33d01eacf01","_type":"span"}],"_type":"block","style":"normal","_key":"2e33d01eacf0"},{"style":"normal","_key":"3e87a74e23aa","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM","_key":"3e87a74e23aa0"},{"_key":"3e87a74e23aa1","_type":"span","marks":[],"text":": "},{"_key":"3e87a74e23aa2","_type":"span","marks":["strong"],"text":"Any take-home messages about how ADHD presents in real-world experience that show how treatment can make a significant difference in a child’s life?"}],"_type":"block"},{"_type":"block","style":"normal","_key":"d4281f85406a","markDefs":[],"children":[{"marks":["strong"],"text":"Leela Magavi, MD:","_key":"d4281f85406a0","_type":"span"},{"_type":"span","marks":[],"text":" The take-home is when a child truly has ADHD and he or she receives treatment, the results are evident and life-changing for everyone involved. I have had the invaluable opportunity to treat Mark, a seven-year-old boy suffering from ADHD. During play therapy, I have learned that the reason he often gets angry at school is because he is tired of other children teasing him about “not reading good.” During another session, he used toy cars to share his goal with me, exclaiming, “I want to be a police officer one day!” As Mark improved with weekly therapy and treatment with Focalin extended release or dexmethylphenidate, a stimulant medication, he gained confidence. This experience was particularly memorable and rewarding.","_key":"d4281f85406a1"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: Older adolescents and young adults have been known to abuse ADHD medications to help improve their studying stamina and grades. Besides being illegal, what are some of the dangers associated with this practice?","_key":"df49158136850"}],"_type":"block","style":"normal","_key":"df4915813685"},{"_type":"block","style":"normal","_key":"93a337bc2faf","markDefs":[],"children":[{"marks":["strong"],"text":"Leela Magavi, MD:","_key":"93a337bc2faf0","_type":"span"},{"_type":"span","marks":[],"text":" Each year, academic expectations build. The competition is real and appears to be increasing relentlessly. It is harder and harder to get into colleges. Even kindergarten and first grade seem harder than they ever used to be. Teens and young adults often use their peers’ ADHD medications, or illegally purchase them to gain a competitive advantage, or use them recreationally. Some individuals even take stimulants solely to stay up later because they have so much to finish and so little time.","_key":"93a337bc2faf1"}]},{"children":[{"_type":"span","marks":[],"text":"The truth of the matter is, when someone does not have ADHD, they may not benefit significantly from taking a stimulant. They may feel more energetic, but the data from pilot studies have suggested that cognition itself may not improve. We do not completely understand the dangers associated with use of stimulants in someone who does not have ADHD as ethical concerns limit our ability to study this. Some of my patients who have admitted to using stimulants without a diagnosis of ADHD have experienced concerns including weight loss, anxiety, depression, psychosis, insomnia, hypertension, and other cardiac concerns. I want to encourage all listeners to spread awareness and encourage friends and loved ones to be evaluated by a physician prior to trying medications.","_key":"fbbe113551250"}],"_type":"block","style":"normal","_key":"fbbe11355125","markDefs":[]},{"_type":"block","style":"normal","_key":"bc181e29b22a","markDefs":[],"children":[{"_key":"bc181e29b22a0","_type":"span","marks":[],"text":"Stimulants can cause myocardial infarction, cardiomyopathy, and even sudden death. Although the risk is low, it is not worth taking. Patients with a personal or family history of cardiac events may require further work-up prior to initiating medications. Due to addiction concerns, some parents do not want their children who have ADHD to take medications. As opposed to those who do not have ADHD, for kids who do have ADHD, we have large, validated studies which indicate the significant and helpful effect of stimulants. Long-term studies suggest that treating ADHD reduces unemployment, divorce and addiction concerns longitudinally."}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"LEM: ADHD treatment options have come a long, and now include various formulations, long-acting dosing, patches, and even a video interface. How should clinicians decide what medications to prescribe to their patients?","_key":"3ebca9ee93aa0"}],"_type":"block","style":"normal","_key":"3ebca9ee93aa"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"f0c525ee36750"},{"_type":"span","marks":[],"text":" It is important to comprehensively assess the child and learn about his or her genetic predisposition, temperament, behavior and life story prior to selecting a medication. There are many options, and new agents continue to gain approval. For children who are young and primarily impulsive and hyperactive, and if really warranted due to functional impairment, I may consider using an alpha agonist such as clonidine extended release also known as Kapvay, or guanfacine extended release also known as Intuniv. These are blood pressure medications. I often use these alongside stimulants as it allows the use of lower stimulant doses.","_key":"f0c525ee36751"}],"_type":"block","style":"normal","_key":"f0c525ee3675"},{"_key":"561fd504fbce","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Alpha agonists do not target inattention as well as stimulants do, and I explain this to parents who prefer nonstimulant options. Other nonstimulant options are Wellbutrin also known as bupropion, which is an antidepressant, and atomoxetine also known as Strattera, which is a selective norepinephrine reuptake inhibitor, also helpful for anxiety. The common stimulant families are methylphenidates and amphetamines. I always start with methylphenidates, and then transition to amphetamines if warranted due to side effect profiles. I use long-acting agents and add on immediate release if warranted for longer duration of action. Patches, liquid formulations and some capsules are helpful when kids have difficulty swallowing. Lisdexamfetamine or Vyvanse is an option for those who have a history of substance use as this medication is metabolized differently, and decreases addiction potential.","_key":"561fd504fbce0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"6605964aab22","markDefs":[],"children":[{"_type":"span","marks":[],"text":"I think it’s wonderful that we are learning more and more about the brain and medications that could help these children. I’m very grateful to my colleagues who are partaking in research and helping us answer these questions. Most recently, which I am delighted to share with parents and listeners, we have learned that a videogame called Endeavor Rx, has been FDA approved for kids between ages 8 and 12 who have been diagnosed with ADHD. For those who are interested, you may join the online waitlist, made available by the developing company, Akili Interactive.","_key":"6605964aab220"}]},{"markDefs":[],"children":[{"marks":["strong"],"text":"LEM: Are there concrete tools or scales to help diagnose ADHD?","_key":"740d652723b80","_type":"span"}],"_type":"block","style":"normal","_key":"740d652723b8"},{"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"c781ce68a6970"},{"text":" ADHD is a clinical diagnosis and symptoms need to be present in more than one setting. Scales and tools such as the Child Behavior Checklist, Conners-Wells, Vanderbilt, Swanson Nolan and Pelham are helpful, but not necessary for diagnosis. I view them as additional pieces of information, and occasionally, to monitor progress.","_key":"c781ce68a6971","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"c781ce68a697","markDefs":[]},{"_type":"block","style":"normal","_key":"15f14613a2d6","markDefs":[],"children":[{"text":"I personally use the Vanderbilt scale most often. I find it interesting to ask mom and dad to complete the Vanderbilt scale independently and compare their responses with the teachers. When the numbers align and are high, this is more indicative of ADHD. If the teacher’s scores are very high, but the parents’ scores are low, this may mean that the teacher needs more help in the classroom setting due to high student to teacher ratio, among other things. If the teacher’s scores are low, and the parents’ scores are high, it may mean that the child is exhibiting behavioral concerns at home for particular reasons. Sometimes, only one parent scores high, which may be due to a mismatch in temperament and personality traits.","_key":"15f14613a2d60","_type":"span","marks":[]}]},{"style":"normal","_key":"cf421e336077","markDefs":[],"children":[{"text":"LEM: Are CT, PET, EEG, and MRI reliable diagnostic tools for children?","_key":"cf421e3360770","_type":"span","marks":["strong"]}],"_type":"block"},{"_type":"block","style":"normal","_key":"b18578dd856d","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"b18578dd856d0"},{"_type":"span","marks":[],"text":" Brain imaging is not warranted for the diagnosis of ADHD. I rarely ever order it unless necessary for another reason. I may consider an EEG or MRI if I am concerned about epilepsy presenting like ADHD or absence seizures during which the child may appear to be staring into