Evaluating for ADHD?

[Stagg737]

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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.

Then we ask why aren't they willing to try non-stimulants. Like I said, there's a difference between patients who come in wanting to try stimulants but being willing to try alternative options vs someone coming in demanding stimulants and only stimulants when it's a new diagnosis. I'm much more comfortable letting the former try stimulants if they're indicated and would question any physician's judgment who is fine just handing stimulants to someone in that latter category without serious questioning as it is absolutely a red flag.

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.

Why so black and white? Stimulants as the first line for legit ADHD is the guideline, it is not law. EBM and guidelines are population level evidence meant as generalizations, and individual cases often require deviation from general guidelines. If everything was just algorithmic, we wouldn't be needed to assess or treat at all. Rigidity with guidelines and standards of care in fields that are as dependent on subjective accounts of symptoms as psych is just bad practice.

 

[ObsequiousAplomb]

I want to add in here on what Stagg and Mass Effect are going back and forth on. There are several signs in any eval that make me less likely to go with controlled medications, and I'm aware that many of these are due to my own countertransferrence:
- insisting on using my first name after correction
- saying "I've earned" or "I'm entitled to" or "it's my right to get" or "you are being unprofessional for not giving me" the specific treatment
- sudden onset of dysfunction in a presentation that doesn't usually do that
- insidious onset of dysfunction in a presentation that doesn't usually do that
- insisting on using the phrase "panic attack" to refer to situations that, based on their description, are not panic attacks, even after psychoeducation
- emailing me or texting my office number instead of sending messages through the portal, even after repeated instruction. If the last text from me is "don't text me, message me on Osmind," then I'm usually prepping myself for the termination speech
- missing multiple appointments without warning

Unfortunately, all of these are rather prominent in the post- TikTok era. People presenting with fear they have BPD usually have all of these but, fascinatingly, low MSI-BPD scores. People presenting with ADHD that wasn't addressed in childhood are also commonly doing the above irksome things. I have to make an effort to set those frustrations aside to make sure I don't under-treat ADHD.

 

[Merovinge]

I want to add in here on what Stagg and Mass Effect are going back and forth on. There are several signs in any eval that make me less likely to go with controlled medications, and I'm aware that many of these are due to my own countertransferrence:
- insisting on using my first name after correction

This has never not been the reddest of red flags from my experience. r of >0.7 with NPD.

 

[clausewitz2]

This has never not been the reddest of red flags from my experience. r of >0.7 with NPD.

Or enacting really unfortunate and unsettling romantic/sexual transference as an attempt at being flirtatious.

 

[Stagg737]

This has never not been the reddest of red flags from my experience. r of >0.7 with NPD.

You can even bump that r to >0.9 when they not only use your first name, but your full first name instead of a preferred name in a condescending tone (ie, calling someone "Daniel" instead of just "Dan").

 

[Mass Effect]

Then we ask why aren't they willing to try non-stimulants.

So you're using wanting evidence-based first-line treatment as a litmus test as to whether or not they're worthy of evidence-based first-line treatment. Dude. Just stop.

Why so black and white? Stimulants as the first line for legit ADHD is the guideline, it is not law. EBM and guidelines are population level evidence meant as generalizations, and individual cases often require deviation from general guidelines. If everything was just algorithmic, we wouldn't be needed to assess or treat at all. Rigidity with guidelines and standards of care in fields that are as dependent on subjective accounts of symptoms as psych is just bad practice.

You ARE being algorithmic and black and white, no matter how much you convince yourself you're not. You're also being incredibly biased against this diagnosis if your inclination is "I won't provide first-line treatment unless they try second-line first". WTH kind of litmus test is that?

 

[clausewitz2]

Moderator note: Let's keep things civil and refrain from personal attacks.

 

[Stagg737]

So you're using wanting evidence-based first-line treatment as a litmus test as to whether or not they're worthy of evidence-based first-line treatment. Dude. Just stop

That’s not what I’m saying at all. It’s not about gauging “worthiness”. It’s about examine their perspectives.

You ARE being algorithmic and black and white, no matter how much you convince yourself you're not. You're also being incredibly biased against this diagnosis if your inclination is "I won't provide first-line treatment unless they try second-line first". WTH kind of litmus test is that?

Again, I’m not saying that and have said differently several times.

You’ve clearly made up your mind about how you believe I practice based on cherry picking from my statements and your responses. I’ve tried to clarify but you seem to be set in your opinion on me. I’m not sure how this is productive, but I hope others are able to understand the context of my statements and I’m happy to clarify further if needed.

 

[Ceke2002]

Or enacting really unfortunate and unsettling romantic/sexual transference as an attempt at being flirtatious.

Off topic, but I so don't get this, I mean I do get erotic transference in therapy is a thing, but it still makes my brain go, "Say what now?". Like I do have a functioning set of eyeballs, I can tell when the Doctor standing/sitting in front of me is an attractive person, but they're still a Doctor. Like have some decorum people.

 

[Ceke2002]

I want to add in here on what Stagg and Mass Effect are going back and forth on. There are several signs in any eval that make me less likely to go with controlled medications, and I'm aware that many of these are due to my own countertransferrence:
- insisting on using my first name after correction
- saying "I've earned" or "I'm entitled to" or "it's my right to get" or "you are being unprofessional for not giving me" the specific treatment
- sudden onset of dysfunction in a presentation that doesn't usually do that
- insidious onset of dysfunction in a presentation that doesn't usually do that
- insisting on using the phrase "panic attack" to refer to situations that, based on their description, are not panic attacks, even after psychoeducation
- emailing me or texting my office number instead of sending messages through the portal, even after repeated instruction. If the last text from me is "don't text me, message me on Osmind," then I'm usually prepping myself for the termination speech
- missing multiple appointments without warning

Unfortunately, all of these are rather prominent in the post- TikTok era. People presenting with fear they have BPD usually have all of these but, fascinatingly, low MSI-BPD scores. People presenting with ADHD that wasn't addressed in childhood are also commonly doing the above irksome things. I have to make an effort to set those frustrations aside to make sure I don't under-treat ADHD.

Honestly this gives me hope, that the majority of people in the TikTok era are clearly too stupid to know how to scam pills, or they're delusional enough to think that kind of behaviour is going to get them a legitimate script. Good, more for the rest of us (medically speaking). 🙂

 

[docloufan]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

 

[Ceke2002]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

As someone who was diagnosed in 1975 I have watched ADHD go from a legitimate diagnosis of a neurodevelopmental disorder that can seriously mess up someone's life, to a trendy fad that can be diagnosed based on how you hold your hands when you walk or how often you bump into things, and of course it's a 'super power' nowadays as well don't you know </sarcasm>. I will always speak against outright dismissal of the disorder, but I do not blame a single one of these Doctors for their biases, or concerns with proper diagnosis, or concerns with prescription liabilities, or any other legitimate concerns that may be expressed, because I am sick to the back teeth of ADHD being treated like some cool fashion accessory. It IS overdiagnosed, and conversely I think that also means it is underdiagnosed because the legitimate cases who would actually benefit from diagnosis and treatment are getting lost in the sea of tiktok-esque noise.

 

[Ironspy]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

Disagreement is not embarrassing. We all see different patient populations and willingness to start a stimulant is vastly different depending on the setting (outpatient child v correctional v eating disorders v outpatient adult v CMH).

I certainly don’t agree with every post but have appreciated the differences of opinion and the (mostly) respectful discussion.

