First time adult ADHD assessment

[iownmle]

Got a question about evaluating ADHD in adults who was not previously diagnosed with ADHD. If patient says he had issues with concentration since age 10 and checks all the boxes on DSM 5, and brings back a Vanderbilt parent informant form filled out (I didn't see the parent filling out the form), would that be enough to diagnose and prescribe stimulant? Am I safeguarding the stimulants enough with this procedure? I usually require UDS if patient has h/o drug use but not if patient denies using drugs in the past. Thanks.

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[VA Hopeful Dr]

Not a psychiatrist, but no that would not be enough for me.

 

[aim-agm]

Age 10 would be relatively late for initial symptoms of ADHD. I remember one kid I saw that was diagnosed at age 11 for symptoms that were observed at age 10...after a Criterion A trauma at age 9.

If they are checking all the DSM 5 boxes, then that means they report having hyperactive symptoms. These are relatively easily observed on exam (e.g. "we've been talking for most of an hour, and this patient has not stopped moving for a second") so if you aren't seeing them, then that means the patient report is unreliable. If you are seeing them, then that would support a diagnosis.

UDS is a good idea even if they deny history of drug use.

 

[clausewitz2]

Got a question about evaluating ADHD in adults who was not previously diagnosed with ADHD. If patient says he had issues with concentration since age 10 and checks all the boxes on DSM 5, and brings back a Vanderbilt parent informant form filled out (I didn't see the parent filling out the form), would that be enough to diagnose and prescribe stimulant? Am I safeguarding the stimulants enough with this procedure? I usually require UDS if patient has h/o drug use but not if patient denies using drugs in the past. Thanks.

What is your normal adult ADHD evaluation process? How are you assessing whether they "check all the boxes"? I think most people on this forum would agree that using a semi-structured interview of some kind can be incredibly helpful here. Talking to collateral is even better. Sure, they are not perfect and with enough effort and a co-conspirator even those methods can be fooled, but at the end of your day you are not a police detective. Sometimes you will get played in psychiatry, no matter what diagnosis you are talking about. It is an inevitable result of being in a position where you can on occasion give someone exactly what they want.

Since the only way to totally avoid this is to never give anyone anything they want ever, it's a trade-off. The optimal amount of getting hoodwinked clinically is non-zero.

 

[iownmle]

i interview adhd like other diagnoses. I first ask them to describe their issue. I ask them about how early they remember their issues with concentration, progression, how they did at school, how their issue impact home or professional lives. I try to talk to a collateral on the phone but not always possible so I just ask the patient to give their parent the Vanderbilt parent informant. I don’t talk with their teachers like child psychiatrist would.

After that I go through the dsm criteria and see if they meet symptoms that they didn’t mention.

Other things are checking pdmp which is not helpful if from another state, get past psych and pcp notes, which they don’t always have, asking about testing accommodations, psychological testing which they definitely don’t have

 

[annoyedpsychiatrist]

1. During interview can usually notice traits of hyperactivity and even impulsivity. For inattentive symptoms, not as noticeable. Ive had some patients where I would of thought they use cocaine, but negative UDS, no prior hx, etc. Were just high energy/scatterbrain.

2. Baseline UDS can be good. I work for a major hospital system and usually have access to prior UDS in many (not all patients). Usually if theres a hx of drug use, then often i can find red flags in the chart. I dont do baseline UDS on everyone, but im also very judicious about who I give controlled medications to. If i have even a hint of doubt though then i will for sure obtain UDS. I may get a random UDS too which may be more revealing sometimes. Some people i have access to prior records and its a slam dunk case and i question it less because everything fits into place. Not typically the case, but sometimes. One limitation is a lot of the 20 year olds are doing nitrous, kratom, kava or other various stuff that may not show in UDS.

3. Collateral information is ideal. I dont trust calling a random person or having a random person fill out a form. I tell the patient to bring their spouse into the office. The source of the information matters as much as the information. Some people are not reliable sources of information...I am flexible. If there are clear schedule conflicts, i may have the collateral source write a signed letter describing the patient, but i prefer face to face collateral. I prefer collateral, but I dont do it for every patient. Sometimes i dont always have immediate access to collateral or sometimes the diagnosis is clear/straightforward.

4. Why are they coming in now? Thats a big thing. Why not a year ago? Two years ago? Etc. Why now? (unless stable on medications)

5. Obtain a clear childhood hx and then move to the present. How is this affecting you now? Show me where your life is impaired. Being written up at work? Constantly losing your wallet/keys every day? House is a disaster? Failing out of school? Specifics matter. Hammer down specific details. I dont like broad statements "i just cant focus". "Work is hard for me". How? Give me an example of how inattention caused a work mishap.

One example. Had a 40 year old come for worsening memory issues. Wasnt even looking for ADHD diagnosis. Did a thorough hx of the patient, she for sure had ADHD. The patient at one point was the accountant for family business and somehow misplaced $5,000 in cash. Threw it away with the mail, husband thinks. There were many other examples similiar to that, and going back to childhood she was a disaster in school. and at home she would always leave everything half finished per the husband

6. Treat comorbid depression/anxiety which can worsen attention

7. How will a stimulant dramatically improve someones life? Thats the million dollar question I always ask myself. if i use a stimulant, my goal is that by doing so objectively their life will have significant improvement, and a higher quality of life.

8. What are they asking for? Are they coming in on huge doses of stimulants and benzos? Sometimes it can be fishy.

9. I review public arrest records when i can. it is public information. It will surprise you what youll find sometimes. Have found many coming for ADHD meds and you can 10 prior arrests for cocaine.


The clinical interview and intuition are your best bet. Putting the pieces together. Sometimes ill treat anxiety/depression first then agree to circle back to possible ADHD later on. if theyre willing to do that, then that is usually a good sign. Some people are genuine with ADHD evals and just looking for help/not sure whats going on. Others, not so much.

Also theres certain prescribers in the area that are pill mills, and obvious about it. if i see patients from those providers, im immediately skeptical and much more hesistant. Also if they have been getting it from a random online clinic.

 

[annoyedpsychiatrist]

What is your normal adult ADHD evaluation process? How are you assessing whether they "check all the boxes"? I think most people on this forum would agree that using a semi-structured interview of some kind can be incredibly helpful here. Talking to collateral is even better. Sure, they are not perfect and with enough effort and a co-conspirator even those methods can be fooled, but at the end of your day you are not a police detective. Sometimes you will get played in psychiatry, no matter what diagnosis you are talking about. It is an inevitable result of being in a position where you can on occasion give someone exactly what they want.