space when they are in fact having a seizure. Brain imaging may also be helpful in post-concussion syndrome in which individuals may have difficulty with inattentiveness and mental fatigue, and may benefit from a stimulant although they do not have ADHD.","_key":"b18578dd856d1"}]},{"style":"normal","_key":"071fafa784b5","markDefs":[],"children":[{"text":"Nevertheless, brain imaging has helped us learn a lot about ADHD. Converging evidence from various imaging studies has helped us assess differences in brain volume, diffusion properties of white matter tracts, and cortical features in typically developing children compared to those with ADHD. Psychoradiology is a developing field and may help guide our treatment planning in the future.","_key":"071fafa784b50","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"a825cba3465b","markDefs":[],"children":[{"text":"LEM: Do you transition patients out of your care to a general psychiatrist?","_key":"a825cba3465b0","_type":"span","marks":["strong"]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"3ac92d5f299c0"},{"_type":"span","marks":[],"text":" Some child psychiatrists only evaluate and treat children, but I treat individuals of all ages and enjoy this diversity. I provide a mixture of medication management and therapy, and establish strong bonds with my patients. I always tell my adolescents that there’s no magic button that turns on and makes an eighteen-year-old instantly an adult. Every individual transitions into adulthood at a different pace. Being an adult is tough, and I evaluate patients at all ages who struggle with this transition. For this reason, I do not think child psychiatrists necessarily need to transition their patients to an adult psychiatrist.","_key":"3ac92d5f299c1"}],"_type":"block","style":"normal","_key":"3ac92d5f299c"},{"children":[{"_type":"span","marks":["strong"],"text":"LEM: We used to hear that children “grow out of” ADHD. Now, data show that adults can and do have the disorder. Is it possible to outgrow ADHD?","_key":"437543176f8f0"}],"_type":"block","style":"normal","_key":"437543176f8f","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Leela Magavi, MD:","_key":"e739231bca740"},{"marks":[],"text":" ADHD is essentially a neurodevelopmental disorder, which can affect individuals at any age. It is chronic in nature, but presentations vary at different life stages. The frontal lobe is the last to develop and mature, and there are many changes that occur with brain plasticity. For example, children display a decrease in symptoms of hyperactivity and impulsivity as they mature. Many children with ADHD still have the condition as adults, and are highly susceptible to other psychiatric disorders. I do evaluate adults who have never been diagnosed with ADHD as children who present to see me for the first time. Some of them experience impulsivity and have difficulty with relationships and work for this reason. Others who were diagnosed as children have relayed that their ADHD symptoms have evolved over time. It is pivotal for physicians to titrate down on medications as warranted and consider discontinuing medication if individuals are faring well off of them and when symptoms no longer affect functionality. In these cases, I like to take a conservative approach and recommend daily exercise, sleep hygiene techniques, and other behavioral strategies.","_key":"e739231bca741","_type":"span"}],"_type":"block","style":"normal","_key":"e739231bca74"},{"_key":"c4a1175098ca","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Finally, every individual with ADHD whom I have had the pleasure of treating has something special to offer. For my kids who ask me if this diagnosis means they are not smart, I remind them that this is not the case. Albert Einstein was suspected to have ADHD and as were other notable people, such as Walt Disney, and Michael Jordan. It is an honor to help kids struggling with ADHD as they grow to recognize their strengths and reach their full potential.","_key":"c4a1175098ca0"}],"_type":"block","style":"normal"}],"documentGroupMapping":null,"taxonomyMapping":[{"_createdAt":"2020-03-26T06:11:21Z","_updatedAt":"2023-03-31T19:04:55Z","_type":"taxonomy","parent":{"_updatedAt":"2023-03-31T19:15:59Z","_rev":"uvXJooXtzvjNOyx50HTt8m","_type":"taxonomy","_id":"pst_taxonomy_53202_clinical","identifier":"topics","isMainTopic":true,"_createdAt":"2020-03-26T06:11:21Z","name":"Topics","parent":null},"perKeywordMapping":["Psychiatry","Neurology"],"_rev":"37333Uv1mHMuPikcnyAeyc","pixelTrackingCode":null,"_id":"pst_taxonomy_8_adhd","identifier":"topics/adhd","cmeType":"per","name":"ADHD"},{"_createdAt":"2020-03-26T06:11:21Z","_rev":"Y3MLYgF1Z7QuWKLEbdmVmR","name":"Child \u0026 Adolescent Psychiatry","_id":"pst_taxonomy_89_childadolescentpsychiatry","identifier":"topics/child-adolescent-psychiatry","_type":"taxonomy","_updatedAt":"2024-02-28T20:56:30Z","parent":{"_updatedAt":"2023-03-31T19:15:59Z","identifier":"topics","_createdAt":"2020-03-26T06:11:21Z","name":"Topics","_id":"pst_taxonomy_53202_clinical","parent":null,"isMainTopic":true,"_rev":"uvXJooXtzvjNOyx50HTt8m","_type":"taxonomy"},"pixelTrackingCode":null}],"_createdAt":"2020-07-10T21:50:41Z","_rev":"d4ilsE5q4PRpxUPL61lL5N","_updatedAt":"2020-08-16T18:30:06Z","is_visible":true,"_type":"article","published":"2020-07-10T04:00:00.000Z","contentCategory":{"_updatedAt":"2020-02-25T09:31:48Z","_createdAt":"2020-02-25T09:31:48Z","_rev":"snQqhhB4O8T5bi1viURsgs","_type":"contentCategory","name":"Podcasts","_id":"93d57b69-2d72-45fe-8b8a-d18e7e7e5f20"},"factCheckAuthors":null,"targeting":{"content_placement":["topics/adhd","topics/child-adolescent-psychiatry"],"document_url":["treating-adhd-children-concerns-controversies-safety-measures"],"document_group":null,"rootDocumentGroup":[],"issue_url":"","publication_url":""},"relatedArticles":[{"title":"Multidisciplinary Inpatient Care for Medically Compromised Youth and Young Adults With Eating Disorders","url":{"_type":"slug","current":"multidisciplinary-inpatient-care-for-medically-compromised-youth-and-young-adults-with-eating-disorders"},"thumbnail":{"_type":"mainImage","alt":"eating disorders","caption":"Wanlee/AdobeStock","asset":{"_ref":"image-75e054327354fd399f1c1b0d16066577da5800d1-5000x3500-jpg","_type":"reference"}},"published":"2024-11-22T17:00:00.488Z"},{"title":"NeuroStar TMS for Adolescents With Major Depressive Disorder: A Look at the New Data","url":{"current":"neurostar-tms-for-adolescents-with-major-depressive-disorder-a-look-at-the-new-data","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"Melissa Fickey","asset":{"_ref":"image-60a8a242efef4dcca3c2e74f18eefed5676af69d-320x400-png","_type":"reference"}},"published":"2024-11-14T17:30:56.510Z"},{"title":"The Cumulative Risks of ADHD","url":{"current":"the-cumulative-risks-of-adhd","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"ADHD","caption":"BillionPhotos.com/AdobeStock","asset":{"_ref":"image-7d07b857014bd601a8354e37ae94367ff9c6f686-4341x3000-jpg","_type":"reference"}},"published":"2024-11-13T20:05:34.845Z"},{"title":"Analysis of Barriers in Mental Health Care for Foster Children: Challenges and Solutions","url":{"current":"analysis-of-barriers-in-mental-health-care-for-foster-children-challenges-and-solutions","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"foster family","caption":"SewcreamStudio/AdobeStock","asset":{"_ref":"image-272e9d97df5e85f9f828b3d13f881139ec4e379e-3506x1987-jpg","_type":"reference"}},"published":"2024-11-13T16:00:44.766Z"},{"title":"Adult ADHD: It's Time to Think Outside the Box","url":{"current":"adult-adhd-its-time-to-think-outside-the-box","_type":"slug"},"thumbnail":{"_type":"mainImage","alt":"adult ADHD","caption":"Aninka/AdobeStock","asset":{"_ref":"image-a4170721b434dcbfcb8faf3b905bd42aece270c9-5616x3744-jpg","_type":"reference"}},"published":"2024-11-08T18:00:51.723Z"},{"title":"Family and Sports Medicine Physician Shares Thoughts on Annual Conference","url":{"_type":"slug","current":"family-and-sports-medicine-physician-shares-thoughts-on-annual-conference"},"thumbnail":{"_type":"mainImage","alt":"Sara Walker","asset":{"_ref":"image-070c6f88f9f2ddeb6b73414cbbe836366d277556-1168x1170-png","_type":"reference"}},"published":"2024-10-30T13:00:00.000Z"}]},{"gptSummary":"Adult ADHD is increasingly recognized as a significant concern in psychiatry, prompting discussions on its screening alongside depression and substance use. New guidelines for managing this disorder are anticipated. Dr. Peter S. Jensen, a prominent figure in child psychiatry and president of The REACH Institute, emphasizes the importance of addressing adult ADHD. With an extensive background in research and advocacy, Dr. Jensen has contributed significantly to the field through numerous publications and leadership roles, underscoring the need for comprehensive mental health assessments.","is_visible":true,"ExcludeFromPubMedXML":false,"title":"Adult ADHD: It's Time to Think Outside the Box","authorMapping":[{"biography":[{"_type":"block","style":"normal","_key":"8ce6a6824c54","markDefs":[{"blank":true,"_type":"link","href":"http://www.thereachinstitute.org/","_key":"7c687b0226b8"},{"blank":true,"_type":"link","href":"https://www.nimh.nih.gov/index.shtml","_key":"2df6e4993d91"}],"children":[{"_type":"span","marks":["strong"],"text":"Dr Jensen","_key":"a8eec3bab7850"},{"_type":"span","marks":[],"text":" ","_key":"44195c7d9ebd"},{"text":"is president and CEO of ","_key":"ba6da17be5f1","_type":"span","marks":["em"]},{"_type":"span","marks":["7c687b0226b8","em"],"text":"The REACH Institute","_key":"a8eec3bab7851"},{"_type":"span","marks":["em"],"text":". 