Adults who do NOT have ADHD

[1edyfirel]

Hi, all--

I'm a new attending several months out of residency. I'm working right now in a purely outpatient setting for a large hospital center. Patients are privately insured and much higher-fxn than I'm used to from residency.

I feel like I'm going to burn out from seeing high-fxn people who have self-diagnosed ADHD and come to me for "ADHD evaluation." I did not see much ADHD in residency, and when I did, attendings were mainly focused on how to NOT give someone a rx for stimulants. That's it. Now it's a decent chunk of my intakes. I've been doing lots of reading myself over the past several months to better understand the dx and how to assess for it. I'm getting more and more confident when I DO make the diagnosis.

My question is: when you think someone does NOT have ADHD, how do you explain this to them?

I never saw this modeled for me, and I'm struggling with this and it's taking up too much emotional energy. My tactic right now is to talk about how ADHD is a neurodev disorder, about the criteria, how it doesn't appear to be causing major dysfunction, but I feel like I'm tripping over the words and just not that confident in it. (I should also clarify, pt doesn't meet criteria for ADHD OR an anxious or affective d/o. I'm seeing a lot of people who for example work in tech and are trying to attain cognitive perfection. If it looks like anxiety or something else contributes to their sx, I of course discuss that with them.)

So literally I'm asking you to virtually model for me what you say and how you explain why you think a person does NOT have ADHD. And also curious about any next steps you suggest for the patient. I tell people that they can always pursue a second opinion. I also mention neuropsych testing, but also tell them it's not necessary for a diagnosis and it's expensive.

And bonus question if you've made it this far: what does your ADHD assessment (other than in-depth clinical interview) look like? The self-reporting screens seem kinda useless to me, especially when a patient has already made the dx for themselves. Do you get collateral? Any screenings you DO find helpful?

Appreciate any insight. Thank you!!

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[adiradirim]

You can offer them executive functioning training if it's available in your area or they can find programs online. There's also a question about how much should psychiatrists participate in "functional enhancement" where you can prescribe "nootropics" despite the absence of a diagnosable psychiatric condition. I'm sure there is a "wellness clinic" in the area that would be happy to take them on for cash pay that you could refer them to.

The best collateral would be parents if they are available. You'd want to know behavioral patterns from young childhood including hyperactivity, ability to build/maintain routines without prompting, organizational skills, and other executive functioning from a young age. Sometimes people recommend school records, but that is likely impossible to get ahold of if they're older and would be difficult to go through. Parents would be able to let you know about any messages home from teachers about sitting still, paying attention, and following through with work.

You could consider getting collateral from their boss or significant other too about the actual amount of dysfunction.

I believe that most self assessments are pointless and people use "neuropsych testing" as a barrier to get patients to give up asking for stimulants.

 

[Merovinge]

I believe that most self assessments are pointless and people use "neuropsych testing" as a barrier to get patients to give up asking for stimulants.

I will say, this is a reasonable barrier to put up in some cases. You do get information from the testing itself that is relatively hard to game if its a competent neuropsychologist administering it (please god no more NP given TOVAs) and the people willing to go through this hoop clearly feel a lot stronger about their concern.

 

[erg923]

Hi, all--

I'm a new attending several months out of residency. I'm working right now in a purely outpatient setting for a large hospital center. Patients are privately insured and much higher-fxn than I'm used to from residency.

I feel like I'm going to burn out from seeing high-fxn people who have self-diagnosed ADHD and come to me for "ADHD evaluation." I did not see much ADHD in residency, and when I did, attendings were mainly focused on how to NOT give someone a rx for stimulants. That's it. Now it's a decent chunk of my intakes. I've been doing lots of reading myself over the past several months to better understand the dx and how to assess for it. I'm getting more and more confident when I DO make the diagnosis.

My question is: when you think someone does NOT have ADHD, how do you explain this to them?

I never saw this modeled for me, and I'm struggling with this and it's taking up too much emotional energy. My tactic right now is to talk about how ADHD is a neurodev disorder, about the criteria, how it doesn't appear to be causing major dysfunction, but I feel like I'm tripping over the words and just not that confident in it. (I should also clarify, pt doesn't meet criteria for ADHD OR an anxious or affective d/o. I'm seeing a lot of people who for example work in tech and are trying to attain cognitive perfection. If it looks like anxiety or something else contributes to their sx, I of course discuss that with them.)

So literally I'm asking you to virtually model for me what you say and how you explain why you think a person does NOT have ADHD. And also curious about any next steps you suggest for the patient. I tell people that they can always pursue a second opinion. I also mention neuropsych testing, but also tell them it's not necessary for a diagnosis and it's expensive.

And bonus question if you've made it this far: what does your ADHD assessment (other than in-depth clinical interview) look like? The self-reporting screens seem kinda useless to me, especially when a patient has already made the dx for themselves. Do you get collateral? Any screenings you DO find helpful?

Appreciate any insight. Thank you!!

Simultaneous "high functioning" and "disorder" is hard to reconcile....no? That may be the first talking point? You treat "disorders"...not variable or fluctuating aspects of functioning that can be explained by about 100 other, normal, life experiences.

The conversation I would model is very easy: "Look, not all "symptoms" need/warrant "medical" treatment. Some of this may just be life." Investigate psychosocial stressors and/or the presence of any other psychiatric disrtbuance from there...

It would be nice if there were a well validated set of attention tests that could identify who has ADHD and who does not. Sadly, no such battery of tests exists and probably never will. Although it is possible for researchers to learn quite a bit about ADHD from small-to-modest mean differences in test performance, attention tests do not improve individual diagnostic accuracy very much.

 

[erg923]

I will say, this is a reasonable barrier to put up in some cases. You do get information from the testing itself that is relatively hard to game if its a competent neuropsychologist administering it (please god no more NP given TOVAs) and the people willing to go through this hoop clearly feel a lot stronger about their concern.

I am ordering this procedure because I think "patient may be full of ****" is not going to be considered medically necessary" (nor should it), and may be considered an abrogation of your duties as a physician when said procedure is only being ordered for that purpose and has no other diagnostic discrinmatory value.