Since the only way to totally avoid this is to never give anyone anything they want ever, it's a trade-off. The optimal amount of getting hoodwinked clinically is non-zero.

yep, i would agree with this 1000%. Ultimately you will probably get it right most of the time. However, no matter what you do, there are times where people say the right things, collateral says the right things, UDS is clean, etc. At the end of the day you can do your due dilligence but you dont know what the pt does when they leave your office

 

[Merovinge]

As a child psychiatrist, the minimum that I would be comfortable with are as follows:
1) Collateral information from parent or legal guardian (presuming they are alive). This is NOT done as a stupid checklist, you need 5 minutes to discuss the actual experience of the person raising the child. If you cannot obtain this from a parent/LG a childhood friend is probably better than nothing.
2) Extensive discussion around history of symptoms and most notably WHY NOW (sorry to steal from the psychodynamic folks). Why now, why now, why now. If this is not a compelling narrative that is logically coherent, I would at the very least be referring out to neuropsych testing. This is also how you accurately work on your differential diagnosis.
3) PDMP check and Utox. If they don't give utox the day of the appointment, I would automatically defer. The most important reason is not to check for THC, but to see if they are already taking stimulants they are not telling you about.
4) I would never prescribe on the first appointment, you need time to get the collateral and this weeds out the people who are desperate for the meds (they will find another doc/NP to get it from)

Of course as I type this, you got a great response as above.

 

[Celexa]

Got a question about evaluating ADHD in adults who was not previously diagnosed with ADHD. If patient says he had issues with concentration since age 10 and checks all the boxes on DSM 5, and brings back a Vanderbilt parent informant form filled out (I didn't see the parent filling out the form), would that be enough to diagnose and prescribe stimulant? Am I safeguarding the stimulants enough with this procedure? I usually require UDS if patient has h/o drug use but not if patient denies using drugs in the past. Thanks.

Are you a troll? Only getting UDS if the pt admits hx of drug use? Are you trying to become the go to pill mill for good liars?

Of course the process you described isn't adequate for quality care. You have to actually do a thorough eval to assess for possible comorbidities and adhd mimics. What does 'problems with concentration' even mean, practically speaking?

There's enough bad mental health care that you're probably mediolegally covered, but 'better than all the people who should be sued but aren't' isn't exactly a standard anyone should aspire to.

You should worry more about doing the patients harm with stimulants they don't need (including but not limited to: poor sleep, undesirable weight loss, increased anxiety....) and failure to treat comorbid conditions or the condition they actually have then just if you're going to get in trouble with some board.

 

[FlowRate]

Lots of good advice above.

Regarding structured interviews, our psychologists use DIVA. I like ACE+ (adult version). I don't do the entire structured interview as written but do like the way they assess for ADHD symptoms and functional impairment. I do the other rule-outs as part of a more typical/unstructured clinical interview.

 

[ObsequiousAplomb]

I do not routinely order a UDS. It's a major waste of resources to order a baseline test without clinical suspicion. One of the biggest ways to be called out for waste fraud and abuse is to order needless tests.

I do conduct a 90+ minute interview where I am actively looking for ADHD signs. If the exam doesn't match up with the interview, I ask about it. if their history doesn't match up (have a college or professional degree with no treatment) then we talk about goals. If they are sniffling a lot or give any other indication of drug use, then we talk about it.

I have found that the people who come to me for an ADHD eval are not fiending for stimulants but are mostly looking for ways to help them in life. If they haven't had a stimulant yet, then they can wait between the first and second visit trying more behavioral interventions. If they don't want to wait / seem suspicious I refer them to someone else for treatment. No skin off my back.

I also don't go harassing their parents for collateral in order to get a low dose stimulant. That's rather invasive and controlling. We aren't police. We treat patients, we don't investigate them.

I don't prescribe stimulants to people with active alcohol or other substance use disorders except for the tobacco smokers with ADHD. If they want to deceive me and then I find out about it later, then we have a conversation. if they have track marks, then of course I refer them to substance treatment.

Again, I charge about 1/10 what the ADHD clinics charge for an eval, but I take 85+ minutes longer to do the assessment. I do review multiple screening forms, including that nice new cross-cut one. I screen for OSA, thyroid disorders, etc.

If I cared any more about which patients are trying to trick me, I'd just stop being a doctor.

 

[romanticscience]

I use the DSM-5 cross-cutting symptom measure. I evaluate the domains the patient positively endorses using the SCID-5-CV. The ADHD module asks if several symptoms were present before age twelve.

To assess for severity, I use the ADHD-RS with my own embedded validity testing (Becke, 2021). I used the CAT-A, but it became too cumbersome to score.

In line with the literature (Ahmad, 2019; Sibley, 2018), complaints of ADHD in adults usually come along with significant co-morbidity. So, usually, after going through the SCID, I'm telling someone that I can't diagnose ADHD because something else better explains it. That something else is usually severe MDD, bipolar, PTSD--dissociative disorder, or substance use. I will usually make a co-morbid diagnosis if anxiety is mild or depression is remitted or part of persistent depressive disorder.

I've been getting many young women with really, really bad PTSD, avoiding their trauma and related emotions, coming to me FROM A THERAPIST for "suspected ADHD." Um, that's hypervigilance!

Yes, doing SCIDs on everyone does take time, but it is easier to tell someone it's likely not ADHD when you tell them their four other diagnoses in need of treatment.

My opinion is that the criteria for ADHD, which were formulated for children, become very non-specific when used in adults who have co-morbid "adult disorders." When I give my PTSD+BPD patients an ASRS, they score off the charts every time!


Ahmad, S. I., Owens, E. B. & Hinshaw, S. P. Little Evidence for Late-Onset ADHD in a Longitudinal Sample of Women. J. Consult. Clin. Psychol. 87, 112–117 (2019).
Becke, M. et al. Non-credible symptom report in the clinical evaluation of adult ADHD: development and initial validation of a new validity index embedded in the Conners’ adult ADHD rating scales. J. Neural Transmission 128, 1045–1063 (2021).
Sibley, M. H. et al. Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. Am. J. Psychiatry 175, 140–149 (2018).

 

[littlefred]

I do not routinely order a UDS. It's a major waste of resources to order a baseline test without clinical suspicion. One of the biggest ways to be called out for waste fraud and abuse is to order needless tests.

I do conduct a 90+ minute interview where I am actively looking for ADHD signs. If the exam doesn't match up with the interview, I ask about it. if their history doesn't match up (have a college or professional degree with no treatment) then we talk about goals. If they are sniffling a lot or give any other indication of drug use, then we talk about it.