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Adults","is_visible":true,"body":[{"asset":{"_type":"reference","_ref":"image-480b7b29f69d9743ec4d45ba543c1fc8e7aa932f-6000x3375-jpg"},"disableTextWrap":false,"_key":"2e09c71be811","widthP":50,"alignment":"left","disableLightBox":true,"_type":"figure","alt":"ADHD","imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"1STunningART/AdobeStock","_key":"5de4f3c538b60"}],"_type":"block","style":"normal","_key":"b548d309db26"}]},{"_type":"block","style":"normal","_key":"e6c9b9f0e836","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"CLINICAL REFLECTIONS","_key":"11f9c42e020e0"}]},{"_key":"8183bcc74619","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Case Vignette","_key":"4d32cd6e40330"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"c79ba3cedd87","markDefs":[],"children":[{"_type":"span","marks":[],"text":"“Simon,” a 21-year-old man, presents for an evaluation of treatment-resistant anxiety. He experiences psychological anxiety, which interferes with his focus and concentration, causing difficulties with initiating and sustaining tasks. A review of his past psychiatric history reveals that he began seeing a therapist for panic attacks and severe anxiety that seemed to come out of nowhere when he was in middle school. He had consulted 3 different psychiatrists but had not found any of their treatments effective. He denies any history of mania or psychosis.","_key":"9cd90f73486b0"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"8272b37840170"}],"_type":"block","style":"normal","_key":"5cdf5dee1872"},{"style":"normal","_key":"ca10fc119f89","markDefs":[],"children":[{"_type":"span","marks":[],"text":"He received cognitive behavior therapy and was subsequently treated with various psychiatric medications, including buspirone, fluoxetine, escitalopram, phenelzine, mirtazapine, bupropion, aripiprazole, quetiapine, olanzapine, pregabalin, clonazepam, lorazepam, valproate, lamotrigine, lithium, and ketamine. However, Simon reports no psychological improvement with these medications. On the contrary, he experienced multiple adverse effects, including a panic-like electric shock reaction with phenelzine, a dystonic reaction with antipsychotics, and 2 grand mal seizures with bupropion. At the time of evaluation, Simon was taking buspirone 30 mg twice daily, pregabalin 150 mg, lamotrigine 200 mg, lithium 450 mg at night, and mirtazapine 30 mg. Simon came in frustrated, requesting to discontinue all his medications. After a thorough evaluation, including a review of his developmental history, it was found that he had exhibited characteristics of inattention and hyperactivity since elementary school. A subsequent Jasper/Goldberg Adult ADD Screening Examination indicated undiagnosed attention-deficit/hyperactivity disorder (ADHD). Simon was therefore started on viloxazine 100 mg, titrated to 200 mg over 1 week while continuing lamotrigine 200 mg and tapering off all other medications.","_key":"525aaccca0460"}],"_type":"block"},{"_type":"block","style":"normal","_key":"5c96a878ada8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"bb5724cb4f960"}]},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"ADHD in Adulthood","_key":"67af674718dd0"}],"_type":"block","style":"normal","_key":"f02e34b2ab1b"},{"_key":"23f1ee651316","markDefs":[{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/topics/adhd","_key":"0ebb173e14ae"}],"children":[{"_type":"span","marks":[],"text":"ADHD is a multifactorial and clinically heterogeneous disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. It can impose significant financial burdens and stress on families and is also associated with adverse academic and vocational outcomes. Although ","_key":"78a017fee66f0"},{"_type":"span","marks":["0ebb173e14ae"],"text":"ADHD","_key":"f8e297773415"},{"marks":[],"text":" is recognized as a childhood-onset neurodevelopmental disorder, its prevalence in adults should also be acknowledged.","_key":"ecfc26ed7d46","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"36bd1d4a41520"}],"_type":"block","style":"normal","_key":"238e8f7abe85"},{"children":[{"_type":"span","marks":[],"text":"A recent meta-analysis has reported that the prevalence of ADHD in children and adolescents is estimated to be 5.29%, the prevalence of ADHD in adults aged 19 to 45 years is estimated to be 2.5%. Approximately 15% children with ADHD will persist into their adulthood, with 40% to 60% partially remitted.","_key":"25eb3d79731e0"},{"marks":["superscript"],"text":"1","_key":"0bd8b8e8e0dc","_type":"span"},{"text":" In some cases, adults remain undiagnosed until they reach their 30s or 40s, only discovering they have ADHD after their children are diagnosed. A national wide investigation done in an East-Asian country indicated a percentage of 34.7% in first year university students presented with symptoms suggestive of probable ADHD.","_key":"a480c25ea38f","_type":"span","marks":[]},{"marks":["superscript"],"text":"2","_key":"e73e40299743","_type":"span"},{"_type":"span","marks":[],"text":" Even in European countries, where ADHD should have been better recognized and treated, the prevalence of undiagnosed ADHD in adult psychiatric patients was 9.27%, and “hidden” ADHD is associated with an increased suicide risk among these patients.","_key":"bc920d345818"},{"_type":"span","marks":["superscript"],"text":"3","_key":"f0b2b80b90d6"}],"_type":"block","style":"normal","_key":"e1a7b30a06fa","markDefs":[]},{"_key":"cbcd2085b330","markDefs":[],"children":[{"marks":[],"text":"","_key":"532e81209b0a0","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Previous review has emphasized that ADHD can persist throughout one's lifespan and often presents as a chronic condition. If left untreated, the symptoms of ADHD can lead to significant psychosocial impairment,","_key":"8d729e80228e0"},{"_type":"span","marks":["superscript"],"text":"4","_key":"452034749254"},{"_type":"span","marks":[],"text":" and leading to maladaptive behaviors including self-medicating by using recreational drugs, alcohol, and nicotine.","_key":"359c09da26bb"},{"_type":"span","marks":["superscript"],"text":"5","_key":"10e0e2b351fa"}],"_type":"block","style":"normal","_key":"eacec2cb260b"},{"_key":"cf0973b9e993","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"b36459dadc4a0"}],"_type":"block","style":"normal"},{"style":"normal","_key":"4a7db3e1935f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Diagnosing adult ADHD is challenging due to limited guidelines and consensus. Once seen as a childhood disorder, ADHD is now recognized to persist into adulthood, but this shift has outpaced clinical approaches, leading to inconsistent diagnosis.","_key":"9b74d7adc0f20"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"4f4a5178680d0"}],"_type":"block","style":"normal","_key":"03860cff7bbf"},{"_key":"c6a425e4bf6b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Key challenges in adult ADHD diagnosis include:","_key":"6554366bb06a0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"2d2a75c4c95a","markDefs":[],"children":[{"text":"1. Symptom overlap. ADHD symptoms in adults (eg, inattention, impulsivity) often overlap with conditions like depression and anxiety, complicating diagnosis.","_key":"c6e4072329b00","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"text":"2. Retrospective diagnosis. Adult diagnosis relies on evaluating childhood symptoms, which may have been undiagnosed or misunderstood.","_key":"7d957495a9210","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"4f2b2387a2d5"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Cultural/societal differences. ADHD prevalence varies by region due to stigma and health care differences, leading to \"hidden\" cases.","_key":"45b6b967de1e0"}],"_type":"block","style":"normal","_key":"c7934544f797"},{"children":[{"_type":"span","marks":[],"text":"4. Gender bias. Women are often underdiagnosed as their symptoms are less hyperactive and more inattentive, sometimes mistaken for stress or mood disorders.","_key":"d8fb0e223c240"}],"_type":"block","style":"normal","_key":"8cfd9cf42b2e","markDefs":[]},{"children":[{"marks":[],"text":"","_key":"b931066961220","_type":"span"}],"_type":"block","style":"normal","_key":"0085e39bcd22","markDefs":[]},{"children":[{"text":"These are some of things a clinician should keep in mind while considering a patient to be suffering from adult ADHD. These include:","_key":"c417be1200a90","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"0bcaaf7a00a1","markDefs":[]},{"markDefs":[],"children":[{"text":"1. Comprehensive history. Gather detailed information on childhood behavior, academic issues, and coping strategies. Family history of ADHD may provide further insights.","_key":"976d069f63960","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"c99bc4f07b74"},{"_key":"d8e9c8806d64","markDefs":[],"children":[{"text":"2. Use diagnostic tools. Employ standardized tools like the Adult ADHD Self-Report Scale (ASRS) to assess