Influx of adult ADHD referrals in outpatient

[When is graduation again?]

Since starting my private practice a few months ago, it seems like over half of new patients are coming with complaints of ADHD symptoms. It's usually people who've never had a diagnosis of it and want treatment. Occasionally it's people on reasonable current regiments, but there have also been some heroic doses of adderall prescribed as well by previous psychiatrists/pcps. Have you all noticed an uptick in these referrals? This wasn't an issue for me in my residency or my previous ACT job, but I'm getting to the point where I may start blocking all ADHD referrals. How are you all handling it?

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[Ironspy]

There is definitely an uptick. My deterrents
1. High fees. Much cheaper to get from pcp
2. 4-8 week min wait time for new appt. There are ways to get stimulants faster
3. I tell prospective patients that the vast majority adult onset attention issues are related to sleep, mood/anxiety and substance use. I say that we will have to address all of these areas before we can properly consider a primary attention disorder

Patients looking to feel and function better are generally ok with the above approach. Patients who just want stimulants now realize that I’m not a good fit for them and move on

 

[annoyedpsychiatrist]

yes, probably over half of what i get are related to stimulants and/or benzos/sedative hypnotics.

Stimulants im more flexible on. Proposed significant deficits in two different settings, and patient appears genuine in relation to these deficits? No hx of significant comorbid SUD? Clean arrest record (besides minor stuff)? Reasonable potential that these deficits started in childhood and patient was undiagnosed? It is very possible that many undiagnosed kids, grow up to be adults and eventually cant overcompensate for their deficits. ADHD hyperactivity/impulsivity is often easier to diagnose compared to inattentive type though.

Benzos i dont get too happy about by comparison since I dont believe they offer a real long term benefit, to be frank. Which I know some people on SDN may disagree with me.

 

[clausewitz2]

If you tell people that is going to require a focused clinical interview separate from the intake appointment (in order to make sure you can cover all of the other things that cause problems with attention before focusing on ADHD per se) and that you are probably going to have to speak to someone who knows them well that they trust about their functioning, I expect you will get crickets from many of these folks.

 

[tr]

If you tell people that is going to require a focused clinical interview separate from the intake appointment (in order to make sure you can cover all of the other things that cause problems with attention before focusing on ADHD per se) and that you are probably going to have to speak to someone who knows them well that they trust about their functioning, I expect you will get crickets from many of these folks.

Agree with above, and also if your purpose is to eliminate these people before ever having to interact with them, you could even put on your website that ADHD evals will require 1) separate interview (DIVA very helpful here) and 2) collateral (can use Conners parent for this if you like), and that you will charge your regular hourly rate for all this. I think that would take care of a lot of it.

 

[When is graduation again?]

Thanks for the suggestions everyone. I've started putting a lot of these things in place already, but I'll make it more explicit on my website and initial consultation calls.

 

[Egg122]

I post on my website that I do not prescribe stimulants or benzodiazepines, my office manager tells patients that before they book and they sign a document in my intake forms that they understand that I will not prescribe them. It has made my quality of life much better and hasn't impacted business too much.

 

[calvnandhobbs68]

Thanks for the suggestions everyone. I've started putting a lot of these things in place already, but I'll make it more explicit on my website and initial consultation calls.

Depends on how you want to approach it too. If you want to treat ADHD but want patients who you’ve diagnosed yourself and you’re confident in the diagnosis, then you could put that you generally don’t accept patients who are already prescribed stimulants. You can also run all new intakes through PDMP a week before you see them to weed this out. That way you weed out all the people coming to find someone because their old candyman retired who had them on 30mg Adderall IR BID or their pcp started them on Adderall and told them they had to go “see psychiatry” to continue it.

Reviewing PDMP also helps you be discretionary about it, probably way less likely to have issues with someone who’s on low dose Focalin or Vyvanse vs high dose IR Ritalin or Adderall.

 

[Merovinge]

I post on my website that I do not prescribe stimulants or benzodiazepines, my office manager tells patients that before they book and they sign a document in my intake forms that they understand that I will not prescribe them. It has made my quality of life much better and hasn't impacted business too much.

I know some docs who do this, but actually do prescribe them as appropriate. Just by having it on the website or introductory paperwork it cuts down those looking for a candydoc dramatically. I don't how I feel about anything less than 100% transparency on prescribing habits, but I certainly have seen that work. Of course you could actually not prescribe those meds as well.

 

[littlefred]

It's become so prevalent that there's even an NIH study discussing it!

Most of the prescriptions (and by proxy diagnosis) are from NPs, both stimulant and non stimulant, and more incidence for females than for males.