I have found that the people who come to me for an ADHD eval are not fiending for stimulants but are mostly looking for ways to help them in life. If they haven't had a stimulant yet, then they can wait between the first and second visit trying more behavioral interventions. If they don't want to wait / seem suspicious I refer them to someone else for treatment. No skin off my back.

I also don't go harassing their parents for collateral in order to get a low dose stimulant. That's rather invasive and controlling. We aren't police. We treat patients, we don't investigate them.

I don't prescribe stimulants to people with active alcohol or other substance use disorders except for the tobacco smokers with ADHD. If they want to deceive me and then I find out about it later, then we have a conversation. if they have track marks, then of course I refer them to substance treatment.

Again, I charge about 1/10 what the ADHD clinics charge for an eval, but I take 85+ minutes longer to do the assessment. I do review multiple screening forms, including that nice new cross-cut one. I screen for OSA, thyroid disorders, etc.

If I cared any more about which patients are trying to trick me, I'd just stop being a doctor.

Not to be facetious but how are you assessing objectively if they have a use disorder if you are not ordering urine drug screen?

How are you going to tell if they are taking the medications as prescribed, not mixing with other potential hazardous substances and not diverting?

I do agree with your first statement about not doing needless tests, but a UDS is pivotal for controlled substance prescription.

If you had a patient that is prescribed a stimulant and has a positive cocaine, would you not change the course of the treatment?

 

[Atreides]

To assess for severity, I use the ADHD-RS with my own embedded validity testing (Becke, 2021). I used the CAT-A, but it became too cumbersome to score.

CAT-A can be administered digitally now; I use it for all my ADHD evals.

 

[romanticscience]

This is off-topic, but how do people consider the use of illicit substances in which they don't actually meet the criteria for DSM-5 use disorder?

Like, if you use cocaine on the weekends to party. So many of the SUD criteria describe someone with essentially an overwhelming compulsion.

 

[Merovinge]

I do not routinely order a UDS. It's a major waste of resources to order a baseline test without clinical suspicion. One of the biggest ways to be called out for waste fraud and abuse is to order needless tests.

I do conduct a 90+ minute interview where I am actively looking for ADHD signs. If the exam doesn't match up with the interview, I ask about it. if their history doesn't match up (have a college or professional degree with no treatment) then we talk about goals. If they are sniffling a lot or give any other indication of drug use, then we talk about it.

I have found that the people who come to me for an ADHD eval are not fiending for stimulants but are mostly looking for ways to help them in life. If they haven't had a stimulant yet, then they can wait between the first and second visit trying more behavioral interventions. If they don't want to wait / seem suspicious I refer them to someone else for treatment. No skin off my back.

I also don't go harassing their parents for collateral in order to get a low dose stimulant. That's rather invasive and controlling. We aren't police. We treat patients, we don't investigate them.

I don't prescribe stimulants to people with active alcohol or other substance use disorders except for the tobacco smokers with ADHD. If they want to deceive me and then I find out about it later, then we have a conversation. if they have track marks, then of course I refer them to substance treatment.

Again, I charge about 1/10 what the ADHD clinics charge for an eval, but I take 85+ minutes longer to do the assessment. I do review multiple screening forms, including that nice new cross-cut one. I screen for OSA, thyroid disorders, etc.

If I cared any more about which patients are trying to trick me, I'd just stop being a doctor.

That is really inconsistent with the literature to describe a UDS prior to rx of a level 2 controlled sub as needless. They cost a few dollars at the most (i.e. under $5). I get that you do a much more extensive interview, but you get no utox and talk to no collateral. I am not sure that A) you are going to feel better when the first patient you prescribe with an amphetamine use disorder dies or that B) the courts are going to agree that you met the standard of care.

We don't accept any patients into our PHP/IOP without talking to a collateral source (for adults, obviously for kids). It's not invasive or investigating, it's spending a few extra minutes to do the right thing for the patient in front of you by getting the most complete picture possible to provide them the best care possible.

I think you are a good doctor and I am not trying to give you specifically a hard time, but I do think it's important for trainees reading these boards to hear differing perspectives.

 

[ObsequiousAplomb]

That is really inconsistent with the literature to describe a UDS prior to rx of a level 2 controlled sub as needless. They cost a few dollars at the most (i.e. under $5). I get that you do a much more extensive interview, but you get no utox and talk to no collateral. I am not sure that A) you are going to feel better when the first patient you prescribe with an amphetamine use disorder dies or that B) the courts are going to agree that you met the standard of care.

We don't accept any patients into our PHP/IOP without talking to a collateral source (for adults, obviously for kids). It's not invasive or investigating, it's spending a few extra minutes to do the right thing for the patient in front of you by getting the most complete picture possible to provide them the best care possible.

I think you are a good doctor and I am not trying to give you specifically a hard time, but I do think it's important for trainees reading these boards to hear differing perspectives.

I'm 100% certain that collateral is not the standard of care outside of peds or forensics. I've never met in person even one psychiatrist who gets collateral on adults. I'm certain of that. Apparently people on this forum like doing uncompensated work that is not the standard of care.

Show me the APA guideline that says you must get a UDS.

$5 adds up on 500 patients, especially of you ever repeat it. Quest and LabCorp are also getting paid a ton more than $5 for a UDS. Based on their website, it's $106 for a 6-panel UDS. That's more than half of what insurance pays me for the 90792. It's 20% more than I would be paid for the 99213 followup for simple ADHD, the bread-and-butter of psychiatry. That's ignoring that the standard of care is to order confirmatory testing on all screening positives before acting on the results, which further drives up costs.
An 11-panel actually costs more than I get paid for a 90792.

 

[ObsequiousAplomb]

This is off-topic, but how do people consider the use of illicit substances in which they don't actually meet the criteria for DSM-5 use disorder?

Like, if you use cocaine on the weekends to party. So many of the SUD criteria describe someone with essentially an overwhelming compulsion.

Using cocaine on the weekends:
Did you ever try to cut back unsuccessfully? Have doctors advised you it's a bad idea and you do it anyway? Do you ever drive high or hungover? Have you ever gone to work hung over or high? Have you ever dodged calls from work while high or hungover? Have you ever done something you regret while high?

In my experience, the answer is almost always yes to all of these, and that qualifies as an SUD.

 

[annoyedpsychiatrist]

This is off-topic, but how do people consider the use of illicit substances in which they don't actually meet the criteria for DSM-5 use disorder?

