Evaluating for ADHD?

[Dopamemes]

---

Members don't see this ad.

As someone who was diagnosed with ADHD in residency, I think the IQ testing really helped make the case. The first time I saw a psychiatrist, it was for depression during med school. ADHD wasn't even remotely on my mind (this was long before the Tik Tok ADHD fad, all I knew about ADHD was that hyperactive kids had it). The psychiatrist I saw at the time was a triple-boarder (psych/child psych/peds) and he was like, "listen, you're not really suffering from MDD. It's that you're struggling with med school because it's taxing you beyond your mental capability." He said he's pretty good at estimating IQ and estimated mine to be between 105 and 110 and that what was happening was a classic case of someone exceeding their academic potential and struggling with med school, thus leading to symptoms of depression. He rx'ed an SSRI, told me to just truck through pre-clinicals, and try to match FM.

Ngl, I legit came out of that convinced I was just dumb. Didn't take the SSRI and just struggled through pre-clinicals. Anki and a pre-made Anki deck is the only reason I passed pre-clinicals and even then, just barely. I did alright on Step 1, about 60th percentile, which was a massive relief because prior to finding that Anki deck, I highly doubt I would've gotten a passing score. Clinicals were a whole different ballgame and I did better there. Finally saw another psychiatrist as an intern when I started slipping up on documentation and making what looked like careless mistakes. I was literally sitting in didactics where the subject was ADHD and I remember thinking, "Wait, what? This isn't just describing everyone?" I still have a text from that day where I texted my wife, "Lol, they're literally just describing normal behavior and calling it ADHD." My wife was like.....no, they're describing you, not everyone. I had really good insurance that covered neuropsychological testing surprisingly (out-of-network at that!) so sought that out and came out with a clear diagnosis of ADHD, combined type. IQ came back as 144 and the neuropsychologist said that really explained how I'd made it as far as residency with what seemed outwardly like no impairment (there was plenty of impairment when he asked thorough clinicals questions, things I hadn't even considered).


Long story short, IQ testing is now what I consider the single most important test outside the clinical interview. I've seen it both ways. Patients with high IQs that explains how they compensated, at least academically, for ADHD. And patients with low IQs that explains why they're struggling (had a recent patient enrolled in a master's program who sought evaluation for ADHD, came back with an IQ of 82).

 

[oliversacks4thewin]

gotcha yeah I didnt see the actual forms that he completed but that makes sense to me thanks for the insight! Yeah this thread has made me think about the schema that different professions use when deciding what assessments to administer. When you do ADHD assessments do you normally give the full WAIS or just parts of it when trying to get a baseline of intellectual functioning and to rule out learning disorders?

Thank you so much for taking the time to respond to my inquiry. I am even more perplexed by the psychologist decision to administer this assessment and the Vanderbilt as many of the questions are verbatim duplicative, as they map quite nicely onto the DSM-5-TR criterion. It seems like a bit of a waste of time for both patient and evaluator to ask the same question twice and really difficult to diagnostically reconcile, if the answers are conflicting.

In my mind its a bit like the following exchange:

Do you have inattention, Mr. Smith.

Yes.

But, really, really?

As for the comments on the value of IQ testing in these scenarios, I am reminded of discussions with my fellow physician colleagues about the dangers of "fishing expeditions" when engaging in diagnostic clarity questions. A relatively elevated ANA, when exploring the underlying etiology of a patient presenting with headache symptoms, can lead to a whole host of other additional labs, appointments, unhelpful treatments, and ultimately overshadow the important part of the patient's presenting story, which may be as simple as lack of hydration. In a very similar vein, why do I need additional data points that can cloud or lead to diagnostic overshadowing, when the goal is to determine the underlying root cause and or presenting symptoms of concerns related to ADHD?

 

[WisNeuro]

Thank you so much for taking the time to respond to my inquiry. I am even more perplexed by the psychologist decision to administer this assessment and the Vanderbilt as many of the questions are verbatim duplicative, as they map quite nicely onto the DSM-5-TR criterion. It seems like a bit of a waste of time for both patient and evaluator to ask the same question twice and really difficult to diagnostically reconcile, if they answers are conflicting.

In my mind its a bit like the following exchange:

Do you have inattention, Mr. Smith.

Yes.

But, really, really?

As for the comments on the value of IQ testing in these scenarios, I am reminded of discussions with my fellow physician colleagues about the dangers of "fishing expeditions" when engaging in diagnostic clarity questions. A relatively elevated ANA, when exploring the underlying etiology of a patient presenting with headache symptoms, can lead to a whole host of other labs, appointments, unhelpful treatments, and ultimately overshadow the important part of the patient presenting story, which may be as simple as lack of hydration. In a very similar vein, why do I need additional data points that can cloud or lead diagnostic overshadowing, when the goal is to determine the underlying root cause and or presenting symptoms of concerns related to ADHD?

In my experience, for psychologists/neuropsychs who do a huge amount of testing (for ADHD and other things) they do seem to be fishing. Essentially, making sure they get some disparate findings that can point out, all the while disregarding data points that don't fit with the narrative that they came in with, in doing their evaluation.

 

[oliversacks4thewin]

@oliversacks4thewin This recent article may be interesting to you:

Prescription Stimulant Use, Misuse, and Use Disorder Among US Adults Aged 18 to 64 Years

This cross-sectional survey study examines the prevalence of prescription stimulant use, misuse, and use disorder among US adults aged 18 to 64 years.

jamanetwork.com

Thank you so much for this! I always love reviewing the literature directly and really appreciate you taking the time to pass this along. As I exist more in the pediatric realm, I'll confess I tend to focus my consumption of literature more towards that population. I'll admit, I glanced over this quickly in-between a busy clinical schedule (as evidenced by my multiple typos and syntax errors I later have to edit throughout this forum lol) and wanted to make sure I came away with the same impressions as the authors intended. I'll have to spend some more time with the article but I saw that there was quite a bit of mention of personal misuse of their own stimulants and less robust evidence or reports of diversion, correct?

 

[R. Matey]

Thank you so much for taking the time to respond to my inquiry. I am even more perplexed by the psychologist decision to administer this assessment and the Vanderbilt as many of the questions are verbatim duplicative, as they map quite nicely onto the DSM-5-TR criterion. It seems like a bit of a waste of time for both patient and evaluator to ask the same question twice and really difficult to diagnostically reconcile, if the answers are conflicting.

If there are differences between say a structured interview and what a patient marks on a narrow band rating scale, you can just ask them about it. Low intra-rater reliability can sometimes lead to interesting conversations about a patient's perception of ADHD symptoms. Not a bad way to get at the source of potential measurement error.