 

[comp1]

This thread is not embarrassing at all. Psychiatry, more than any other medical specialty, is done by consensus. This is how consensus is developed. You can find a citation for any perspective you would like to argue.

 

[Orgone]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

Actually ... it's people who are rigidly self-assured of their own righteousness and infallibility, who just know that whatever opinion they have arrived at is The One Truth to Rule Them All, and who enjoy telling anyone who thinks differently or disagrees with their opinion that such disagreement proves them to be a Total Mindless Idiot - it's these people who are an absolute embarrassment to their profession, whichever one that might be.

 

[bashir]

A propos of nothing in particular, I have been meaning to share my experience on this thread, as a psychiatrist recently diagnosed with ADHD. However I have been very busy and since starting vyvanse I have the capacity to resist the temptation to post until time allows. Happy to see the thread is still active!

I'm a woman over 40. Completed residency 5+ years ago. I never really considered the idea that I may have ADHD until my husband was diagnosed last year.

My husband's diagnosis was initially very confusing for me, as the person who theoretically knows him best and also happens to be a psychiatrist. I didn't want to question his therapist, who seemed decent from what I could tell, and whom he'd been seeing for a couple years. But I just didn't really see it. We've been together since we were teenagers. He was the one to whom I had always delegated (usually by default-- not taking care of it myself) all manner of necessary life tasks that were too boring or tedious or required too much sustained attention for me (though I never thought of it in those terms until recently). In the early years of our relationship I am sure I would have lost my driver's license for unpaid speeding tickets, had he not been there noticing them in the foot space of my passenger seat and reminding me to take care of them. He is an entrepreneur and has always been the primary caregiver to our kids and has run the household without a whole lot of help from me. Not particularly well, mind you, (house generally a disorganized mess, rarely a home cooked meal) a source of ongoing shame for him, but better than I would do. I always tried to stay grateful and reassure him he was doing great, life is just hard with young kids. But life was perplexingly hard for us before we had kids too, and now that the kids were getting older and generally getting to be pretty self sufficient, it was STILL REALLY HARD. And I was aware that I was like a third child to him at times, with my contributing to the chaos of the household more than the running of it. My car would always be a pitted out mess, only cleaned if I knew I was going to have to give someone a ride, or if he nagged me about it enough. His vehicle he managed to keep reasonably clean so as not to embarrass the kids when he drove their friends to school. I couldn't set good a good example for the kids--they thought it was normal to always have dirty clothes strewn across the floor in all rooms of the house. I resisted my husband's attempts to get me more involved in our finances. I bought whatever I wanted and luckily didn't have extravagant tastes, so it kinda sorta worked, though his repeated attempts to get me to follow a budget frustrated both of us. I recognize in retrospect that I was so easily overwhelmed by many tasks requiring sustained attention that I would avoid them at all costs and leave him holding the bag.

When my husband was diagnosed, I thought "well bully for him, he has a reason for why things are always so hard for him and I guess I'm just a lazy, undisciplined, careless, thoughtless, slob." I was kind of jealous he seemed to have a treatable condition vs my character flaws, but I still didn't consider the diagnosis for myself. Probably in part because NOT having a mental illness, in a family where almost everyone else did, was a weirdly central part of my identity. The fact that women are expected to do all the things I routinely failed at would have reinforced shame in a lot of women. I was able to rationalize the fact that my husband was the one who (usually) remembered to buy birthday gifts for our nieces and nephews as evidence of our progressive marriage, and spare myself a lot of the shame that way by turning my deficit into a feminist win for us both.

Slowly it started to dawn on me, maybe I didn't recognize his ADHD because I had it too, and actually mine was in many ways more severe than my husband's--or maybe l just had less experience learning coping strategies to manage it, because I had relied so much on him for so long. I had never read the criteria and had them resonate with me personally. Instead I think I often didn't recognize it in adult patients because I was using my own experiences as a barometer of what's normal, and actually, I'm not normal. This has been a jarring realization that frankly has really shaken up my professional identity and has left me wondering how many patients I have seen for whom I have not been effective at diagnosing or treating ADHD.

Practice patterns varied in my residency program around diagnosing and treating ADHD in adults, but the attendings I most respected taught that ADHD is a clinical diagnosis; while psychological testing may be useful as a way to get another opinion in tricky cases where the diagnosis is suspected but not clear, it should not generally be used as a hoop to make people jump through, or to offload responsibility for diagnosis to another clinician. That's not appropriate.

So that's how I have typically operated, doing my best good faith attempt to make a clinical diagnosis, but I am looking at patients on my panel now with fresh eyes and seeing cases I missed before. I also think back to one-off psychiatric consultations I performed on an integrated care rotation in residency, where attention problems were a common chief complaint. How many people did I send off on an ssri, saying "let's treat the anxiety first and see how you feel then" who actually had ADHD and would have had the anxiety resolve spontaneously on appropriate treatment? Even the cases where it seemed obvious they had ADHD, if there were also enough anxiety or depression symptoms to justify it I would usually say "let's try an ssri first and reevaluate once you're not feeling so depressed/anxious." Looking back on it now, I think there were times I essentially kicked the can down the road for a patient I could have helped dramatically and quickly, and it makes me sad to think about.

Once I started to suspect I had it, I talked to my psychiatrist friends who have known me since residency, and there was a general vibe of "I didn't want to be the one to say something, but yeah..." Past experiences all took on a new lens. Could I really have ADHD, when being a good student was practically my whole identity? I was a top student in my high school, but was I actually a "good student"? It wasn't that uncommon for me to miss deadlines. Not many people knew that, but my teachers all liked me and let me get away with a lot. I ended up going to a small liberal arts college where I knew the faculty well--the kind of place professors routinely invite students to their homes. I recall one professor who had a reputation for being a hard ass, who required a journal of our thoughts on all the reading assignments, to be turned in at the end of the semester. I don't know what I thought would happen not doing it, but there was always something else that was a higher priority and the end of the semester came and I didn't have anything to hand in (though I'd read all the assignments and participated actively in class discussions). I remember going to the professor's office to basically beg for mercy, and how disappointed he seemed in himself when he didn't have the heart to fail me, and offered to give me an incomplete to allow me time to do the journal. Somehow I managed to write my English thesis that was supposed to take the whole semester in a week-long writing binge fueled by caffeine and sheer panic. So...yeah. it's possible to get through high school and college and even medical school and residency and not recognize the level of dysfunction one is experiencing-- especially if the person is able to somehow escape the worst consequences of that dysfunction, as I was.

Medical school was an adaptive environment for me. I didn't love it by any means, but the high level of structure kept me doing what I needed to be doing. Studying all the time was relatively easy for me because I knew if I didn't I would probably fail, have no career prospects and be in debt forever. That was plenty motivating, especially because the consequences were not far off or vague or unpredictable. You don't study all the time, you will fail. I was an average medical student. If I had pursued a PhD I don't think I would have ever finished it.

Residency wasn't too bad in the first two years, which were all inpatient at my relatively low intensity program. I never really had to see a high volume of patients. Third year was the best of times and the worst of times. I discovered my love of outpatient, but with more patients to see daily and less pressure to get the notes done immediately, I just couldn't cope. My supervisors were not paying enough attention to my documentation habits, and I went weeks without writing notes, and then would have to fess up to my husband about how behind I was, so I could go in on a Saturday and binge write weeks' worth of notes (from my disorganized chicken scratch hand notes).