 

[PikminOC]

I am ordering this procedure because I think "patient may be full of ****" is not going to be considered "medically necessary" (nor should it), and may be considered an abrogation of your duties as a physician when said procedure is only being ordered for that purpose and has no other diagnostic discrinmatory value.

That's not what Ive found. The people who have gone thru the testing have been very happy they did it to learn about themselves.

 

[Merovinge]

I am ordering this procedure because I think "patient may be full of ****" is not going to be considered medically necessary" (nor should it), and may be considered an abrogation of your duties as a physician when said procedure is only being ordered for that purpose and has no other diagnostic discrinmatory value.

I'd say that's a slightly tainted and skeptic version of my post indicating in some cases it is worthwhile. I practice exclusively pediatric psychiatry, so outside of some very unusual situations I never use neuropsychologic testing for assistance with ADHD (although many of my patients benefit from learning about real learning disabilities they have). However, having trained through adult residency I absolutely understand there are cases where symptoms are apparently present, collateral is limited for assorted reasons, and have extra information is both medically necessary and the opposite of an abrogation of our duties. I know this is a hot button topic for you based on years of previous posts, so I'll leave this discussion there for the rest reading at home.

 

[Old&InTheWay]

This is why I support the legalization of "medical meth." You could get a card for any subtle cognitive difficulties and people could self-treat high functioning ADHD with stimulants they buy from the local amphetamine dispensary. "Teeth are too nice" would also be a qualifying condition.

 

[Stagg737]

This is why I support the legalization of "medical meth." You could get a card for any subtle cognitive difficulties and people could self-treat high functioning ADHD with stimulants they buy from the local amphetamine dispensary. "Teeth are too nice" would also be a qualifying condition.

Why not just tell them to go get some Kratom? It's basically a weak stimulant at lower doses anyway.

ETA: /s

 

[Alemo]

Why not just tell them to go get some Kratom? It's basically a weak stimulant at lower doses anyway.

I hope this is sarcasm. That’s some nasty **** and it can prompt what’s basically an opiate withdrawal syndrome.

 

[Alemo]

I’m only a PGY3, but that said I feel as if this is an area we’ve seen come up over and over again. My understanding is that collateral information is the most important source of information. As was said, it should be an enduring life long pattern Semi-objective markers like grades, inability to hold jobs or advance in them, or ability to read books or sit through movies are important. Do they forget things frequently? Are they late a lot? Are they annoying to their friends? Do they speak impulsively in conversation? Is there a family history?
The NNCI (national neuroscience curriculum) has a great video on the neurobiology of ADHD that reviews the symptoms. Some things we don’t always think about are the inability to switch attention from something, or mild hyperactivity (tics or repetitive motor behaviors?). Anxiety is the most common co-morbidity. Neuropsychological testing can be a “hurdle” but I suppose those with severe actual ADHD might not get the test performed. Trauma should be ruled out. I’ve found trauma related conditions to be the most difficult things to suss out from ADHD.

 

[clausewitz2]

Pragmatically doing a semi-structured interview seems to make it easier for people who are quite sure that all of their problems are the result of an amphetamine deficiency to accept that perhaps that's not the best solution. Probably makes it easier on both parties to be able to attribute some portion of the blame to a formal instrument, face-saving and less likely the person across from you is directly rejecting you or disbelieving you.

At the risk of becoming a totally broken record, sleep history is critical. A surprisingly large number of people come in to see me convinced they have ADHD and leave with a script for a sleep study, and wouldn't you know, when their sleep improves, they have a much easier time concentrating on things and are less distractible!

 

[futureapppsy2]

Neuropsych testing for ADHD will not give you valid/reliable data for diagnostic purposes. ADHD assessment should always include some collateral data (preferably related to childhood sx [parent, aunt, etc] but if that’s not available, at least get collateral reporting from a spouse, boss, etc).

 

[Stagg737]

I hope this is sarcasm. That’s some nasty **** and it can prompt what’s basically an opiate withdrawal syndrome.

Obviously. It can cause legitimate withdrawal and opiate-like OD symptoms as higher doses hit both Kappa and Mu receptors pretty hard. One of my medicine co-residents had a patient in the ICU who died of a Kratom OD and has had 1 or 2 other patients he's treated on inpatient medicine d/t excessive Kratom use. I've started asking all my patient on intake if they use Kratom and educated many more than I thought I would on it's effects which they are almost always shocked to hear about.

I’m only a PGY3, but that said I feel as if this is an area we’ve seen come up over and over again. My understanding is that collateral information is the most important source of information. As was said, it should be an enduring life long pattern Semi-objective markers like grades, inability to hold jobs or advance in them, or ability to read books or sit through movies are important. Do they forget things frequently? Are they late a lot? Are they annoying to their friends? Do they speak impulsively in conversation? Is there a family history?

I would not count the questions as hard factors, but they can score some brownie points towards an ADHD diagnosis if they positively report some of the lesser known symptoms adults tend to display. Those may include having difficulties retaining info during conversations because they're "waiting their turn" to speak so they don't forget what they were going to say, coming back to something in conversation which was moved on from 5-10 minutes earlier, non-linear circumstantiality to their thought processes which is observable during interview, or development of coping techniques which include excessive lists, alarms, or scheduled distractions to stay on task. Most commonly, those adults who come in requesting an ADHD eval who actually have it often come in after their child is diagnosed with ADHD and they realize that the questions described their childhood.

Collateral is still king though. I've typically found that when talking to family or friends of the patient about the above topics, those with true ADHD actually under-report how significant those symptoms are compared to what the collateral individual sees. I've had more than a few "omg, that's my spouse/child/whatever" when I start asking the collateral individual about specific aspects. I've also found that those with legit ADHD concerns are less insistent on stimulants and more willing to try Wellbutrin first to manage their symptoms.

 

[myPsychAlt]

Why not just tell them to go get some Kratom? It's basically a weak stimulant at lower doses anyway.

ETA: /s

Pt of mine gave himself a nice set of seizures after mixing Kratom and Adderall.

Then filed a complaint against me because I wouldn't Rx him his "life saving) adderall.