 

[Chromium Surfer]

Thank you so much for taking the time to respond to my inquiry. I am even more perplexed by the psychologist decision to administer this assessment and the Vanderbilt as many of the questions are verbatim duplicative, as they map quite nicely onto the DSM-5-TR criterion. It seems like a bit of a waste of time for both patient and evaluator to ask the same question twice and really difficult to diagnostically reconcile, if the answers are conflicting.

In my mind its a bit like the following exchange:

Do you have inattention, Mr. Smith.

Yes.

But, really, really?

As for the comments on the value of IQ testing in these scenarios, I am reminded of discussions with my fellow physician colleagues about the dangers of "fishing expeditions" when engaging in diagnostic clarity questions. A relatively elevated ANA, when exploring the underlying etiology of a patient presenting with headache symptoms, can lead to a whole host of other additional labs, appointments, unhelpful treatments, and ultimately overshadow the important part of the patient's presenting story, which may be as simple as lack of hydration. In a very similar vein, why do I need additional data points that can cloud or lead to diagnostic overshadowing, when the goal is to determine the underlying root cause and or presenting symptoms of concerns related to ADHD?

No problem at all! I have enjoyed reading your comments and the insight you are sharing while balancing your busy clinic schedule 🙂

Just to clarify I dont think he took the Vanderbilt rating scale. From what I saw and then trying to look up what the acronyms meant my crude understanding of the the behavioral rating scales he completed were the following: The Behavior Rating Inventory of Executive Function - Adults (BRIEF-A), The BAARS-IV: current symptom and childhood symptom forms ( thanks to you and Rmatey for clearing up how the adult form also has questions about childhood), Conners Adult ADHD rating scale, Wender Utah Rating scale and also GAD-7, PHQ-9 scales.

 

[oliversacks4thewin]

To respond to both above statements.

@R. Matey, I totally agree and will often do so during my assessments, as I agree, it can lead to some really illuminating evidence for/against diagnosis. My thought was moreso, why have a person answer the same objective question on two different pieces of paper, when they essentially read the same? If they did answer a certain question as a "2" on one form and a "3" on another form and this changed the overall significance factor, is this a factor that should be weighed? Is it more evidence of inattention, or due to reporting differences, or other external factors, as will be evidenced by my own next personal point to @Chromium Surfer? Does that not now require clinical judgement that could have been more readily assessed through interview, so why am I asking twice on the forms, that I now have to put into a report?

@Chromium Surfer, it is always a pleasure to discuss this, as I enjoy exchanges in training and clinical experiences, as ours have likely differed across a variety of different providers who have engaged in the discussed topic. You got me there on some inattention, which I attributed to a relatively busy schedule! While I was incorrect in stating the Vanderbilt, the Connors is very much also in the same line of asking face-valid questions consistent with criterion of the DSM-5-TR. It's made me chuckle multiple times to hold up all 3 specific measures and say "hey...wait a second..." as they read very, very similar.

 

[Ceke2002]

In my experience, for psychologists/neuropsychs who do a huge amount of testing (for ADHD and other things) they do seem to be fishing. Essentially, making sure they get some disparate findings that can point out, all the while disregarding data points that don't fit with the narrative that they came in with, in doing their evaluation.

I must admit I have always wondered if all of the extra tests and stuff that were done when I got a diagnosis as an adult in the late 90s were actually necessary, or whether it was a case of ticking some arbitrary boxes for the State Health Department in order to get prescribing permission for Dexamphetamine. Not that I expected to just walk in and be handed a diagnosis, but it did seem like a bit of a three ring circus at times, with lots of repeating questions with slightly different wording. At one point I remember thinking, "Why do you keep asking me the same thing, are you trying to catch me out if I'm lying?"

The (very) little I remember from my childhood diagnosis didn't seem as involved as getting a diagnosis as an adult. Perhaps because at the time the treatment tended to be more behavioural modification and dietary changes rather than medication. Just surmising.

 

[Ceke2002]

gotcha yeah I didnt see the actual forms that he completed but that makes sense to me thanks for the insight! Yeah this thread has made me think about the schema that different professions use when deciding what assessments to administer. When you do ADHD assessments do you normally give the full WAIS or just parts of it when trying to get a baseline of intellectual functioning and to rule out learning disorders?

I would love to look into the history of diagnostic tests for ADHD, I really should set aside some time to do that. I can imagine the diagnostic test(s) for children would have changed significantly since my initial diagnosis in 1975, and like you said how then do different practitioners or professions decide which tests to administer? I can imagine there was a need for more comprehensive testing when it went from the comparative rarity of having a child assessed in the 1970s vs the flood of assessment requests in much later years.

 

[Mass Effect]

I think the concept of people going undiagnosed until their 40's and all parroting the same social media "examples" of (mild) deficit is a new phenomenon. Also, well controlled prospective studies showed that a significant chunk of people developed out of ADHD. It's all retrospective recall studies that are supporting the idea that it's a life-long illness for the majority.

So while the concept may not be new, the current cultural moment with explosion in demand for diagnosis and treatment in seemingly functional adults without a childhood history of diagnosis IS a new thing. It's led to a gargantuan rise in diagnosis and prescription of stimulant medications in adults, which may not be as risky as opioids but are not wholly benign.

The 40 yo of today was the 6 yo of the 80s, the time when hyperactive children were certainly treated while inattentive children fell through the cracks (the DSM didn't even recognize inattentive children until the 1980s; before that it was only hyperkinetic AKA hyperactive kids who met criteria), where corporal punishment was used to keep children in line in school and at home, where many children were lachkey kids.

So it's believable to me that there are many patients out there -- likely with inattentive type -- who got by without a diagnosis. No diagnosis doesn't mean no history.

I'll add my agreement that sending patients to a psychologist for eval is a cop-out. You are 100% capable of doing ADHD evaluations. If you choose not to, then it's a choice, and you have every right to make that choice But saying that you aren't able to as if it's something inherent in your profession or education, is false.

 

[Mass Effect]

I think more awareness via social media might be drive more people to the office, but it's a very debatable point whether people suffered in silence under different monikers (e.g., "ditzy", "dumb", "blond", "head in the clouds", "space cadet", "airhead", "scattered brain", "Absent minded") or the promise of performance enhancing drugs results in an significant uptick in malingering. My guess that likely both are true. ADHD as a category is catching wind similar to how multiple personality disorder or pediatric bipolar did in past eras likely due in part to the neurodivergence movement and the availability of social media. That makes my job harder because malingers don't like being told no (I've had a few yellers, but mostly people storm out), but it's also been a catalyst to some folks to who actually ADHD to finally get care or for others to get clarity on what's going on with them. All of that is separate from online pill mills, which do harm to patients and should be illegal.

This. Looking back, I knew many kids who were labeled "ditzy" or "airhead". Some of them may have been, but not all. The two I'm thinking of I knew really well. In retrospect, both likely had inattentive ADHD and it wasn't diagnosed.