This pattern with notes continued in my attending life until I finally got a boss who was paying attention, and willing to offer support and guidance while also holding me accountable for timely documentation. Thank God! Between this boss and Vyvanse for myself and my husband, I may actually survive!

I absolutely love to read and learn and I love psychiatry. I loved majoring in English in college -most of the time it didn't feel like work, the key to success with ADHD. Someday in the not too distant future I hope to have most of my note writing automated and then I can see more patients, which I love to do. I am coming to terms with the fact that I actually learned very little about ADHD in residency, and doing a lot of self study now, both from a clinical perspective and a self help perspective. I'm starting to learn a heck of a lot of new coping strategies, which will help me and my patients with ADHD. The one I fell into by sheer dumb luck is one of the best--do what you love. It's a good idea for everyone, but I think I would have sucked at any job I tried that didn't consistently bring me as much joy and satisfaction as the study and practice of psychiatry does.

If you got this far, thanks for reading this novel. Tl;dr: yes ADHD can present for the first time in adults, especially intelligent women with inattentive subtype. There are all kinds of valid reasons it may not have been recognized before, but if it's been there all along and causing dysfunction here and now, for God's sake treat it! Not to say that people misdiagnosing themselves based on tiktok, or trying to get stimulants to sell them doesn't happen--of course it does. But please don't be one of those people who would rather fail to adequately treat a hundred people with ADHD than let one malingerer pull one over on them. And don't be like me and be afraid to pull the trigger on the diagnosis when it's staring you in the face.

One fun fact I learned from an excellent master course on ADHD at APA this year--atomoxetine works terribly on average compared to stimulants, but that's because it works about as well as a stimulant for some people and not really at all for other people. So it's reasonable to try it first if someone is up for an every single day medication, and would prefer to avoid stimulants for whatever reason, but if it doesn't work for them don't belabor it, move on.

 

[Ceke2002]

A propos of nothing in particular, I have been meaning to share my experience on this thread, as a psychiatrist recently diagnosed with ADHD. However I have been very busy and since starting vyvanse I have the capacity to resist the temptation to post until time allows. Happy to see the thread is still active!

I'm a woman over 40. Completed residency 5+ years ago. I never really considered the idea that I may have ADHD until my husband was diagnosed last year.

My husband's diagnosis was initially very confusing for me, as the person who theoretically knows him best and also happens to be a psychiatrist. I didn't want to question his therapist, who seemed decent from what I could tell, and whom he'd been seeing for a couple years. But I just didn't really see it. We've been together since we were teenagers. He was the one to whom I had always delegated (usually by default-- not taking care of it myself) all manner of necessary life tasks that were too boring or tedious or required too much sustained attention for me (though I never thought of it in those terms until recently). In the early years of our relationship I am sure I would have lost my driver's license for unpaid speeding tickets, had he not been there noticing them in the foot space of my passenger seat and reminding me to take care of them. He is an entrepreneur and has always been the primary caregiver to our kids and has run the household without a whole lot of help from me. Not particularly well, mind you, (house generally a disorganized mess, rarely a home cooked meal) a source of ongoing shame for him, but better than I would do. I always tried to stay grateful and reassure him he was doing great, life is just hard with young kids. But life was perplexingly hard for us before we had kids too, and now that the kids were getting older and generally getting to be pretty self sufficient, it was STILL REALLY HARD. And I was aware that I was like a third child to him at times, with my contributing to the chaos of the household more than the running of it. My car would always be a pitted out mess, only cleaned if I knew I was going to have to give someone a ride, or if he nagged me about it enough. His vehicle he managed to keep reasonably clean so as not to embarrass the kids when he drove their friends to school. I couldn't set good a good example for the kids--they thought it was normal to always have dirty clothes strewn across the floor in all rooms of the house. I resisted my husband's attempts to get me more involved in our finances. I bought whatever I wanted and luckily didn't have extravagant tastes, so it kinda sorta worked, though his repeated attempts to get me to follow a budget frustrated both of us. I recognize in retrospect that I was so easily overwhelmed by many tasks requiring sustained attention that I would avoid them at all costs and leave him holding the bag.

When my husband was diagnosed, I thought "well bully for him, he has a reason for why things are always so hard for him and I guess I'm just a lazy, undisciplined, careless, thoughtless, slob." I was kind of jealous he seemed to have a treatable condition vs my character flaws, but I still didn't consider the diagnosis for myself. Probably in part because NOT having a mental illness, in a family where almost everyone else did, was a weirdly central part of my identity. The fact that women are expected to do all the things I routinely failed at would have reinforced shame in a lot of women. I was able to rationalize the fact that my husband was the one who (usually) remembered to buy birthday gifts for our nieces and nephews as evidence of our progressive marriage, and spare myself a lot of the shame that way by turning my deficit into a feminist win for us both.

Slowly it started to dawn on me, maybe I didn't recognize his ADHD because I had it too, and actually mine was in many ways more severe than my husband's--or maybe l just had less experience learning coping strategies to manage it, because I had relied so much on him for so long. I had never read the criteria and had them resonate with me personally. Instead I think I often didn't recognize it in adult patients because I was using my own experiences as a barometer of what's normal, and actually, I'm not normal. This has been a jarring realization that frankly has really shaken up my professional identity and has left me wondering how many patients I have seen for whom I have not been effective at diagnosing or treating ADHD.

Practice patterns varied in my residency program around diagnosing and treating ADHD in adults, but the attendings I most respected taught that ADHD is a clinical diagnosis; while psychological testing may be useful as a way to get another opinion in tricky cases where the diagnosis is suspected but not clear, it should not generally be used as a hoop to make people jump through, or to offload responsibility for diagnosis to another clinician. That's not appropriate.

So that's how I have typically operated, doing my best good faith attempt to make a clinical diagnosis, but I am looking at patients on my panel now with fresh eyes and seeing cases I missed before. I also think back to one-off psychiatric consultations I performed on an integrated care rotation in residency, where attention problems were a common chief complaint. How many people did I send off on an ssri, saying "let's treat the anxiety first and see how you feel then" who actually had ADHD and would have had the anxiety resolve spontaneously on appropriate treatment? Even the cases where it seemed obvious they had ADHD, if there were also enough anxiety or depression symptoms to justify it I would usually say "let's try an ssri first and reevaluate once you're not feeling so depressed/anxious." Looking back on it now, I think there were times I essentially kicked the can down the road for a patient I could have helped dramatically and quickly, and it makes me sad to think about.

Once I started to suspect I had it, I talked to my psychiatrist friends who have known me since residency, and there was a general vibe of "I didn't want to be the one to say something, but yeah..." Past experiences all took on a new lens. Could I really have ADHD, when being a good student was practically my whole identity? I was a top student in my high school, but was I actually a "good student"? It wasn't that uncommon for me to miss deadlines. Not many people knew that, but my teachers all liked me and let me get away with a lot. I ended up going to a small liberal arts college where I knew the faculty well--the kind of place professors routinely invite students to their homes. I recall one professor who had a reputation for being a hard ass, who required a journal of our thoughts on all the reading assignments, to be turned in at the end of the semester. I don't know what I thought would happen not doing it, but there was always something else that was a higher priority and the end of the semester came and I didn't have anything to hand in (though I'd read all the assignments and participated actively in class discussions). I remember going to the professor's office to basically beg for mercy, and how disappointed he seemed in himself when he didn't have the heart to fail me, and offered to give me an incomplete to allow me time to do the journal. Somehow I managed to write my English thesis that was supposed to take the whole semester in a week-long writing binge fueled by caffeine and sheer panic. So...yeah. it's possible to get through high school and college and even medical school and residency and not recognize the level of dysfunction one is experiencing-- especially if the person is able to somehow escape the worst consequences of that dysfunction, as I was.

