Every veteran has ADHD?

[kookfu]

Seems like >50% of my new outpatient intakes are for ADHD/Adderall requests. Most didn't have ADHD symptoms as a child, but had emergence of symptoms with depression/insomnia/ptsd/insomnia/head injuries during & after their service. Some have treated the comorbidities, some haven't. But an NP or PCP already put them on stimulants and now the patients refuse to come off. It's easier to justify taking them off if they're abusing drugs, but still each encounter is draining.

When I give them the amphetamine or Ritalin, almost everyone is happy. Although I know it's helping them focus, I feel torn about giving them a med that causes immediate mild euhporic effects, and thus reinforcing the idea that they have ADHD, even if it is just the narcotic making them feel great.

I get that rates of "ADHD" are higher in this population, but are we just going to give amphetamine to 25% of the veterans for every problem that could impact attention/focus? Didn't we already learn this lesson with benzos and opiates? Please advise

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[comp1]

So I don't know if this will be viewable by everybody, but at least within the VA, here are some resources:

ADHD Sharepoint

I particularly recommend the malingering of ADHD video from May. That said, these are also things you should be discussing with your clinic manager and chief psychiatrist.

 

[Jules A]

Good luck with that.

 

[MedMan80]

I remember at the VA as a trainee, it was sometimes hard to handle the entitlement. All the vets really had to do was escalate until they got approval for what they wanted..

 

[littlefred]

I remember at the VA as a trainee, it was sometimes hard to handle the entitlement. All the vets really had to do was escalate until they got approval for what they wanted..

Or write a letter to their state senator. Another classic one is calling the local news channel.

 

[annoyedpsychiatrist]

Its not just the VA, its everywhere. Our outpatient clinic ADHD intakes have taken off like crazy. Used to it would be like like 20-25% were ADHD evals. This year, ive been doing the math, roughly 40-60% of my evals have turned into ADHD evals. Its absurd. Its simple, social media, news articles, etc have convinced everyone that ADHD is the source of all their problems and if they simple "fixed" their ADHD, that went unrecognized, then they would be cured. I even have stable f/us who are now asking if they have ADHD. A lot of them. It is honestly become a big problem.

 

[romanticscience]

IMHO, the general neurotic syndrome has found a new name, yet again! Anxiety, depression, and bipolar are so out of style. This time, though, the treatment is a controlled substance and suggested to you more strongly (social media) than a TV commercial.

 

[littlefred]

America’s First Amphetamine Epidemic 1929–1971: A Quantitative and Qualitative Retrospective With Implications for the Present

Using historical research that draws on new primary sources, I review the causes and course of the first, mainly iatrogenic amphetamine epidemic in the United States from the 1940s through the 1960s. Retrospective epidemiology indicates that the absolute ...

www.ncbi.nlm.nih.gov

I wonder what happened in 1970? Hmm.

 

[PsyDr]

Seems like >50% of my new outpatient intakes are for ADHD/Adderall requests. Most didn't have ADHD symptoms as a child, but had emergence of symptoms with depression/insomnia/ptsd/insomnia/head injuries during & after their service.

It's a neurodevelopmental disorder. The DSM5 requires onset of symptoms in childhood.

 

[aim-agm]

Seems like >50% of my new outpatient intakes are for ADHD/Adderall requests. Most didn't have ADHD symptoms as a child, but had emergence of symptoms with depression/insomnia/ptsd/insomnia/head injuries during & after their service. Some have treated the comorbidities, some haven't. But an NP or PCP already put them on stimulants and now the patients refuse to come off. It's easier to justify taking them off if they're abusing drugs, but still each encounter is draining.

When I give them the amphetamine or Ritalin, almost everyone is happy. Although I know it's helping them focus, I feel torn about giving them a med that causes immediate mild euhporic effects, and thus reinforcing the idea that they have ADHD, even if it is just the narcotic making them feel great.

I get that rates of "ADHD" are higher in this population, but are we just going to give amphetamine to 25% of the veterans for every problem that could impact attention/focus? Didn't we already learn this lesson with benzos and opiates? Please advise

If there don't seem to be any problems caused by the stimulant, and there is a reasonable (even if not convincing) basis to believe if it is indicated, I usually am open to continuing it at least temporarily. If for example I think the inattention is because of PTSD but the stimulant seems to be important to function and isn't causing issues, I usually make a plan that we'll continue the stimulant for a limited period (to avoid impairments in function), treat the PTSD expeditiously, and then titrate off the stimulant.

If there is concern that the stimulant is causing problems and/or I can't see a basis for using it, then I'd tell the veteran that if they continue treatment with me I am going to be titrating off the stimulant. If they want to pursue treatment in the community instead, I decide on whether to bridge the script for a brief period on a case-by-case basis.

I have had a great deal of success in convincing veterans to trial bupropion, an NRI, or alpha-2 agonist, which are generally reasonable choices for what they actually have, can enhance attention in general (at least former two), and may have other benefits for comorbid conditions (e.g. NRIs can help with migraines and some pains). Even veterans with ADHD tend to want to try them when educated, because they are much simpler to be on (not limited to 30 day scripts with no refills, don't need to go through the rigamarole of assessment every time they move, etc.).

For some conditions stimulants, particularly methylphenidate, aren't necessarily the wrong choice. They can be reasonable in cases of head injury, are a later line treatment for depression, and a very late line but at least sometimes effective treatment for PTSD.

 

[kookfu]

IMHO, the general neurotic syndrome has found a new name, yet again! Anxiety, depression, and bipolar are so out of style. This time, though, the treatment is a controlled substance and suggested to you more strongly (social media) than a TV commercial.