 

[Mass Effect]

I'm not a fan of the M-F and PRN dosing of stimulants. I was trained specifically against this and my clinical experience supports that. People who "don't like" stimulants and want occasional stimulant use tend to be ones with questionable ADHD diagnoses. By definition, ADHD manifests itself and causes impairment in multiple domains. It makes no sense to then prescribe ADHD medication only during work hours or when someone is trying to get extra work then. That smells more of performance enhancement than ADHD.

I know there's a trend to downplay the morbidity and mortality of ADHD but the data is certainly out there. And that morbidity and mortality is not occurring Monday to Friday from 9am to 4pm. It's coming from increased fatal car accidents, it's missing doctor's appointments, it's relationships withering away, it's lack of exercise, it's eating junk food, etc.

I'm not sure what a "less cognitive demanding day" is, but if someone only has ADHD when sitting at a desk at work for 8 hours but not when they get home or on weekends, I strongly question whether they truly have impairment in multiple domains.

PRN dosing makes a lot of sense actually. You call it performance enhancing and yes it is, for someone with a performance deficit relative to their peers. Someone with ADHD has a deficit at baseline. That's the point. Not everyone has super severe ADHD, but it's serious enough that they would lose their job without it or their household would go to hell without it during the week, when they're working all day, having to shuttle the kids around, do the grocery shopping, pick up scripts for an elderly parent, and make dinner. This type of daily schedule may be difficult even in those without ADHD, but with ADHD, it's just undoable for them, so they take the med. But why should they be forced to take it on Saturday if they're just bumming around poolside or watching TV all day?

 

[Mass Effect]

What exactly do all of these tests do emotionally for you as a provider? It must be something big. Are you all subjecting people reporting depression to this? Do an H&P and treat the patient. Honestly....

Thank you for stating the obvious. This diagnosis brings out some of the weirdest things in our profession. The DSM spells out the criteria. It's in black and white, just as it is for every other disorder. Diagnostic tools, while helpful in cases where you just can't figure it out, should not be a barrier we put up because we're afraid to sign our name to a new diagnosis. If you're scared to prescribe because it's a controlled substance or just don't have the time to try to evaluate malingerers, then just choose not to evaluate for ADHD or choose to not prescribe controlled subs at all and refer out ADHD patients. But I can't justify making patients jump through a bunch of hoops and delay diagnosing for months or longer.

 

[comp1]

Stimulants are performance enhancing for nearly everyone regardless of whether they have ADHD or not. They might be slightly more performance enhancing for someone with a deficit compared to the average population, but the literature is not clear. They might be just as enhancing, relatively, for someone with superior functioning. Their illicit use in elite colleges tends to support this. Stimulants are not like insulin or even a SSRI. That's where the entire issue arises.

 

[Mass Effect]

I like having as much data as possible before putting someone on a daily schedule 2 drug. There's a big difference between someone coming in for depression and willing to start on an antidepressant vs someone coming in declaring they have ADHD (diagnosed by tiktok) and demanding amphetamines.

I mean, I terminate patients who come in demanding anything. But "having as much data as possible" is not only unnecessary, it's very rarely good care. Rule out for medical conditions, get collateral if available (and don't punish the patient if not available) and make the diagnosis based on the evidence. If you can't, then administer a test or maybe refer for neuropsych testing if absolutely necessary. But it shouldn't be the go-to for the majority of cases. We don't need a million dollar workup for ADHD.

 

[Mass Effect]

It is also almost impossible to malinger depression 30 hours a week surrounded by therapists and psychiatrists.

You clearly have no experience with the borderline wing of the PHP where I trained.

 

[Mass Effect]

This was my question. It's not like their partner is a dispassionate rater here.

In adult patients, collateral is usually limited. History should still be here though.

I agree the profile is suspect.

 

[Mass Effect]

Overall at least based on the initial responses I received, it seems like their experience is highly atypical which at least to me aligns with the collective shock we all had after they shared their diagnosis.

Those report cards account for the history. That does sound like ADHD in K-5 at least.

 

[Mass Effect]

I actually do know a high-achieving physician who was diagnosed with ADHD in their 50s. Despite being high achieving, their profile was textbook ADHD-PI in many ways (goes off on tangents, has to be frequently redirected in conversation, late to almost everything, took an entire sabbatical primarily to mass delete the 1000s and 1000s of unread emails from their inbox, has entire days where they sit in front of the computer and don’t do anything because they keep being distracted by anything and everything, etc) with a long history of seeking assessment/treatment for it because they were chronically distressed by their inability to consistently complete stuff with no one ever making a diagnosis other than “just need a new work style” and recommending behavioral stuff that the patient could never remember to do or plan enough to implement . In this case, I honestly do think them being legitimately genius-level intelligent played into it, as did being in a job where productivity is assessed less frequently (primarily academic research). Very extensive family history of adhd and consistent collateral dating back to childhood as well. Very unusual cause, though.

I've seen patients like this. It happens more often than this field would like to believe.

 

[Mass Effect]

4. Are they willing to try non-stimulant options? The only time I start stimulants in a new ADHD patient is if they can prove they've been previously (appropriately) diagnosed and treated with a reasonable stimulant dose. If patients aren't willing to try bupropion or atomoxetine before stimulants, that should be a major red flag. I've consistently (almost 100%) found that patients with legit ADHD are willing to try any medication option that may be helpful and are fine with trying non-stimulants to avoid the hassles with prescribing and shortages, cost, and side effects of stimulants. They're typically also forthcoming about positives of non-stimulant meds after trying them even if they don't feel the med is a magic pill that completely fixes.

Wait, wait, wait. Patients wanting the literal standard of care, first-line treatment for a medical condition is a red flag?!? I couldn't possibly disagree with this more if you lit me on fire and told me I had to. That's bonkers.

 

[Chromium Surfer]

Those report cards account for the history. That does sound like ADHD in K-5 at least.

Thanks for chiming inAfter looking at my other posts where I provided more context what were your overall thoughts and did anything else in my comments sound like ADHD? If it helps posts with relevant context were #65, 70, 89, 90, 95,106,

I've seen patients like this. It happens more often than this field would like to believe.

Would love to hear more about your experiences with this generally and what it looked like if you are comfortable sharing. Not sure how common it will be to encounter patients who were "high functioning but masking" and it would be nice to hear about other encounters people have had with people that fit into this crudely defined bucket. But I totally understand if you are not comfortable talking about past patient encounters.!

 

[docloufan]

Much of this whole thread's diagnosis debate comes down to a lack of perceived "availability" from a treating psychiatrist....whether this is emotional, (lack of) expertise, or actual time available. Right?

Either way, its bad, and doesn't speak well to the state of clinical psychiatry.