Medical school was an adaptive environment for me. I didn't love it by any means, but the high level of structure kept me doing what I needed to be doing. Studying all the time was relatively easy for me because I knew if I didn't I would probably fail, have no career prospects and be in debt forever. That was plenty motivating, especially because the consequences were not far off or vague or unpredictable. You don't study all the time, you will fail. I was an average medical student. If I had pursued a PhD I don't think I would have ever finished it.

Residency wasn't too bad in the first two years, which were all inpatient at my relatively low intensity program. I never really had to see a high volume of patients. Third year was the best of times and the worst of times. I discovered my love of outpatient, but with more patients to see daily and less pressure to get the notes done immediately, I just couldn't cope. My supervisors were not paying enough attention to my documentation habits, and I went weeks without writing notes, and then would have to fess up to my husband about how behind I was, so I could go in on a Saturday and binge write weeks' worth of notes (from my disorganized chicken scratch hand notes).

This pattern with notes continued in my attending life until I finally got a boss who was paying attention, and willing to offer support and guidance while also holding me accountable for timely documentation. Thank God! Between this boss and Vyvanse for myself and my husband, I may actually survive!

I absolutely love to read and learn and I love psychiatry. I loved majoring in English in college -most of the time it didn't feel like work, the key to success with ADHD. Someday in the not too distant future I hope to have most of my note writing automated and then I can see more patients, which I love to do. I am coming to terms with the fact that I actually learned very little about ADHD in residency, and doing a lot of self study now, both from a clinical perspective and a self help perspective. I'm starting to learn a heck of a lot of new coping strategies, which will help me and my patients with ADHD. The one I fell into by sheer dumb luck is one of the best--do what you love. It's a good idea for everyone, but I think I would have sucked at any job I tried that didn't consistently bring me as much joy and satisfaction as the study and practice of psychiatry does.

If you got this far, thanks for reading this novel. Tl;dr: yes ADHD can present for the first time in adults, especially intelligent women with inattentive subtype. There are all kinds of valid reasons it may not have been recognized before, but if it's been there all along and causing dysfunction here and now, for God's sake treat it! Not to say that people misdiagnosing themselves based on tiktok, or trying to get stimulants to sell them doesn't happen--of course it does. But please don't be one of those people who would rather fail to adequately treat a hundred people with ADHD than let one malingerer pull one over on them. And don't be like me and be afraid to pull the trigger on the diagnosis when it's staring you in the face.

One fun fact I learned from an excellent master course on ADHD at APA this year--atomoxetine works terribly on average compared to stimulants, but that's because it works about as well as a stimulant for some people and not really at all for other people. So it's reasonable to try it first if someone is up for an every single day medication, and would prefer to avoid stimulants for whatever reason, but if it doesn't work for them don't belabor it, move on.

First of all, it's lovely to see you on here again. Secondly thank you so very much for sharing your story, despite my having a diagnosis prior a lot of it mirror my own experience. I wish you all the best as you embark on this new chapter of life discovery. If you ever need someone to talk to that can listen and go, "Oh wow, me too', and mean it, you are more than welcome to attack my inbox on here.

 

[psydocc]

Overall....this whole thread should be an absolute embarrassment to the profession of clinical psychiatry. Vast disagreement about basic bread and butter management of the most emerging diagnosis in psychiatry in the 21st century. Personal bias. Professional bias. Training bias. Lack of training bias. Prescription liability phobia/bias. Unbelievable.

Where do we turn from here, folks? What's next?

It's so easy to say this when you're not the one writing the prescription.

 

[Ceke2002]

Okay, genuine question (not seeking medical advice, I already have a diagnosis, I don't need another one (or a fourth one to be precise).

Is randomly falling down strange rabbit holes of information and study actually an ADHD thing, or more of a general quirk of human nature? For example, if you're in the middle of doing something domestically inclined (trying to tidy the house, put some laundry through, stack the dishwasher, etc, etc), then you decide to take a small break to recharge the old brain matter, and next thing you know it's several hours later and you've been glued to a computer screen studying, let's say Forensic Pathology. You're not unfocused, or distracted, quite the opposite. I know people talk about 'hyperfocus' but what differentiates 'ADHD hyperfocus' from your everyday kind of, 'Wow I did not know this subject was so fascinating, let me immerse myself in it' kind of focus? Or are they the same thing?

Accessible studies on this phenomena appreciated as always, please and thank you.

(edited to add: Questions like this arising always make me chuckle at the prospect of me actually being in medical school (had my physical health issues not eventually precluded me from that path), "No Professor, I haven't actually completed the assigned work, but here's a 1500 word essay on expected patterns of injury from falls of varying heights, and a demonstration of a 12 lead EKG". Something tells me I wouldn't have been given points for trying. )

 

[oliversacks4thewin]

Okay, genuine question (not seeking medical advice, I already have a diagnosis, I don't need another one (or a fourth one to be precise).

Is randomly falling down strange rabbit holes of information and study actually an ADHD thing, or more of a general quirk of human nature? For example, if you're in the middle of doing something domestically inclined (trying to tidy the house, put some laundry through, stack the dishwasher, etc, etc), then you decide to take a small break to recharge the old brain matter, and next thing you know it's several hours later and you've been glued to a computer screen studying, let's say Forensic Pathology. You're not unfocused, or distracted, quite the opposite. I know people talk about 'hyperfocus' but what differentiates 'ADHD hyperfocus' from your everyday kind of, 'Wow I did not know this subject was so fascinating, let me immerse myself in it' kind of focus? Or are they the same thing?

Accessible studies on this phenomena appreciated as always, please and thank you.

(edited to add: Questions like this arising always make me chuckle at the prospect of me actually being in medical school (had my physical health issues not eventually precluded me from that path), "No Professor, I haven't actually completed the assigned work, but here's a 1500 word essay on expected patterns of injury from falls of varying heights, and a demonstration of a 12 lead EKG". Something tells me I wouldn't have been given points for trying. )

I'll let Dr. Barkley answer some of this, as his response will be much better than anything I can articulate:



He has additional part 2 and 3, if you are further interested.

 

[R. Matey]

I know people talk about 'hyperfocus' but what differentiates 'ADHD hyperfocus' from your everyday kind of, 'Wow I did not know this subject was so fascinating, let me immerse myself in it' kind of focus? Or are they the same thing?

There's a long debate in the literature whether people with ADHD actually hyperfocus or they're just perseverating (i.e., you get distracted by forensic pathology initially due to ADHD, but is maintained via perseveration given that ADHD can and often does dysregulate various emotional states). Last I checked, Barkley takes the perseveration view, which is consistent with his theory that ADHD is the result of underdeveloped executive functions.

 

[Ceke2002]

I'll let Dr. Barkley answer some of this, as his response will be much better than anything I can articulate:



He has additional part 2 and 3, if you are further interested.

