Attention Deficit Hyperactivity Disorder and Bipolar Disorder: Diagnosis, Treatments, and Clinical Considerations: A Narrative Review

Attention-deficit Hyperactivity Disorder is one of the most common childhood mental health disorders, affecting about 5.6% of the population worldwide. Several studies have specifically shown a high prevalence of comorbid mood disorders, such as depression and bipolar disorder (BD), in those diagnosed with ADHD. Several common symptoms of ADHD are also found in BD, which are characterized by alternating periods of euthymia and mood disturbances. The inattention and impulsivity of ADHD can be seen in manic and hypomanic episodes of BD. Over the past decade, there has been an increased interest in research between the correlation of ADHD and pediatric bipolar disorder (PBD) in children. Some experts hypothesize that more children are comorbidly diagnosed with ADHD and PBD because of how many clinicians treat children with ADHD. Other factors, which may affect the dual diagnoses of ADHD and PBD, are overlapping diagnostic criteria for the two disorders, the inevitable biases seen when one disorder is diagnosed without the other, and related risk factors leading to prodromal relationships. By examining clinical trials, a better understanding of whether ADHD and PBD have a stepwise progression or if other factors influence these comorbidities, such as blurred lines of diagnostic criteria. Those with ADHD are also at an increased risk of impairment at work and in social settings. This manuscript explores both progression of this disease and its clinical connections to other disorders.

Counting, Coping, and Navigating the Flux: A Focused Ethnographic Study of HIV and Diabetes Self-Management

Approximately 10–15% of people living with HIV are also diagnosed with diabetes. To manage their two chronic conditions, people must undertake certain activities and adopt behaviors. Due to overlapping symptoms, complex medication regimens, and heavy patient workloads, implementing these self-management practices can be difficult. In this focused ethnography, data were collected from semi-structured interviews and limited participant-observation with a selected subset of participants to gain insight into self-management challenges and facilitators. We conducted interviews and multiple observations with 22 participants with HIV+T2DM over the period of 9 months. Participants experienced numerous barriers to self-management in the areas of diet, medication adherence, and mental health. Social and familial support, as well as consistent access to care, were facilitators for optimal self-management. At the same time participants’ lives were in a unique flux shaped by the dual diagnoses, and therefore, required constant mental and physical adjustments, thus illustrating challenges of managing chronicity.

1094 Diagnosis of Diabetic Ketoacidosis Delayed Due to Concomitant Acute-On-Chronic Pancreatitis

The objective of this clinical case is to highlight the importance of recognition and prompt management of diabetic ketoacidosis (DKA) in older patients with comorbidities such as acute pancreatitis. A 61-year-old gentleman initially presented to the hospital with severe left upper quadrant/epigastric pain and vomiting. He had a background of chronic pancreatitis, diabetes secondary to pancreatitis and alcohol excess. Based on his raised inflammatory markers and CT findings which showed pancreatic pseudocyst compressing on the spleen, a diagnosis of acute-on-chronic pancreatitis and possible intra-abdominal sepsis was made. He was subsequently commenced on piperacillin with tazobactam and given fluids. His abdominal pain persisted despite initial treatment. His blood glucose levels were within normal range, but his ketone levels were found to be consistently high since admission. Two days later, he presented with reduced consciousness and generalised abdominal tenderness; his arterial blood gas showed a very severe metabolic acidosis. A diagnosis of DKA was then made – he was commenced on the DKA treatment protocol and was transferred to the Intensive Care Unit for stabilisation. He gradually made a recovery and was later transferred from the ICU to the endocrinology ward. DKA usually presents in younger patients with type 1 diabetes. Given the background of this patient, his presentation was largely attributed to a surgical cause. Clinicians must remain alert to the possibility of dual diagnoses relating to abdominal pain, which in this case were a surgical cause (pancreatitis) and a medical cause (DKA).