And statements like "Are they willing to try non-stimulant options? The only time I start stimulants in a new ADHD patient is if they can prove they've been previously (appropriately) diagnosed and treated with a reasonable stimulant dose" are just terrible. Terrible patient shifting burden there, right? What is this treatment decision/approach based on, anyway? You cant do this. You cant assume a prior diagnosis and/or assessment to base YOUR care plan on. Just cant do it. Full stop.

This is really not that complicated, folks. Comorbidity is common across ALL psychiatric diagnoses and the DSM has the "Not Otherwise Accounted for by" clause for a reason...in addition to criteria for ADHD (and some actual instruction on best-practice assessment for it). It's always, always, always, going to come down to a clinical judgment based on the whole of your training in psychiatry and psychology.

 

[Stagg737]

Wait, wait, wait. Patients wanting the literal standard of care, first-line treatment for a medical condition is a red flag?!? I couldn't possibly disagree with this more if you lit me on fire and told me I had to. That's bonkers.

Patients demanding and not just asking about stimulants when they haven't even been diagnosed or appropriately evaluated is the problem. My point was that if patients want a specific treatment vs improvement in their condition that should be a red flag and warrants further exploration, NOT that it's inappropriate to start stimulants for ADHD or

Much of this whole thread's diagnosis debate comes down to a lack of perceived "availability" from a treating psychiatrist....whether this is emotional, (lack of) expertise, or actual time available. Right?

Either way, its bad, and doesn't speak well to the state of clinical psychiatry.

And statements like "Are they willing to try non-stimulant options? The only time I start stimulants in a new ADHD patient is if they can prove they've been previously (appropriately) diagnosed and treated with a reasonable stimulant dose" are just terrible. Terrible patient shifting burden there, right? What is this treatment decision/approach based on, anyway? You cant do this. You cant assume a prior diagnosis and/or assessment to base YOUR care plan on. Just cant do it. Full stop.

This is really not that complicated, folks. Comorbidity is common across ALL psychiatric diagnoses and the DSM has the "Not Otherwise Accounted for by" clause for a reason...in addition to criteria for ADHD (and some actual instruction on best-practice assessment for it). It's always, always, always, going to come down to a clinical judgment based on the whole of your training in psychiatry and psychology.

To the bolded, I shouldn't have used hyperbole as there are some patients where it is fairly obvious from the first encounter that ADHD is almost certainly the primary diagnosis. This missed the underlying point again though. It's the point that adults coming in without a previous diagnosis or treatment history who have made it that far without prior treatment need careful examination like I assume you're suggesting. I'm not saying to rely on a previous diagnosis, but if they were evaluated as a child and can provide documentation of evaluations and successful treatment of a neurodevelopmental disorder in childhood then that carries weight and needs to be considered. It's only a part, granted a very important part if present, of the complete evaluation. To your last point, I loathe psychiatrists diagnosing ADHD in 20-30 minutes after just directly asking DSM criteria without fully evaluating symptoms and other causes. Pretty sure I've made that clear on this site multiple times, but can see why my previous statement would be taken the way you did.

 

[docloufan]

Patients demanding and not just asking about stimulants when they haven't even been diagnosed or appropriately evaluated is the problem. My point was that if patients want a specific treatment vs improvement in their condition that should be a red flag and warrants further exploration, NOT that it's inappropriate to start stimulants for ADHD or


To the bolded, I shouldn't have used hyperbole as there are some patients where it is fairly obvious from the first encounter that ADHD is almost certainly the primary diagnosis. This missed the underlying point again though. It's the point that adults coming in without a previous diagnosis or treatment history who have made it that far without prior treatment need careful examination like I assume you're suggesting. I'm not saying to rely on a previous diagnosis, but if they were evaluated as a child and can provide documentation of evaluations and successful treatment of a neurodevelopmental disorder in childhood then that carries weight and needs to be considered. It's only a part, granted a very important part if present, of the complete evaluation. To your last point, I loathe psychiatrists diagnosing ADHD in 20-30 minutes after just directly asking DSM criteria without fully evaluating symptoms and other causes. Pretty sure I've made that clear on this site multiple times, but can see why my previous statement would be taken the way you did.

I mean, ok.

I just cant get over the statement that you would not prescribe first-line treatment for ADHD unless there is prior diagnosis (and "proof" of such, whatever that means) AND treatment with the same agent in the past. This is beyond bizarre, not to mention crazy to openly admit. I mean, what value would you (as a trained Psychiatrist) even add to the equation in a scenario like that? I'm sure you are also aware that ADHD awareness is very, very young, and even now days, most kids diagnosed don't go thru any kind of real assessment that you will be able to scrutinized beyond their pediatrician visits. I think you are vastly overestimating MH assessment/treatment contacts in this country. Most kids just don't get them. Ever. Period. Sorry, but its gonna be hard to get out of the corner you painted yourself in with that statement. Although, I do think you backtracked a bit and said that you would indeed do your own assessment...which is obviously good.... and bare minimum.

I don't know any psychiatrist that asks questions out of the DSM to make ANY diagnosis (much less ADHD) and then calls it a day/done. But the avoidance of proper assessment for this diagnosis in particular does really get to me. And I don't really understand what this is fully about? Its an "availability" thing certainly...but I'm not buying that it's just about a lack of time.

 

[FlowRate]

I mean, ok.

I just cant get over the statement that you would not prescribe first-line treatment for ADHD unless there is prior diagnosis (and "proof" of such, whatever that means) AND treatment with the same agent in the past. This is beyond bizarre, not to mention crazy to openly admit. I mean, what value would you (as a trained Psychiatrist) even add to the equation in a scenario like that? I'm sure you are also aware that ADHD awareness is very, very young, and even now days, most kids diagnosed don't go thru any kind of real assessment that you will be able to scrutinized beyond their pediatrician visits. I think you are vastly overestimating MH assessment/treatment contacts in this country. Most kids just don't get them. Ever. Period. Sorry, but its gonna be hard to get out of the corner you painted yourself in with that statement. Although, I do think you backtracked a bit and said that you would indeed do your own assessment...which is obviously good.... and bare minimum.

I don't know any psychiatrist that asks questions out of the DSM to make ANY diagnosis (much less ADHD) and then calls it a day/done. But the avoidance of proper assessment for this diagnosis in particular does really get to me. And I don't really understand what this is fully about? Its an "availability" thing certainly...but I'm not buying that it's just about a lack of time.

That's not what he said. He said that his treatment approach is to generally ("almost always") start with non-stims unless someone is resuming prior treatment. This should be non-controversial (in adults, especially those without a prior diagnosis/treatment.) Although the title of this paper ends with "in primary care," I think it's a great concise review. https://chadd.org/wp-content/uploads/2021/02/combinepdf.pdf (the first paper in that giant PDF.)

