The Scatter-Brained Mother Whose Daughter Has ADHD, Like Mother, Like Daughter

To prepare for this Discussion:

Note: To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number. (Already attached with this posting)

Case 2: Volume 1, Case #14: The scatter-brained mother whose daughter has ADHD, like mother, like daughter

Review this week’s Learning Resources and reflect on the insights they provide.

Go to the Stahl Online website and examine the case study you were assigned.

Take the pretest for the case study.

Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.

Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).

Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.

Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.

Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.

Review the posttest for the case study.

By Day 3

Post a response to the following:

Provide the case number in the subject line of the Discussion.

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.

Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Clancy, C.M., Change, S., Slutsky, J., & Fox, S. (2011). Attention deficit hyperactivity disorder: Effectiveness of treatment in at-risk preschoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment. Table B. KQ2: Long-term(>1 year) effectiveness of interventions for ADHD in people 6 years and older.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 12, “Attention Deficit Hyperactivity Disorder and Its Treatment”

Stahl, S. M., & Mignon, L. (2012). Stahl’s illustrated attention deficit hyperactivity disorder. New York, NY: Cambridge University Press.

To access the following chapter, click on the Illustrated Guides tab and then the ADHD tab.

Chapter 4, “ADHD Treatments”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For ADHD

armodafinil

amphetamine (d)

amphetamine (d,l)

atomoxetine

bupropion

chlorpromazine

clonidine

guanfacine

haloperidol

lisdexamfetamine

methylphenidate (d)

methylphenidate (d,l)

modafinil

reboxetine

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Optional Resources

Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. doi:10.2165/11599630-000000000-00000

Psychiatric Times. (2016). A 5-question quiz on ADHD. Retrieved from http://www.psychiatrictimes.com/adhd/5-question-quiz-adhd?GUID=AA46068B-C6FF-4020-8933-087041A0B140&rememberme=1&ts=22072016

Course Texts

These course texts are available through Stahl Online Resources http://ezp.waldenulibrary.org/login?url=http://stahlonline.cambridge.org/

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
PATIENT FILE

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PATIENT FILE

The Case: The scatter-brained mother whose daughter has ADHD, like mother, like daughter

The Question: How often does ADHD run in families?

The Dilemma: When you see a child with ADHD should you also evaluate the parents and siblings?

Pretest Self Assessment Question (answer at the end of the case)

Patients with comorbid ADHD and anxiety should in general not be prescribed stimulants

A. True B. False

Patient Intake • 26-year-old woman • Has a daughter with ADHD • Psychiatrist noted symptoms in the mother and suggested she come

in for her own evaluation • See the previous Case 13, p 133 for presentation of the daughter’s

case

Psychiatric History • During interviews with the patient’s daughter (also attended by the

patient) over the past several months, it was not only noted that the daughter has ADHD with comorbid ODD, but that the mother also exhibited multiple symptoms consistent with lifelong and undiagnosed ADHD including

– Mother misses appointments or is late for appointments – Often appears disorganized – Did not fi ll out her child’s forms on time – Did not deliver forms to her child’s teacher, forgot, lost them – Admits being very disorganized since her second child started

school – Feels overwhelmed by two children and her life circumstances – Could also have some signs of depression – Can’t get organized to take her child to CBT – Has a hard time keeping a regular schedule and also keeping her

daughter on a regular schedule of going to bed and waking up – Was unable to remember to remove the daughter’s skin patch

unless she set a cell phone alarm – All these suggest further evaluation of the mother is indicated

since ADHD commonly runs in families and has a very high genetic contribution

Downloaded from http://stahlonline.cambridge.org by IP 192.168.60.239 on Wed Jul 26 03:25:23 BST 2017 Stahl Online © 2017 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

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• Has always done poorly academically • Has always felt intimidated by any type of testing • In addition, reports that she has always been worried about the future

and fi nancial stability of her family • Says she sometimes mentally “freezes when it gets to be too much” • When her eight year old daughter was diagnosed with ADHD, she

suddenly realized that she had similar problems as a child • The psychiatrist explained to her that ADHD was highly heritable and

that there was a 75% chance of having a child with ADHD if both parents have ADHD and thus was asked to fi ll out an Adult ADHD screening form

Social and Personal History • High school drop out, age 17 after getting pregnant • Married age 17, divorced 2 years later • Two children, ages 8 and 6 • Smoker • No drug or alcohol abuse • Single mother works full time in retail • Father not much involved with his children