Like, if you use cocaine on the weekends to party. So many of the SUD criteria describe someone with essentially an overwhelming compulsion.

if your insight is low enough to use cocaine on the weekends to party then you can rest assured you will not be getting controlled medications form me lol

 

[annoyedpsychiatrist]

I'm 100% certain that collateral is not the standard of care outside of peds or forensics. I've never met in person even one psychiatrist who gets collateral on adults. I'm certain of that. Apparently people on this forum like doing uncompensated work that is not the standard of care.

Show me the APA guideline that says you must get a UDS.

$5 adds up on 500 patients, especially of you ever repeat it. Quest and LabCorp are also getting paid a ton more than $5 for a UDS. Based on their website, it's $106 for a 6-panel UDS. That's more than half of what insurance pays me for the 90792. It's 20% more than I would be paid for the 99213 followup for simple ADHD, the bread-and-butter of psychiatry. That's ignoring that the standard of care is to order confirmatory testing on all screening positives before acting on the results, which further drives up costs.
An 11-panel actually costs more than I get paid for a 90792.

so the UDS part both sides I can see. Theres no harm in a baseline UDS is how I look at it. And if theyre motivated to get treatment, then they will be willing to pay for it. That being said, i can see how a routine UDS may not always be needed in some patients: you have access to most of their records and no obvious SUD, no prior arrest records, no major red flags in the story, no endorsed substance use/reason to believe otherwise, etc. So i can see both sides to an argument. I have some young people who i dont start on a stimulant right away, treat their comorbid conditions, get to know them/build trust, and Im extremely confident that they dont have an active SUD. It varies. If I have even a hint of doubt though, im getting a UDS along with further information.


The collateral part is hard in the adult world. I will say in reality, besides obvious things like straightforward MDD/GAD/etc, collateral can make a huge difference at times. I have so many vague cases where I really dont know if its bipolar 2 vs ADHD vs SUD vs personality disorder, etc. Most of my patients im able to reasonably pinpoint the diagnosis, but some people are very poor historians, with vague presentations/sx and collateral can be super useful. That being said, im not tracking down family and calling outside of business hours. I tell the patient to bring family to the apt, collateral should be done during apt time, not after.

 

[Candidate2017]

Are you a troll? Only getting UDS if the pt admits hx of drug use? Are you trying to become the go to pill mill for good liars?

I don't think OP is a troll, just someone with lackluster residency training. ADHD screening is (should be) one of the bread and butter skills taught by residency.

This is off-topic, but how do people consider the use of illicit substances in which they don't actually meet the criteria for DSM-5 use disorder?

Like, if you use cocaine on the weekends to party. So many of the SUD criteria describe someone with essentially an overwhelming compulsion.

DSM criteria for SUDs is flawed because criteria basically won't be met if patient has poor insight or is in denial. Imagine if DSM criteria for psychotic disorders were written like SUD criteria.

I'd be ok coding it as stimulant use disorder, mild, cocaine.

 

[clausewitz2]

I don't think OP is a troll, just someone with lackluster residency training. ADHD screening is (should be) one of the bread and butter skills taught by residency.



DSM criteria for SUDs is flawed because criteria basically won't be met if patient has poor insight or is in denial. Imagine if DSM criteria for psychotic disorders were written like SUD criteria.

I'd be ok coding it as stimulant use disorder, mild, cocaine.

Serious question, do you code someone who has a beer or glass of wine most nights as having alcohol use disorder?

 

[Merovinge]

I'm 100% certain that collateral is not the standard of care outside of peds or forensics. I've never met in person even one psychiatrist who gets collateral on adults. I'm certain of that. Apparently people on this forum like doing uncompensated work that is not the standard of care.

Show me the APA guideline that says you must get a UDS.

$5 adds up on 500 patients, especially of you ever repeat it. Quest and LabCorp are also getting paid a ton more than $5 for a UDS. Based on their website, it's $106 for a 6-panel UDS. That's more than half of what insurance pays me for the 90792. It's 20% more than I would be paid for the 99213 followup for simple ADHD, the bread-and-butter of psychiatry. That's ignoring that the standard of care is to order confirmatory testing on all screening positives before acting on the results, which further drives up costs.
An 11-panel actually costs more than I get paid for a 90792.

75. Clinicians should consider more frequent screening for stimulant misuse in patients who take prescribed psychostimulant medications is from ASAM's guidelines.

I'm a bit surprised that you have 500 patient's on amphetamines as an adult psychiatrist, how many patient's are on your total panel? FWIW, we spend under $25 for GC/mass spec confirmatory testing through Quest. I find it interesting that you are very worried over a few dollars of lab tests per patient but seem to have far less concerns about the risk of doing harm to a person in front of you. I can't tell you how much money is frivolously spent in our healthcare system, much less spending money on following reputable guidelines.

 

[FlowRate]

I don't think OP is a troll, just someone with lackluster residency training. ADHD screening is (should be) one of the bread and butter skills taught by residency.

Honestly, it's not that long ago that adults presenting with primary concern for ADHD was a relatively rare thing. I don't feel like academic psychiatry has reached a point where it has a handle on how to deal with the new "adults with a chief complaint of 'their (undiagnosed) ADHD'"-thing that we've been seeing increasingly over the last ~6-10 years (and especially post-pandemic.) I'd honestly be impressed if anyone who's been in attending practice for more than 4 years feels like they got robust training in how to handle this new phenomenon.

 

[Stagg737]

I don't think OP is a troll, just someone with lackluster residency training. ADHD screening is (should be) one of the bread and butter skills taught by residency.



DSM criteria for SUDs is flawed because criteria basically won't be met if patient has poor insight or is in denial. Imagine if DSM criteria for psychotic disorders were written like SUD criteria.

I'd be ok coding it as stimulant use disorder, mild, cocaine.

Why even bother with the SUD label? Just say "cocaine abuse". Any use of an illicit substance is abuse, and XXX abuse/dependence are still valid ICD codes.

Serious question, do you code someone who has a beer or glass of wine most nights as having alcohol use disorder?

That depends on if you go through the full DSM criteria for AUD and they report 2 symptoms. If they're staying home to drink instead of going out because they get a craving then it meets criteria. I'll avoid my soap box on the problems of the newer diagnostic criteria for SUDs and the stupidity of eliminating the 'abuse' and 'dependence' modifiers, but it can be shockingly easy to meet criteria for a use disorder depending on how symptom reporting is interpreted.

 

[ObsequiousAplomb]

75. Clinicians should consider more frequent screening for stimulant misuse in patients who take prescribed psychostimulant medications is from ASAM's guidelines.