No only that, but the social media apps that advertise it directly cause and exacerbate symptoms

 

[calvnandhobbs68]

I even have stable f/us who are now asking if they have ADHD. A lot of them. It is honestly become a big problem.

one of my least favorite freaking things....my functional 20yo who's been stable on lexapro for the past year and checked off 0s for concentration and fidgeting on their PHQ-9 the last 4 times who's asking if their anxiety/depressive disorder is actually "ADHD".

No only that, but the social media apps that advertise it directly cause and exacerbate symptoms

And pharmaceutical companies. Supernus (makes Qelbree) literally sends me crap every couple weeks about checking if any of my patients "might have ADHD" or "recognizing the hidden signs of ADHD in women".

 

[FlowRate]

one of my least favorite freaking things....my functional 20yo who's been stable on lexapro for the past year and checked off 0s for concentration and fidgeting on their PHQ-9 the last 4 times who's asking if their anxiety/depressive disorder is actually "ADHD".

And, in my experience, it's usually 15 minutes into a 30-minute follow-up slot where I'm still getting the vibe that they have something else they want to bring up, so they finally drop their "ADHD" concern and expect me to figure it out in 15 minutes... After which I usually educate that ADHD intakes are usually my most time consuming and that it'll take one or two additional follow-up appointments to arrive at a conclusion.

 

[clausewitz2]

If there don't seem to be any problems caused by the stimulant, and there is a reasonable (even if not convincing) basis to believe if it is indicated, I usually am open to continuing it at least temporarily. If for example I think the inattention is because of PTSD but the stimulant seems to be important to function and isn't causing issues, I usually make a plan that we'll continue the stimulant for a limited period (to avoid impairments in function), treat the PTSD expeditiously, and then titrate off the stimulant.

I definitely get the appeal of this approach and it probably works out okay for people who genuinely want to pursue effective treatment for PTSD, but for those who are more ambivalent about exposure-based therapies it seems like this would be a good way to guarantee they never try them.

 

[Sushirolls]

It is not just the VA, its everywhere.
Recent pubs on CV risk with ongoing stimulants adds to the Risk Benefit discussion, that is helping reduce some fervor.

 

[aim-agm]

I definitely get the appeal of this approach and it probably works out okay for people who genuinely want to pursue effective treatment for PTSD, but for those who are more ambivalent about exposure-based therapies it seems like this would be a good way to guarantee they never try them.

I agree, if the veteran's goal isn't actual treatment but rather staying on a stimulant, I wouldn't entertain continuing it.

In these situations, the initial main focus of treatment is pharmacologic. Typically the initial goal of treatment is controlling symptoms well enough with medications that they aren't causing significant dysfunction and aren't getting in the way of psychotherapy.

 

[Ironspy]

Psychiatrists don’t want the general public to know that everyone has ADHD and needs an emotional support crocodile and psychedelics.

 

[calvnandhobbs68]

Psychiatrists don’t want the general public to know that everyone has ADHD and needs an emotional support crocodile and psychedelics.

Sometimes I feel like telling people "you know I get paid MORE if I diagnose you with ADHD right? because now you have two chronic conditions requiring medication treatment so you'll automatically be a 99214 forever for me".

 

[aim-agm]

Sometimes I feel like telling people "you know I get paid MORE if I diagnose you with ADHD right? because now you have two chronic conditions requiring medication treatment so you'll automatically be a 99214 automatically forever for me".

"If you actually had ADHD, I could write for a stimulant and see you briefly every couple months forever for what the kids these days* call 'eazy money.' Unfortunately for both of us, you don't have ADHD."

*: Disclaimer - I have no earthly idea what kids these days call anything

 

[Jules A]

I agree, if the veteran's goal isn't actual treatment but rather staying on a stimulant, I wouldn't entertain continuing it.

Have you actually tried this?

 

[aim-agm]

Have you actually tried this?

Yes, although I've been lucky that the situation doesn't happen all that often. Sometimes veteran gets on board with my recommendations, sometimes they fire me and ask for another provider or for community referral. I got my first congressional patient advocate report for not prescribing a stimulant not too long ago, which if I don't miss my guess is a rite of passage as a VA psychiatrist.

 

[Jules A]

Yes, although I've been lucky that the situation doesn't happen all that often. Sometimes veteran gets on board with my recommendations, sometimes they fire me and ask for another provider or for community referral. I got my first congressional patient advocate report for not prescribing a stimulant not too long ago, which if I don't miss my guess is a right of passage as a VA psychiatrist.

You haven’t been fully indoctrinated until you’ve gotten the “this is why vets blow their brains out” in response to refusing their demand of a controlled substance.

 

[Merovinge]

Yes, although I've been lucky that the situation doesn't happen all that often. Sometimes veteran gets on board with my recommendations, sometimes they fire me and ask for another provider or for community referral. I got my first congressional patient advocate report for not prescribing a stimulant not too long ago, which if I don't miss my guess is a right of passage as a VA psychiatrist.

We need to clone you and disseminate your clones throughout our VA. Would reduce veteran suicide overnight.

 

[futureapppsy2]

You haven’t been fully indoctrinated until you’ve gotten the “this is why vets blow their brains out” in response to refusing their demand of a controlled substance.

I’m on the clinical side of benefits, and I’ve gotten that response for not immediately approving VA funds for a veteran’s desired high-end technology.

 

[comp1]

Congressional requests are a lot more enjoyable to read and respond to from psychotic patients than from patient seeking stimulants. They're probably more helpful for everyone involved as well.