Here's the study Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022 - PubMed

 

[littlefred]

I know some docs who do this, but actually do prescribe them as appropriate. Just by having it on the website or introductory paperwork it cuts down those looking for a candydoc dramatically. I don't how I feel about anything less than 100% transparency on prescribing habits, but I certainly have seen that work. Of course you could actually not prescribe those meds as well.

Just ask the DEA or amend your DEA prescriptions to schedules 3 and below. Can't prescribe schedule 2 if your DEA doesn't allow it. Big brain move.

 

[Egg122]

I know some docs who do this, but actually do prescribe them as appropriate. Just by having it on the website or introductory paperwork it cuts down those looking for a candydoc dramatically. I don't how I feel about anything less than 100% transparency on prescribing habits, but I certainly have seen that work. Of course you could actually not prescribe those meds as well.

I follow that rule pretty closely. I've made one exception for a patient needing outpatient care after a hospitalization for catatonia who needed a very slow benzo taper because that is a completely appropriate use of the med but otherwise I won't prescribe either to new patients.

 

[annoyedpsychiatrist]

I really dont think it has be as stressful though. There are many people who genuinely benefit from stimulants. I will say that usually the ones who shouldnt be on stimulants, its often pretty clear. Perhaps theres some that are smart about it, but many are not so smart about it. Realistically stimulants are lower risk than benzos. You have to keep in mind, that there was a lot of stigma in relation to ADHD back in the day so its not unreasonable that people go through life undiagnosed. Plus youre in control and can stop them at any point if you start getting bad vibes, as opposed to benzos.

Sometimes people go into the clinic wanting stimulants for what they perceive as ADHD but really arent stimulant seeking, theyre just not sure what theyre dealing with and want help. I really try to give people a chance, because if you give people a chance, sometimes they will surprise you (sometimes in a bad way, lol).

 

[comp1]

The VAST majority of all people would "benefit" from stimulants, at least subjectively and even more so on objective tests. These are, by definition, performance enhancing drugs and powerful ones. That said, I actually agree they are lower risk than benzos (alcohol in a pill), but then I basically never prescribe benzos outside of emergent agitation. So saying they are lower risk than benzos isn't really saying much. The important thing about ADHD is not how much stimulants helped or might help, but the type and duration of specific impairments over the course of a lifetime, ideally from external observers as described above as opposed to self report.

 

[Sushirolls]

*Side track comment.
Don't you hate it when you quote some ones post, type a big ol' response. Before posting it... you double check, re-read everything, and realize you totally conceptualized their post wrong... and they actually just sort of said what you just typed out.
**Resume discussion.

 

[clozareal]

I'd like to play devil's advocate.

Outside of diversion, cardiovascular side effects (doesn't happen in a vast majority of patients on stimulants, probably about 4% in the most recent study), psychosis (probably a 1 in 660 risk), and other manageable side effects (appetite suppression and insomnia), what are the other risks of stimulant medications?

I'm not super convinced on the data that using stimulants leads to a higher risk of stimulant use disorder. There are people who abuse them, but people also abuse alcohol (binge drinking, getting drunk), marijuana, and nicotine/tobacco and many would not meet criteria for a substance use disorder. Using stimulants earlier on may actually decrease risk of other substance use disorders. Most people do not develop tolerance or dose escalate above FDA max and if they do, a tolerance break almost always helps.

Our clinical guidelines say "don't prescribe unless they have ADHD" but I'd like to argue this is more of a moralistic and cultural decision rather than a clinical one. If these medications can help a vast majority of people do better with minimal risk, then why not? We say nothing about the dermatologist providing Botox down the street or the plastic surgeon doling out BBLs to almost anyone who can pay. There seems to be a double standard.

 

[annoyedpsychiatrist]

I'd like to play devil's advocate.

Outside of diversion, cardiovascular side effects (doesn't happen in a vast majority of patients on stimulants, probably about 4% in the most recent study), psychosis (probably a 1 in 660 risk), and other manageable side effects (appetite suppression and insomnia), what are the other risks of stimulant medications?

I'm not super convinced on the data that using stimulants leads to a higher risk of stimulant use disorder. There are people who abuse them, but people also abuse alcohol (binge drinking, getting drunk), marijuana, and nicotine/tobacco and many would not meet criteria for a substance use disorder. Using stimulants earlier on may actually decrease risk of other substance use disorders. Most people do not develop tolerance or dose escalate above FDA max and if they do, a tolerance break almost always helps.