 

[VA Hopeful Dr]

Pragmatically doing a semi-structured interview seems to make it easier for people who are quite sure that all of their problems are the result of an amphetamine deficiency to accept that perhaps that's not the best solution. Probably makes it easier on both parties to be able to attribute some portion of the blame to a formal instrument, face-saving and less likely the person across from you is directly rejecting you or disbelieving you.

At the risk of becoming a totally broken record, sleep history is critical. A surprisingly large number of people come in to see me convinced they have ADHD and leave with a script for a sleep study, and wouldn't you know, when their sleep improves, they have a much easier time concentrating on things and are less distractible!

This shouldn't surprise anyone who has done residency

 

[clausewitz2]

This shouldn't surprise anyone who has done residency

And yet, it is so rare for me to see other psychiatrists in my system ask a single blessed question beyond establishing 'DFA/SCD/EMA'

 

[robellis]

And yet, it is so rare for me to see other psychiatrists in my system ask a single blessed question beyond establishing 'DFA/SCD/EMA'

What do these mnemonics stand for?

 

[clausewitz2]

What do these mnemonics stand for?

Difficulty falling asleep/ sleep continuity disturbance / early morning awakening

 

[Crayola227]

That's not what Ive found. The people who have gone thru the testing have been very happy they did it to learn about themselves.

Well so maybe the key here between the two viewpoints, is as often is the case, informed decision-making. Explaining to the patient the limits of the test, what its likely utility is/or is not, what you expect it to tell you guys, and the downside of the expense. If someone understands that you think the test is not necessary, but weighing the potential harms, it's something that you're willing to order to allow the patient some self-discovery if they want to pay for that, then I don't think it's unethical.

 

[tr]

I will say, this is a reasonable barrier to put up in some cases. You do get information from the testing itself that is relatively hard to game if its a competent neuropsychologist administering it (please god no more NP given TOVAs) and the people willing to go through this hoop clearly feel a lot stronger about their concern.

I think collateral from multiple informants is a better gatekeeping mechanism. Getting one's elderly parents to fill out a Conners-observer is a significant hoop and has the advantage of providing more clinically relevant information while also avoiding the waste of money and the neuropsychologist's time.

 

[VA Hopeful Dr]

And yet, it is so rare for me to see other psychiatrists in my system ask a single blessed question beyond establishing 'DFA/SCD/EMA'

Probably also why we seem to be under diagnosing sleep apnea

 

[Liquid8]

I would not count the questions as hard factors, but they can score some brownie points towards an ADHD diagnosis if they positively report some of the lesser known symptoms adults tend to display. Those may include having difficulties retaining info during conversations because they're "waiting their turn" to speak so they don't forget what they were going to say, coming back to something in conversation which was moved on from 5-10 minutes earlier, non-linear circumstantiality to their thought processes which is observable during interview, or development of coping techniques which include excessive lists, alarms, or scheduled distractions to stay on task. Most commonly, those adults who come in requesting an ADHD eval who actually have it often come in after their child is diagnosed with ADHD and they realize that the questions described their childhood.

Collateral is still king though. I've typically found that when talking to family or friends of the patient about the above topics, those with true ADHD actually under-report how significant those symptoms are compared to what the collateral individual sees. I've had more than a few "omg, that's my spouse/child/whatever" when I start asking the collateral individual about specific aspects. I've also found that those with legit ADHD concerns are less insistent on stimulants and more willing to try Wellbutrin first to manage their symptoms.

Have had very similar observations. The more subtle inattention features that aren't typically found on DSM criteria or common self report scales are invaluable, and less prone to being gamed. Similar detail on employment history, relationships and household chores, paying bills and shopping also offer good insights into potential disorganisation.

 

[birchswing]

I've said before, and maybe others have said it here, that I think it's possible ADHD could be undiagnosed until it's "met its match" in terms of the challenging material presented to that person. I said that because the OP mentioned seeing patients working in high tech fields. Is it not possible their intelligence superseded their penchant for fielding too much incoming data up until the data became too much?

Latent inhibition - Wikipedia

I guess it depends on what you consider normal and a derivation from normal for the processing of incoming data. But if the standard through the psychological tests is one particular way (and I don't know what that is), can you really know what it is if another measure, like intelligence, is compensating for it? If you're only testing overall performance (again I don't know what's on the tests--but say recall from a story), you're looking at overall functioning more than a specific deficit. And overall functioning might result from very high strength in one area and weakness in another to average out?

 

[clausewitz2]

Have had very similar observations. The more subtle inattention features that aren't typically found on DSM criteria or common self report scales are invaluable, and less prone to being gamed. Similar detail on employment history, relationships and household chores, paying bills and shopping also offer good insights into potential disorganisation.

Can't leave out making lists for trips to the store or tasks and consistently losing them. Phenomenology, folks; systematically listen for and ask about the qualitative experiences that come along with various diagnoses and it gets a lot easier to pattern match and a lot harder to fake. If you have a robust enough knowledge of these sorts of subtle features the people who are going to be able to mislead you are usually the people who did experience whatever disorder at some point, cf. successful malingering of psychosis.

 

[Candidate2017]

My question is: when you think someone does NOT have ADHD, how do you explain this to them?

I used to do like you and give them the academic speech. But the hardcore stimulant seekers will persist. They will get their stimulants some way, somehow. With the persistent ones, I now explain in a minute or two then give them a list of other clinics from whom they can seek another opinion.

 

[watto]

I've said before, and maybe others have said it here, that I think it's possible ADHD could be undiagnosed until it's "met its match" in terms of the challenging material presented to that person. I said that because the OP mentioned seeing patients working in high tech fields. Is it not possible their intelligence superseded their penchant for fielding too much incoming data up until the data became too much?

Latent inhibition - Wikipedia

I guess it depends on what you consider normal and a derivation from normal for the processing of incoming data. But if the standard through the psychological tests is one particular way (and I don't know what that is), can you really know what it is if another measure, like intelligence, is compensating for it? If you're only testing overall performance (again I don't know what's on the tests--but say recall from a story), you're looking at overall functioning more than a specific deficit. And overall functioning might result from very high strength in one area and weakness in another to average out?

