Professor Sam Cortese discusses ADHD, research in relation to clinical decision-making in child and adolescent psychiatry, the importance of systematic reviews, and his work on the European ADHD Guidelines Group and its work on ADHD management during the covid-19 pandemic.
Professor Cortese also talks about his work relationship between mental and physical health conditions, and as lead researcher for the collaborative outcome study on health and functioning during infection times, the COH-Fit Study.
Samuele Cortese, Child and Adolescent Psychiatrist, is Professor of Child and Adolescent Psychiatry at the University of Southampton and Honorary Consultant Child Psychiatrist at the Solent NHS Trust. He is also Adjunct Associate Professor at the University of New York, USA. His main clinical and research interests focus on the epidemiology, neurobiology and treatment of neurodevelopmental disorders (in particular on ADHD) and on evidence-based practice in child psychiatry. Dr. Cortese is author/co-author of more than 200 papers in international peer-reviewed journals. He is on the editorial board of the Journal of the American Academy of Child and Adolescent Psychiatry, (JAACAP), Child and Adolescent Mental Health (CAMH), Evidence Based Mental Health (EBMH), CNS Drugs and on the advisory board of the Journal of Child Psychology and Psychiatry. Dr. Cortese is a member of the European Network for Hyperkinetic Disorder (EUNETHYDIS), the European ADHD Guidelines Group (EAGG), and the Child & Adolescent Neuropsychopharmacology Network of the European College of Neuropsychopharmacology (ECNP).
Interviewer: Hello, and welcome to the ‘In Conversation’ podcast series for the association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. If you’re a fan of our ‘In Conversation’ series, please subscribe on iTunes or your preferred streaming platform. Let us know how we did with a rating or review and do share with friends and colleagues. Today I’m interviewing Sam Cortese. Professor of Child and Adolescent Psychiatry at the University of Southampton and Associate editor of the journal CAMH. In 2019 Sam was awarded the Kramer Pollnow Prize for Excellence in Biological Research in Child and Adolescent Psychiatry.
Sam, thanks for joining me. Can you start by saying a little bit about yourself by way of an introduction?
Prof. Sam Cortese: Thank you. Hi, Jo and everyone and thanks for having me. So yeah, as you said I’m currently a Professor of Child and Adolescent Psychiatry at the University of Southampton and also a Honorary Consultant child adolescent psychiatrist for Solent NHS Trust.
In terms of my background I completed my medical degree at the University of Verona in Italy where I was also trained in Child and Adolescent Neuropsychiatry. So actually in Italy the training is slightly different. There is a combined training, combining paediatric neurology and child and adolescent psychiatry.
Then after this I moved to Paris in France where I worked as basically the equivalent of what is here, a clinical lecturer. So clinical activity, but also research and teaching and then I briefly worked almost one year as a consultant in Tours, another city France and following these I had I was awarded a fellowship, a European Agency.
One of those fellowships which are called Marie Curie, which allowed me to spend a couple of years as a Postdoc Fellow in New York being trained in neuroimaging applied to child psychiatry and then also to spend one year back to Europe in Italy and then for a number of personal and professional reasons I moved actually to the UK in 2013 where I first worked as a Locum Consultant in Cambridgeshire and Peterborough Foundation trust, and then I got a position as Associate Professor and Honorary Consultant in Southampton and finally was promoted last year to full Professor.
So yeah, that’s my trajectory which as you can see probably, you know, I think I moved quite a lot, probably more than the average of my colleagues, but you know, look at other colleagues it’s not so frequent. We all tend to move quite a lot because this is the nature of our work and, you know, working as a researcher implies, you know networks and being in touch with different institutions.
Interviewer: Right. It sounds like a very international career that you’ve had so far. Sam your research aims to inform clinical decision-making in child and adolescent psychiatry with a specific focus on ADHD. How did this come to be an area of interest for you?
Prof. Sam Cortese: So it’s always interesting. You know looking back I think, well actually I think your question can be split in two. So why the topical research which is a clinical decision making, in adolescent psychiatry and why the specific focus on ADHD. So in relation to the first point I would say that as a clinician, of course, I was always interested in being able to treat in the best possible way the patients and I have to say was quite annoyed sometimes when I used to see a number of colleagues also including mental supervisors.
Adopting some, you know, strategies, intervention strategies which were not really up to date based on evidence. It was more on tradition and you know, we do like this here. So, you know, you need to do the same. So I was very keen to, you know, become proficient in intervention and knowledgeable in interventions which are really supported by the best available evidence.