Medical History • None notable • BP normal • BMI normal • Normal lab tests

Family History • 8-year-old daughter: recently diagnosed with ADHD • Other family history unknown as the patient was adopted • See the previous Case 13, p 133 for presentation of the daughter’s

case

Patient Intake • The last time the patient brought her child to see the psychiatrist, the

mother was asked to fi ll out her own checklist, the Adult ADHD Self Report Scale Symptom Checklist

– She endorsed many items, mostly inattentive but not really hyperactive or impulsive such as:

– Having trouble wrapping up the fi nal details of a project once the challenging parts have been done

– Diffi culty getting things in order – Diffi culty remembering appointments or obligations

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– Making careless mistakes on diffi cult projects – Diffi culty keeping attention on repetitive work – Misplacing things at home and work – Distracted by activity around her – Diffi culty unwinding and relaxing when having time to herself – Diffi culty focusing/listening during conversations

• Earlier, the mother was also requested to obtain copies of her report cards from fi rst and second grade

– Her own mother had kept these in storage – Showed grades that were quite low – Her teachers had commented on some of the problems endorsed

in the adult ADHD checklist that she continues to experience as an adult

• Asked how these problems affect her life, she states that: – They cause great diffi culty managing family matters – She used to be unable to stay focused in conversations with her

ex-husband, which made him feel she did not care about him • Additional complaints include:

– Constantly feeling overwhelmed with taking care of the two children while working fulltime

– Blaming herself for her daughter’s academic diffi culties – Feeling very emotional and overwhelmed

– “I’m sorry, doctor, but two kids are just too much for this single mom”

• Having diffi culty sleeping and being irritable with the children at night, which she regrets later on

• Has many worries, about fi nances, about the future, about her children’s futures, about getting a better job, about getting her own education, about fi nding a new partner

Based on just what you have been told so far about this patient’s history and symptoms, what do you think is her diagnosis?

• Appropriate response to her circumstances with her severe psychosocial stressors

• Mostly just stress and anxiety • ADHD • ADHD and stress • Generalized anxiety disorder (GAD) • Major depressive episode • ADHD and GAD • Other

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Attending Physician’s Mental Notes: Initial Psychiatric Evaluation • Here is a case that indeed is ADHD, but her symptoms also suggest

that she suffers from GAD – Constant worry – Feeling on edge – Fatigue – Diffi culty concentrating and her mind going blank – Irritability – Trouble sleeping

• Most adults with ADHD are comorbid for a second psychiatric disorder, and the most common is GAD

• Also, this patient is a smoker which may be related to her ADHD since a disproportionate number of ADHD patients smoke, perhaps because of the therapeutic effects of nicotine on ADHD symptoms

How would you treat her?

• Stimulant for her ADHD • SSRI/SNRI for her GAD • Benzodiazepine as need for GAD and insomnia • Stimulant plus an SSRI/SNRI or benzo for both ADHD and GAD • CBT for both ADHD and GAD • Other

Attending Physician’s Mental Notes, Initial Psychiatric Evaluation, Continued • It seems as though the primary disorder is ADHD and it will be

simplest if this is treated fi rst, with a single drug, probably a stimulant • An SSRI/SNRI and/or benzodiazepine can be added at a later time

once the actions of the stimulant are evident • Even though patients with GAD alone or even normal controls may be

“over stimulated” by a stimulant, in many cases of ADHD comorbid with GAD, the stimulant is paradoxically calming and well tolerated and even works for GAD symptoms as well as ADHD symptoms without having to prescribe a second medication for the GAD

• Any stimulant could be chosen but not all are explicitly approved for treatment of ADHD in adults

• She was started on mixed salts d,l amphetamine XR (Adderall XR) • She was referred to a local mental health training program where she

could possibly get CBT for free or for a reduced rate from a trainee receiving supervision

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Case Outcome: First, Second, and Third Interim Followup Visits, Weeks 4, 8 and 12 • Due to scheduling issues, by the time the patient had her fi rst CBT

session, she had already been titrated to 20 mg of mixed salts of d,l – amphetamine XR

• She thought that the medication had already started to help her and in fact that she would not have been able to cooperate with the CBT assignments had she not been on the medication

• Because of lack of side effects but continuing ADHD and GAD symptoms, the dose of d,l-amphetamine XR increased to 30 mg (off label since the maximum approved dosage for adults is 20 mg)