It's not exactly my approach. When I get the absolute slam-dunk severe ADHD patients, I often start with stimulants, because their symptom reports include life- or livelihood- threatening examples and I want immediate response. For most of the mild-moderate inattentive-only highly subjective/neurotic cases, I usually start with one of the non-stims.

 

[Stagg737]

I mean, ok.

I just cant get over the statement that you would not prescribe first-line treatment for ADHD unless there is prior diagnosis (and "proof" of such, whatever that means) AND treatment with the same agent in the past. This is beyond bizarre, not to mention crazy to openly admit. I mean, what value would you (as a trained Psychiatrist) even add to the equation in a scenario like that? I'm sure you are also aware that ADHD awareness is very, very young, and even now days, most kids diagnosed don't go thru any kind of real assessment that you will be able to scrutinized beyond their pediatrician visits. I think you are vastly overestimating MH assessment/treatment contacts in this country. Most kids just don't get them. Ever. Period. Sorry, but its gonna be hard to get out of the corner you painted yourself in with that statement. Although, I do think you backtracked a bit and said that you would indeed do your own assessment...which is obviously good.... and bare minimum.

I don't know any psychiatrist that asks questions out of the DSM to make ANY diagnosis (much less ADHD) and then calls it a day/done. But the avoidance of proper assessment for this diagnosis in particular does really get to me. And I don't really understand what this is fully about? Its an "availability" thing certainly...but I'm not buying that it's just about a lack of time.

Flow responded fairly well to this already, but I pointed out that my previous statement was hyperbole and NOT how I actually practice. I've said plenty of times in this forum that I see some patients that you can tell after talking to them for 5 minutes that they almost certainly have ADHD. After talking to these patients for 90 minutes, I typically don't have a problem doing a trial of a low dose stimulant unless there's some other concern (heavy cannabis or other drug use, severe anxiety or depression needing priority, obvious drug seeking, etc).

This whole thread was started because of someone who has been high functioning and is now a med student or resident that no one really thought had ADHD suddenly getting a diagnosis. I wasn't clear, but for less obvious cases like the one in this thread that "proof", ie documentation of previous testing and treatment (yes, I ask patients to bring prior medical records if available, this should obviously be standard), can clarify things a lot. Also, many psychiatric conditions require more than one appointment to appropriately formulate and diagnose. You going to diagnose PDs on the first appointment without convincing collateral? If not, why would you be doing the same for neurodevelopmental disorders? Especially when they could easily be angling for an addictive substance? You really don't know any psychiatrists that don't just run through DSM criteria, diagnoses everything they hit criteria for and just treat off that? If you don't then you're extremely fortunate and I'd love to practice in your world.

As for your point about access, my outpatient clinic is a telehealth consult clinic for over half of a state. I'm literally one of 2-3 psychiatrists covering that entire area. Of the 3-4 CMHCs only one of them has an actual psychiatrist to my knowledge. The rest are NPs of varying competence which I know because the PCPs often refer their patients to me for a second opinion or guidance when the patients don't want more meds thrown at them for diagnoses they don't even know are correct. I've been doing this clinic long enough to know which NPs seem to have decent clinical intuition and which ones are terrible. So yea, not oblivious to the access issue in the least bit. I'm not saying that someone that wasn't assessed as a kid doesn't get care from me or that I won't prescribe stimulants. I'm saying that if they never got or needed treatment previously and their condition and dysfunction isn't obvious then we're not just evaluating for an ADHD diagnosis, we're assessing if they even need treatment at all, which we should be doing for ANY psych complaint.

 

[Merovinge]

That's not what he said. He said that his treatment approach is to generally ("almost always") start with non-stims unless someone is resuming prior treatment. This should be non-controversial (in adults, especially those without a prior diagnosis/treatment.) Although the title of this paper ends with "in primary care," I think it's a great concise review. https://chadd.org/wp-content/uploads/2021/02/combinepdf.pdf (the first paper in that giant PDF.)

It's not exactly my approach. When I get the absolute slam-dunk severe ADHD patients, I often start with stimulants, because their symptom reports include life- or livelihood- threatening examples and I want immediate response. For most of the mild-moderate inattentive-only highly subjective/neurotic cases, I usually start with one of the non-stims.

The CHADD folks are the generally awesome and often include the top pediatric psychologists and psychiatrics although I know Nassir Ghaemi certainly has a controversial flare to himself. I use that site to refer people to all the time (patients, parents, educators).

 

[Chromium Surfer]

Flow responded fairly well to this already, but I pointed out that my previous statement was hyperbole and NOT how I actually practice. I've said plenty of times in this forum that I see some patients that you can tell after talking to them for 5 minutes that they almost certainly have ADHD. After talking to these patients for 90 minutes, I typically don't have a problem doing a trial of a low dose stimulant unless there's some other concern (heavy cannabis or other drug use, severe anxiety or depression needing priority, obvious drug seeking, etc).

This whole thread was started because of someone who has been high functioning and is now a med student or resident that no one really thought had ADHD suddenly getting a diagnosis. I wasn't clear, but for less obvious cases like the one in this thread that "proof", ie documentation of previous testing and treatment (yes, I ask patients to bring prior medical records if available, this should obviously be standard), can clarify things a lot. Also, many psychiatric conditions require more than one appointment to appropriately formulate and diagnose. You going to diagnose PDs on the first appointment without convincing collateral? If not, why would you be doing the same for neurodevelopmental disorders? Especially when they could easily be angling for an addictive substance? You really don't know any psychiatrists that don't just run through DSM criteria, diagnoses everything they hit criteria for and just treat off that? If you don't then you're extremely fortunate and I'd love to practice in your world.

As for your point about access, my outpatient clinic is a telehealth consult clinic for over half of a state. I'm literally one of 2-3 psychiatrists covering that entire area. Of the 3-4 CMHCs only one of them has an actual psychiatrist to my knowledge. The rest are NPs of varying competence which I know because the PCPs often refer their patients to me for a second opinion or guidance when the patients don't want more meds thrown at them for diagnoses they don't even know are correct. I've been doing this clinic long enough to know which NPs seem to have decent clinical intuition and which ones are terrible. So yea, not oblivious to the access issue in the least bit. I'm not saying that someone that wasn't assessed as a kid doesn't get care from me or that I won't prescribe stimulants. I'm saying that if they never got or needed treatment previously and their condition and dysfunction isn't obvious then we're not just evaluating for an ADHD diagnosis, we're assessing if they even need treatment at all, which we should be doing for ANY psych complaint.

I assume that you are referencing my question about my cousin? I didnt mean to monopolize this thread haha. My understanding is that this thread started when an ouptaitnet psychiatrist asked about how to manage the uptick in ADHD eval requests and recommendations for how to improve their ability to diagnose ADHD. I really liked your thoughtful reply that shared a holistic approach to evaluation and thats going to stick with me, so thanks again!