There's a long debate in the literature whether people with ADHD actually hyperfocus or they're just perseverating (i.e., you get distracted by forensic pathology initially due to ADHD, but is maintained via perseveration given that ADHD can and often does dysregulate various emotional states). Last I checked, Barkley takes the perseveration view, which is consistent with his theory that ADHD is the result of underdeveloped executive functions.

Thank you so much for these replies. I will take a look at those videos when I've some sleep. I am very interested, and appreciative of the information. 🙂

 

[FlowRate]

Okay, genuine question (not seeking medical advice, I already have a diagnosis, I don't need another one (or a fourth one to be precise).

Is randomly falling down strange rabbit holes of information and study actually an ADHD thing, or more of a general quirk of human nature? For example, if you're in the middle of doing something domestically inclined (trying to tidy the house, put some laundry through, stack the dishwasher, etc, etc), then you decide to take a small break to recharge the old brain matter, and next thing you know it's several hours later and you've been glued to a computer screen studying, let's say Forensic Pathology. You're not unfocused, or distracted, quite the opposite. I know people talk about 'hyperfocus' but what differentiates 'ADHD hyperfocus' from your everyday kind of, 'Wow I did not know this subject was so fascinating, let me immerse myself in it' kind of focus? Or are they the same thing?

Accessible studies on this phenomena appreciated as always, please and thank you.

(edited to add: Questions like this arising always make me chuckle at the prospect of me actually being in medical school (had my physical health issues not eventually precluded me from that path), "No Professor, I haven't actually completed the assigned work, but here's a 1500 word essay on expected patterns of injury from falls of varying heights, and a demonstration of a 12 lead EKG". Something tells me I wouldn't have been given points for trying. )

Not specifically about you but about patient reports along similar lines. Part of the challenge is that procrastination behavior is common and multifactorial. Boring and tedious things are boring and tedious and anything else is interesting and exciting in comparison. Avoidant behavior relieves anxiety/dread about doing annoying things until it doesn't.

I pretty much never diagnose ADHD when procrastination is the ONLY "symptom."

--

Also to the above about anxiety/ADHD, I believe consensus (despite what pro-ADHD sources will say) is still that ADHD is a diagnosis of exclusion in adults. If there's a concurrent apparent anxiety disorder, you're not wrong to treat that first, as mood and anxiety disorders very commonly cause difficulties with attention/"executive function."

 

[futureapppsy2]

Also to the above about anxiety/ADHD, I believe consensus (despite what pro-ADHD sources will say) is still that ADHD is a diagnosis of exclusion in adults. If there's a concurrent apparent anxiety disorder, you're not wrong to treat that first, as mood and anxiety disorders very commonly cause difficulties with attention/"executive function."

Same thing with untreated/poorly treated depression.

As an aside, I went to a talk by Barkley in grad school and he had a wonderful quote about ADHD and adult employment: “Impulsivity is the difference between wanting to tell your boss to **** off and actually telling your boss to **** off.”

 

[aim-agm]

There's a long debate in the literature whether people with ADHD actually hyperfocus or they're just perseverating (i.e., you get distracted by forensic pathology initially due to ADHD, but is maintained via perseveration given that ADHD can and often does dysregulate various emotional states). Last I checked, Barkley takes the perseveration view, which is consistent with his theory that ADHD is the result of underdeveloped executive functions.

IIRC, the "attention" is the function that will allow or disallow conscious awareness of stimuli, and to maintain or dismiss that awareness. Correct me if I'm wrong, my understanding is that ADHD is considered a dysregulation of attention function rather than a deficit per se. Generally dysfunction of attention with tend to fail to gatekeep awareness (i.e. distractibility) or maintain awareness (i.e. lack of focus) but it could also fail in not having awareness (i.e. inattention) or excessive persistence of awareness - with the phenomena of "hyperfocus" being both dysfunctionally persistent awareness of something and inappropriate suppression of awareness of everything else.

 

[Stagg737]

Also to the above about anxiety/ADHD, I believe consensus (despite what pro-ADHD sources will say) is still that ADHD is a diagnosis of exclusion in adults. If there's a concurrent apparent anxiety disorder, you're not wrong to treat that first, as mood and anxiety disorders very commonly cause difficulties with attention/"executive function."

Same thing with untreated/poorly treated depression.

As an aside, I went to a talk by Barkley in grad school and he had a wonderful quote about ADHD and adult employment: “Impulsivity is the difference between wanting to tell your boss to **** off and actually telling your boss to **** off.”

This is standard and imo the biggest reason not to start stimulants on an initial eval. It is exceptionally rare that I get a referral for "ADHD eval" and the patient doesn't have significant depression or anxiety confounding the picture, typically lifelong anxiety. When someone has been dealing with severe anxiety since childhood or has a significant trauma history and a trauma disorder, why would we start them on a med that's almost certainly going to worsen that instead of trying to address that anxiety first and see if those ADHD symptoms improve or resolve (which they frequently do).

Rarely I'll come across a patient where all their anxiety stems from significant ADHD symptoms and their inability to function because of ADHD and I actively try to differentiate these patients. But more often than not, patients have anxiety and TikTok told them their symptoms are really ADHD so they get sent to me.

 

[oliversacks4thewin]

IIRC, the "attention" is the function that will allow or disallow conscious awareness of stimuli, and to maintain or dismiss that awareness. Correct me if I'm wrong, my understanding is that ADHD is considered a dysregulation of attention function rather than a deficit per se. Generally dysfunction of attention with tend to fail to gatekeep awareness (i.e. distractibility) or maintain awareness (i.e. lack of focus) but it could also fail in not having awareness (i.e. inattention) or excessive persistence of awareness - with the phenomena of "hyperfocus" being both dysfunctionally persistent awareness of something and inappropriate suppression of awareness of everything else.

Your statement actually required me to pull out a few old cognitive neuroscience text books, so good on you for making me have to go revisit some old cobwebby memories lol.

If I understand your statement correctly (and I may be off, so please feel free to correct), it sounds like you are referencing both the posterior and anterior attentional networks. If we are discussing direct damage to the posterior attention network, say from an ABI, like a stroke, that could result in unilateral neglect, in which the patient is technically experiencing deficits to "attention" from a bottom-up perspective.

If we are discussing the ability to inhibit your automatic response to a stimuli though (a top-down mediated process, a la executive functioning associated), then literature tends to suggest this is more closely associated with the anterior attention network and Stephen Stahl is even careful to include "impulsivity" in his description of ADHD and is quick to remind readers that these executive dysfunctions are not just isolated to ADHD but can also appear in schizophrenia, MDD, mania, anxiety, pain, and disorders of sleep and wakefulness. The difficulty from there is that you get into the whole host of various theories on attention (bottleneck theory, automatic vs. controlled processing, and feature-integration, which can include discussions on distributed attention vs. focused attention) and the discussion gets even messier. Literally, books have been written about these theories to attempt to better understand the complex realities of these situations. All this to say, yes, it could be related to difficulties with inhibiting and incorrectly attending to a maladaptive stimuli, but this also can just be representative of a normative pattern for attentional processes. The most compelling research (see Stahl's Essential Psychopharmacology for exhaustive list of references) suggests this is due to poor "tuning" of prefrontal cortex by DA and NE due to observed neurodevelopmental delays in prefrontal cortical synaptic connections in ADHD. But this again introduces clouded talks about phasic DA stimulation and how this hypothetically improves learning and reward structures in conjunction with "tuning" NE into "sweet spots" (which is way too high in anxiety, acute stress, and mania, with impaired working memory correlates, as well...so has to be carefully approached) through a a complex dance associated with the locus coeruleus and the VTA... I mean it, it gets very complex, very fast, lol.