• Her BP and pulse were stable on the 30 mg dose but she felt jittery particularly in the morning and around noon; she also felt very anxious about her job situation and being able to provide for her family

• Dose lowered to 25 mg, but the jitteriness persisted so the dosage was further lowerd to 20 mg

• The jitteriness abated but her ADHD symptoms were not well controlled on the 20 mg dose anymore

• Instructed to stay on 20 mg for two more weeks as she is going on vacation and not to change the dose until after her vacation and then retry the 25 mg dose again

• Complained of feeling overwhelmed and irritable • For most patients, a week between dosing adjustments for a stimulant

being used to treat ADHD is quite adequate • Weekly intervals give patients and clinicians a chance to see the way

that the dosage is working though the spectrum of challenges that occur in a typical week

• As vacations do not represent typical activities for a week, special consideration must be given to the effectiveness of medication changes that are done while a patient is on vacation

– Many adults with ADHD may relax on vacation and not challenge themselves with cognitive loads and multitasking so may appear to be better even without a medication change

– Other adults with ADHD, especially women with young children, may actually fi nd vacation more challenging

– For example, a parent with ADHD taking a family vacation with several children in tow may fi nd the planning and organization for the trip more taxing than anything encountered at work or during the normal routine at home

– It can also be diffi cult to manage timing the medication appropriately when traveling to different time zones

PATIENT FILE

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Case Outcome: Fourth Interim Followup, Week 16 • “Glad to be back from vacation” • “I don’t think I could have even got through our vacation without my

medication, but I still have a hard time holding things together” • On at least 20 mg/day dosage of d,l-amphetamine XR combined with

CBT for 12 weeks, including a couple of weeks back from vacation, the patient still has problems with

– Organizing her day – Procrastinating – Following instructions – Losing items such as her keys which make her late for

appointments/activities • On the few days that the patient missed, and thus skipped, her

medication inadvertently she realized that the medication was really helping her concentrate and get through the day even though she remains symptomatic

• Knowing that she could achieve better functioning on medication she asked if other medications might accomplish this without the jittery and anxious feelings

• While other medication options were discussed, the CBT was continued which was slightly less helpful

How would you treat her now?

• Start lisdexamfetamine 30 mg once in the morning and titrate the dosage by 20 mg each week until an optimal dosage is achieved

• Start d-methylphenidate XR 10 mg once in the morning and titrate the dosage by 10 mg each week until an optimal dosage is achieved

• Start OROS methylphenidate 18 mg once in the morning and titrate the dosage by 18 mg each week until an optimal dose is achieved

• Start atomoxetine 40 mg a day and increase to 80 mg after one week

Attending Physician’s Mental Notes: Fourth Interim Followup, Week 16 • Lisdexamfetamine, d-methylphenidate XR, OROS methylphenidate,

and atomoxetine are all FDA-approved for the treatment of adults with ADHD

• On the one hand, the patient found her amphetamine-based stimulant to be very effective, and thus another long-acting stimulant would be reasonable

• On the other hand, she had jitteriness with the stimulant, and thus a non-stimulant would be equally reasonable

• After explaining the options, the patient elected to try another long- acting stimulant

PATIENT FILE

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• d-methylphenidate uses a bead-based technology similar to the mixed salts amphetamine XR in that 50 percent of the beads are immediate- release and 50 percent delayed-released

• Methylphenidate LA and d-methylphenidate XR employ the same patented SODAS technology in their delivery systems, but other long- acting forms of stimulants with beaded delivery systems vary due to proprietary differences in their manufacturing processes

• For instance, one formulation of methylphenidate utilizes a capsule that contains a ratio of 30 percent immediate-release beads and 70 percent delayed-released beads

• Although the different technologies used in beaded forms of stimulants can have clinical implications in individual cases, they all follow a similar design scheme:

– A bolus of stimulant medication becomes bioavailable rather quickly as the immediate-release beads dissolve

– Over time, the coating on the delayed-release beads deteriorates, allowing the stimulant contained within the bead to be released

– The medication within the delayed-release bead becomes bioavailable about four hours after the patient swallows the capsule

• Lisdexamfetamine is the only stimulant preparation that is a prodrug: – In its prodrug form, a lysine molecule is attached to

dextroamphetamine – Dextroamphetamine will not be active until the lysine is cleaved

from it – Cleaved lysine is an amino acid that does not contribute to the

clinical effi cacy of this medication • Lisdexamfetamine could be a good choice for multiple reasons:

– It uses a different delivery system that appears to have a more consistent interval to maximum concentration (Cmax)

• It is conceivable that the jitteriness this patient was experiencing was related more to the l-isomer than to the d-isomer

• A nonstimulant such as atomoxetine may be particularly useful in a patient who has stimulant related side effects, because atomoxetine does not cause these side effects

• Also, atomoxetine may be particularly useful in patients with comorbid anxiety

Case Outcome: Fourth Interim Followup, Week 16, Continued • In the end, the patient and the attending physician agreed upon a trial

of OROS methylphenidate (Concerta) • Main reasons for this choice:

– To be able to compare the benefi ts the patient experienced on an amphetamine preparation with those of a methylphenidate

PATIENT FILE

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preparation since patients may experience differing tolerabilities as well as effi cacies on methylphenidate versus amphetamine

– To be able to test the uniqueness of the OROS delivery system in terms of attained effi cacy with better tolerability

• OROS methylphenidate uses a delivery system that is quite different from beaded delivery systems:

– Coating of OROS methylphenidate contains 32 percent of the medication

– Remainder of medication is contained within a permeable membrane that allows water from the gut to enter once the coating of methylphenidate dissolves away

– Different concentrations of methylphenidate in gel form are contained in two compartments

– A push compartment absorbs water and expands like a sponge does, pushing the methylphenidate gel out of the hole at the opposite end

Case Outcome: Fifth Interim Followup, Week 20 • The patient’s dose was titrated from 18 mg to 72 mg over the course

of four weeks • Although she did not feel jittery, OROS methylphenidate 72 mg once a

day did not seem to work as well as the mixed salts amphetamine at 30 mg a day

• She voiced concerns that the dosage was more than double that of the mixed salts amphetamine dosage that was tried

• The psychiatrist explained that methylphenidate compounds are half as potent as amphetamine ones, and that 72 mg/day is an approved dose in adults

• She was reminded that her blood pressure and pulse had remained in the normal range throughout the titration, and she was told that some of the methylphenidate gel may remain inside the delivery system and not be bioavailable (inherent properties of OROS technology)

• After documenting that information about off-label use was given to the patient, the psychiatrist recommended to further increase the dose of OROS methylphenidate to 90 mg

Case Outcome: Sixth Interim Followup, Week 24 • The patient felt that 90 mg of OROS methylphenidate worked at least as

well as 30 mg of the mixed salts of d,l amphetamine XR • Her blood pressure and pulse increased a bit from baseline, but they

were still in the middle of the normal range

PATIENT FILE

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• She still has some problems with organization and losing items, but she indicates she would continue CBT to address these

• Similar to when she was on the amphetamine compound, once her ADHD symptoms abated, her anxious feelings became more prominent

– “It’s like now that I can concentrate on my daily tasks, I also feel much more anxious about the fi nancial security of my children, and I often feel my throat tighten when I think about the fi nancial impact of the girls going to college”

– “The thought of losing my job or getting sick frightens me . . . what would happen to the girls?”

– She has trouble falling asleep at night, as her mind does not shut off

ADHD is often comorbid with other psychiatric disorders and one disorder can mask the symptoms of another. In the present case, this patient exhibits symptoms of anxiety, probably generalized anxiety disorder, especially more prominent every time her ADHD symptoms abate. How would you address the patient’s anxiety at this point?

• Augment with a benzodiazepine • Augment with buspirone • Augment with a selective serotonin reuptake inhibitor (SSRI) or SNRI • Incorporate techniques to resolve anxiety into ongoing CBT

Case Outcome: Seventh and Eighth Interim Followup, Weeks 24 and 36 • Incorporating techniques to resolve anxiety into the patient’s ongoing

CBT would likely be most appropriate, prior to attempting to add a medication

• A letter was sent suggesting this to the CBT therapist, but after 12 weeks, this led to limited benefi t, and thus medication augmentation was considered

• Benzodiazepines, buspirone, and SSRIs/SNRIs can all be used to treat generalized anxiety disorder and are not contraindicated with stimulants

• After discussion of the options, paroxetine was prescribed to augment her stimulant and her CTB

Case Outcome: Ninth Interim Followup, Week 48 • After three months on OROS methylphenidate and paroxetine, while

continuing her CBT, at fi rst the patient stated that she “had her life back” • Then, after thinking back over the past year of treatment, and to how

she had been since childhood she stated, “No, I don’t have my life back – I fi nally have a life!”