Sort of, kind of, parenthetically related, I just read this great study on Elite Cognitive Performers - people who are at the top end in executive functioning capabilities. They seemed to recruit frontal systems very well even when sleep-restricted IF they were presented with high salience / more interesting tasks, but things that required more rudimentary attention were negatively impacted by less sleep.

The effect of sleep restriction on cognitive performance in elite cognitive performers: a systematic review

AbstractStudy Objectives. To synthesize original articles exploring the effects of sleep restriction on cognitive performance specifically for Elite Cognit

academic.oup.com

 

[robellis]

Can't leave out making lists for trips to the store or tasks and consistently losing them. Phenomenology, folks; systematically listen for and ask about the qualitative experiences that come along with various diagnoses and it gets a lot easier to pattern match and a lot harder to fake. If you have a robust enough knowledge of these sorts of subtle features the people who are going to be able to mislead you are usually the people who did experience whatever disorder at some point, cf. successful malingering of psychosis.

How do you get such a good understanding of the subtle features? Too many just rely on the dsm...

 

[erg923]

How do you get such a good understanding of the subtle features? Too many just rely on the dsm...

I think that death happened long ago.

I like @clausewitz2post, but "subtle features" is probably not great phraseology here. The "schizophrenic float" (50s?) may just have been medication side effects, for example... right? And do we really want to go too far down the "subtle features" path here...lest we get to the watered down and horribly abused "Disruptive Mood Dysregulation Disorder" thing?

I would err on the side that while the DSM doesn't rule all...it IS there for a reason. As is the clause about "CURRENT" functional impairment. No one should be medicating an ADHD diagnosis just because the patient "had it" when they were in school a few years ago. Sometimes people can learn to compensate some of their cognitive/mental disabilities over time. Psychiatry doesn't have to medically treat them forever...

 

[meow1985]

Hi, all--

I'm a new attending several months out of residency. I'm working right now in a purely outpatient setting for a large hospital center. Patients are privately insured and much higher-fxn than I'm used to from residency.

I feel like I'm going to burn out from seeing high-fxn people who have self-diagnosed ADHD and come to me for "ADHD evaluation." I did not see much ADHD in residency, and when I did, attendings were mainly focused on how to NOT give someone a rx for stimulants. That's it. Now it's a decent chunk of my intakes. I've been doing lots of reading myself over the past several months to better understand the dx and how to assess for it. I'm getting more and more confident when I DO make the diagnosis.

My question is: when you think someone does NOT have ADHD, how do you explain this to them?

I never saw this modeled for me, and I'm struggling with this and it's taking up too much emotional energy. My tactic right now is to talk about how ADHD is a neurodev disorder, about the criteria, how it doesn't appear to be causing major dysfunction, but I feel like I'm tripping over the words and just not that confident in it. (I should also clarify, pt doesn't meet criteria for ADHD OR an anxious or affective d/o. I'm seeing a lot of people who for example work in tech and are trying to attain cognitive perfection. If it looks like anxiety or something else contributes to their sx, I of course discuss that with them.)

So literally I'm asking you to virtually model for me what you say and how you explain why you think a person does NOT have ADHD. And also curious about any next steps you suggest for the patient. I tell people that they can always pursue a second opinion. I also mention neuropsych testing, but also tell them it's not necessary for a diagnosis and it's expensive.

And bonus question if you've made it this far: what does your ADHD assessment (other than in-depth clinical interview) look like? The self-reporting screens seem kinda useless to me, especially when a patient has already made the dx for themselves. Do you get collateral? Any screenings you DO find helpful?

Appreciate any insight. Thank you!!

I have a whole algorithm. First, I tell people there can be a lot of "dead ringers" for ADHD and that when all other possible things are ruled out (depression, anxiety, PTSD, sleep problems, medical problems), what's left is likely ADHD. I also validate that there *is* a spectrum of severity and medicating ADHD is on some level about where you are vs where you want to be, but the medications are serious business (carry a lot of risk, have a lot of associated rules), so it's important to be darn sure that we've got the right diagnosis. If not used in the right person for the right reason, the meds can be addictive and cause other unnecessary harm.

^^almost exact words there

I do my usual psychiatric interview and for ADHD, I literally go through the criteria. I mentally rank them by "yes, always!" to "meh, maybe/sometimes," and "no, not really." Anything less than 5+ "yes, always!" leads me to say, "well, it's not a slam dunk, let's get more information." If there are 5+ yes, always! I say, "well, let's just confirm" with collateral. I also assess daily functional issues such as losing things and minor driving infractions.

I have them fill out an objective metric and have people who know they now and who knew them as kids fill it out. A lot of people with ADHD give really vague answers, that's just part of the presentation, so collateral and objective information is huge. I also send them for labs and if needed a sleep study.

If neither surveys nor interview are "slam dunks" but there's no other clear explanation, I may offer neuropsych testing as the "gold standard" for pick up mild ADHD. If they decline or get frustrated, I say, "look, if I felt it was the best thing to medicate this, I would. But with the way things are, I just don't feel that the benefits justify the risks."

Oh, and I almost always start with a non-controlled medication for ADHD such as bupropion or strattera. If there are any other contributing conditions, I treat those first. Stimulants are almost never on the table until all the info and rule-outs are in.

 

[robellis]

I have a whole algorithm. First, I tell people there can be a lot of "dead ringers" for ADHD and that when all other possible things are ruled out (depression, anxiety, PTSD, sleep problems, medical problems), what's left is likely ADHD. I also validate that there *is* a spectrum of severity and medicating ADHD is on some level about where you are vs where you want to be, but the medications are serious business (carry a lot of risk, have a lot of associated rules), so it's important to be darn sure that we've got the right diagnosis. If not used in the right person for the right reason, the meds can be addictive and cause other unnecessary harm.

^^almost exact words there

I do my usual psychiatric interview and for ADHD, I literally go through the criteria. I mentally rank them by "yes, always!" to "meh, maybe/sometimes," and "no, not really." Anything less than 5+ "yes, always!" leads me to say, "well, it's not a slam dunk, let's get more information." If there are 5+ yes, always! I say, "well, let's just confirm" with collateral. I also assess daily functional issues such as losing things and minor driving infractions.