I'm a bit surprised that you have 500 patient's on amphetamines as an adult psychiatrist, how many patient's are on your total panel? FWIW, we spend under $25 for GC/mass spec confirmatory testing through Quest. I find it interesting that you are very worried over a few dollars of lab tests per patient but seem to have far less concerns about the risk of doing harm to a person in front of you. I can't tell you how much money is frivolously spent in our healthcare system, much less spending money on following reputable guidelines.

I do not have 500. I have 50 total patients as I'm mostly a therapy practice. I warn people extensively about the risks of the medications. It's disingenuous to claim I'm not worried about the person in front of me. Your posts here seem like you think I'm murdering people with stimulants.

It seems clear to me that people ITT are ordering a UDS because they are worried about themselves, not because they are worried about their patients
Idk where you're getting GC for $25. That sounds absurd since even Medicaid pays $2500 for that here.

Nothing under 75 says "you must get a UDS before an Rx"

 

[Merovinge]

I do not have 500. I have 50 total patients as I'm mostly a therapy practice. I warn people extensively about the risks of the medications. It's disingenuous to claim I'm not worried about the person in front of me. Your posts here seem like you think I'm murdering people with stimulants.

Idk where you're getting GC for $25. That sounds absurd since even Medicaid pays $2500 for that here.

Nothing under 75 says "you must get a UDS before an Rx"

You are saying no screening. They are saying more frequent. People intentionally don't say you MUST do things in guidelines to protect doctors from lawsuits (which is a wise idea).

I'm not sure what to tell you about GC testing, I literally just got back from talking to a CMO from another facility earlier this week and they pay under $50 for the test. We pay approx $25. I have seen the actual bills. We have some patients that get 10 GC/MS tests in the span of 6-10 weeks of treatment and it doesn't bat an eye for our working class patient population. This test used to be preposterously expensive, I don't how addictionlogists did things back in the day, but it is widely available now. I have parents that make $25/hour that can afford to buy utoxes for their kids...

 

[aim-agm]

One thing that has made ADHD assessments much less stressful for me is that more often than not adults respond well to bupropion and/or atomoxetine (or desipramine), and I have occasionally been surprised by guanfacine. I can tolerate a lot more diagnostic uncertainty with one of those than I can with an amphetamine or methylphenidate.

Usually there is a clear comorbid condition (e.g. anxiety, depression, PTSD,etc.) or it's a differential (e.g. ADHD vs. early childhood trauma) that makes one of the meds a reasonable choice regardless. Particularly for an NRI, if there is a reasonable degree of suspicion for ADHD and there is a comorbid medical condition that might benefit from the med (e.g. migraines, pain) then there is a sound clinical reason to trial it.

The significant majority of patients (even those already on an amphetamine or methylphenidate) are very willing to trial one of these meds, particularly after educating about how much more convenient and uncomplicated being on a non-controlled med is.

 

[ObsequiousAplomb]

You are saying no screening. They are saying more frequent. People intentionally don't say you MUST do things in guidelines to protect doctors from lawsuits (which is a wise idea).

I'm not sure what to tell you about GC testing, I literally just got back from talking to a CMO from another facility earlier this week and they pay under $50 for the test. We pay approx $25. I have seen the actual bills. We have some patients that get 10 GC/MS tests in the span of 6-10 weeks of treatment and it doesn't bat an eye for our working class patient population. This test used to be preposterously expensive, I don't how addictionlogists did things back in the day, but it is widely available now. I have parents that make $25/hour that can afford to buy utoxes for their kids...

I wasn't reading screening as UD screening, but as asking screening. It says screening for amphetamine misuse, which would mean we need to order GC/MS to tell which amphetamine, if we are talking UD screening. Because I'm always asking misuse screening questions, I am ALWAYS screening, not NEVER screening.

If I'm wrong, I'll gladly change my view and my practice.

 

[ObsequiousAplomb]

One thing that has made ADHD assessments much less stressful for me is that more often than not adults respond well to bupropion and/or atomoxetine (or desipramine), and I have occasionally been surprised by guanfacine. I can tolerate a lot more diagnostic uncertainty with one of those than I can with an amphetamine or methylphenidate.

Usually there is a clear comorbid condition (e.g. anxiety, depression, PTSD,etc.) or it's a differential (e.g. ADHD vs. early childhood trauma) that makes one of the meds a reasonable choice regardless. Particularly for an NRI, if there is a reasonable degree of suspicion for ADHD and there is a comorbid medical condition that might benefit from the med (e.g. migraines, pain) then there is a sound clinical reason to trial it.

The significant majority of patients (even those already on an amphetamine or methylphenidate) are very willing to trial one of these meds, particularly after educating about how much more convenient and uncomplicated being on a non-controlled med is.

Is there any acceptable evidence that non-TCA NRIs help with pain? Or with migraines? I was under the impression there was not.

That being said, I do agree with what you are saying. Careful history is the standard of care and the gold standard for ADHD diagnosis. Psychometric tests are for charlatans and snake oil salesmen. If there's something that isn't ADHD higher in the differential than ADHD, then treat that other condition first.

 

[littlefred]

Is there any acceptable evidence that non-TCA NRIs help with pain? Or with migraines? I was under the impression there was not.

That being said, I do agree with what you are saying. Careful history is the standard of care and the gold standard for ADHD diagnosis. Psychometric tests are for charlatans and snake oil salesmen. If there's something that isn't ADHD higher in the differential than ADHD, then treat that other condition first.

I think patients will take advantage of you and word will get out that you prescribe stimulants without urine testing and other practices that other doctors are doing.

There is a clear primary gain to obtain stimulants and if you are not wanting to see that, that's fine.

The NIH recently came out with statistics of excessive stimulant prescriptions and diagnosis by mostly midlevel providers and also you've probably read the threads on Done and Cerebral.

How are your practices any different to theirs? At least they did urine drug testing for a change.

 

[ObsequiousAplomb]

I think patients will take advantage of you and word will get out that you prescribe stimulants without urine testing and other practices that other doctors are doing.

There is a clear primary gain to obtain stimulants and if you are not wanting to see that, that's fine.

The NIH recently came out with statistics of excessive stimulant prescriptions and diagnosis by mostly midlevel providers and also you've probably read the threads on Done and Cerebral.

How are your practices any different to theirs? At least they did urine drug testing for a change.

Well, instead of asking you could read what I said. Which is an extensive difference.

I clearly see the primary gain. Why are you so certain I'm blind to it? Or are you lashing out at my practice without actually reading what I said so that you can justify your dogmatic view that urine drug screens are actually helpful? Because they're the easiest test to cheat. Or are you blind to the secondary gain to cheat a UDS if that's all you do to assess ADHD?