 

[Ceke2002]

Patients demanding and not just asking about stimulants when they haven't even been diagnosed or appropriately evaluated is the problem. My point was that if patients want a specific treatment vs improvement in their condition that should be a red flag and warrants further exploration, NOT that it's inappropriate to start stimulants for ADHD or

Pfft, amateurs. 😏

But seriously drug seekers who are a little more educated in what they're doing can be a lot harder to spot, so I wouldn't blame any physician for adopting an abundance of caution in these sorts of situations (provided of course it didn't mean care for legitimate patients suffered).

 

[FatherPsychiatry]

The CHADD folks are the generally awesome and often include the top pediatric psychologists and psychiatrics although I know Nassir Ghaemi certainly has a controversial flare to himself. I use that site to refer people to all the time (patients, parents, educators).

Funny catching up on this thread while I had Substack opened in another window, and I follow Dr. Ghaemi's Substack. Sort of interesting he is on that paper about diagnosing ADHD in primary care, whereas he himself does not believe ADHD is a valid diagnosis.

See his comment here

What am I excited about in psychiatry, and not excited about

A brief interview at the APA meeting in LA last week

ghaemi.substack.com

 

[comp1]

Practically everything Dr. Ghaemi has ever written would generate a thread this long. He doesn't like the DSM and he doesn't like psychedelics, so it's not surprising he doesn't like ADHD (as a concept) or stimulants.

 

[Merovinge]

Funny catching up on this thread while I had Substack opened in another window, and I follow Dr. Ghaemi's Substack. Sort of interesting he is on that paper about diagnosing ADHD in primary care, whereas he himself does not believe ADHD is a valid diagnosis.

See his comment here

What am I excited about in psychiatry, and not excited about

A brief interview at the APA meeting in LA last week

ghaemi.substack.com

Yup as I mentioned other than Dr. Ghaemi, most of the CHADD contributors are rock solid. Dr. Ghaemi is a just another topic onto himself. Spent like 1/2 an hour discussing him and his history at a meet-and-greet one of the days of APA this year.

 

[FlowRate]

Funny catching up on this thread while I had Substack opened in another window, and I follow Dr. Ghaemi's Substack. Sort of interesting he is on that paper about diagnosing ADHD in primary care, whereas he himself does not believe ADHD is a valid diagnosis.

See his comment here

What am I excited about in psychiatry, and not excited about

A brief interview at the APA meeting in LA last week

ghaemi.substack.com

I mean, if I'm following the links correctly, he doesn't think most diagnoses are valid. And he has a point. Hence RDOC's attempt to come up with a more valid conceptual framework to study.

 

[Stagg737]

I assume that you are referencing my question about my cousin? I didnt mean to monopolize this thread haha. My understanding is that this thread started when an ouptaitnet psychiatrist asked about how to manage the uptick in ADHD eval requests and recommendations for how to improve their ability to diagnose ADHD. I really liked your thoughtful reply that shared a holistic approach to evaluation and thats going to stick with me, so thanks again!

No need to apologize, we're all here to share and learn. Glad I could be helpful and hopefully I was more clear with some of my other responses. For PCPs, being able to handle the obvious cases and knowing basic treatments and what reasonable treatment is (ie, starting low dose stimulants or non-stimulants and not jumping straight to Adderall IR 30mg TID) should be the goal.

 

[Merovinge]

No need to apologize, we're all here to share and learn. Glad I could be helpful and hopefully I was more clear with some of my other responses. For PCPs, being able to handle the obvious cases and knowing basic treatments and what reasonable treatment is (ie, starting low dose stimulants or non-stimulants and not jumping straight to Adderall IR 30mg TID) should be the goal.

But have you seen the patient satisfaction scores for the folks who have all patients in Adderall 30mg TID and Xanax 2mg TID?!

When I was in med school I worked with a PCP who was known for being sympathetic to all his patients, would see patient's come limp with a cane into his office to get Oxy 10mg QID, no utoxes, no pill checks, no required improvement in functional status, and one day I left to go to my car for lunch when the same patient was just casually strolling through the parking lot spinning the cane in her hand. He was a very nice human being, but man does that stick with you as a MS3.

 

[Just D.O. it]

irrational fear of being ensnared in a DEA investigation

Not irrational. If you run a high productivity practice that generates above whatever they define as average or reasonable in the area, and also happen to write controlled substances (even if the two are unrelated). There is an extreme burden on you to prove your innocence. Unlike criminal charges, Uncle Sam does not need to prove you guilty beyond a reasonable doubt to restrict your prescribing, your license, or your ability to bill insurance.

 

[Stagg737]

But have you seen the patient satisfaction scores for the folks who have all patients in Adderall 30mg TID and Xanax 2mg TID?!

When I was in med school I worked with a PCP who was known for being sympathetic to all his patients, would see patient's come limp with a cane into his office to get Oxy 10mg QID, no utoxes, no pill checks, no required improvement in functional status, and one day I left to go to my car for lunch when the same patient was just casually strolling through the parking lot spinning the cane in her hand. He was a very nice human being, but man does that stick with you as a MS3.

Oh come on, we both know that starting high doses of stimulants is irresponsible unless you're also starting Xanax at least 1mg TID or they're already on an unopposed benzo to maintain their stimulant/benzo balance. /s

Your point is another reason I don't hand out stimulants to anyone who "meets criteria" for ADHD though. I've encountered some pretty impressive malingerers, and when we're talking about meds that are easily abused, potentially very dangerous, and have street value it's worth being cautious about who we're giving these meds to.

 

[clozareal]

Do you have a link to the study (that is accessible to lay persons to read)? Please and thank you. I'm on a medical studies reading binge at the moment. 🙂

Here is the study! Super delayed.

Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study - PubMed

The findings raise the possibility that adults presenting with the ADHD symptom picture may not have a childhood-onset neurodevelopmental disorder. If this finding is replicated, then the disorder's place in the classification system must be reconsidered, and research must investigate the...

pubmed.ncbi.nlm.nih.gov

 

[FlowRate]

But have you seen the patient satisfaction scores for the folks who have all patients in Adderall 30mg TID and Xanax 2mg TID?!

When I was in med school I worked with a PCP who was known for being sympathetic to all his patients, would see patient's come limp with a cane into his office to get Oxy 10mg QID, no utoxes, no pill checks, no required improvement in functional status, and one day I left to go to my car for lunch when the same patient was just casually strolling through the parking lot spinning the cane in her hand. He was a very nice human being, but man does that stick with you as a MS3.