I have them fill out an objective metric and have people who know they now and who knew them as kids fill it out. A lot of people with ADHD give really vague answers, that's just part of the presentation, so collateral and objective information is huge. I also send them for labs and if needed a sleep study.

If neither surveys nor interview are "slam dunks" but there's no other clear explanation, I may offer neuropsych testing as the "gold standard" for pick up mild ADHD. If they decline or get frustrated, I say, "look, if I felt it was the best thing to medicate this, I would. But with the way things are, I just don't feel that the benefits justify the risks."

Oh, and I almost always start with a non-controlled medication for ADHD such as bupropion or strattera. If there are any other contributing conditions, I treat those first. Stimulants are almost never on the table until all the info and rule-outs are in.

Wow, you guys are crazy strict..this is certainly not the norm where I practice and stimulants are certainly first line in many cases

 

[meow1985]

Wow, you guys are crazy strict..this is certainly not the norm where I practice and stimulants are certainly first line in many cases

Not us, just me. I'm sort of my clinic's resident ADHD expert, though. I don't shy away from the term "legal meth" in my discussions with patients, either. And you should see me enforce controlled medicine contracts.
I'd say the only reason why stimulants would be first line for me is if someone's literally unsafe due to their ADHD symptoms, or time is of the essence otherwise, such as the diagnosis *is* slam dunk and they're failing their classes.

 

[rjs2131]

Wow, you guys are crazy strict..this is certainly not the norm where I practice and stimulants are certainly first line in many cases

Agree with this...I’m a CAP but see young adults as well and if I have enough suspicion for ADHD, I’ll often trial a low-dose stimulant fairly early on in the process. Typically see some kind of response almost immediately and the risks are fairly low in someone with no SUD or cardiac history.

The benefits can be pretty impactful - if a stimulant can change someone’s quality of life and improve their ability to function, I prefer not to delay. Sure there’s the occasional patient who is drug-seeking but I haven’t seen this to be common at all in my practice.

 

[birchswing]

Agree with this...I’m a CAP but see young adults as well and if I have enough suspicion for ADHD, I’ll often trial a low-dose stimulant fairly early on in the process. Typically see some kind of response almost immediately and the risks are fairly low in someone with no SUD or cardiac history.

The benefits can be pretty impactful - if a stimulant can change someone’s quality of life and improve their ability to function, I prefer not to delay. Sure there’s the occasional patient who is drug-seeking but I haven’t seen this to be common at all in my practice.

This is what happened to me with my childhood psychiatrist. I unfortunately think a language barrier prevented him from gauging my reported response, which was in fact a drastic improvement (and no less after being abruptly taken off of Ativan for the week that I had a trial of Adderall). I wouldn't try a stimulant now, though, due to cardiac concerns. I think it was a huge missed opportunity and misdiagnosis. That week was the only time that I was able to finish an AP exam, and I got a 5 on each. It was incredible not having to flee—and this was off the Ativan. The others I never was able to stay for. I spent much of high school in hallways due to vocal ticcing and what I believe was misdiagnosed as "panic" and treated with benzodiazepines.

 

[meow1985]

Agree with this...I’m a CAP but see young adults as well and if I have enough suspicion for ADHD, I’ll often trial a low-dose stimulant fairly early on in the process. Typically see some kind of response almost immediately and the risks are fairly low in someone with no SUD or cardiac history.

The benefits can be pretty impactful - if a stimulant can change someone’s quality of life and improve their ability to function, I prefer not to delay. Sure there’s the occasional patient who is drug-seeking but I haven’t seen this to be common at all in my practice.

The problem is, even people without ADHD could benefit from a stimulant when faced with tasks they do not want to do. And people may not have a history of SUD... until they develop one. I've also seen many people with legitimate ADHD who get psychologically dependent on their adderall simply because it is so life-changing for them. But somehow no one feels this way about their bupropion or their lexapro, even if they describe significantly positive changes in their lives as a result of those meds. Why do we think that is, hmmm? No one has ever threatened my life or caused drama with my staff over their bupropion, either.

There are a lot of substance use disorders in my practice and community, hence the difference in approach. Also, just like OP, I get a lot of high functioning adults seeking enhancement.

If I have a high index of suspicion, they're healthy, and there aren't a lot of other things it could be, I'm like, "ok, let's try a non controlled option while we get collateral and basic labs. Once collateral is in, we can try controlled." If they're crashing their car due to ADHD, I'll start stimulants with collateral pending. It's usually a difference of a few weeks only. In fairly obvious clinical cases, I just get collateral to make sure the patient isn't making things up or a very good actor.

But OP asked about gray areas and mild cases, which is where a thorough evaluation is needed, and then a discussion of how, in your opinion, the risks of treatment do not justify the benefits... if that is in fact your opinion.

 

[birchswing]

Why do we think that is, hmmm?

Without even thinking about it, I read this in the Church Lady's voice (Dana Carvey, SNL).

 

[rjs2131]

The problem is, even people without ADHD could benefit from a stimulant when faced with tasks they do not want to do. And people may not have a history of SUD... until they develop one. I've also seen many people with legitimate ADHD who get psychologically dependent on their adderall simply because it is so life-changing for them. But somehow no one feels this way about their bupropion or their lexapro, even if they describe significantly positive changes in their lives as a result of those meds. Why do we think that is, hmmm? No one has ever threatened my life or caused drama with my staff over their bupropion, either.

There are a lot of substance use disorders in my practice and community, hence the difference in approach. Also, just like OP, I get a lot of high functioning adults seeking enhancement.

If I have a high index of suspicion, they're healthy, and there aren't a lot of other things it could be, I'm like, "ok, let's try a non controlled option while we get collateral and basic labs. Once collateral is in, we can try controlled." If they're crashing their car due to ADHD, I'll start stimulants with collateral pending. It's usually a difference of a few weeks only. In fairly obvious clinical cases, I just get collateral to make sure the patient isn't making things up or a very good actor.

But OP asked about gray areas and mild cases, which is where a thorough evaluation is needed, and then a discussion of how, in your opinion, the risks of treatment do not justify the benefits... if that is in fact your opinion.