All of this to say, it is very complex, and difficult to consider and requires a really focused (no pun intended) approach to diagnosing and treating, as has been the suggestion I have been making across this thread. Having said that, I, similar to Barkley, sincerely doubt that specific psychological measures are going to adequately encapsulate all of these complex facets and that is where I turn to my well trained colleagues in psychiatry and psychology to utilize our clinical judgement to assess and to determine the presence of a condition that can be impactfully treated, when appropriately identified.

 

[aim-agm]

This is as good a place as any to make known my pet peeve that the only non-controlled specific DRI (bupropion) inhibits the metabolism of both the high-affinity specific NRIs (atomoxetine, desipramine), in particular because it is often more reasonable to start with the latter (e.g. comorbid anxiety) and then you are in an awkward position if you have to then augment with the former.

 

[Taddy Mason]

This is as good a place as any to make known my pet peeve that the only non-controlled specific DRI (bupropion) inhibits the metabolism of both the high-affinity specific NRIs (atomoxetine, desipramine), in particular because it is often more reasonable to start with the latter (e.g. comorbid anxiety) and then you are in an awkward position if you have to then augment with the former.

Bupropion is actually much more of an NRI. It goes through significant first pass metabolism with its active metabolites being much, much more physiologically present and active than the parent drug and all of which are significantly more noradrenergic than they are dopaminergic. Sertraline is actually more of a DRI than bupropion.

 

[Ceke2002]

Not specifically about you but about patient reports along similar lines. Part of the challenge is that procrastination behavior is common and multifactorial. Boring and tedious things are boring and tedious and anything else is interesting and exciting in comparison. Avoidant behavior relieves anxiety/dread about doing annoying things until it doesn't.

I pretty much never diagnose ADHD when procrastination is the ONLY "symptom."

--

Also to the above about anxiety/ADHD, I believe consensus (despite what pro-ADHD sources will say) is still that ADHD is a diagnosis of exclusion in adults. If there's a concurrent apparent anxiety disorder, you're not wrong to treat that first, as mood and anxiety disorders very commonly cause difficulties with attention/"executive function."

Same thing with untreated/poorly treated depression.

As an aside, I went to a talk by Barkley in grad school and he had a wonderful quote about ADHD and adult employment: “Impulsivity is the difference between wanting to tell your boss to **** off and actually telling your boss to **** off.”

This is definitely a pet peeve of mine; this idea that some have touted (hopefully fewer in number these days) whereby a diagnosis of ADHD somehow supersedes all other issues and/or diagnoses. I remember the Psychiatrist who (re) diagnosed me as an adult being genuinely surprised that I still wanted to work on other issues, because apparently a diagnosis of ADHD magically made everything else disappear. Anxiety was ADHD, major clinical depression was ADHD, everything was ADHD. Even his attitude to stimulants (dexamphetamine in my case), although legitimately prescribed, was one of "Take this pill, it will replace all other medication you have ever needed".

Obviously other conditions can worsen symptoms of ADHD, or make it harder to manage said symptoms. It seems prudent to me to treat those conditions alongside the ADHD (and also investigate to rule out non ADHD causes of ADHD like symptoms), rather than metaphorically holding aloft a medication and declaring it's the 'one pill to rule them all'.

 

[R. Matey]

IIRC, the "attention" is the function that will allow or disallow conscious awareness of stimuli, and to maintain or dismiss that awareness. Correct me if I'm wrong, my understanding is that ADHD is considered a dysregulation of attention function rather than a deficit per se. Generally dysfunction of attention with tend to fail to gatekeep awareness (i.e. distractibility) or maintain awareness (i.e. lack of focus) but it could also fail in not having awareness (i.e. inattention) or excessive persistence of awareness - with the phenomena of "hyperfocus" being both dysfunctionally persistent awareness of something and inappropriate suppression of awareness of everything else.

We might be saying the same thing. Barkley views ADHD as a product of a deficit in inhibitory control, which is an executive function that impacts other executive functions. Inhibitory control is your ability to suppress impulses.

 

[Liquid8]

This is definitely a pet peeve of mine; this idea that some have touted (hopefully fewer in number these days) whereby a diagnosis of ADHD somehow supersedes all other issues and/or diagnoses. I remember the Psychiatrist who (re) diagnosed me as an adult being genuinely surprised that I still wanted to work on other issues, because apparently a diagnosis of ADHD magically made everything else disappear. Anxiety was ADHD, major clinical depression was ADHD, everything was ADHD. Even his attitude to stimulants (dexamphetamine in my case), although legitimately prescribed, was one of "Take this pill, it will replace all other medication you have ever needed".

Obviously other conditions can worsen symptoms of ADHD, or make it harder to manage said symptoms. It seems prudent to me to treat those conditions alongside the ADHD (and also investigate to rule out non ADHD causes of ADHD like symptoms), rather than metaphorically holding aloft a medication and declaring it's the 'one pill to rule them all'.

I think some psychiatrists have a saviour complex regarding ADHD, becoming blinkered, seeing it in everything and being too eager in using heroic dosages as well as being dismissive of other explanations like substance dependence. Some of these doctors have run into issues with the national regulator, but also become de-facto thought leaders in the Australian ADHD space.

Can remember one talking about treating a patient who first presented in their 70s with an ABI on Concerta 54 QID and Ritalin IR 40mg QID, because the patient seemed to have misunderstood their initial dose instructions and was taking Ritalin every hour. To me the dosing (a long acting agent 4x a day!?) and rationale for this sounded completely insane.

I can remember another one talking about encountering a high rate of what he called “treatment resistant ADHD” and recommending a cocktail of medications including multiple high-dose stimulants combined with lamotrigine, reboxetine, memantine and other off label drugs to nearly all their patients.

So that made me think: my experience over the last 10 years in my private practice is that low doses of stimulants typically work well in most adult patients, those who were diagnosed in childhood typically manage with less medication as an adult (which I put down to frontal lobe development), have rarely needed to use high doses of stimulants and never needed to add additional agents like the ones noted above; so the thought occurred to me – if the usual treatments aren’t working, is it actually ADHD you’re dealing with and does the diagnosis need to be reviewed?

 

[Ceke2002]

I think some psychiatrists have a saviour complex regarding ADHD, becoming blinkered, seeing it in everything and being too eager in using heroic dosages as well as being dismissive of other explanations like substance dependence. Some of these doctors have run into issues with the national regulator, but also become de-facto thought leaders in the Australian ADHD space.

Can remember one talking about treating a patient who first presented in their 70s with an ABI on Concerta 54 QID and Ritalin IR 40mg QID, because the patient seemed to have misunderstood their initial dose instructions and was taking Ritalin every hour. To me the dosing (a long acting agent 4x a day!?) and rationale for this sounded completely insane.

I can remember another one talking about encountering a high rate of what he called “treatment resistant ADHD” and recommending a cocktail of medications including multiple high-dose stimulants combined with lamotrigine, reboxetine, memantine and other off label drugs to nearly all their patients.

So that made me think: my experience over the last 10 years in my private practice is that low doses of stimulants typically work well in most adult patients, those who were diagnosed in childhood typically manage with less medication as an adult (which I put down to frontal lobe development), have rarely needed to use high doses of stimulants and never needed to add additional agents like the ones noted above; so the thought occurred to me – if the usual treatments aren’t working, is it actually ADHD you’re dealing with and does the diagnosis need to be reviewed?