I've posted about this before, the correlation between benzo And/Or stimulant prescribing rate and press ganey scores is pretty high in our practice. The number I posted before was too high (I accidentally had the "set to origin" flag active in excel at the time) but IIRC it's something like R^2 of 0.4-0.5, which is still pretty darn high. There seems to be a strong threshold effect where no one with less than X rate (about 20%) is in the top half of press ganey scores. And when the spread from 0%ile press ganey to 100%ile press ganey is like 20% of respondents not giving you top marks on everything, it's understandable that having a higher rate of "appropriate no" patient encounters can quickly lead to enough not-extremely-positive survey responses to tank your relative patient satisfaction ranking.

(We don't take PG scores alone all that seriously, it's one small component of many factors used to evaluate physicians.)

 

[Stagg737]

Here is the study! Super delayed.

Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study - PubMed

The findings raise the possibility that adults presenting with the ADHD symptom picture may not have a childhood-onset neurodevelopmental disorder. If this finding is replicated, then the disorder's place in the classification system must be reconsidered, and research must investigate the...

pubmed.ncbi.nlm.nih.gov

There are some major problems with that paper's methods. The childhood diagnoses were made using criteria from the DSM-III vs adult diagnoses made use criteria for DSM-V, which are quite different. From the study's supplemental material:

"DSMIII diagnosis of childhood Attention Deficit Disorder with Hyperactivity (ADDH) required 8 symptoms (3 of 5 inattention symptoms, 3 of 6 impulsivity symptoms, AND 2 of 5 hyperactivity symptoms). ADD without hyperactivity could be diagnosed in children who lacked any symptoms of hyperactivity. Symptoms must onset before age 7 years. Reports from both parents and teachers were recommended.
DSM5 diagnosis of adult Attention Deficit /Hyperactivity Disorder (ADHD) required 5 symptoms (5 of 9 inattention symptoms or 5 of 9 impulsivity/hyperactivity symptoms). Several symptoms must onset before age 12 years. Several symptoms must be present in two or more settings. Symptoms must interfere with functioning. "

So immediately have a problem with incongruence as these aren't even using the same stringency to make the diagnoses. There are studies from years ago also suggesting that with the revision of criteria from the DSM-III to DSM-IV the prevalence of diagnoses increased significantly. So how many of these adults may have not been diagnosed as kids because of change of criteria?

Also, their assessment of co-morbidities is just a mess. For kids and adults, if the patient met criteria for ADHD it was diagnosed regardless of co-morbidities (except for adults with schizophrenia). But wait! Their methods show that there wasn't significant prevalence of most adult co-morbidities anyway! Except the methods are faulty again. Diagnoses for co-morbid disorders like depression or anxiety were only counted if they were present at the time of multiple assessments. So if those adults were suffering from anxiety or even an SUD during their adult assessments that were positive for ADHD but NOT during previous assessment, the anxiety/SUD/whatever disorder wasn't counted. Kind of weird they'd be willing to diagnose ADHD in adults without previous symptoms as they're doing but completely disregard new co-morbid disorders occurring simultaneously, right? Also, they didn't assess for personality disorders at all, which is, uh, not great considering the only co-morbidity they're saying adults newly diagnosed with ADHD showed as kids was conduct disorder seems kind of really relevant.

Then there's the issues with the differences in IQ and other developmental measures...I could go on, but the study is honestly just kind of a mess and trying to connect dots that weren't even obtained correctly. The biggest thing I get from this is actually confirming the idea that we need to be assessing for other co-morbidities more thoroughly before we just slap an ADHD diagnosis on adults who check all the boxes. Just more data against the categorical model of the DSM and more reason for a shift to more dimensional models that can aid actual thorough formulations.

 

[Ceke2002]

Here is the study! Super delayed.

Is Adult ADHD a Childhood-Onset Neurodevelopmental Disorder? Evidence From a Four-Decade Longitudinal Cohort Study - PubMed

The findings raise the possibility that adults presenting with the ADHD symptom picture may not have a childhood-onset neurodevelopmental disorder. If this finding is replicated, then the disorder's place in the classification system must be reconsidered, and research must investigate the...

pubmed.ncbi.nlm.nih.gov

Firstly, thank you very much for that. Secondly, wow, that is interesting. After reading that synopsis I'm thinking either 1) Adult onset of ADHD may be a thing, 2) There's a lot more people BS'ing about having ADHD than previously thought, or 3) if some of these folks (based on year of birth and age of childhood testing) were diagnosed with Hyperkinetic Reaction of Childhood, the Adult correlation numbers may indicate that HROC is its own separate entity that may or may not lead into a later diagnosis of Adult ADHD. Then of course there's option 4, which is I'm half asleep, not having a great day, and have just completely misread the text.

 

[Ceke2002]

There are some major problems with that paper's methods. The childhood diagnoses were made using criteria from the DSM-III vs adult diagnoses made use criteria for DSM-V, which are quite different. From the study's supplemental material:

"DSMIII diagnosis of childhood Attention Deficit Disorder with Hyperactivity (ADDH) required 8 symptoms (3 of 5 inattention symptoms, 3 of 6 impulsivity symptoms, AND 2 of 5 hyperactivity symptoms). ADD without hyperactivity could be diagnosed in children who lacked any symptoms of hyperactivity. Symptoms must onset before age 7 years. Reports from both parents and teachers were recommended.
DSM5 diagnosis of adult Attention Deficit /Hyperactivity Disorder (ADHD) required 5 symptoms (5 of 9 inattention symptoms or 5 of 9 impulsivity/hyperactivity symptoms). Several symptoms must onset before age 12 years. Several symptoms must be present in two or more settings. Symptoms must interfere with functioning. "

Yeah this was the part that was confusing to me. Dates of birth for participants are stated as around 1972/73, if they're looking for symptom onset prior to age 7 then that comes under a diagnosis of Hyperkinetic Reaction of Childhood, because ADHD wasn't actually a diagnosis until 1980. Is my brain just not braining at the moment?

 

[Mass Effect]

Patients demanding and not just asking about stimulants when they haven't even been diagnosed or appropriately evaluated is the problem. My point was that if patients want a specific treatment vs improvement in their condition that should be a red flag and warrants further exploration, NOT that it's inappropriate to start stimulants for ADHD or

Patients insisting on first line treatment to treat a medical condition and improve their symptoms is not a red flag. I would do the same for any ailment I have if my doc insisted on second or third line treatment for their own comfort. We weren't talking about people without a diagnosis. Your post was talking about people with ADHD. You said "I've consistently (almost 100%) found that patients with legit ADHD are willing to try any medication option that may be helpful and are fine with trying non-stimulants to avoid the hassles with prescribing and shortages, cost, and side effects of stimulants."

So they already have the diagnosis of ADHD in your scenario, as if patients with legit ADHD who are unwilling to try second or third line meds are shady. That is completely false and gives an inaccurate impression to those outside psych (like the poster asking the question) and stigmatizes patients who want legit care for their condition.

 

[Mass Effect]

That's not what he said. He said that his treatment approach is to generally ("almost always") start with non-stims unless someone is resuming prior treatment.