This is one of those grey areas in our field - it really depends on how you practice. From my understanding, stimulant use for ADHD actually reduces the likelihood of SUD in the future (and many individuals with a SUD have untreated ADHD - I've come across several parents of children with ADHD who were just never diagnosed/treated).

Sure, there is a risk of a patient with no SUD starting a stimulant and developing a SUD...but I think this is pretty rare, especially in the controlled environment of doctor-patient where you have control over the type of stimulant and dose. If there is truly concern, there are plenty of longer-acting options that are less prone to abuse.

The point about people without ADHD potentially benefitting from a stimulant - definitely a consideration and makes for an interesting discussion. I'm sure there are people adamantly against "cognitive enhancement", but at the same time I wonder about what the actual harm is you are trying to prevent. If there is no substantial risk of arrhythmia/heart issues or someone developing a SUD, why the hesitation? Why not help someone perform a bit better at their job/school, be a bit more organized/focused for their family, feel more confident in themselves, etc etc? Obviously there are exceptions but in my experience, the pros generally outweigh the cons in this type of situation. If I can help someone function better and it would generally result in a positive impact on their life/relationships, I'm all for it.

 

[Stagg737]

I've also seen many people with legitimate ADHD who get psychologically dependent on their adderall simply because it is so life-changing for them. But somehow no one feels this way about their bupropion or their lexapro, even if they describe significantly positive changes in their lives as a result of those meds. Why do we think that is, hmmm? No one has ever threatened my life or caused drama with my staff over their bupropion, either.

To the bolded: would you stop someone's insulin because they became psychologically dependent on it because it is so life-changing? I realize this is pretty extreme hyperbole, but if a person legitimately has ADHD why would you take away a proven treatment because of psychological dependency has made life so much better? Especially when this is what the medication is supposed to do. This actually seems unethical to me and possibly breaking the standard of non-maleficence by with-holding a stimulant (assuming there's not another legitimate reason for discontinuation).

I actually have more than a couple of patients who feel the same way about their Bupropion as some patients feel about their stimulant. I've never been physically threatened, but I have had a few patients start crying/become labile when I talked about decreasing the dose or stopping it.

Stimulants for ADHD have the strongest evidence for treatment efficacy out of anything in our field, and while I understand the hesitation to prescribe them to someone with mild symptoms or a questionable diagnosis I don't understand the hesitancy to trial low-doses in those with moderate to severe cases without other contraindications.

How do you get such a good understanding of the subtle features? Too many just rely on the dsm...

To clarify one of my earlier statements, the subtle features are just hints and details that tell you that further examination is warranted or can help confirm your suspicions in patients who you're not sure about. They shouldn't be used as diagnostic criteria, just pieces that to see whether they fit into the puzzle or not. Like @erg923 said, the DSM criteria, while not perfect, does give a good basic set of criteria. I also agree that many patients with the more subtle features or just mild symptoms in general can benefit just as much from therapy and learning different skills than actually starting medications.

 

[sloh]

"The point about people without ADHD potentially benefitting from a stimulant - definitely a consideration and makes for an interesting discussion. I'm sure there are people adamantly against "cognitive enhancement", but at the same time I wonder about what the actual harm is you are trying to prevent. If there is no substantial risk of arrhythmia/heart issues or someone developing a SUD, why the hesitation? Why not help someone perform a bit better at their job/school, be a bit more organized/focused for their family, feel more confident in themselves, etc etc? Obviously there are exceptions but in my experience, the pros generally outweigh the cons in this type of situation. If I can help someone function better and it would generally result in a positive impact on their life/relationships, I'm all for it."

Out of curiosity, for those of you who practice psychiatry, is there really little downside to using stimulants for cognitive enhancement in those with no ADHD?

 

[clausewitz2]

Out of curiosity, for those of you who practice psychiatry, is there really little downside to using stimulants for cognitive enhancement in those with no ADHD?

1) Could make people have trouble sleeping
2) Can suppress appetite, a major concern if someone has a history of restricting-type eating disorder behaviors
3) Probably increased risk of mania in people with bipolar d/o iff it is monotherapy, if they are on some kind of mania prophylaxis registry data suggests this is not a real issue
4) Cardiac problems with certain kinds of arrhythmias
5) Possible diversion
6) Insurance is not going to pay for it without a very limited range of diagnoses being documented

They're not risk-free medications. They're not 100% benign and there are reasons not to be ultra-liberal with them. But quite honestly in terms of actual significant risks to the patient that are likely to happen neuroleptics are way worse.

 

[hallowmann]

I have a whole algorithm. First, I tell people there can be a lot of "dead ringers" for ADHD and that when all other possible things are ruled out (depression, anxiety, PTSD, sleep problems, medical problems), what's left is likely ADHD. I also validate that there *is* a spectrum of severity and medicating ADHD is on some level about where you are vs where you want to be, but the medications are serious business (carry a lot of risk, have a lot of associated rules), so it's important to be darn sure that we've got the right diagnosis. If not used in the right person for the right reason, the meds can be addictive and cause other unnecessary harm.

^^almost exact words there

I do my usual psychiatric interview and for ADHD, I literally go through the criteria. I mentally rank them by "yes, always!" to "meh, maybe/sometimes," and "no, not really." Anything less than 5+ "yes, always!" leads me to say, "well, it's not a slam dunk, let's get more information." If there are 5+ yes, always! I say, "well, let's just confirm" with collateral. I also assess daily functional issues such as losing things and minor driving infractions.

I have them fill out an objective metric and have people who know they now and who knew them as kids fill it out. A lot of people with ADHD give really vague answers, that's just part of the presentation, so collateral and objective information is huge. I also send them for labs and if needed a sleep study.

If neither surveys nor interview are "slam dunks" but there's no other clear explanation, I may offer neuropsych testing as the "gold standard" for pick up mild ADHD. If they decline or get frustrated, I say, "look, if I felt it was the best thing to medicate this, I would. But with the way things are, I just don't feel that the benefits justify the risks."

Oh, and I almost always start with a non-controlled medication for ADHD such as bupropion or strattera. If there are any other contributing conditions, I treat those first. Stimulants are almost never on the table until all the info and rule-outs are in.