symptoms.","_key":"cf7a641929ad0","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"94992a513d96","markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Assess developmental milestones. Examine the developmental trajectory, noting if symptoms persisted into adulthood even with coping strategies.","_key":"8244155701b30"}]},{"children":[{"text":"4. Evaluate functional impairment. Diagnose ADHD only if symptoms impair major areas of life (work, relationships, etc).","_key":"ccf2bee5a24a0","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"376535c5d94e","markDefs":[]},{"_type":"block","style":"normal","_key":"8d1af34d086b","markDefs":[],"children":[{"_type":"span","marks":[],"text":"5. Rule out other conditions. Conduct differential diagnoses to exclude psychiatric conditions with similar symptoms.","_key":"ee9bd28033710"}]},{"style":"normal","_key":"df92cee40474","markDefs":[],"children":[{"text":"6. Psychoeducation and collaboration. Educate patients on ADHD as a lifelong condition and collaborate with other specialists for comprehensive care.","_key":"c8813cf9c7a20","_type":"span","marks":[]}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"7. Consider subtle symptoms. Watch for less overt symptoms in adults, like procrastination, emotional dysregulation, or chronic lateness.","_key":"82342300658a0"}],"_type":"block","style":"normal","_key":"864805faa4ed"},{"_key":"54ca78332806","markDefs":[],"children":[{"marks":[],"text":"","_key":"95941b2297b40","_type":"span"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Improving global ADHD guidelines and diagnostic consistency requires cross-cultural studies and refinement of tools like the ","_key":"d8e70cdb938e0"},{"_type":"span","marks":["em"],"text":"DSM-5","_key":"d8e70cdb938e1"},{"_type":"span","marks":[],"text":". Clinicians should combine thorough history-taking, structured tools, and functional assessment to accurately diagnose and treat adult ADHD. Education and addressing the stigma are also key to bridging the gap in adult ADHD diagnosis and care.","_key":"d8e70cdb938e2"}],"_type":"block","style":"normal","_key":"7250d2b03270"},{"children":[{"_type":"span","marks":[],"text":"","_key":"676ca03b21bc0"}],"_type":"block","style":"normal","_key":"cf13f9ac2eb7","markDefs":[]},{"markDefs":[],"children":[{"text":"Psychological Burden","_key":"bb2f1b7a29b70","_type":"span","marks":["strong"]}],"_type":"block","style":"normal","_key":"792124e6595b"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The underlying ADHD symptoms experienced by adults can lead to functional impairments, affecting their academic and vocational performance, daily activities, and social interactions. These impairments may further contribute to a significant psychological burden.","_key":"1e1e5f32be250"}],"_type":"block","style":"normal","_key":"0d798da204dd"},{"_key":"39efd0ef5625","markDefs":[],"children":[{"_key":"adb72b84db910","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal"},{"_key":"4274104dc55e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"In today's fast-paced modern society, patients' procrastination, inattentiveness, and disruptive behaviors, if unnoticed and untreated, can place them in difficult situations, leading to significant psychosocial stress, which may further contribute to the development of other psychiatric disorders. Undiagnosed ADHD can have negative impacts on self-esteem and self-worth,","_key":"a2d69d2b30760"},{"_key":"104b2c45cce6","_type":"span","marks":["superscript"],"text":"5"},{"marks":[],"text":" and is associated with higher rates of current depression, alcohol abuse, and greater emotional and interpersonal difficulties when compared with patients who do not have ADHD.","_key":"16b583c30733","_type":"span"},{"_type":"span","marks":["superscript"],"text":"6,7","_key":"2e7d8c0cf292"},{"marks":[],"text":" Research has shown that undiagnosed adults with potential ADHD symptoms may have a higher coexistence of mental comorbidities, sleep problems, and physical comorbidities, they also experience greater work productivity impairment, increased health care resource usage, and lower health-related quality of life.","_key":"02d0bfdb04c3","_type":"span"},{"text":"8","_key":"35c0d7c53e3e","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal"},{"_key":"d6a6463ae4e7","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"60beb00895ce0"}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":["strong"],"text":"ADHD and its Comorbidities","_key":"f29860f45df20"}],"_type":"block","style":"normal","_key":"e2be4d7b278e","markDefs":[]},{"style":"normal","_key":"26ae4be16984","markDefs":[{"_type":"link","href":"https://www.psychiatrictimes.com/topics/bipolar","_key":"fbfcb8be7eaa","nofollow":true,"blank":true},{"href":"https://www.psychiatrictimes.com/topics/major-depressive-disorder","_key":"8036786d0e72","nofollow":true,"blank":true,"_type":"link"},{"nofollow":true,"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F0c19b9683fbb83270537c15f6647d225b38727a0-402x376.jpg%3Ffit%3Dcrop%26auto%3Dformat\u0026w=828\u0026q=75","_key":"9cc5026f6df6"}],"children":[{"_type":"span","marks":[],"text":"Prevalence of ADHD is 2.5% in adults.","_key":"ba85512325ab0"},{"_type":"span","marks":["superscript"],"text":"1","_key":"27b8d9e61313"},{"_type":"span","marks":[],"text":" Individuals with ADHD have symptoms like deficient inhibitions, problems with memory, decision-making, and emotional decision-making, which can lead to a misdiagnose as they are symptoms of other conditions. ADHD shares symptomatology with ","_key":"cd058883908b"},{"_type":"span","marks":["8036786d0e72"],"text":"major depressive disorder","_key":"4d3fd273e94e"},{"_type":"span","marks":[],"text":" (MDD; low hedonic tone, irregular sleep, and appetite), generalized anxiety disorder (GAD; fidgeting, irritability), ","_key":"ba88112b052c"},{"_type":"span","marks":["fbfcb8be7eaa"],"text":"bipolar disorder","_key":"f968901c4531"},{"_type":"span","marks":[],"text":" (episodic fluctuations, excessive talking), and substance use disorder (SUD; social withdrawal) (as illustrated in ","_key":"f22339d7d75d"},{"_type":"span","marks":["strong","9cc5026f6df6"],"text":"Figure","_key":"ba85512325ab1"},{"_key":"ba85512325ab2","_type":"span","marks":[],"text":"). ADHD has an especially high prevalence with bipolar disorder, with rates ranging from 9.5% to 21.2%."},{"text":"9","_key":"31ec43e5c85a","_type":"span","marks":["superscript"]},{"text":" With MDD, ADHD prevalence has been reported to be between 9% to 16%.","_key":"da0d12c6ae05","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"10","_key":"6a2f49d86fa7"},{"_type":"span","marks":[],"text":" There is also an increased risk of ADHD in patients of GAD, with risk rising by about 50% more than in the general population.","_key":"370a1aeb62b6"},{"_type":"span","marks":["superscript"],"text":"11","_key":"20124d2d6934"},{"text":" ADHD is more common in patients with social anxiety. Finally, SUD is about twice as likely in patients with ADHD. It is bidirectional, arising due to neurological factors, increased impulsivity, other comorbidities, and any attempts to self-medicate.","_key":"f9ff414ee573","_type":"span","marks":[]}],"_type":"block"},{"disableTextWrap":false,"_key":"5ae70fa9e25d","widthP":50,"disableLightBox":true,"alt":"Figure. Adult ADHD and Various Comorbid Disorders","imgcaption":[{"_key":"cae505994764","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure.","_key":"32413b859ef90"},{"_type":"span","marks":[],"text":" Adult ADHD and Various Comorbid Disorders","_key":"32413b859ef91"}],"_type":"block","style":"normal"}],"alignment":"right","blank":true,"asset":{"_ref":"image-0c19b9683fbb83270537c15f6647d225b38727a0-402x376-jpg","_type":"reference"},"_type":"figure"},{"markDefs":[],"children":[{"text":"","_key":"bf669a3552060","_type":"span","marks":[]}],"_type":"block","style":"normal","_key":"832579b100cd"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"ADHD is a common but often underrecognized and undertreated psychiatric disorder in adults, presenting with symptoms from other possible diagnoses. Screening for ADHD in adults presenting with these comorbidities can identify patients who may benefit from targeted management. While ADHD in adults presents variably, it can often be detected with a few key clinical questions and validated assessment scales like Adult ADHD Self-Report Scale (ASRS) or the Conners' Adult ADHD Rating Scales (CAARS). Early and effective treatment of ADHD can significantly improve long-term psychiatric and functional outcomes. When ADHD coexists with other psychiatric conditions, the more severe disorder should be prioritized in treatment. In the coming years, more work on genetic and organic causes of ADHD may help identify new points for targeted treatment and ultimately help the patients.","_key":"737f29683c100"},{"_type":"span","marks":["superscript"],"text":"12","_key":"3ab0c1d8a5a7"}],"_type":"block","style":"normal","_key":"9a658a073593"},{"children":[{"_type":"span","marks":[],"text":"","_key":"c829a039374f0"}],"_type":"block","style":"normal","_key":"6b7f3c4a43b4","markDefs":[]},{"_key":"53fb1f8d44cd","markDefs":[],"children":[{"text":"Concluding Thoughts","_key":"6c9bd9735a080","_type":"span","marks":["strong"]}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"249fe31744e8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Identifying