For "legit" ADHD. He literally says they have ADHD and he considers it a red flag if they don't want non-stimulants when non-stimulants are first line treatment.

This should be non-controversial (in adults, especially those without a prior diagnosis/treatment.) Although the title of this paper ends with "in primary care," I think it's a great concise review. https://chadd.org/wp-content/uploads/2021/02/combinepdf.pdf (the first paper in that giant PDF.)

Why wouldn't it be controversial? In what other medical condition are we starting with second or third line treatments and treating the patient like a "red flag" if they ask for first line?

It's not exactly my approach. When I get the absolute slam-dunk severe ADHD patients, I often start with stimulants, because their symptom reports include life- or livelihood- threatening examples and I want immediate response.

That's exactly the point. You're following standard of care.

 

[Mass Effect]

This whole thread was started because of someone who has been high functioning and is now a med student or resident that no one really thought had ADHD suddenly getting a diagnosis. I wasn't clear, but for less obvious cases like the one in this thread that "proof", ie documentation of previous testing and treatment (yes, I ask patients to bring prior medical records if available, this should obviously be standard), can clarify things a lot.

Most adults are not going to have documentation from childhood and many have never been treated, but that doesn't mean they're less worthy of treatment now. Non-stimulants is just delaying care when care could actually have significant impact on their life.

Also, many psychiatric conditions require more than one appointment to appropriately formulate and diagnose. You going to diagnose PDs on the first appointment without convincing collateral? If not, why would you be doing the same for neurodevelopmental disorders? Especially when they could easily be angling for an addictive substance?

I don't diagnose PDs on first visit without collateral because part of the criteria for PD is that it's a pattern of behavior over a lifetime in various situations. ADHD includes has no such criteria if the childhood history is there. There's also no good treatment for PDs. It involves longterm therapy, which you can actually start or refer for even without the definitive diagnosis. If a person comes in and talks about their 3 divorces and multiple work situations, PD is part of my differential, but I'd need to get to know the person better before making the diagnosis, but that's not a reason to delay DBT skills or referral for therapy.

If someone comes in and you learn without a doubt that they had trouble with attention since 1st grade, failed three grades in school, got kicked out of college, lose jobs, can't keep their home clean/organized, and have had 10 MVA's in the past 5 years, there is no reason not to prescribe a stimulant, assuming no medical contraindications.

 

[Stagg737]

Patients insisting on first line treatment to treat a medical condition and improve their symptoms is not a red flag. I would do the same for any ailment I have if my doc insisted on second or third line treatment for their own comfort. We weren't talking about people without a diagnosis. Your post was talking about people with ADHD. You said "I've consistently (almost 100%) found that patients with legit ADHD are willing to try any medication option that may be helpful and are fine with trying non-stimulants to avoid the hassles with prescribing and shortages, cost, and side effects of stimulants."

So they already have the diagnosis of ADHD in your scenario, as if patients with legit ADHD who are unwilling to try second or third line meds are shady. That is completely false and gives an inaccurate impression to those outside psych (like the poster asking the question) and stigmatizes patients who want legit care for their condition.

You're misinterpreting what I'm saying. I'm saying that patients who have ADHD causing dysfunction, not necessarily those who have been previously diagnosed, are willing to try any meds that will be helpful. I'm not saying we don't give them stimulants. In my scenario they typically haven't been diagnosed yet.

Most adults are not going to have documentation from childhood and many have never been treated, but that doesn't mean they're less worthy of treatment now. Non-stimulants is just delaying care when care could actually have significant impact on their life.

It's silly to assume that non-stimulants will not have life changing effects for patients with ADHD (says the adult psychiatrist with ADHD not diagnosed as a child who was successfully treated with non-stimulants). Again, not saying adults with ADHD shouldn't have stimulants. Treating them with non-stimulants is still treatment and sometimes more effective overall than stimulants. I'm just against the "you checked all the boxes, here's your adderall" approach that is often implemented and completely inappropriate.

If someone comes in and you learn without a doubt that they had trouble with attention since 1st grade, failed three grades in school, got kicked out of college, lose jobs, can't keep their home clean/organized, and have had 10 MVA's in the past 5 years, there is no reason not to prescribe a stimulant, assuming no medical contraindications.

Sure. Those aren't the cases I'm talking about though. See the rest of the thread.

 

[comp1]

I'd actually be much more likely to diagnose a personality disorder on a first visit than ADHD. There's nothing magical about PDs or ADHD that prevents a diagnosis on a first visit while somehow still allowing you to diagnosis MDD. The primary difference between ADHD and a PD is that there's less direct secondary gain in a PD diagnosis.

 

[futureapppsy2]

I'd actually be much more likely to diagnose a personality disorder on a first visit than ADHD. There's nothing magical about PDs or ADHD that prevents a diagnosis on a first visit while somehow still allowing you to diagnosis MDD. The primary difference between ADHD and a PD is that there's less direct secondary gain in a PD diagnosis.

I’d be really wary of diagnosing a PD on a first visit, especially if a patient is very ill and hasn’t been receiving EBP or if they’re in an acute crisis state. ADHD I would definitely want collateral to diagnose.

 

[Mass Effect]

You're misinterpreting what I'm saying. I'm saying that patients who have ADHD causing dysfunction, not necessarily those who have been previously diagnosed, are willing to try any meds that will be helpful. I'm not saying we don't give them stimulants. In my scenario they typically haven't been diagnosed yet.

Finish that statement though. You're saying patients who have ADHD causing dysfunction are more likely to be open to non-stimulants. So what about the patients who have ADHD causing dysfunction who aren't willing to try non-stimulants? That's where you bring in the red flag and that's what I'm pushing back on.

It's silly to assume that non-stimulants will not have life changing effects for patients with ADHD (says the adult psychiatrist with ADHD not diagnosed as a child who was successfully treated with non-stimulants). Again, not saying adults with ADHD shouldn't have stimulants. Treating them with non-stimulants is still treatment and sometimes more effective overall than stimulants.

Stimulants are first line for a reason. Treating them with non-stimulant when standard of care dictates stimulants in absence of contraindications isn't optimal treatment, regardless of your own experience.

 

[Mass Effect]

I'd actually be much more likely to diagnose a personality disorder on a first visit than ADHD. There's nothing magical about PDs or ADHD that prevents a diagnosis on a first visit while somehow still allowing you to diagnosis MDD. The primary difference between ADHD and a PD is that there's less direct secondary gain in a PD diagnosis.

Actually, that's not the primary difference. The primary difference is lack of insight and in many cases, unwillingness to acknowledge they fit criteria. Neither can really be compared to MDD. MDD is relatively easy to spot and it's often in the patient's chief complaint. Assuming you rule out medical causes first, MDD and GAD are relatively easy compared to PD and ADHD.