I generally agree with this, but stimulants are first line. If they have real and non-mild ADHD, that should be tried. I've actually had crazy luck with Vyvanse as far as side effects and stability when its covered, but its often not.

The problem is, even people without ADHD could benefit from a stimulant when faced with tasks they do not want to do. And people may not have a history of SUD... until they develop one. I've also seen many people with legitimate ADHD who get psychologically dependent on their adderall simply because it is so life-changing for them. But somehow no one feels this way about their bupropion or their lexapro, even if they describe significantly positive changes in their lives as a result of those meds. Why do we think that is, hmmm? No one has ever threatened my life or caused drama with my staff over their bupropion, either. ...

I mean, the change is pretty dramatic for people with true ADHD. I will also say I have a handful of people that get pretty pissed at me over the potential of missing a day or so of their Wellbutrin. I do find it weird, but people become attached to meds that help them, which I think is fair.

As for SUD, know plenty of people with ADHD that developed SUD usually in the context of untreated ADHD. Its amazing the better choices people make when they're less impulsive and think about consequences, its why we treat them, right?

...I actually have more than a couple of patients who feel the same way about their Bupropion as some patients feel about their stimulant. I've never been physically threatened, but I have had a few patients start crying/become labile when I talked about decreasing the dose or stopping it.

Stimulants for ADHD have the strongest evidence for treatment efficacy out of anything in our field, and while I understand the hesitation to prescribe them to someone with mild symptoms or a questionable diagnosis I don't understand the hesitancy to trial low-doses in those with moderate to severe cases without other contraindications...

Agreed.

1) Could make people have trouble sleeping
2) Can suppress appetite, a major concern if someone has a history of restricting-type eating disorder behaviors
3) Probably increased risk of mania in people with bipolar d/o iff it is monotherapy, if they are on some kind of mania prophylaxis registry data suggests this is not a real issue
4) Cardiac problems with certain kinds of arrhythmias
5) Possible diversion
6) Insurance is not going to pay for it without a very limited range of diagnoses being documented

They're not risk-free medications. They're not 100% benign and there are reasons not to be ultra-liberal with them. But quite honestly in terms of actual significant risks to the patient that are likely to happen neuroleptics are way worse.

The bolded is absolutely true. We tend to obsess over prescribing certain meds because of the surveillance level that is mandated when in fact we prescribe plenty of horrible meds for people every day that are worse. The risk of potentially inappropriately starting an adult on a low dose long-acting stimulant for mild ADHD is unlikely to be as detrimental as misdiagnosing someone with substance induced psychosis with schizophrenia and starting them on antipsychotics for years, but the latter seems to happen way more.

 

[1edyfirel]

I have a whole algorithm. First, I tell people there can be a lot of "dead ringers" for ADHD and that when all other possible things are ruled out (depression, anxiety, PTSD, sleep problems, medical problems), what's left is likely ADHD. I also validate that there *is* a spectrum of severity and medicating ADHD is on some level about where you are vs where you want to be, but the medications are serious business (carry a lot of risk, have a lot of associated rules), so it's important to be darn sure that we've got the right diagnosis. If not used in the right person for the right reason, the meds can be addictive and cause other unnecessary harm.

^^almost exact words there

I do my usual psychiatric interview and for ADHD, I literally go through the criteria. I mentally rank them by "yes, always!" to "meh, maybe/sometimes," and "no, not really." Anything less than 5+ "yes, always!" leads me to say, "well, it's not a slam dunk, let's get more information." If there are 5+ yes, always! I say, "well, let's just confirm" with collateral. I also assess daily functional issues such as losing things and minor driving infractions.

I have them fill out an objective metric and have people who know they now and who knew them as kids fill it out. A lot of people with ADHD give really vague answers, that's just part of the presentation, so collateral and objective information is huge. I also send them for labs and if needed a sleep study.

If neither surveys nor interview are "slam dunks" but there's no other clear explanation, I may offer neuropsych testing as the "gold standard" for pick up mild ADHD. If they decline or get frustrated, I say, "look, if I felt it was the best thing to medicate this, I would. But with the way things are, I just don't feel that the benefits justify the risks."

Oh, and I almost always start with a non-controlled medication for ADHD such as bupropion or strattera. If there are any other contributing conditions, I treat those first. Stimulants are almost never on the table until all the info and rule-outs are in.

Thanks for this! A couple questions: 1) what objective metric do you use (and have friends/family use)? 2) how do you do collateral? Do you schedule a family visit? Do you call family? (Trying to figure out how I would work this into my workday/workweek.

 

[FlowRate]

ADHD is a huge proportion of my intakes. It bugs me a lot. I do my best to figure out if there's any other potential issue contributing and that's where I spend the majority of my time. Barring an alternative explanation, IMO there's miniscule ability to really differentiate ADHD from not in the adults who are convinced they have it. I certainly also have the "you've always been an excellent high performer" talk with the rare few who that applies to, especially the ones who are more open minded about not having the diagnosis. But the majority are in the uncomfortable gray zone of "Meh, maybe they have ADHD. I don't exactly have a convincing reason to say it's not ADHD." And the amount of time that would be required to do all kinds of collateral gathering would burn me out even more. Plus, do you really expect some 40 year old's 70 year old parent to accurately remember what their kid was like 30 years ago?

I think one of the underlying problems is that most of our diagnoses are really spectra. So how bad to you have to be at executive function to qualify for ADHD?

The other issue is that "ADHD" is probably serving some defensive/avoidant purpose for some.

 

[sloh]

Interesting post by Scott Alexander today:

"There's a lot of confusion around the difference between amphetamine and methamphetamine. On the one hand you have anti-psychiatry activists who will say that using Adderall for ADHD is exactly like giving kids crystal meth; on the other you'll have people who say that obviously normal amphetamine is okay, but meth-amphetamine is a demonic substance that will hijack your brain and destroy your life. The truth is more complicated."