In terms of ADHD I think, you know, at the beginning I didn’t have any specific focus on any specific disorder. Probably one of the reasons why I became particularly interested in ADHD was the fact that it is one, it is a disorder for which we have probably the most efficacious at least in the short-term medications, pharmacological treatment.
So the effect of this medication can be quite spectacular and when we look at the evidence base and what the number in terms of effect size tell us about the effect of this medication. Clearly they are quite, they’re way better than other medications we use in psychiatry. So I was kind of fascinated and intrigued by the effect of this medication.
So probably this is one of the reasons and because I had the feeling that we can do something quite quickly and in an important way.
Interviewer: Thank you. Your work involves matter analytical approaches and evidence synthesis. Why are systematic reviews and methods of this sort is so important when it comes to child and adolescent mental health research?
Prof. Sam Cortese: Sure. So I would say they are important of course across medicine in general, in psychiatry, but equally probably in child and adolescent mental health research and also clinical practice because for quite a long time this field has lag behind in terms of implementing rigorous methodology, and when I speak with some colleague I often hear, you know, sentences like this treatment is evidence-based.
It’s supported by evidence, but when it comes to looking at the real quality of this evidence it can be very different across different interventions.
So I think that in general everybody is talking about evidence, evidence based treatment, but then we don’t really know what this means. So I think that of course evidence synthesis is at the highest level in terms of informing clinical practice because it does not rely just on one individual study. Rather it takes into consideration the body of research. and of course it’s just one of the elements that we need to take into account in decision-making.
Other elements those are the preferences of the patients and their family and the particular circumstances. So, you know, people often at times think that a meta-analysis provide the absolute and ultimate truth. It’s the decision making. This is not absolutely true. It was an element but, you know, an intervention which may be supported by high level of evidence in general may not be the preferred intervention for a specific patient.
So I think we need to strike a balance between, you know, using the evidence but also using our clinical science and the human relationship with the patient should not be forgotten of course.
Interviewer: Yeah, that’s hugely important. Sam, you work for the European ADHD Guidelines Group. What’s your role within this group?
Prof. Sam Cortese: Sure. Well first of all the European ADHD Guidelines Group is a working group of another larger network, which is called UNIKI*. This is a complex name. It stands for European Network of Hyperkinetic Disorders and the working group made by clinicians and other researchers. We work for free. We are now paid. This is mostly in our spare time. Evening, weekends and so on and so forth and our really goal, our remit is really to first appraise the evidence via reviews, systematic reviews of the need to meta-analysis, as I said, and then translate this, use this to support clinical recommendations in terms of management of ADHD or related conditions.
So I’m one of the members and during the years I started working for the European ADHD Guidelines Group or EAGG in 2010 I think. Over the years I have taken the lead on a number of projects of the group, in particular appraising the evidence in terms of the efficacy of cognitive training, neuro feedback for ADHD and more recently medication.
So large work which aimed to compare the efficacy and tolerability of different medications for ADHD, and this has been, I guess, quite important work because it has informed the Guidelines Group around the world, still informing and I think it’s important to highlight however touch, even though the name actually of the group says guidelines we don’t really produce guidelines such as, for instance, the NICE.
Everybody is familiar with the NICE Guidelines. So our job in ways is quite different. So we try to provide the recommendation which are usually not covered by this general guidelines, such as the NICE Guidance or more specific aspects that are important in the clinical practice. So we are not really a guideline group, but because the process of guidance include is a very complex one.
It includes analysis of cost effectiveness of the treatment. Includes stakeholders and patients’ opinion. So we don’t do this, but we try really to provide guidance on clinically relevant topics.
Interviewer: I understand you’ve recently produced guidance for the European Group on ADHD management during the covid-19 pandemic. Are you able to share some of the key recommendations from that?
Prof. Sam Cortese: Sure. So as you said, yes, we published this quite recently, a couple of months ago, and really the rationale for that was to try to support our colleagues in decision making during this challenging, unprecedented times.
I guess the main reason why we did this was that a number of colleagues were uncertain as to whether they should or they had to continue or start an assessment for ADHD or how to treat these patients in terms of pharmacological and especially non-pharmacological treatment.
So a number of colleagues were really uncertain and our concern was that due to this go to this particular restriction, due to COVID pandemic and number of clinicians were not able to implement an effective treatment for these patients. So we thought that not treating these patients in a way was more risky than treating them given the concerns of the COVID pandemic in terms of exposure to the patient.