And again, patients who give me the impression they're pooling the wool over my eyes don't get a stimulant. I have been incredibly clear about that here. Anyone who says they heard about me from anywhere but my website or their insurance is under extra scrutiny, and would most likely get a UDS ordered.

 

[aim-agm]

Is there any acceptable evidence that non-TCA NRIs help with pain? Or with migraines? I was under the impression there was not.

Yes...desipramine works at low doses when it activity is purely NRI
Also, duloxetine works. Duloxetine is not a TCA.

Also, my clinical experience is that atomoxetine works. Not acceptable evidence per se, but consistent with the prediction based on desipramine and duloxetine that the essential quality for treating pain is NRI activity.

 

[ObsequiousAplomb]

Yes...desipramine works at low doses when it activity is purely NRI
Also, duloxetine works. Duloxetine is not a TCA.

Also, my clinical experience is that atomoxetine works. Not acceptable evidence per se, but consistent with the prediction based on desipramine and duloxetine that the essential quality for treating pain is NRI activity.

Okay. So desipramine is a TCA, and I was asking about non-TCAs. Cymbalta is an SNRI, not an NRI

 

[Stagg737]

Yes...desipramine works at low doses when it activity is purely NRI
Also, duloxetine works. Duloxetine is not a TCA.

Also, my clinical experience is that atomoxetine works. Not acceptable evidence per se, but consistent with the prediction based on desipramine and duloxetine that the essential quality for treating pain is NRI activity.

Interesting, I haven't seen those effects with atomoxetine, but also haven't looked for it, so will keep this in the back of my mind going forward...

Okay. So desipramine is a TCA, and I was asking about non-TCAs. Cymbalta is an SNRI, not a TCA.

Cymbalta has solid evidence and I see it help patients significantly with some frequency. In residency I had several patients who took Sunosi and said it was better than opiates. Like, clutching their pearls, "please do anything but take this away" level of perceived helpfulness. I also had several patients on milnacipran who felt it was quite helpful for pain, so worth it for them even if the data for it isn't great.

 

[ObsequiousAplomb]

Interesting, I haven't seen those effects with atomoxetine, but also haven't looked for it, so will keep this in the back of my mind going forward...


Cymbalta has solid evidence and I see it help patients significantly with some frequency. In residency I had several patients who took Sunosi and said it was better than opiates. Like, clutching their pearls, "please do anything but take this away" level of perceived helpfulness. I also had several patients on milnacipran who felt it was quite helpful for pain, so worth it for them even if the data for it isn't great.

Cymbalta has been effective for some of my chronic pain patients. It has absolutely exacerbated migraines in my patients, which is consistent with the evidence that it is harmful in treating headaches.

Effexor has been helpful at low doses for my migraine patients, and not at all helpful for chronic pain other than migraines.

But again, these are not NRIs. My question was about the claim that NRIs are helpful in migraines or chronic pain. I'm also dubious to the claim that non-TCA NRIs are helpful in any condition outside of ADHD. I believe that those drugs were forced through the FDA process for ADHD because they absolutely failed to help in other conditions.

I'd absolutely consider desipramine, imipramine, Elavil, or doxepin for ADHD comorbid with other psychiatric or pain or headache diagnoses.

 

[splik]

It seems clear to me that people ITT are ordering a UDS because they are worried about themselves, not because they are worried about their patients
Idk where you're getting GC for $25. That sounds absurd since even Medicaid pays $2500 for that here.

There should be a public outcry for waste of tax payers dollars if your state medicaid is paying anywhere near $2500 for a urine drug screen. In my state, it pays between $10 to 43.50. In the contract cigna provided me they will reimburse between $15-20 for a UDS. UDS is cheap. Even the quest and labcorp prices are sticker prices, not what is actually paid by insurance.

 

[Stagg737]

Cymbalta has been effective for some of my chronic pain patients. It has absolutely exacerbated migraines in my patients, which is consistent with the evidence that it is harmful in treating headaches.

Effexor has been helpful at low doses for my migraine patients, and not at all helpful for chronic pain other than migraines.

But again, these are not NRIs. My question was about the claim that NRIs are helpful in migraines or chronic pain. I'm also dubious to the claim that non-TCA NRIs are helpful in any condition outside of ADHD. I believe that those drugs were forced through the FDA process for ADHD because they absolutely failed to help in other conditions.

I'd absolutely consider desipramine, imipramine, Elavil, or doxepin for ADHD comorbid with other psychiatric or pain or headache diagnoses.

Are you talking about "pure" NRIs or just those with significant NRI effects? If the former, then you're really talking about a tiny number of meds available in the US. If the latter, I've found plenty of meds with noradrenergic effects (TCAs, milnacipran and Sunosi, cymbalta, even effexor/pristiq) helpful for chronic pain (and some types of headaches). Atomoxetine also has decent evidence for treatment of anxiety, though I believe those studies looked specifically at people/CAP with ADHD with co-morbid anxiety disorders. That said, I have seen patients with who were convinced they had ADHD where I felt it was questionable report improvements in anxiety with atomoxetine even with minimal perceived effects on ADHD.

I have never heard of or used doxepin for ADHD, pain, or headaches.

 

[ObsequiousAplomb]

Are you talking about "pure" NRIs or just those with significant NRI effects? If the former, then you're really talking about a tiny number of meds available in the US. If the latter, I've found plenty of meds with noradrenergic effects (TCAs, milnacipran and Sunosi, cymbalta, even effexor/pristiq) helpful for chronic pain (and some types of headaches). Atomoxetine also has decent evidence for treatment of anxiety, though I believe those studies looked specifically at people/CAP with ADHD with co-morbid anxiety disorders. That said, I have seen patients with who were convinced they had ADHD where I felt it was questionable report improvements in anxiety with atomoxetine even with minimal perceived effects on ADHD.

I have never heard of or used doxepin for ADHD, pain, or headaches.

Because the person I was asking was specifically saying they use atomoxetine for comorbidities, I was asking about pure NRIs.

I'm aware of all those SNRIs and their uses. Admittedly, never tried milnacipran nor levomilnacipran. Not because I don't trust them, but because I've never used them so I have no experience with them. I don't like to start Pristiq, but I've continued it for people.

Doxepin has a strong evidence base for pain. According to some studies, it's better than Elavil. I'd go for it for someone with ADHD symptoms, anxiety, and insomnia. I don't think there's much evidence for it in ADHD like there is for imipramine or desipramine, so I'd use it for someone who doesn't have OSA but has pain and insomnia that I think are majorly contributing to their executive dysfunction.