Our clinical guidelines say "don't prescribe unless they have ADHD" but I'd like to argue this is more of a moralistic and cultural decision rather than a clinical one. If these medications can help a vast majority of people do better with minimal risk, then why not? We say nothing about the dermatologist providing Botox down the street or the plastic surgeon doling out BBLs to almost anyone who can pay. There seems to be a double standard.

100%. This has been my stance on it. Objectively if you have some who is failing out of college, struggling at work, and struggling as a parent, and they get prescribed a stimulant, and now theyre passing school, excelling in work, and they're a better parent to their kid then what really matters the most? Because in psychiatry you will never be 100% accurate with diagnosis, and ADHD in adults is not an easy thing to diagnose. You can try to get access to collateral, but how do you know the collateral isnt biased either way? Ive seen many spouses lie. You can observe and see hyperactivity and impulsivity but not always inattention in adults.

Realistically most people tolerate stimulants as mentioned above. So yes there is a significant difference that and benzos.

Personally I think if we start refusing people on stimulants/benzos/etc then it makes it harder to argue that were specialist and distinct from NPs and have a broad array of knowledge. I think as psychiatrists we should be able to do it all. I manage ADHD, anxiety, mood disorders, movement disorders, neurocognitive disorders, some general neurology, etc. Ultimately patients dont have to agree with the treatment plan but I do like to give people a chance at least. Ive tapered many people off benzos, all the time quite frankly. Many people are on them because they just did what their doctor told them, and their doctor sucked.

Just my opinion.

 

[tr]

I'd like to play devil's advocate.

Outside of diversion, cardiovascular side effects (doesn't happen in a vast majority of patients on stimulants, probably about 4% in the most recent study), psychosis (probably a 1 in 660 risk), and other manageable side effects (appetite suppression and insomnia), what are the other risks of stimulant medications?

I'm not super convinced on the data that using stimulants leads to a higher risk of stimulant use disorder. There are people who abuse them, but people also abuse alcohol (binge drinking, getting drunk), marijuana, and nicotine/tobacco and many would not meet criteria for a substance use disorder. Using stimulants earlier on may actually decrease risk of other substance use disorders. Most people do not develop tolerance or dose escalate above FDA max and if they do, a tolerance break almost always helps.

Our clinical guidelines say "don't prescribe unless they have ADHD" but I'd like to argue this is more of a moralistic and cultural decision rather than a clinical one. If these medications can help a vast majority of people do better with minimal risk, then why not? We say nothing about the dermatologist providing Botox down the street or the plastic surgeon doling out BBLs to almost anyone who can pay. There seems to be a double standard.

I don't have an ethical issue with neuroenhancement but I do resent being forced into the position of gatekeeper.
Dealer isn't a career path that interests me.
And since the DEA is monitoring all of us, I feel obligated to adhere to their standards of practice.

 

[Merovinge]

I'd like to play devil's advocate.

Outside of diversion, cardiovascular side effects (doesn't happen in a vast majority of patients on stimulants, probably about 4% in the most recent study), psychosis (probably a 1 in 660 risk), and other manageable side effects (appetite suppression and insomnia), what are the other risks of stimulant medications?

I'm not super convinced on the data that using stimulants leads to a higher risk of stimulant use disorder. There are people who abuse them, but people also abuse alcohol (binge drinking, getting drunk), marijuana, and nicotine/tobacco and many would not meet criteria for a substance use disorder. Using stimulants earlier on may actually decrease risk of other substance use disorders. Most people do not develop tolerance or dose escalate above FDA max and if they do, a tolerance break almost always helps.

Our clinical guidelines say "don't prescribe unless they have ADHD" but I'd like to argue this is more of a moralistic and cultural decision rather than a clinical one. If these medications can help a vast majority of people do better with minimal risk, then why not? We say nothing about the dermatologist providing Botox down the street or the plastic surgeon doling out BBLs to almost anyone who can pay. There seems to be a double standard.

Outside of 3 huge issues, what is the issue? Diversion is what allows people to have stimulant use disorders, being able to buy pharmaceutical grade Adderall opens up a different door to stimulant use disorders in the same way that oxy increased the amount of opioid use disorder cases (compared to say just purchasing heroin on the street).

We had a resident die in my city from taking Adderall to stay up for a 24 hour shift, obviously had underlying cardiac issues but shockingly got this through diversion (as do a very high percent of medical students).

The risks of psychosis/mania are clearly significant with Adderall, I have seen so many of these cases I can't even count anymore. Causing someone to be psychotic and or manic both carry significant risks to life/livelihood.