We produced it actually to Guidance, the first one which is the main one and then a second one which is more specific for the pharmacological treatment, and again the main point is that despite the carrier restriction it is possible to assess and to manage remotely most cases patients and their families with ADHD.
So the guidelines actually include some tips in terms of how to support with behavioural strategies children and adolescents and their families were struggling, and these tips were originally built on previous work conducted by our group and other groups in terms of behavioural treatment for ADHD.
Then one of the group members Professor Edmund Sonuga-Barke went on developing further this, these tips into a comprehensive resource which is known as the families under pressure and it’s free for all parents, and the second part of the recommendation was around the pharmacological treatment and the main point that we made was that it is possible under certain circumstances to assess remotely and to start the pharmacologic treatment without the face-to-face contact provided that and the baseline assessment is done by other colleagues or by the family themselves in terms of measuring blood pressure, height and weight and know the parameters which are necessary.
So I think we are receiving some preliminary feedback on this work and I think that we’re were pleased to hear that it has been considered a useful tool and after all I think it has confirmed what a number of clinicians were already doing, but they felt reassured knowing that a kind of official body as the European ADHD Guidelines Group recommended what they were already implementing in a way in their clinics.
Interviewer: Right, and if somebody is listening to this podcast and they want to access those resources is there a website they can go to?
Prof. Sam Cortese: Sure. So an important point we wanted to publish this as an open access document. Unfortunately when we as academics publish our papers most of the time the access is not open. So you need to pay.
This means that a number of colleagues, especially those who don’t have academic affiliations are not able to access these papers. We thought that this was no good at all because we wanted this to be quickly available to the community and in an easy way. So we were lucky to publish these two documents. The main one and the addendum in the journal which is the Lancet Child and Adolescent Mental Health, which is part of the Lancet family of Jonas. The Lancet family of journals are publishing for free open access all the Covid-19 related papers. So it’s enough to just Google ADHD management, covid-19 Lancet and the document will be available for free via the Internet.
Interviewer: That’s great. Thank you. While we’re on the topic of COVID you’re also a lead researcher for the collaborative outcome study on health and functioning during infection times. The COH-Fit Study. This is the largest study into the mental and physical impact of Covid-19 on communities around the world. Can you tell us a bit more about this important study?
Prof. Sam Cortese: Yes. Thank you. So, yeah, I’m lucky to being involved in this very large study which is led by two colleagues. So, one in the United States and Germany. I actually worked both in the United States and German which is quite challenging, with Professor Christoph Correll who is an Adult, and also Child Adolescent Psychiatrist and the second colleague was the second PI in the study is Doctor Marco Solmi from the University of Padua, Italy. So quite close to my home town Verona.
So this is a large survey which includes more than 250 collaborators across the world and is across more than 100 countries and it is addressed both to others but also to children, adolescents and children aged 6 or more and I am an coordinating the section for the UK.
So the main purpose of these large survey is to understand, to better understand how people are coping during this challenging time and to find the possible risk, but also protective factors for mental and physical well-being. So I think that the survey in general it takes around 30 minutes to be completed and the version for children is simple and it takes around 15 minutes and the purpose is really to understand.
There is a quite a long questionnaire which covers basically all the aspects of psychopathology but also social well-being and the ultimate goal is really to inform guidance and future policy and practices in terms of really understanding how to strengthen the risk, the protective factors and to address the risk factors and to inform ultimately preventive strategies should another pandemic occur in the future.
Interviewer: And what’s the time scale on that study? When will there be some sort of…?
Prof. Sam Cortese: Yeah, so that’s an interesting question. Actually, we plan three waves. So one wave during the pandemic. Then the second wave after six month after the WHO declares the end of the pandemic and another wave 12 months after the WHO declares the end of the pandemic because we want to know also what’s going to happen after the pandemic.
The specific timeline it’s quite tricky because actually we don’t know exactly what’s going to happen and it’s possible that the situation may vary across countries. So another advantage of conducting the same survey across countries is that we have the same questions, so we will be able to also understand to which extent different ways of coping with the pandemic in times of governmental decisions and restrictions have influenced in a way the outcome.