In my experience, I don't like to use the SNRIs for "ADHD patients" because they tend to inhibit cyp2d6 and the patients invariably don't respond well enough to avoid a stimulant. They also tend to be just as poorly if not worse tolerated than TCAs in my patients, and considerably less effective.

I've definitely had surprising results from chronic pain relief in patients with Cymbalta, and those patients say "my ADHD got better." Those tend to not be patients that I have diagnosed with ADHD, though.

In a possibly surprising reversal to some here, I do consider a UDS for chronic pain patients. I also universally don't prescribe controlled substances (other than gabapentinoids for neuropathic pain) to patients with chronic pain. I'm too concerned that it will lead to substance abuse problems. I refer them to pain management practices if they want a CS.

I do also want to clarify - anyone with a family history of substance abuse or who mentions a friend with substance problems would get a UDS from me. Anyone who says they tried a friend's Adderall and it helped doesn't get a stimulant from me. Anyone who drinks doesn't get one. We tend to trust patients words on the alcohol consumption, right? Or do others order labs to screen for alcohol use? Why's marijuana any different? IME, people who use marijuana can't help themselves from sharing that fact. People who use cocaine usually look like cocaine users.

 

[ObsequiousAplomb]

There should be a public outcry for waste of tax payers dollars if your state medicaid is paying anywhere near $2500 for a urine drug screen. In my state, it pays between $10 to 43.50. In the contract cigna provided me they will reimburse between $15-20 for a UDS. UDS is cheap. Even the quest and labcorp prices are sticker prices, not what is actually paid by insurance.

Again, I never said a UDS costs that much, but that confirmation testing does.

 

[aim-agm]

Okay. So desipramine is a TCA, and I was asking about non-TCAs. Cymbalta is an SNRI, not an NRI

You seem stuck on "TCA" as a particularly meaningful category in this context. Better to think about mechanisms of action.
Consider this: if a patient is on MAOi, its only recommended to add clomipramine if you want to kill the patient, but it is reasonable to add desipramine to treat hypotension and prevent tyramine-induced hypertension (and theoretically if you are trying to treat migraines- literature indicates MAOIs work for those!).

In my experience, I don't like to use the SNRIs for "ADHD patients" because they tend to inhibit cyp2d6 and the patients invariably don't respond well enough to avoid a stimulant. They also tend to be just as poorly if not worse tolerated than TCAs in my patients, and considerably less effective.

I don't use duloxetine or venlefaxine or any other SNRI for ADHD. First, they tend to have too little NRI potency to work. Second, the SRI activity does nothing for the ADHD and can only contribute to side effects. Why would you even consider an SNRI for ADHD?

 

[aim-agm]

Interesting, I haven't seen those effects with atomoxetine, but also haven't looked for it, so will keep this in the back of my mind going forward...

Cymbalta has solid evidence and I see it help patients significantly with some frequency. In residency I had several patients who took Sunosi and said it was better than opiates. Like, clutching their pearls, "please do anything but take this away" level of perceived helpfulness. I also had several patients on milnacipran who felt it was quite helpful for pain, so worth it for them even if the data for it isn't great.

Atomoxetine also has decent evidence for treatment of anxiety, though I believe those studies looked specifically at people/CAP with ADHD with co-morbid anxiety disorders.

I use atomoxetine (or desipramine) pretty frequently for anxiety, sometimes as monotherapy, and it is reliably effective whether or not patient has comorbid ADHD. Only treat adults, can't comment on kids. Also very useful for PTSD and of course depression.


This might be a hot take, but: I think SNRIs should be much less preferred than an NRI or SRI+NRI
- SRNIs are less potent as NRIs compared to atomoxetine/desipramine, and tend to be less potent SRIs than a lot of other SRIs. Better to use two meds that are really good at one thing each, than one med that is meh at two things.
- If you are looking for NRI activity, then use an NRI. Why add potential adverse effects of serotonin reuptake inhibition?
- Relatedly, you can't titrate NRI and SRI activity independently. If a patient is on duloxetine for pain and mood, and the mood symptoms resolved at 40 mg but the pain symptoms haven't, you can't just increase norepinephrine reuptake inhibition without also increasing serotonin.
- Similarly, if the psychiatric symptoms resolve (e.g. patient gets good therapy) but the comorbid condition (e.g. migraines) hasn't, you can't titrate off an SNRI. With an SRI+NRI, you could titrate off the now unnecessary SRI.
- SNRIs tend to have rigid maximum doses. SRIs tend to have more flexibility (e.g. sertraline dosing for OCD goes up to 400 mg). So, for a good number of SRIs, if you have worked your way up to maximum typical dose and it is well tolerated with good but partial response, you can trial uptitration. You can't do that with SNRIs (or at least duloxetine and venlafaxine).

*steps off soapbox*

 

[sloh]

They also tend to be just as poorly if not worse tolerated than TCAs in my patients, and considerably less effective.

Which side effects are most common and bothersome for your patients?

 

[sloh]

SNRIs tend to have rigid maximum doses. SRIs tend to have more flexibility (e.g. sertraline dosing for OCD goes up to 400 mg). So, for a good number of SRIs, if you have worked your way up to maximum typical dose and it is well tolerated with good but partial response, you can trial uptitration. You can't do that with SNRIs (or at least duloxetine and venlafaxine)*

Why do SNRI’s have more rigid ceiling doses?

 

[Candidate2017]

Why even bother with the SUD label? Just say "cocaine abuse". Any use of an illicit substance is abuse, and XXX abuse/dependence are still valid ICD codes.

Exactly. For occasional use, I usually click ICD "[substance] use unspecified, uncomplicated". Depending on the day, that's what usually pops up first in my EMR diagnosis search.

Serious question, do you code someone who has a beer or glass of wine most nights as having alcohol use disorder?

I wouldn't be opposed to coding daily alcohol use similarly (or ICD above), given new evidence on alcohol. I haven't met anyone whose psychiatric issues and health haven't improved upon reduction/cessation of alcohol. Also, alcohol vs. cocaine are different beasts.

As an aside, I see a clinical correlation with higher income and risk of developing cardiac issues from cocaine at a relative young age (heart failure, pacemakers, etc.). I suspect my richer, younger patients had their hearts hammered with actual cocaine, while my poorer patients are just smoking a lot of baby power.

 

[Merovinge]

Because the person I was asking was specifically saying they use atomoxetine for comorbidities, I was asking about pure NRIs.

I'm aware of all those SNRIs and their uses. Admittedly, never tried milnacipran nor levomilnacipran. Not because I don't trust them, but because I've never used them so I have no experience with them. I don't like to start Pristiq, but I've continued it for people.