ADHD correctly is essential, especially when it is hidden by cooccurring illnesses. Properly identifying ADHD, particularly when it is masked by comorbid conditions, plays a significant role in developing an appropriate treatment plan. Such cases have been documented, demonstrating the challenges in diagnosing ADHD when other disorders are present.","_key":"d54e2154e9cf0"},{"_key":"a9bdb0398003","_type":"span","marks":["superscript"],"text":"13"},{"_type":"span","marks":[],"text":" This marks the importance of screening for ADHD, particularly in patients with treatment-resistant anxiety or MDD. In these situations, a misdiagnosis may result in the patient receiving poor treatment and unsuitable medication, worsening their condition. Therefore, a thorough evaluation for ADHD should be a standard component of the diagnostic process in patients who do not respond to conventional therapies for anxiety or MDD. Identifying ADHD early improves the efficacy of treatment and enhances the overall quality of life for the patient by addressing the cause of their symptoms.","_key":"bc7b168a0e90"}]},{"style":"normal","_key":"86a89fd89e21","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"15d3a72d72d50"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Parikh ","_key":"bd830cfa74ef0"},{"_type":"span","marks":["em"],"text":"is a faculty member at Weill Cornell Medical College and Second Arc Psychiatric Associates in White Plains, New York. ","_key":"bd830cfa74ef1"},{"_type":"span","marks":["strong"],"text":"Dr Chen ","_key":"bd830cfa74ef2"},{"_type":"span","marks":["em"],"text":"works in the Department of Psychiatry at Second Xiangya Hospital of Central South University in Changsha, China. ","_key":"bd830cfa74ef3"},{"_type":"span","marks":["strong"],"text":"Dr Patel ","_key":"bd830cfa74ef4"},{"_type":"span","marks":["em"],"text":"works at the Government Medical College and New Civil Hospital in Gujarat, India.","_key":"bd830cfa74ef5"}],"_type":"block","style":"normal","_key":"eaab8e830aed"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"a947f504c5ae0"}],"_type":"block","style":"normal","_key":"1dff7f422fc3"},{"children":[{"_type":"span","marks":["strong"],"text":"References","_key":"10d8d5e397ba0"}],"_type":"block","style":"normal","_key":"092bc44bd0e3","markDefs":[]},{"markDefs":[{"_key":"825a89d42ee5","blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/31982036/"}],"children":[{"_type":"span","marks":[],"text":"1. Posner J, Polanczyk GV, Sonuga-Barke E. ","_key":"f078b58042790"},{"_type":"span","marks":["825a89d42ee5"],"text":"Attention-deficit hyperactivity disorder","_key":"f078b58042791"},{"_type":"span","marks":["825a89d42ee5","em"],"text":".","_key":"f078b58042792"},{"_type":"span","marks":["em"],"text":" Lancet","_key":"b3bc61cacf71"},{"marks":[],"text":". 2020;395(10222):450-462.","_key":"f078b58042794","_type":"span"}],"_type":"block","style":"normal","_key":"1b6cb5b19b5d"},{"style":"normal","_key":"652317f0ebbf","markDefs":[{"blank":true,"_type":"link","href":"https://pubmed.ncbi.nlm.nih.gov/38079098/","_key":"9c4d1d8a08f0"}],"children":[{"text":"2. Al-Yateem N, Slewa-Younan S, Halimi A, et al. 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","gptTakeaways":"• Anorexia nervosa treatment is inadequate, with high relapse rates and significant mortality risks, highlighting the need for improved strategies.\n\n• Malnutrition, particularly zinc deficiency, plays a critical role in anorexia nervosa, affecting neurochemistry and mental health.\n\n• Zinc supplementation has shown promise in improving anorexia nervosa symptoms and aiding recovery, despite challenges in detecting deficiency.\n\n• Adolescents are particularly vulnerable to zinc deficiency due to increased nutritional demands during puberty, exacerbating anorexia nervosa risk.\n\n• A comprehensive approach, including nutritional supplementation, is crucial for effective anorexia nervosa management, as current calorie-focused strategies are insufficient.","factCheckAuthorMapping":null,"documentGroupMapping":null,"documentGroup":null,"taxonomyMapping":[{"_rev":"L7yG3IvIye3EpJsuLOjEtL","pixelTrackingCode":null,"identifier":"topics/eating-disorders","cmeType":"per","_type":"taxonomy","name":"Eating Disorders","_updatedAt":"2023-03-31T19:14:25Z","parent":{"isMainTopic":true,"_type":"taxonomy","name":"Topics","_id":"pst_taxonomy_53202_clinical","_updatedAt":"2023-03-31T19:15:59Z","identifier":"topics","_createdAt":"2020-03-26T06:11:21Z","_rev":"uvXJooXtzvjNOyx50HTt8m","parent":null},"_createdAt":"2020-03-26T06:11:21Z","perKeywordMapping":["Psychiatry","Neurology","Endocrinology, Diabetes, and Metabolism"],"_id":"pst_taxonomy_150_eatingdisorders"},{"name":"Integrative Psychiatry","_id":"pst_taxonomy_214_integrativepsychiatry","parent":{"identifier":"topics","isMainTopic":true,"_type":"taxonomy","name":"Topics","_updatedAt":"2023-03-31T19:15:59Z","_createdAt":"2020-03-26T06:11:21Z","_rev":"uvXJooXtzvjNOyx50HTt8m","_id":"pst_taxonomy_53202_clinical","parent":null},"perKeywordMapping":["Psychiatry","Neurology"],"pixelTrackingCode":null,"cmeType":"per","_updatedAt":"2023-03-31T19:17:29Z","_type":"taxonomy","identifier":"topics/integrative-psychiatry","_createdAt":"2020-03-26T06:11:21Z","_rev":"L7yG3IvIye3EpJsuLOjiN1"}],"url":"think-zinc-micronutrient-supplementation-for-the-treatment-of-anorexia-nervosa","published":"2024-10-23T14:00:00.000Z","drugMentions":"{\"drug_mentions\": [\"olanzapine\", \"zinc sulfate\", \"zinc gluconate\"]}","_rev":"iwIk0EhdBdoIVjJwZYmrf5","is_visible":true,"authors":[{"displayName":"James M. Greenblatt, MD","url":"james-m-greenblatt-md"}],"_createdAt":"2024-10-21T13:25:52Z","title":"Think Zinc: Micronutrient Supplementation for the Treatment of Anorexia Nervosa","ExcludeFromPubMedXML":false,"articleType":"News","body":[{"disableLightBox":true,"_type":"figure","imgcaption":[{"style":"normal","_key":"6755faf502b4","markDefs":[],"children":[{"_type":"span","marks":[],"text":"airborne77/AdobeStock","_key":"ae6a3a6ed2950"}],"_type":"block"}],"alt":"zinc","widthP":50,"disableTextWrap":false,"asset":{"_ref":"image-d317fa2d9323d07e840ce12c68e77f15be801efc-3888x2592-jpg","_type":"reference"},"_key":"3d57ab13e265","alignment":"left"},{"_key":"181621fd4336","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Our model for treating anorexia nervosa (AN) is broken. Treatments are so poorly effective that it has been labeled “a crisis in care.”","_key":"e9ad3f026d280"},{"_type":"span","marks":["superscript"],"text":"1","_key":"acc89036baba"},{"text":" Relapse rates often exceed 25%.","_key":"b6b37eaf2f1a","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"2","_key":"cd98ec554995"},{"_type":"span","marks":[],"text":" Patients with AN have a 5-fold higher risk for death from any cause and are 18 times more likely to commit suicide as compared with the standard population.","_key":"62e2cae80141"},{"_type":"span","marks":["superscript"],"text":"3","_key":"12b64c38281f"},{"_type":"span","marks":[],"text":" Based on these dismal statistics, it is hard to argue that the standard model of treatment is not tragically inadequate.","_key":"ccbfce126842"}],"_type":"block","style":"normal"},{"style":"normal","_key":"66b5d9ca1ec3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"b4d8e0379c8b0"}],"_type":"block"},{"style":"normal","_key":"4d4a3f234c06","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Despite the complexity of AN as a mental health disorder, research points to a fundamental factor that has long been overlooked in standard treatment models. AN is the product of more than inadequate calories; it is the product of malnutrition. The brain requires specific nutrients to function. If these nutrients are severely restricted, mental health is compromised.","_key":"742adc1365f10"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"c16509e17a110"}],"_type":"block","style":"normal","_key":"8df7fa6af966"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"When these foundational nutritional problems are corrected directly with supplementation, neurochemistry is restored and patients can more readily engage in psychotherapeutic interventions and treatment. Recovery becomes an attainable goal when the core, underlying issue of malnutrition in AN is addressed. Focusing on calorie intake alone does not address these core deficits adequately.","_key":"a144589a85710"}],"_type":"block","style":"normal","_key":"9c1a6257bdd6"},{"style":"normal","_key":"0fc3eb86fa7d","markDefs":[],"children":[{"text":"","_key":"20cc603020b70","_type":"span","marks":[]}],"_type":"block"},{"style":"normal","_key":"d34dde9427dc","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Beyond Genetics: The Critical Role of Zinc Deficiency in AN","_key":"177482dfdc680"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"AN has long been recognized as a condition that is difficult to treat. It currently lacks a US Food and Drug Administration (FDA)-approved treatment. The only medication that has shown some benefits for its core symptoms is olanzapine, which provides a modest improvement in body mass index.","_key":"d2e6716b0d980"},{"_type":"span","marks":["superscript"],"text":"4","_key":"a3a269bd113e"},{"marks":[],"text":" While progress has been made on counseling approaches, the evidence does not yet support their efficacy when