So I guess that the main advantage because I guess everybody has seen a lot of surveys in these days, these weeks and I guess the unique aspect of this survey is really that it includes a large number of countries which makes possible these comparison. Also some individuals who may not be comfortable with the English language may access the translated version of Covid in their native language from other countries, and it is an anonymous survey and it is easily accessible via Internet.
So we think that it will generate a number of important data. So far 60,000 people have completed the survey. Unfortunately less than 800 from the UK. So we really need to do more. The reason is also because due to a delay with the Committee we started a little bit later compared to other countries, but I will want to really everybody to complete this questionnaire.
It is not addressed to any particular sub-group of the population. It’s open to everyone but we are of course particularly interested in vulnerable sub-groups like children and people, individuals with mental or physical conditions but it is open to everybody.
Interviewer: And to access that could one just Google COH-FIT?
Prof. Sam Cortese: Sure. Yeah. It’s www.coh-fit.com with a hyphen after the H. COH-Fit. Yeah.
Interviewer: Yeah. COH-fit.
Prof. Sam Cortese: Yeah.
Interviewer: Great. Sam, what else are you currently researching that excites you?
Prof. Sam Cortese: Yeah, I think that a particular topic of interest now is really the relationship between mental and physical health conditions. Not only then ADHD but across a number of disorders and the reason I think why I’m quite excited about this is because I think that from the scientific point of view, understanding the links between mental and somatic or physical conditions may allow us to better understand the causes and the pathophysiology of mental conditions and also from a clinical point of view. I think that it doesn’t really make sense to split these two aspects.
I think that sometimes as psychiatrists we tend to focus just on the mental aspects. We look just our patients, just you know, the brain and the mind but they are really important connections between mental and somatical aspects. A comprehensive management may be really needed. I’m thinking for instance when I started with this topic I was particularly interested, for instance, on the relationship between ADHD and obesity which was a relation that seemed quite odd at the beginning because people thought well actually these children move a lot.
So, you know, they they should be thin, rather than overweight. When we look at the average weight and the prevalence of obesity in individuals with ADHD this is higher than the average individuals without ADHD.
This does not mean of course that everybody with ADHD is overweight but means that if you have ADHD you are more likely to become, to present with overweight or obesity, and this is very important for the management of these individuals because, for instance, it has been shown that if you treat ADHD in individuals with obesity where ADHD had never been diagnosed, if you treat it correctly this may have also a positive impact on a weight reduction.
So it’s really important to improve the global outcome of the individual, and then from there I started to move, I moved to other disorders and now I’m leading a larger scale project which really aims to understand better the connection between a large number of mental condition and the large number of somatic or physical conditions and I think that this will be informative for future research but also in terms of clinical practice.
Interviewer: Yeah. It’s a really fascinating area. Sam, you’ve got many hats. One of them is you are the Associate Editor of CAMH. The journal recently celebrated its 25th birthday. I’m just wondering what the highlights have been for you so far in that particular role.
Prof. Sam Cortese: Yes. Yeah I was very pleased when I was compacted. It was in 2018 by the Chief Editor to act as an Associate Editor for the journal with a specific focus on the area of systematic reviews and meta-analysis. So basically I manage the papers, the systematic review and meta-analysis that are submitted to the journal, and I think that it is fair to state that since then CMH has strengthen the methodological rigor and the quality of the papers accepted for publication.
In relation more specifically the thing to the section systematic reviews and meta-analysis I think we have introduced more rigorous requirements, so that we ask all those to adhere to the recommendations for the conduct and reporting of high quality systematic news and meta-analysis in the field.
So we I think we contribute to really increase the rigor, the methodological rigor of the journal.
Interviewer: CAMH is lauded for helping practitioners convert evidence into practice. So what makes it so successful at this?
Prof. Sam Cortese: I think it’s really a balance I would say between, as I said, methodological rigor but also, you know, clinical focus. So CAMH is a journal which really speaks the language I think of practitioners. The problem I think and, you know, I’m on the editorial board of other Jonas and I spent quite a lot of time reading papers from different journals.
I think that nowadays there are studies which are so complex based on such a complex and methodology that sometimes and clinicians who don’t have a particular academic or research angle struggle understanding really, what does this paper mean and what the findings where.
I think that CAMH is unique in that because, yes as I mentioned it speaks the language of clinicians. Quite clinical friendly, but at the same time it is based on a strong evidence base focus and methodological rigor. So I think it is one of the ideal resources for busy clinicians because of course nowadays everybody is very busy. So they need something which… They need to make choices and I think that CAMH is really a fundamental resource for everybody working in the field of child and adolescent mental health.