Doxepin has a strong evidence base for pain. According to some studies, it's better than Elavil. I'd go for it for someone with ADHD symptoms, anxiety, and insomnia. I don't think there's much evidence for it in ADHD like there is for imipramine or desipramine, so I'd use it for someone who doesn't have OSA but has pain and insomnia that I think are majorly contributing to their executive dysfunction.

In my experience, I don't like to use the SNRIs for "ADHD patients" because they tend to inhibit cyp2d6 and the patients invariably don't respond well enough to avoid a stimulant. They also tend to be just as poorly if not worse tolerated than TCAs in my patients, and considerably less effective.

I've definitely had surprising results from chronic pain relief in patients with Cymbalta, and those patients say "my ADHD got better." Those tend to not be patients that I have diagnosed with ADHD, though.

In a possibly surprising reversal to some here, I do consider a UDS for chronic pain patients. I also universally don't prescribe controlled substances (other than gabapentinoids for neuropathic pain) to patients with chronic pain. I'm too concerned that it will lead to substance abuse problems. I refer them to pain management practices if they want a CS.

I do also want to clarify - anyone with a family history of substance abuse or who mentions a friend with substance problems would get a UDS from me. Anyone who says they tried a friend's Adderall and it helped doesn't get a stimulant from me. Anyone who drinks doesn't get one. We tend to trust patients words on the alcohol consumption, right? Or do others order labs to screen for alcohol use? Why's marijuana any different? IME, people who use marijuana can't help themselves from sharing that fact. People who use cocaine usually look like cocaine users.

The point of the utox prior to first script is to tell if the person is already getting the stimulant elsewhere (or I suppose worse like undisclosed opioids/cocaine). There's a much bigger rabbit hole to go down with THC, but that's not why you get the screening <$5 cup. Even if you are somewhere that confirmatory testing is cost prohibitive, it should be a very small number that are coming up amp + as a false positive (and you'll have a good idea being that you know their med list).

This idea that we are all-knowing as seasoned psychiatrists and can just tell who is using what substances by looking at them is a pet-peeve of mine. We can tune our minds to give us hints, but we need to verify to be physicians instead of fortune tellers. My partner orders tests that cost hundreds to thousands of dollars without batting an eye and she is relatively conservative compared to her peers in surgery. I think it is pure intellectualism to deny a basic utox based on cost as being good care. ASAM is definitely recommending you consider regular utox screening when prescribing amphetamines, but clearly does not want to put any timeline on it so it is not held against psychiatrists when it isn't done. I may disagree with your style of practice but I certainly don't want you to lose a lawsuit over it.

 

[ObsequiousAplomb]

You seem stuck on "TCA" as a particularly meaningful category in this context. Better to think about mechanisms of action.
Consider this: if a patient is on MAOi, its only recommended to add clomipramine if you want to kill the patient, but it is reasonable to add desipramine to treat hypotension and prevent tyramine-induced hypertension (and theoretically if you are trying to treat migraines- literature indicates MAOIs work for those!).

I don't use duloxetine or venlefaxine or any other SNRI for ADHD. First, they tend to have too little NRI potency to work. Second, the SRI activity does nothing for the ADHD and can only contribute to side effects. Why would you even consider an SNRI for ADHD?

I'm aware of all those things. I was simply asking about had been literally said, that someone was prescribing atomoxetine for migraines and chronic pain. I don't use SNRIs for ADHD at all either. People come to me from psychiatrists who were trying them off-label for ADHD instead of the other classes of medications people do use for ADHD.

 

[ObsequiousAplomb]

The point of the utox prior to first script is to tell if the person is already getting the stimulant elsewhere (or I suppose worse like undisclosed opioids/cocaine). There's a much bigger rabbit hole to go down with THC, but that's not why you get the screening <$5 cup. Even if you are somewhere that confirmatory testing is cost prohibitive, it should be a very small number that are coming up amp + as a false positive (and you'll have a good idea being that you know their med list).

This idea that we are all-knowing as seasoned psychiatrists and can just tell who is using what substances by looking at them is a pet-peeve of mine. We can tune our minds to give us hints, but we need to verify to be physicians instead of fortune tellers. My partner orders tests that cost hundreds to thousands of dollars without batting an eye and she is relatively conservative compared to her peers in surgery. I think it is pure intellectualism to deny a basic utox based on cost as being good care. ASAM is definitely recommending you consider regular utox screening when prescribing amphetamines, but clearly does not want to put any timeline on it so it is not held against psychiatrists when it isn't done. I may disagree with your style of practice but I certainly don't want you to lose a lawsuit over it.

I admit that most of my patients at least convincingly pretend to be wary of stimulants when I'm discussing risks, benefits, and alternatives. I think that's why most at least play the game of asking for something other than a schedule II at the first visit. I also admit y'all've convinced me and I'll be ordering screening UDSs for everyone over the next few months and see how it goes. Hopefully I won't be too surprised.

I saw that 30% of Americans may be iron deficient recently. Think we should be screening that more seriously?

 

[Stagg737]

I admit that most of my patients at least convincingly pretend to be wary of stimulants when I'm discussing risks, benefits, and alternatives. I think that's why most at least play the game of asking for something other than a schedule II at the first visit. I also admit y'all've convinced me and I'll be ordering screening UDSs for everyone over the next few months and see how it goes. Hopefully I won't be too surprised.

I saw that 30% of Americans may be iron deficient recently. Think we should be screening that more seriously?

I actually do often order iron labs if a patient is depressed or anxious and also has specific physical symptoms (fatigue, hair/nail problems, RLS-like symptoms, cold intolerance, pica, etc). I'm also quick to refer for sleep studies if there's any signs of OSA. Have caught a couple of cases that PCPs said were "definitely not OSA" until they did a sleep study in a lab.

 

[ObsequiousAplomb]

I actually do often order iron labs if a patient is depressed or anxious and also has specific physical symptoms (fatigue, hair/nail problems, RLS-like symptoms, cold intolerance, pica, etc). I'm also quick to refer for sleep studies if there's any signs of OSA. Have caught a couple of cases that PCPs said were "definitely not OSA" until they did a sleep study in a lab.

Yeah I usually wait for an extra symptom in addition to depression, like you mentioned. Same thing with thyroid symptoms for thyroid testing. Now I'm wondering if I should for all my depressed patients, if the rate is as high as that study claims.

I usually do the full STOP-BANG on everyone. It's been a challenge convincing PCPs to send them to sleep medicine even when they meet criteria for further screening.