compared with an active placebo.","_key":"a694debd4852","_type":"span"},{"_type":"span","marks":["superscript"],"text":"5","_key":"a2e613d9f984"}],"_type":"block","style":"normal","_key":"60a9ef75ac16"},{"_key":"4c5f85bf7f14","markDefs":[],"children":[{"text":"","_key":"898099d411640","_type":"span","marks":[]}],"_type":"block","style":"normal"},{"children":[{"_type":"span","marks":[],"text":"Data have long suggested that AN is the direct product of an individual’s susceptibility, often related to genetic factors and preexisting nutritional deficiencies. Genetics is well known to set the stage for AN, with studies showing a heritability of between 50% and 60%.","_key":"24448e8b80bd0"},{"_type":"span","marks":["superscript"],"text":"6","_key":"592607b70a2d"},{"_type":"span","marks":[],"text":" When a genetic predisposition collides with micronutrient deficiencies essential for all aspects of human biology, a diverse array of psychological and physical symptoms can develop. Recovery from malnutrition requires essential vitamins, minerals, amino acids, and fatty acids, not simply calories.","_key":"ed6a34f1c52c"}],"_type":"block","style":"normal","_key":"fe583f8173ff","markDefs":[]},{"_key":"1f534390532e","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"8340f35cb4480"}],"_type":"block","style":"normal"},{"_key":"bcb1e0ae13d4","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Starvation’s Dark Mirror: The Minnesota Starvation Experiment’s Insights","_key":"af927b5a752f0"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"a26b3d8799ac","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Evidence suggesting that malnutrition is a major contributing factor to AN initially stems from a controversial study: the Minnesota Starvation Experiment. During World War II, 36 men were willingly starved. The scientific understanding of starvation was poor and strategies to treat starvation safely were mostly unknown. As such, the Minnesota Starvation Experiment was designed to further our scientific understanding of starvation and its remediation.","_key":"54491032fb2a0"},{"_type":"span","marks":["superscript"],"text":"7","_key":"e81affcb48c6"}]},{"_key":"8f1a7f9c701a","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7ed6bbd7396d0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"The men were specifically chosen for being in both good physical and mental health. The study included 6 months of semi-starvation where participants lost 25% of their body weight consuming approximately 1600 calories per day. During the starvation phase, the men developed symptoms similar to an eating disorder. They obsessed over food, even developing rituals around meal times. The Minnesota Multiphasic Personality Inventory (MMPI) of the starving subjects looked remarkably similar to patient’s struggling with AN.","_key":"62a3b282531e0"},{"_type":"span","marks":["superscript"],"text":"8","_key":"4b0ddd825b9d"},{"_type":"span","marks":[],"text":" Levels of hypochondriasis, depression, and hysteria increased markedly.","_key":"0332ad4b15a9"},{"_type":"span","marks":["superscript"],"text":"9","_key":"dea9ddf6534c"},{"_type":"span","marks":[],"text":" Even after recovery and weight restoration, some of the men continued to have problems with abnormal eating habits for years after the study’s conclusion.","_key":"00333373af69"},{"_type":"span","marks":["superscript"],"text":"8","_key":"9861f8cab1a8"},{"_key":"5017e94af50c","_type":"span","marks":[],"text":" The simple act of reduced caloric intake had produced a state shockingly similar to an eating disorder in previously healthy subjects."}],"_type":"block","style":"normal","_key":"c460ffd8dd52"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"75b94154666c0"}],"_type":"block","style":"normal","_key":"d0071b9b711b"},{"children":[{"_type":"span","marks":["strong"],"text":"The Zinc Deficiency Connection, Unraveling the Biochemical Roots of AN","_key":"af40f79273dc0"}],"_type":"block","style":"normal","_key":"07c30a637e9d","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Further suggestive evidence on the role of malnutrition stems from research around zinc deficiency. In the 1970s, studies exploring zinc deficiency started to show a startling similarity to the symptoms of AN, including weight loss, reduced food intake, poor appetite, gastrointestinal disturbances, and skin abnormalities. Based on the similarities, authors even speculated as to the role of zinc as an etiological factor for AN.","_key":"309889b32c780"},{"_type":"span","marks":["superscript"],"text":"10","_key":"4e17852019ef"},{"_type":"span","marks":[],"text":" Beyond symptoms around food intake, zinc is well known to have other roles in mental health. It influences neurotransmission and plays a crucial role in neurogenesis.","_key":"0c75063abc99"},{"_type":"span","marks":["superscript"],"text":"11,12","_key":"3b2dce570dec"},{"_type":"span","marks":[],"text":" The mineral also has a prominent role as an antioxidant and anti-inflammatory agent.","_key":"6803f53adb78"},{"text":"13","_key":"09523ddf0ddd","_type":"span","marks":["superscript"]}],"_type":"block","style":"normal","_key":"721c98466a94"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"efd534c5b5680","_type":"span"}],"_type":"block","style":"normal","_key":"8bebd6d1d0fe"},{"_key":"4978277eed4f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"These effects appear relevant for a number of mental health conditions also commonly associated with AN, including depression,","_key":"feedef55a9890"},{"marks":["superscript"],"text":"14","_key":"7ec6527131fe","_type":"span"},{"text":" anxiety,","_key":"2767a2d6ed98","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"15","_key":"2e1282e947e9"},{"text":" and obsessive-compulsive disorder.","_key":"2f7775c1ea9f","_type":"span","marks":[]},{"_type":"span","marks":["strikethrough","superscript"],"text":"16","_key":"bf48933050e7"},{"text":" Lower levels of zinc have also been documented in schizophrenia","_key":"80836eb9b9a2","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"17","_key":"52d37f00c53a"},{"_key":"043e09b8857b","_type":"span","marks":[],"text":" and could contribute to the psychotic features sometimes associated with AN."}],"_type":"block","style":"normal"},{"style":"normal","_key":"a20c5a27df65","markDefs":[],"children":[{"marks":[],"text":"","_key":"6d2961e37ed70","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"f749d98bc49b","markDefs":[],"children":[{"text":"The Perfect Storm: How Puberty Sets the Stage for Zinc Deficiency and AN","_key":"57b7968f1b830","_type":"span","marks":["strong"]}]},{"children":[{"_type":"span","marks":[],"text":"When is an individual most commonly at risk for zinc deficiency? The same age most often associated with AN onset: adolescence. The average age of onset for AN is during adolescence, although research shows that AN age of onset is decreasing.","_key":"d4451bad8e720"},{"_type":"span","marks":["superscript"],"text":"18","_key":"a5763021ceea"},{"_type":"span","marks":[],"text":" These changes parallel the fact that puberty is also starting at an earlier age.","_key":"6e81513f4809"},{"marks":["superscript"],"text":"19 ","_key":"731c58766cec","_type":"span"},{"_type":"span","marks":[],"text":"Notably, puberty is a metabolically demanding process that requires adequate zinc and other nutrients for normal growth, development, and maturation.","_key":"9301ce4e9e39"},{"_key":"42389d5dcf40","_type":"span","marks":["superscript"],"text":"20"},{"_type":"span","marks":[],"text":" However, puberty is often when individuals eat a poor diet, are under increasing social stressors, and may engage in more physical activity, increasing their body’s demands for zinc even further.","_key":"a82ae9016689"}],"_type":"block","style":"normal","_key":"66377a9c4d56","markDefs":[]},{"style":"normal","_key":"19e7f1f7c22b","markDefs":[],"children":[{"_key":"69d532a70e6f0","_type":"span","marks":[],"text":""}],"_type":"block"},{"_key":"adf8c27cedc3","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F719a8eb0ab7e597a878d7b2b07e4cae09ea867cd-1290x1050.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"7e2c7fe1d3bf","nofollow":true}],"children":[{"_key":"d3dfc10a2f740","_type":"span","marks":[],"text":"This constellation of factors can easily lead to a deficiency in zinc. Symptoms of zinc deficiency include a reduced sense of taste, decreased appetite, digestive disturbances, and weight loss. This leads to a positive feedback loop, as shown in the "},{"marks":["strong","7e2c7fe1d3bf"],"text":"Figure","_key":"d3dfc10a2f741","_type":"span"},{"_key":"d3dfc10a2f742","_type":"span","marks":[],"text":", further depleting zinc and other critical nutrients and entrenching the symptoms of AN in genetically susceptible individuals."