Interviewer: Sam in an age where so much unregulated material can be accessed what more can be done to promote evidence-based science in your view?
Prof. Sam Cortese: Well I think that first of course it’s important to continue implementing and supporting journals like CAMH who really provide a balance between methodological rigor and evidence-based, but probably this is not enough to reach a large number of colleagues. So I think it’s also important to do what ACAMH as an association is doing to provide digest and summaries and interviews on this content and to make this content available for free when possible, because one of the main problems is really the access to these resources and academics have the luxury, so to speak, that they’re able to access because they can rely on, you know, accounts paid by their libraries of their University but number of clinicians don’t have this chance.
So I guess it’s really important to provide additional, alternative ways of accessing and not only the standard, the usual paper. So, you know, podcasts like this, webinars these are really important resources and actually, I mean, I got to know the first podcast where I go to know about you actually.
I remember I was listening in my car going to work because. I mean I live in Winchester and I work in Southampton which is roughly 20, 25 minutes by car, and I thought it’s going to make good use of this time in my daily life. So I think I started listening to podcasts during my trip to to work. So I think that this is really important and of course these tools can also be implemented in a more formal way, such as CPD groups, CPD discussions. So I think that we are really looking forward to a different way of acquiring knowledge.
Interviewer: Especially for the people when they’re, as you say, time strapped really.
Prof. Sam Cortese: Indeed, indeed.
Interviewer: Sam, what else is in the pipeline for you that you’d like to mention?
Prof. Sam Cortese: Well when thinking of the future, I think that what really I’m interested in is anything which is around prediction because, I mean, arguably the most important thing as researchers and clinicians we want to know is not about the past. It’s about the future.
So if I treat a patient will the patient respond to this treatment, and if I see a patient now how will this patient be in five years time? So I think science of prediction is very interesting and is being implemented in psychiatry and hopefully progressively more also in child and adolescent psychiatry and psychopathology.
In fact when I think back on my researches so far, as we mentioned earlier, I publish, we publish quite a lot of meta-analysis. So that evidence centres of, you know, what is the state of the art of our knowledge, for instance, the efficacy or tolerability of treatments. The problem with this quite standard approach is that this provides the results which are true at the group level.
So in other terms we say, you know in this methodology we found for instance, I don’t know, and finding it was the most efficacious or the best tolerated medication in children or amphetamines were the most efficacious in children with ADHD. This is true at the group level. So these are averages but when I see a patient I don’t see a group level patient. I see an individual patient with their own specificities.
So we can we can use quite advanced meta-analytic and evidence synthesis method to get insight on efficacy, effectiveness, tolerability of medication at the individual level. So this will entail a lot of work and collecting large data sets and we also entail a change in mind-set in how we do research much more based on sharing data, because we cannot do this just based on one single data set from a lab.
We really need to access larger data sets, but I think that these should be the goal and I think probably will be the main goal of my future activity for the next year because we really need to provide the best treatment and an individual lab. This is what we call Precision Psychiatry basically.
Interviewer: Thank you, and finally Sam what is your takeaway message for those listening to our conversation?
Prof. Sam Cortese: Well I think that if they were able to listen in these is a really good start because actually as I said I’m a clinician myself and I know how busy clinicians are under pressure. I will say that despite this everybody surely find the time to stay abreast and to update their knowledge in the main areas in terms of child adolescent mental health.
So I would say that we should really find the time to look at the best evidence and a good way is really to look at evidence synthesis of papers, which really provides a comprehensive overview and do have a link to the clinical practice. Unfortunately there are a lot of papers that seems more theoretical exercise out there, rather than you release a tool which is really helpful for practitioners, but thanks to the work of Jonas, like CAMH Association, like ACAMH clinicians are really able to access the best evidence in a relatively short period of time and, you know, to inform their clinical practice.
So this will be my first take on message. The second one I think that as a clinical academic my role is to really, to bridge the gaps between the academic and the clinical world and it looks like the action always start from academics. So academics want to know what clinician thinks, but I will say that clinicians could be more proactive in highlighting what they think are the main research priorities because this will be extremely helpful to academics.
So we really need to bridge these gaps and everybody needs to play a crucial role in this process.
Interviewer: Brilliant. Sam, thank you so much. Great to speak to you. For more details on Professor Sam Cortese please visit the ACAMH website www.acamh.org and Twitter at acahm.