Know Your Amphetamines

In the 1950s, a shady outfit called Obetrol Pharmaceuticals made a popular over-the-counter diet pill called Obetrol...

astralcodexten.substack.com

 

[clausewitz2]

ADHD is a huge proportion of my intakes. It bugs me a lot. I do my best to figure out if there's any other potential issue contributing and that's where I spend the majority of my time. Barring an alternative explanation, IMO there's miniscule ability to really differentiate ADHD from not in the adults who are convinced they have it. I certainly also have the "you've always been an excellent high performer" talk with the rare few who that applies to, especially the ones who are more open minded about not having the diagnosis. But the majority are in the uncomfortable gray zone of "Meh, maybe they have ADHD. I don't exactly have a convincing reason to say it's not ADHD." And the amount of time that would be required to do all kinds of collateral gathering would burn me out even more. Plus, do you really expect some 40 year old's 70 year old parent to accurately remember what their kid was like 30 years ago?

I think one of the underlying problems is that most of our diagnoses are really spectra. So how bad to you have to be at executive function to qualify for ADHD?

The other issue is that "ADHD" is probably serving some defensive/avoidant purpose for some.

It totally becomes an identity issue for some people. I have had a patient write me a long, angry email about how they "know" they have ADHD and demanding to be diagnosed with it even after a) we did a full ACE+ that wasn't all that close to meeting criteria and b) I was already prescribing them stimulants for an unrelated reason. If you're reasonably clever but have not lived up to expectations, whether those are yours or those of others, of course you want a medical label to explain why it's not your fault.

I don't mind doing ADHD intakes as such and am happy to prescribe appropriately, but I have a hard time justifying bringing a lot of these folks back more than q6 weeks at most, and it often seems to end up around every two months. What bugs me is that this is "see you a few times a year, barely get to know you" thing is not what I went into private practice for.

 

[Mass Effect]

Not us, just me. I'm sort of my clinic's resident ADHD expert, though. I don't shy away from the term "legal meth" in my discussions with patients, either. And you should see me enforce controlled medicine contracts.
I'd say the only reason why stimulants would be first line for me is if someone's literally unsafe due to their ADHD symptoms, or time is of the essence otherwise, such as the diagnosis *is* slam dunk and they're failing their classes.

Stimulants are considered first line for legit, diagnosed ADHD and they can be life-changing for people, even if they're not unsafe. Do you only prescribe SSRIs if the patient is suicidal? There's this fear of ADHD and stimulants in psychiatrists when ADHD is a legitimate psychiatric disorder and people for whatever reason refuse to treat it despite overwhelming evidence one has it, unless the patient's life is in shambles. I think this seems wrong.

I agree with @clausewitz2 . The goal is to rule out anything else that could be causing the symptoms (and sleep is very likely, which is why I make so many sleep referrals). I get collateral on those I can, but even if you can't, the diagnostic criteria is clear.

I also have a handful of older patients who don't have ADHD, but have cognitive difficulties for other reasons (MS, cancer) and in some cases, I might prescribe a low-dose stimulant. I go over risks of course and make sure they understand all that. But quality of life matters, imo.

 

[FlowRate]

If you're reasonably clever but have not lived up to expectations, whether those are yours or those of others, of course you want a medical label to explain why it's not your fault.

I don't mind doing ADHD intakes as such and am happy to prescribe appropriately, but I have a hard time justifying bringing a lot of these folks back more than q6 weeks at most, and it often seems to end up around every two months. What bugs me is that this is "see you a few times a year, barely get to know you" thing is not what I went into private practice for.

And during the pandemic it's often looking for an excuse/aid for working from home while also managing your kids who aren't in school. Working from home can be hard for lots of (otherwise normal) people, anyone who did it before the pandemic (I did for a year, 5 years ago) would tell you that. I think there's some expectation that it's the "new normal" and thus should be easy.

Agreed on that front, as well. Unless they have a really hard time tolerating stimulants, most are a couple of follow-ups and then I have no reason to see the pt again except to fulfill controlled sub prescribing requirements. It's maybe the one time I wish I had a midlevel I could use for all of the follow-ups and the mounting volume of monthly refill requests.

 

[VA Hopeful Dr]

And during the pandemic it's often looking for an excuse/aid for working from home while also managing your kids who aren't in school. Working from home can be hard for lots of (otherwise normal) people, anyone who did it before the pandemic (I did for a year, 5 years ago) would tell you that. I think there's some expectation that it's the "new normal" and thus should be easy.

Agreed on that front, as well. Unless they have a really hard time tolerating stimulants, most are a couple of follow-ups and then I have no reason to see the pt again except to fulfill controlled sub prescribing requirements. It's maybe the one time I wish I had a midlevel I could use for all of the follow-ups and the mounting volume of monthly refill requests.

You can always punt your stable ADHD patients back to us in primary care. Most of us will gladly take that, especially if you've done the evaluation and initial treatment parts.

 

[Mass Effect]

You can always punt your stable ADHD patients back to us in primary care. Most of us will gladly take that, especially if you've done the evaluation and initial treatment parts.

Most PCPs will and thank you for that. But I have run into some PCPs who insist prescription of controlled subs are beyond their scope of practice (we're talking highly educated, young MDs here) and will just put in another psych referral to some other psychiatrist. I had a PCP do this recently. The patient was a college student with ADHD dx since 3rd grade, taking Adderall XR 20 mg, tolerating fine, no issues. No co-mobridities. No hx of or present substance abuse. Patient was transitioning from peds to adult PCP and the adult PCP sent this patient to me for eval. I confirmed the diagnosis and sent back. PCP wants a psychiatrist to follow this patient just to refill.

 

[VA Hopeful Dr]

Most PCPs will and thank you for that. But I have run into some PCPs who insist prescription of controlled subs are beyond their scope of practice (we're talking highly educated, young MDs here) and will just put in another psych referral to some other psychiatrist. I had a PCP do this recently. The patient was a college student with ADHD dx since 3rd grade, taking Adderall XR 20 mg, tolerating fine, no issues. No co-mobridities. No hx of or present substance abuse. Patient was transitioning from peds to adult PCP and the adult PCP sent this patient to me for eval. I confirmed the diagnosis and sent back. PCP wants a psychiatrist to follow this patient just to refill.

Yeah that does happen sometimes, usually the young ones are pretty new grads full of "I'm going to save the world from evil controlled substances". That tends to get smoothed out with time.

That said, always have the patient call their PCP to make sure they're OK taking over.