I'm very pro stimulant in child/adolescent ADHD when properly diagnosed, I can't tell you how many scripts I've done, but feeling like I-want-a-stimulantitis should be treated with Adderall just seems wildly misplaced to me. First do no harm is a big part of medical practice for a reason and is very applicable here.

 

[clozareal]

100%. This has been my stance on it. Objectively if you have some who is failing out of college, struggling at work, and struggling as a parent, and they get prescribed a stimulant, and now theyre passing school, excelling in work, and they're a better parent to their kid then what really matters the most? Because in psychiatry you will never be 100% accurate with diagnosis, and ADHD in adults is not an easy thing to diagnose. You can try to get access to collateral, but how do you know the collateral isnt biased either way? Ive seen many spouses lie. You can observe and see hyperactivity and impulsivity but not always inattention in adults.

ADHD (and autism) are the main diagnoses we try to get collateral on. We never routinely get collateral on depression, anxiety, PTSD on whether they are actually having low appetite, not sleeping well, or even if that traumatic event happened. I think it plays into the stigma of ADHD that we don't believe patients report.

 

[clozareal]

Outside of 3 huge issues, what is the issue? Diversion is what allows people to have stimulant use disorders, being able to buy pharmaceutical grade Adderall opens up a different door to stimulant use disorders in the same way that oxy increased the amount of opioid use disorder cases (compared to say just purchasing heroin on the street).

I mean if they're not a diversion risk. I obviously won't prescribe to anyone with a red or yellow flag for diversion. The addiction risk for opiates is much higher than the addiction risk of standard doses of stimulants (I'm not talking about meth).

I definitely agree with do no harm, but some of those side effects can be managed and adverse outcomes are of course not desired.

 

[FlowRate]

It's become so prevalent that there's even an NIH study discussing it!

Most of the prescriptions (and by proxy diagnosis) are from NPs, both stimulant and non stimulant, and more incidence for females than for males.

Here's the study Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022 - PubMed

Not surprising, given the hard push by pharma companies and telehealth drug dealing companies to expand the popular conception of what "ADHD" is and to convince as many women as possible that they have "it." (See: earnings call where some pharma company talked about adult women as untapped market for stimulants.)

Our clinical guidelines say "don't prescribe unless they have ADHD" but I'd like to argue this is more of a moralistic and cultural decision rather than a clinical one. If these medications can help a vast majority of people do better with minimal risk, then why not? We say nothing about the dermatologist providing Botox down the street or the plastic surgeon doling out BBLs to almost anyone who can pay. There seems to be a double standard.

In addition to what others point out, I think encouraging people to identify with their thought distortions is not particularly doctorly. A large swath of this new "ADHD" patient population are extremely neurotic and have inaccurate self appraisal. By telling them they have "ADHD" and giving them stimulants, we're saying "yes, your lack of ability to measure up to your own impossible standards is due to a fault outside of your 'self' and the treatment is Adderall." And maybe they go on to "function better" with their Ritalin, sleeping 4 hours a night, grinding insane hours at work, simultaneously being a single parent and in evening courses for their master's degree, or whatever. I don't know if that leaves people better off, physically or psychologically, in the long run.

Certainly that's not everyone who presents with these concerns, but I think some patients' fixation on "their ADHD" is denial of the real issues, which include normal human limitations.

As to your moral point, I think it's moral injury for us as doctors, as others said, to be forced into the role of stimulant gatekeeper (drug dealer.) This is why I not-so-jokingly joke that I wish Adderall was a behind-the-counter med like pseudoephedrine. Let people procure up to a 1-month supply of 60mg TDD Adderall (or equivalent) per month, with ID and PDMP check, and leave me out of it.

 

[comp1]

If stimulants really are amazingly safe with minimal abuse risk and there's no issue with pretty much everyone taking them for massive long term and stable benefits over a lifetime, they should be OTC. Physicians should not be involved. At most there should be a warning on the side like Sudafed saying that it's not good to take with high blood pressure and a pharmacist available to answer questions. The fact of the matter is that stimulants are not really that safe. It's not a matter of moralizing. It's not even about ADHD. Concretely, these are drugs rats will push a lever to get directly injected into their brain. They will not do that for Olanzapine or Sertraline. Any drug with that power needs tight oversight.

 

[calvnandhobbs68]

ADHD (and autism) are the main diagnoses we try to get collateral on. We never routinely get collateral on depression, anxiety, PTSD on whether they are actually having low appetite, not sleeping well, or even if that traumatic event happened. I think it plays into the stigma of ADHD that we don't believe patients report.