Ah yes, the good old 'let's just throw pills at it' approach to Psychiatry. I had a GP in the earlyish 2000s who was like that, wanna be Psych I think. I didn't respond to medication (non ADHD treatment) in a timely enough manner, so he just kept piling more meds on and increasing dosages up to stupid levels, before eventually just refusing to see me at all. I'm not sure if he even considered that what I actually needed was therapy in conjunction with a reasonable dose of medication. Last conversation I had with him he actually rang me at home to consult on what dose of an antidepressant he should prescibe another patient. Definitely a WTF moment for me, and I told him as much.

The Psych who first diagnosed and treated me as an adult had taken over from another Psychiatrist who was apparently the main provider of ADHD diagnosis and treatment in South Australia at the time. The previous Doctor had apparently committed suicide after being busted rorting medicare. I know this, because it's what the other Psych decided to open our session with. Like, dude I did not need to know that. Oddly enough the proper diagnosis and correct treatment of ADHD (with generally low doses of dexamphetamine) was the only thing he was strict on due to concerns about trouble with the medical board. Having sex with patients, and running an unlicensed inpatient clinic for Naltrexone rapid detox was fine, but he really needed to be fully by the book when it came to ADHD. Sad to say, but you can't make this sh1t up.

In terms of medication for ADHD I did great on a relatively low dose of dexamphetamine (from memory it was around 10-15mgs a day). I hadn't been treated with medication as a child, and didn't know any other kids who had either until the early 80s; much later on I was essentially self medicating with speed and meth. Being on a properly dosed amphetamine medication was like night and day for me, it just so happened that taking speed everyday turned out to not be as fun as it sounded because side effects are a thing. To be honest I am currently considering whether or not I can afford another round of testing and look at possibly trying out non stimulant treatments for ADHD (for a number of health reasons it's becoming increasingly difficult for me to cope with ADHD symptoms sans medication). Trouble is everywhere I see advertised in Melbourne just seems really dodgy to me, like a bunch of places trying to cash in on the latest ADHD trend.

 

[FatherPsychiatry]

Hot off the press:
Published Online: June 25, 2025

Increased Prescribing of Attention-Deficit/Hyperactivity Disorder Medication and Real-World Outcomes Over Time​

Question Do the real-world benefits of attention-deficit/hyperactivity disorder (ADHD) medications in reducing adverse outcomes change as prescription rates increase in the population?

Findings In this nationwide study of 247 420 ADHD medication users in Sweden from 2006 to 2020, ADHD medication use was consistently associated with lower risks of self-harm, unintentional injury, traffic crashes, and crime, while some of these associations weakened as prescriptions rates increased.

Meaning These results demonstrated that ADHD medications were consistently associated with reduced risks of several serious real-world outcomes, but these associations appear to weaken alongside shifts in the patient population, highlighting the need for ongoing review of treatment guidelines.

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2835661

 

[Ceke2002]

Hot off the press:
Published Online: June 25, 2025

Increased Prescribing of Attention-Deficit/Hyperactivity Disorder Medication and Real-World Outcomes Over Time​

Question Do the real-world benefits of attention-deficit/hyperactivity disorder (ADHD) medications in reducing adverse outcomes change as prescription rates increase in the population?

Findings In this nationwide study of 247 420 ADHD medication users in Sweden from 2006 to 2020, ADHD medication use was consistently associated with lower risks of self-harm, unintentional injury, traffic crashes, and crime, while some of these associations weakened as prescriptions rates increased.

Meaning These results demonstrated that ADHD medications were consistently associated with reduced risks of several serious real-world outcomes, but these associations appear to weaken alongside shifts in the patient population, highlighting the need for ongoing review of treatment guidelines.

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2835661

Ooh, stuff to read, thank you. This looks very interesting. I'd a hazard a guess (without yet having read the paper) that medication for people with legit ADHD and seriously life impacting symptoms would be life changing; those with a legit diagnosis who perhaps have less prominent symptoms would probably benefit slightly less with medication (perhaps more of a non stimulant option combined with non pharmacological intervention; and those who are FOS might either under or over sell how great ADHD medication is with little to no clinically observable (genuine) improvements in ADLs.

 

[cara susanna]

The point of the tests is to reduce the anxiety of the person ordering it through some sort of medicolegal fantasy that when the DEA busts down their door they can wave these test results in front of them to be spared.

As a psychologist who can't stand the field's reliance on the unsupported practice of "ADHD testing," this is 100% hitting the nail on the head.

(Sorry, all, just saw this thread and am getting caught up. Interesting discussion!)

 

[calvnandhobbs68]

Hot off the press:
Published Online: June 25, 2025

Increased Prescribing of Attention-Deficit/Hyperactivity Disorder Medication and Real-World Outcomes Over Time​

Question Do the real-world benefits of attention-deficit/hyperactivity disorder (ADHD) medications in reducing adverse outcomes change as prescription rates increase in the population?

Findings In this nationwide study of 247 420 ADHD medication users in Sweden from 2006 to 2020, ADHD medication use was consistently associated with lower risks of self-harm, unintentional injury, traffic crashes, and crime, while some of these associations weakened as prescriptions rates increased.

Meaning These results demonstrated that ADHD medications were consistently associated with reduced risks of several serious real-world outcomes, but these associations appear to weaken alongside shifts in the patient population, highlighting the need for ongoing review of treatment guidelines.

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2835661

Interesting paper, will probably be helpful to solidify long term more severe real world benefits.

I didn't get too far in depth with it yet but one very odd thing they didn't address was the fact that their absolute number of events for crime in the "no medication" timeframes actually went down over time despite an increasing number of person years. Take a look at Figures 2 and 3 for instance. It also trends down overall from 2006-2020. This is NOT the case for the "medication" timeframe, in which the absolute number (we're not talking about rate, just absolute number of events) increases with your overall number of person years increasing.

This is honestly really odd that your total number of events wouldn't at least hold steady and would significantly impact their analysis for the IRR. It also isn't explained by sex differences (which would be an obvious thing you'd want to look at for crime right...females commit less crimes than males). No, the trend is the same for females and males in Figure 3.

 

[Ceke2002]

Interesting paper, will probably be helpful to solidify long term more severe real world benefits.

I didn't get too far in depth with it yet but one very odd thing they didn't address was the fact that their absolute number of events for crime in the "no medication" timeframes actually went down over time despite an increasing number of person years. Take a look at Figures 2 and 3 for instance. It also trends down overall from 2006-2020. This is NOT the case for the "medication" timeframe, in which the absolute number (we're not talking about rate, just absolute number of events) increases with your overall number of person years increasing.

This is honestly really odd that your total number of events wouldn't at least hold steady and would significantly impact their analysis for the IRR. It also isn't explained by sex differences (which would be an obvious thing you'd want to look at for crime right...females commit less crimes than males). No, the trend is the same for females and males in Figure 3.