}],"_type":"block","style":"normal"},{"blank":true,"disableLightBox":true,"alt":"Figure. The Positive Feedback Loop of Zinc Deficiency as a Potential Cause of AN ","_key":"6ba0ff220b0f","widthP":48,"asset":{"_type":"reference","_ref":"image-719a8eb0ab7e597a878d7b2b07e4cae09ea867cd-1290x1050-png"},"disableTextWrap":false,"_type":"figure","alignment":"right","imgcaption":[{"_key":"8f13d7e377e7","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Figure.","_key":"477441ead30a"},{"_type":"span","marks":[],"text":" The Positive Feedback Loop of Zinc Deficiency as a Potential Cause of AN","_key":"d3a66d161c30"}],"_type":"block","style":"normal"}]},{"children":[{"_type":"span","marks":[],"text":"","_key":"f9bfc7ad41a80"}],"_type":"block","style":"normal","_key":"303b360e3d59","markDefs":[]},{"markDefs":[],"children":[{"marks":["strong"],"text":"The Elusive Diagnosis: Challenges in Detecting Zinc Deficiency in AN","_key":"cfce4c7887fd0","_type":"span"}],"_type":"block","style":"normal","_key":"dcabfd5928a7"},{"markDefs":[],"children":[{"_key":"b9106bdd11830","_type":"span","marks":[],"text":"Evaluating zinc levels in AN is not straightforward. Blood assays of zinc are known to be poorly correlated with intake. The body has numerous physiological mechanisms to maintain plasma levels in the face of reduced input."},{"_type":"span","marks":["superscript"],"text":"21","_key":"a251912e3d9c"},{"marks":[],"text":" Increased intake has been shown to have only marginal effects on plasma levels,","_key":"def0d6041288","_type":"span"},{"_type":"span","marks":["superscript"],"text":"22","_key":"cb60cdfe429d"},{"_type":"span","marks":[],"text":" with some studies finding no correlation.","_key":"093f3406e39c"},{"_type":"span","marks":["superscript"],"text":"23","_key":"dcb106467896"},{"_type":"span","marks":[],"text":" In states of starvation or reduced food intake, the catabolic state itself appears to cause increases of serum zinc due to tissue breakdown,","_key":"e78f02c63eac"},{"_type":"span","marks":["superscript"],"text":"24,25","_key":"f13dd3c90be3"},{"_type":"span","marks":[],"text":" which can further complicate zinc assessment.","_key":"a2ec932b64a4"}],"_type":"block","style":"normal","_key":"527375d416f5"},{"style":"normal","_key":"825b75650ec6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"c6f5800a186b0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"Research studies have reported lower levels of zinc in AN patients,","_key":"08a34e527c500"},{"_type":"span","marks":["superscript"],"text":"26-28","_key":"b77986a16141"},{"text":" albeit with some inconsistencies.","_key":"f55cc8b5f3a6","_type":"span","marks":[]},{"_type":"span","marks":["superscript"],"text":"29,30","_key":"593ee5148af6"},{"_type":"span","marks":[],"text":" And dietary analysis shows a clear pattern of poor intake in patients with AN.","_key":"2400cd21a06d"},{"_type":"span","marks":["superscript"],"text":"31-33","_key":"d325b8bd9062"},{"marks":[],"text":" Due to these factors, zinc deficiency is common, yet often difficult to detect.","_key":"e502bdc8b64b","_type":"span"}],"_type":"block","style":"normal","_key":"501a3353d14d"},{"style":"normal","_key":"dc9ee1a6b47d","markDefs":[],"children":[{"marks":[],"text":"","_key":"f8db0afd37ed0","_type":"span"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Clinical Breakthroughs: How Zinc Supplementation Offers New Hope","_key":"719d5f773f890"}],"_type":"block","style":"normal","_key":"1353f8c9917c"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"To further assess the possibility of malnutrition as a core component of AN, it is worth exploring the published data on zinc treatment directly. The first case report exploring zinc for AN was published in 1984.","_key":"aced1f3db97f0"},{"_key":"42b938d18aed","_type":"span","marks":["superscript"],"text":"34"},{"marks":[],"text":" The case involved a 13-year-old girl with depression and AN, weighing just 37 kg. Her sense of taste was poor, so zinc deficiency was suspected. With zinc supplementation, her mood improved rapidly with weight restoration occurring over the ensuing 4 months. Due to her improvements, zinc was discontinued. Ten months later, she was starting to relapse and her sense of taste was again decreased. Zinc supplementation was reinstated and within 2 months, her weight and mood again normalized.","_key":"bb3c00bea54e","_type":"span"}],"_type":"block","style":"normal","_key":"fdc3b570911b"},{"_type":"block","style":"normal","_key":"617e1724f085","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"fab020f8c4a10"}]},{"_type":"block","style":"normal","_key":"4ac3ec2d6501","markDefs":[],"children":[{"_type":"span","marks":[],"text":"Most of the clinical trials with zinc in AN have been small. The first double-blind, placebo-controlled trial included just 13 patients.","_key":"b5ae057265960"},{"_type":"span","marks":["superscript"],"text":"35 ","_key":"b93d54078db9"},{"_type":"span","marks":[],"text":"Of these, 6 were given 50 mg of zinc per day as zinc sulfate with the remainder receiving placebo for 6 months. While the patients receiving zinc had significant improvements in anxiety and depressive symptoms, they also showed nonsignificant improvements in height, weight, and skin abnormalities. Most likely, a larger trial was needed to achieve full statistical significance.","_key":"56dd9c00c4ab"}]},{"style":"normal","_key":"611ac2bef9f1","markDefs":[],"children":[{"marks":[],"text":"","_key":"c30b7d807eb00","_type":"span"}],"_type":"block"},{"children":[{"_type":"span","marks":[],"text":"A shorter trial exploring zinc supplementation in patients with AN concluded that zinc deficiency may be a contributing factor to continued eating disorder symptoms.","_key":"f07158ccee660"},{"_type":"span","marks":["superscript"],"text":"36","_key":"514e0fdeac7c"},{"_type":"span","marks":[],"text":" In the study, patients who were hospitalized and not supplemented with zinc still had a poor zinc status even with “adequate” intake from food. By way of comparison, zinc-supplemented patients had a significantly improved zinc status over the same time period.","_key":"1c3e8b17c7c2"}],"_type":"block","style":"normal","_key":"9a1b2097b9df","markDefs":[]},{"_key":"9c22abe38f20","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7ae77aa5e28f0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"text":"Intravenous (IV) zinc may be useful to more rapidly replete zinc in patients with AN. A case study of a 16-year-old female with AN from Japan found resolution of gastrointestinal symptoms, including vomiting, abdominal pain, and diarrhea.","_key":"fda9577867640","_type":"span","marks":[]},{"text":"37","_key":"5d4dd6117fc5","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" After a week of IV zinc followed by oral supplementation, her weight was also rapidly restored over a 1-month timeframe.","_key":"f8da5319c093"}],"_type":"block","style":"normal","_key":"694a30a7bb39"},{"_type":"block","style":"normal","_key":"8af700cca749","markDefs":[],"children":[{"text":"","_key":"26fe7ab407ab0","_type":"span","marks":[]}]},{"markDefs":[],"children":[{"_key":"fe5226d881e00","_type":"span","marks":[],"text":"Probably the strongest evidence for zinc comes from the largest double-blind, placebo-controlled trial that included 35 inpatients with AN."},{"_type":"span","marks":["superscript"],"text":"38","_key":"5df812b034b4"},{"_type":"span","marks":[],"text":" The trial used just 14 mg of zinc per day (from 100 mg of zinc gluconate). The patients receiving zinc had increases in body mass index that occurred twice as fast as those on placebo. Of the patients in the study, only 3 had low levels of serum zinc, indicating that serum levels are not necessarily indicative of who will benefit from zinc treatment.","_key":"66eccee3219e"}],"_type":"block","style":"normal","_key":"d9d00cfb40de"},{"markDefs":[],"children":[{"marks":[],"text":"","_key":"162a66d08f9e0","_type":"span"}],"_type":"block","style":"normal","_key":"cdf6ebadabc9"},{"_key":"7e43449ed07a","markDefs":[{"blank":true,"_type":"link","href":"https://www.psychiatrictimes.com/_next/image?url=https%3A%2F%2Fcdn.sanity.io%2Fimages%2F0vv8moc6%2Fpsychtimes%2F7d81491e80cc3cd78ed0aee58ec5701c4b05c46d-1616x824.png%3Ffit%3Dcrop%26auto%3Dformat\u0026w=3840\u0026q=75","_key":"584a041e84b1","nofollow":true}],"children":[{"_type":"span","marks":[],"text":"Unfortunately, no recent clinical trials of zinc treatment for AN have been published. With the clinical data available, a review from Australia in 2023 recommended updating national inpatient treatment guidelines for AN to include zinc supplementation.","_key":"71eb66fad4fe0"},{"_type":"span","marks":["superscript"],"text":"39","_key":"05dc9d7b6040"},{"text":" The recommendation was made based on the evidence for faster weight restoration with its inclusion. The ","_key":"046d4c7143f5","_type":"span","marks":[]},{"_type":"span","marks":["strong","584a041e84b1"],"text":"Table","_key":"71eb66fad4fe1"},{"_type":"span","marks":[],"text":" summarizes the clinical studies of zinc for AN to date.","_key":"71eb66fad4fe2"},{"marks":["superscript"],"text":"28,35,36,38,40","_key":"c69e24301d02","_type":"span"}],"_type":"block","style":"normal"},{"disableLightBox":true,"alt":"Table. Clinical Trials of Zinc Supplementation in AN28,35,36,38,40","blank":true,"imgcaption":[{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Table.","_key":"1439d1ce1d3f0"},{"marks":[],"text":" Clinical Trials of Zinc Supplementation in AN","_key":"d2579c2d4f4d","_type":"span"},{"_type":"span","marks":["superscript"],"text":"28,35,36,38,40","_key":"3887bdc8da49"}],"_type":"block","style":"normal","_key":"662a88dce039"}],"_key":"4ac74f3f5cfd","asset":{"_ref":"image-7d81491e80cc3cd78ed0aee58ec5701c4b05c46d-1616x824-png","_type":"reference"},"disableTextWrap":false,"_type":"figure","alignment":"right","widthP":60},{"style":"normal","_key":"97247e9f9e18","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9eb7b291b4950"}],"_type":"block"},{"_type":"block","style":"normal","_key":"cf6ed854aa00","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"The