Effects of Verb Network Strengthening Treatment on Sound-Level and Speech Production Errors in Individuals With Aphasia and Acquired Apraxia of Speech

Purpose This retrospective pilot study investigated whether sound-level and speech production errors decreased in confrontation naming following Verb Network Strengthening Treatment (VNeST) for four participants with acquired apraxia of speech (A-AOS) and aphasia for whom lexical retrieval was previously reported. Specifically, we investigated a potential increase in correct number of syllables per word and posttreatment changes across three domains of speech: segmental production, fluency, and prosody. It was hypothesized that treatment shown to increase lexical retrieval in persons with aphasia and A-AOS could potentially facilitate a reduction in sound-level and speech production errors consistent with dual diagnoses of A-AOS and aphasia. Method Naming responses from four participants with aphasia and A-AOS who previously participated in VNeST studies were investigated for correct number of syllables per word and measures of segmental speech, fluency, and prosody. Results Significant gains in at least one measure of speech production were reported for three of the participants. One participant demonstrated decreased segmental speech errors, two showed significant reduction on syllable segmentation, and two demonstrated a significant reduction on false starts and pauses. Significant gains in production of correct number of syllables were limited to one participant, and one participant did not demonstrate increased accuracy on any measure of speech production. Conclusions While speech production errors consistent with motor speech impairment cannot always be definitively distinguished from the confound of aphasia, two participants produced significantly decreased segmentation of syllables, a characteristic unique to A-AOS. The sound-level and speech production changes recorded may be attributed to a combination of interacting motor and language processes and resource allocation. In addition, specific components of VNeST may have contributed to speech production changes. Future work will focus on a prospective study of effects of language therapy (e.g., VNeST) on measures of speech production with investigation beyond the single-word level.

How well do international clinical guidelines on mental health and substance misuse address their coexistence? a systematic review of scope, quality and inclusivity

Objective: It is estimated that up to 75% of patients with severe mental illness (SMI) also have substance use disorder (SUD). The aim of this systematic review is to explore the scope, quality and inclusivity of international clinical guidelines on mental health and/or substance misuse in relation to diagnosis and treatment of such co-existing disorders and considerations for wider social and contextual factors in treatment recommendations.Method: A protocol (PROSPERO CRD42020187094) driven systematic review was conducted. A systematic search was undertaken using six databases including MEDLINE, Cochrane Library, EMBASE, PsychInfo from 2010 till June 2020; and webpages of guideline bodies and professional societies. Guideline quality was assessed based on ‘Appraisal of Guidelines for Research & Evaluation II’ (AGREE II) tool. Data was extracted using a pre-piloted structured data extraction form and synthesized narratively. Reporting was based on PRISMA guideline.Result: A total of 12,644 records were identified. Of these, 21 guidelines were included in this review. Three of the included guidelines were related to coexisting disorders, 11 related to SMI, and 7 guidelines were related to SUD. Seven (out of 18) single disorder guidelines did not adequately recommend the importance of diagnosis or treatment of concurrent disorders despite their high co-prevalence. The majority of the guidelines (n = 15) lacked recommendations for medicines optimisation in accordance with concurrent disorders (SMI or SUD) such as in the context of drug interactions. Social cause and consequence of dual diagnoses such as homelessness and safeguarding and associated referral pathways were sparsely mentioned.Conclusion: Despite very high co-prevalence, clinical guidelines for SUD or SMI tend to have limited considerations for coexisting disorders in diagnosis, treatment and management. There is a need to improve the scope, quality and inclusivity of guidelines to offer person-centred and integrated care.

Helhetlige tjenestetilbud i en liten kommune

One of the three municipalities that participated in the ROPIT project was a relatively small one. In this chapter, we take a closer look at how the distinctive features of a small municipality can affect how services are provided to persons with dual diagnoses. It seems as though the work is characterized by collaboration between service providers and service recipients as well as a flexible and pragmatic approach within the services, but such flexibility is not explicit in the relation between the municipality’s other services. However, this is not a unique situation for small municipalities. There is reason to believe that larger municipalities do not necessarily provide better services for persons with dual diagnoses. Yet how they choose to organize their services according to given goals and priorities in order to achieve coordinated services will vary.