PATIENT FILE

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Case Debrief • It took a long time to get both the ADHD and GAD recognized • It took over a year of trial and error and combination treatment to

attain a remission of symptoms • Real remission will come when sustained improvement of symptoms

leads to better functional outcomes, not only less subjective distress, but now perhaps the chance for an education, a better job, and having enough emotional reserve to develop another relationship

• Stopping smoking might be a goal to tackle in the next year as well

Take-Home Points • ADHD is highly heritable • It is not uncommon for adults with previously undiagnosed ADHD to

recognize their own symptoms once their child is diagnosed • A multigenerational approach should be considered for parents who

have ADHD and who care for children with ADHD • In the patient’s case, by addressing her own ADHD issues, she also

felt she could be a better parent to her daughter with ADHD

Performance in Practice: Confessions of a Psychopharmacologist • What could have been done better here?

– Perhaps ADHD could have been recognized earlier – Perhaps CBT could have been implemented earlier – Perhaps she should have been more actively engaged or have had

more serious discussions about smoking cessation already • Possible action item for improvement in practice

– Make a concerted effort to keep contact with low cost CBT resources in the community

– Make a more concerted effort to encourage smoking cessation

Tips and Pearls • Prescribing stimulants to an ADHD patient is very much like tailoring a

“bespoke” treatment, one case at a time • That is, some patients respond very differently to amphetamine than

they do to methylphenidate • Many patients respond very differently to one controlled dosage

pattern versus another • Look for comorbidities in adult ADHD, including both anxiety

disorders and substance dependence/abuse (especially smoking) • True remission means reduction not just in symptoms of ADHD, but

in the comorbid conditions as well

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Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case – ADHD rating scales for adults – Contributions of genetics to ADHD

Table 1: Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Instructions

162

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PATIENT FILE

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Figure 1: Average Genetic Contribution of ADHD Based on Twin Studies

ADHD is one of the most genetically loaded medical or psychiatric conditions, higher than schizophrenia, asthma or breast cancer.

Posttest Self Assessment Question: Answer

Patients with comorbid ADHD and anxiety should in general not be prescribed stimulants

A True B False Answer: B

References 1. Franke B, Neale BM, and Faraone SV. Genome-wide association

studies in ADHD. Hum Genet 2009; 126(1): 13–50 2. Haberstick BC, Timberlake D, Hopfer CJ et al. Genetic and

environmental contributions to retrospectively reported DSM-IV childhood attention defi cit hyperactivity disorder. Psychol Med 2008; 38(7): 1057–66

3. McLoughlin G, Ronald A, Kuntsi J et al. Genetic support for the dual nature of attention defi cit hyperactivity disorder: substantial genetic overlap between the inattentive and hyperactive-impulsive components. J Abnorm Child Psychol 2007; 35(6): 999–1008

4. Todd RD, Rasmussen ER, Neuman RJ et al. Familiality and heritability of subtypes of attention defi cit hyperactivity disorder in a population sample of adolescent female twins. Am J Psychiatry 2001; 158(11): 1891–8

5. Faraone SV, Advances in the genetics and neurobiology of attention defi cit hyperactivity disorder, Biol Psychiatry 2006; 60: 1025–7

Twin studies: ADHD is genetic

Hudziak, 2000 Nadder, 1998

Levy, 1997 Sherman, 1997

Silberg, 1996 Gjone, 1996

Thapar, 1995 Schmitz, 1995

Edelbrock, 1992 Gillis, 1992

Goodman, 1989 Willerman, 1973

Breast cancer Asthma Schizophrenia Height

Average genetic contribution of ADHD based on twin studies

ADHD mean

0 0.2 0.4 0.6 0.8 1

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6. Stahl SM, Stahl’s Illustrated Attention Defi cit Hyperactivity Disorder, Cambridge University Press, New York, 2009

7. Stahl SM, Attention Defi cit Hyperactivity Disorder and its Treatment, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 863–98

8. Stahl SM, Atomoxetine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 51–5

9. Stahl SM, d,l methylphenidate, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 329–35

10. Stahl SM, Mixed Salts of d,l Amphetamine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 39–44

11. Stahl SM, Paroxetine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 409–15

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