I double checked, and they don't mention or break down what crimes were committed in the period in question. For the medication group I'm wondering if a lot of the crime rate had to do with other substance use. Anecdotal/observational only, but I have previously noticed that for those who may have been self medicating with something like crystal meth/ice, being put on a stimulant medication for ADHD can trigger intense cravings for illicit forms of amphetamines, leading to difficulties with medication compliance. Not sure how it all works brain wise, but taking Dexamphetamine when you were still using and/or abusing something like crystal meth, just sort of flipped this switch in your head and had you absolutely fiending to go out and score. Didn't seem to matter that you'd already taken an amphetamine based medication, once that kicked in it was almost immediate and intense cravings for the other stuff. It was a noticeable enough concern that, once I realised the potential risk, I actually delayed getting a diagnosis as an adult until I was in a substance abuse treatment program and knew I would be fairly closely monitored. I wonder if they factored that in when choosing subjects for the study?

 

[calvnandhobbs68]

I double checked, and they don't mention or break down what crimes were committed in the period in question. For the medication group I'm wondering if a lot of the crime rate had to do with other substance use. Anecdotal/observational only, but I have previously noticed that for those who may have been self medicating with something like crystal meth/ice, being put on a stimulant medication for ADHD can trigger intense cravings for illicit forms of amphetamines, leading to difficulties with medication compliance. Not sure how it all works brain wise, but taking Dexamphetamine when you were still using and/or abusing something like crystal meth, just sort of flipped this switch in your head and had you absolutely fiending to go out and score. Didn't seem to matter that you'd already taken an amphetamine based medication, once that kicked in it was almost immediate and intense cravings for the other stuff. It was a noticeable enough concern that, once I realised the potential risk, I actually delayed getting a diagnosis as an adult until I was in a substance abuse treatment program and knew I would be fairly closely monitored. I wonder if they factored that in when choosing subjects for the study?

No, in a study like this you don't "choose" subjects in the traditional sense. It's all based off national registry data. For this study:

"Crime was defined as any conviction for a crime from the National Crime Register; if the date of the crime was unavailable, the date of conviction was used."

They were also supposed to adjust for medications used for substance use disorders at least:

"Furthermore, we explicitly adjusted for time-varying covariates, including age per calendar year, concurrent use of other psychotropic medication, including antipsychotics (ATC code N05A); anxiolytics, hypnotics, and sedatives (ATC code N05B or N05C); antidepressants (ATC code N06A); antiepileptic drugs (ATC code N03A), and drugs used in addictive disorders (substance use disorders; ATC code N07B), as well as seasonality in Sweden (school/work season: September to June; or summer holiday season: July to August)."

It also wouldn't explain why you have opposing absolute event trends in the on-medication vs off-medication time periods with person-years increasing overall.

 

[Ceke2002]

No, in a study like this you don't "choose" subjects in the traditional sense. It's all based off national registry data. For this study:

"Crime was defined as any conviction for a crime from the National Crime Register; if the date of the crime was unavailable, the date of conviction was used."

They were also supposed to adjust for medications used for substance use disorders at least:

"Furthermore, we explicitly adjusted for time-varying covariates, including age per calendar year, concurrent use of other psychotropic medication, including antipsychotics (ATC code N05A); anxiolytics, hypnotics, and sedatives (ATC code N05B or N05C); antidepressants (ATC code N06A); antiepileptic drugs (ATC code N03A), and drugs used in addictive disorders (substance use disorders; ATC code N07B), as well as seasonality in Sweden (school/work season: September to June; or summer holiday season: July to August)."

It also wouldn't explain why you have opposing absolute event trends in the on-medication vs off-medication time periods with person-years increasing overall.

Thank you for the explanation, much appreciated.

 

[clausewitz2]

Interesting paper, will probably be helpful to solidify long term more severe real world benefits.

I didn't get too far in depth with it yet but one very odd thing they didn't address was the fact that their absolute number of events for crime in the "no medication" timeframes actually went down over time despite an increasing number of person years. Take a look at Figures 2 and 3 for instance. It also trends down overall from 2006-2020. This is NOT the case for the "medication" timeframe, in which the absolute number (we're not talking about rate, just absolute number of events) increases with your overall number of person years increasing.

This is honestly really odd that your total number of events wouldn't at least hold steady and would significantly impact their analysis for the IRR. It also isn't explained by sex differences (which would be an obvious thing you'd want to look at for crime right...females commit less crimes than males). No, the trend is the same for females and males in Figure 3.

Dr. Claude (Opus 4) responded thusly:

"
This is an excellent observation that points to a potentially important limitation in the study's methodology. The decreasing absolute number of crime events during "no medication" periods despite increasing person-years is indeed counterintuitive and suggests something systematic is happening.


Here are the most likely explanations:

1.​

As ADHD prescribing expanded from 0.6% to 2.8% of the population, the characteristics of who contributes "no medication" time fundamentally changed:

• Early period (2006-2010): The "no medication" time likely came from severely impaired individuals who hadn't yet been diagnosed/treated, plus gaps in treatment for the small number already diagnosed
• Later period (2016-2020): The "no medication" time increasingly came from brief treatment gaps among a much larger, less severely impaired treated population

This would create systematically different comparison groups over time, potentially biasing the IRRs.

2.​

In a self-controlled case series, timing matters:

• People diagnosed later in the study contribute their highest-risk years to "no medication" time in earlier periods
• As they age and start treatment, their lower-risk years contribute to "medication" time in later periods
• This creates an artificial appearance of medication benefit that's actually partly due to aging/maturation

3.​

Individuals with the most severe outcomes (imprisonment, death, emigration) drop out of the cohort. Since these high-risk individuals were more likely to be unmedicated in early years, their removal disproportionately reduces "no medication" crime events over time.

4.​

The study uses 30-day gaps to define medication periods. As prescribing practices evolved toward more continuous treatment, the nature and frequency of these gaps likely changed, altering what "no medication" actually represents.

Key Implications​

This pattern suggests the study's estimates of medication effectiveness may be overestimated, particularly for crime outcomes. The decreasing trend in IRRs over time (0.73→0.81→0.84 for crime) might partly reflect this bias rather than truly declining medication effectiveness.


The authors should have:

1. Shown absolute numbers in their main results
2. Conducted sensitivity analyses examining different gap definitions
3. Tested for violations of the self-controlled case series assumption that event risk is stable over time
4. Potentially restricted analyses to incident users to avoid some of these biases

This is a subtle but important limitation that affects interpretation of the study's core findings about changing medication effectiveness over time."

 

[calvnandhobbs68]

🤣 haha thanks Dr. Claude, I concur

 

[FatherPsychiatry]

Dr. Claude (Opus 4) responded thusly:

"

Cool! How do you like Claude? Been wanting to dip my toes in some AI, tried some of the free stuff (chatGPT, CoPilot and OpenEvidence) but not Claude yet, although read its pretty good.

 

[Stagg737]

Cool! How do you like Claude? Been wanting to dip my toes in some AI, tried some of the free stuff (chatGPT, CoPilot and OpenEvidence) but not Claude yet, although read its pretty good.

Just be careful what you tell Claude, it may try to blackmail you!

 

[clausewitz2]

Cool! How do you like Claude? Been wanting to dip my toes in some AI, tried some of the free stuff (chatGPT, CoPilot and OpenEvidence) but not Claude yet, although read its pretty good.

It is definitely my go to. Generally you are going to want to try out one of Claude, ChatGPT or Gemini, everyone else are also-rans at the moment. Ideally and specifically you'd be using Opus 4 for Claude, o3 for ChatGPT if you're asking it to do anything complex, and Gemini 2.5 Flash (Pro has its uses but if you're not coding Flash honestly seems fine).