Multidimensional Nutritional Deficits in AN","_key":"21316d51a4f60"}]},{"children":[{"_type":"span","marks":[],"text":"While zinc is often one of the key deficiencies, other essential micronutrients are important to consider. Iron, folate, vitamin B12, vitamin D, amino acids, and essential fatty acids are all commonly deficient in patients with AN.","_key":"db9395e984170"}],"_type":"block","style":"normal","_key":"b4835fbd16c2","markDefs":[]},{"_key":"42ccf755e3e6","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"0dc9db4b45490"}],"_type":"block","style":"normal"},{"_key":"9c064eea5997","markDefs":[],"children":[{"marks":[],"text":"Celiac disease is another potential trigger for AN, having a higher prevalence in patients with AN.","_key":"b3f4588c55850","_type":"span"},{"text":"41","_key":"6e8f441e1e15","_type":"span","marks":["superscript"]},{"_type":"span","marks":[],"text":" Due to the malabsorption seen in celiac disease with gluten consumption, it can easily exacerbate nutritional deficits leading to malnutrition and weight loss. In susceptible patients, celiac disease can be the trigger that pushes nutritional deficits over the edge, disrupting normal brain biochemistry and spiraling into AN. When present, celiac disease also complicates recovery, especially when undiagnosed. Weight gain can be virtually impossible in celiac disease unless gluten is removed from the diet.","_key":"3503a07666cd"}],"_type":"block","style":"normal"},{"_key":"941803bb90a3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"3393dc1bf0c40"}],"_type":"block","style":"normal"},{"_key":"021ec5623a58","markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Malnourished Minds: Why Nutritional Supplements Are Critical for Treating AN","_key":"73d1d20c17c20"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"AN is a condition that has roots in malnutrition and is commonly comorbid with depression, anxiety, and other mental health conditions. Standard treatment approaches often focus on calorie intake above all else, even when these calories are ultra-processed food. This is likely one of the reasons for the very high relapse rates in AN.","_key":"c18092bd60230"}],"_type":"block","style":"normal","_key":"679245817630"},{"children":[{"_key":"8b614048783b0","_type":"span","marks":[],"text":""}],"_type":"block","style":"normal","_key":"6c8fba6872f3","markDefs":[]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"We know ultra-processed foods contribute to mental health problems, including depression and anxiety.","_key":"73176d0febbd0"},{"_type":"span","marks":["superscript"],"text":"42","_key":"56d48d31eb6c"},{"_type":"span","marks":[],"text":" Consuming large amounts of empty calories increases the demands on a body that is already devoid of the nutrients needed to metabolize these junk foods. It is well past time that we realized that ultra-processed foods should not be the primary source of calories used in the treatment of any mental health condition, especially AN. Increasing calorie intake at any cost is not an effective strategy. Patients struggling with AN need more than just calories, they also need to replace micronutrient deficiencies that are disrupting neurochemistry.","_key":"8f5fd1292bb1"}],"_type":"block","style":"normal","_key":"7252258e8cc6"},{"style":"normal","_key":"968eb207e1d3","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"7938a2d06ecb0"}],"_type":"block"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"AN is a life-threatening condition, and the current medical treatment approach is in desperate need of research-based strategies that will improve outcomes. Treating relevant nutrient deficiencies is one of the most neglected interventions in modern psychiatry. As such, our current therapeutic model is disjointed and inadequate, marred by a deficiency in research and a lack of focus on the underlying causes of AN.","_key":"7d0d0b56745a0"}],"_type":"block","style":"normal","_key":"05d0fb45e5ff"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"e2b566d6df440"}],"_type":"block","style":"normal","_key":"4410ec3f5fc6"},{"children":[{"_type":"span","marks":[],"text":"While it may seem obvious, the common thread that links together every case of AN is malnutrition. From my own experience, every patient with an eating disorder that I have worked with has been malnourished. Once this malnourishment takes root, it disrupts physiology and brain chemistry. Treating these nutritional deficiencies is the most overlooked component in our current approach to AN. Patients with AN seldom improve if the profound biochemical imbalances are not addressed directly. Nutritional supplementation is a critical key that can often open a path to recovery.","_key":"2bb8c9fbd6a20"}],"_type":"block","style":"normal","_key":"31ff3ecf7dd2","markDefs":[]},{"_key":"912e12671a28","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9726a84d758e0"}],"_type":"block","style":"normal"},{"markDefs":[],"children":[{"_type":"span","marks":["strong"],"text":"Dr Greenblatt ","_key":"b77fbe26bff00"},{"marks":["em"],"text":"is the chief medical officer of Psychiatry Redefined, an online educational platform for integrative and functional psychiatry.","_key":"b77fbe26bff01","_type":"span"}],"_type":"block","style":"normal","_key":"6a9507fb6a83"},{"_key":"deba9af497db","markDefs":[],"children":[{"_type":"span","marks":[],"text":"","_key":"9eac00b12c970"}],"_type":"block","style":"normal"},{"_type":"block","style":"normal","_key":"b5110fffd95a","markDefs":[],"children":[{"marks":["strong"],"text":"References","_key":"657f7e0968d70","_type":"span"}]},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"1. Kaye WH, Bulik CM. Treatment of patients with anorexia nervosa in the US—a crisis in care. ","_key":"5ab74ec53be40"},{"_type":"span","marks":["em"],"text":"JAMA Psychiatry","_key":"5ab74ec53be41"},{"_type":"span","marks":[],"text":". 2021;78(6):591-592.","_key":"5ab74ec53be42"}],"_type":"block","style":"normal","_key":"d4f52713ff1f"},{"markDefs":[],"children":[{"_type":"span","marks":[],"text":"2. Khalsa SS, Portnoff LC, McCurdy-McKinnon D, Feusner JD. What happens after treatment? A systematic review of relapse, remission, and recovery in anorexia nervosa. ","_key":"e1339d60edb40"},{"_type":"span","marks":["em"],"text":"J Eat Disord","_key":"e1339d60edb41"},{"marks":[],"text":". 2017;5:20.","_key":"e1339d60edb42","_type":"span"}],"_type":"block","style":"normal","_key":"7601fabe975c"},{"style":"normal","_key":"cb5eec8710c8","markDefs":[],"children":[{"_type":"span","marks":[],"text":"3. Keshaviah A, Edkins K, Hastings ER, et al. Re-examining premature mortality in anorexia nervosa: a meta-analysis redux. ","_key":"8b92f6b8badb0"},{"_key":"8b92f6b8badb1","_type":"span","marks":["em"],"text":"Compr Psychiatry"},{"_type":"span","marks":[],"text":". 2014;55(8):1773-1784.","_key":"8b92f6b8badb2"}],"_type":"block"},{"style":"normal","_key":"197078067a41","markDefs":[],"children":[{"_type":"span","marks":[],"text":"4. Fornaro M, Mondin AM, Billeci M, et al. Psychopharmacology of eating disorders: systematic review and meta-analysis of randomized controlled trials. ","_key":"e452e900cb5f0"},{"_key":"e452e900cb5f1","_type":"span","marks":["em"],"text":"J Affect Disord"},{"marks":[],"text":". 2023;338:526-545.","_key":"e452e900cb5f2","_type":"span"}],"_type":"block"},{"_type":"block","style":"normal","_key":"b438d7ada436","markDefs":[],"children":[{"_type":"span","marks":[],"text":"5. van den Berg E, Houtzager L, de Vos J, et al. Meta-analysis on the efficacy of psychological treatments for anorexia nervosa. ","_key":"eb6dbbbd8f300"},{"_type":"span","marks":["em"],"text":"Eur Eat Disord Rev J Eat Disord Assoc","_key":"eb6dbbbd8f301"},{"_type":"span","marks":[],"text":". 2019;27(4):331-351.","_key":"eb6dbbbd8f302"}]},{"_type":"block","style":"normal","_key":"57c4ee22766f","markDefs":[],"children":[{"_type":"span","marks":[],"text":"6. Bang L, Bahrami S, Hindley G, et al. Genome-wide analysis of anorexia nervosa and major psychiatric disorders and related traits reveals genetic overlap and identifies novel risk loci for anorexia nervosa. ","_key":"63b46ebd1b530"},{"text":"Transl Psychiatry","_key":"63b46ebd1b531","_type":"span","marks":["em"]},{"_type":"span","marks":[],"text":". 2023;13(1):1-9.","_key":"63b46ebd1b532"}]},{"children":[{"_type":"span","marks":[],"text":"7. Baker D, Keramidas N. ","_key":"11d5a6a7dade0"},{"_type":"span","marks":["40a0f073d4c3"],"text":"The psychology of hunger.","_key":"11d5a6a7dade1"},{"_type":"span","marks":["em"],"text":"Monitor on Psychology","_key":"11d5a6a7dade2"},{"_type":"span","marks":[],"text":". 2013;44(9):66.","_key":"11d5a6a7dade3"}],"_type":"block","style":"normal","_key":"7e624c0cad62","markDefs":[{"_type":"link","href":"https://www.apa.org/monitor/2013/10/hunger","_key":"40a0f073d4c3"}]},{"style":"normal","_key":"72f1992da64b","markDefs":[{"_key":"8eb585421860","_type":"link","href":"https://www.archivesofpsychology.org/index.php/aop/article/view/50"}],"children":[{"_type":"span","marks":[],"text":"8. Eckert ED, Gottesman II, Swigart SE, Casper RC. 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