If I can reframe that….the fact that we get collateral for ADHD and ASD (along with relatively standardized observations for ASD) is probably the reason they’re some of the diagnoses with the highest inter rater reliability.

 

[annoyedpsychiatrist]

I think people are missing the counterpoint being provided. Im not saying we should give everyone a stimulant that asks. All im saying is that, they typically are a relatively safe medication from a side effect profile, for the most part and that the stigma attached to them affects their ability to be prescribed to the right people.

If you do a proper interview, close follow ups, and you're objective then you can typically prescribe these medications to the right people. There are often many, many signs that a person is using them for the wrong reasons.

I have many patients who are originally from other countries, for example, where they had no access to psychiatrists as a child and mental health treatment was largely stigmatized. Kids with ADHD become adults with ADHD.

Ultimately I try my best to believe the patient, but i also obtain as much collateral as I can from prior records. The one perk of working for a large hospital system is often there are a variety of other notes already on the patient, labs, sleep studies, etc.

 

[Ironspy]

I think people are missing the counterpoint being provided. Im not saying we should give everyone a stimulant that asks. All im saying is that, they typically are a relatively safe medication from a side effect profile, for the most part and that the stigma attached to them affects their ability to be prescribed to the right people.

If you do a proper interview, close follow ups, and you're objective then you can typically prescribe these medications to the right people. There are often many, many signs that a person is using them for the wrong reasons.

I have many patients who are originally from other countries, for example, where they had no access to psychiatrists as a child and mental health treatment was largely stigmatized. Kids with ADHD become adults with ADHD.

Ultimately I try my best to believe the patient, but i also obtain as much collateral as I can from prior records. The one perk of working for a large hospital system is often there are a variety of other notes already on the patient, labs, sleep studies, etc.

What you’re missing is that most diagnoses in adult psychiatry do not require extensive collateral and having an influx of “adult adhd” evaluations in private practice is an administrative burden. Unlike in large systems, this burden isn't shared with other staff/departments and it takes away from patient care and is frankly frustrating after a while when >>50% of these patients do not have a good story for adhd after investigation

 

[allantois]

Shut down tele prescribing of CII, this will solve itself

 

[littlefred]

Shut down tele prescribing of CII, this will solve itself

Good luck with that. The cat is out of the bag!

 

[shibamomm]

Yes everyone with any difficulty concentrating thinks they have ADHD. I work for a community service board and we only prescribe stimulants to children/adolescents. Adults only if they transferred from our child clinic. This is part of why I love my setting as I don’t have to argue multiple times daily about the stimulant issue.

It’s tough because certainly ADHD could have been missed for adults coming in fresh looking for treatment. However, by definition, the symptoms needed to have emerged in childhood. Addiction is my passion and stimulants are addicting! They are snorted, injected, and not to mention diverted. I’m not against prescribing them as obviously they can be beneficial but I agree that the soft cases need to be weeded out and are burdensome.

In residency, we required most adults to undergo neuropsych testing if we could not gather collateral that supported the childhood diagnosis. Those who truly had a problem, waited the 6 months for that testing and returned to our clinic. That really helped me feel more comfortable with the vague cases.

 

[Mad Jack]

"I don't prescribe stimulants unless you have a clean urine toxicology" should clear out most of them. The number of people that started smoking cannabis with legalization in my state and suddenly found themselves struggling with attention issues is a real headache. I would say 95% of my focus and attention patients use cannabis daily

 

[annoyedpsychiatrist]

Yes everyone with any difficulty concentrating thinks they have ADHD. I work for a community service board and we only prescribe stimulants to children/adolescents. Adults only if they transferred from our child clinic. This is part of why I love my setting as I don’t have to argue multiple times daily about the stimulant issue.

It’s tough because certainly ADHD could have been missed for adults coming in fresh looking for treatment. However, by definition, the symptoms needed to have emerged in childhood. Addiction is my passion and stimulants are addicting! They are snorted, injected, and not to mention diverted. I’m not against prescribing them as obviously they can be beneficial but I agree that the soft cases need to be weeded out and are burdensome.

In residency, we required most adults to undergo neuropsych testing if we could not gather collateral that supported the childhood diagnosis. Those who truly had a problem, waited the 6 months for that testing and returned to our clinic. That really helped me feel more comfortable with the vague cases.

that was one of the few perks of community health at my job. They always had UDS prior and we didnt do stimulants for the adults either. But then theres the 15 min med check for the patient on 30 psych meds and acutely decompensating...and all the other negatives...

I did always wonder if the pediatric patients we did stimulants for had parents who would just use their meds...

 

[clausewitz2]

Yes everyone with any difficulty concentrating thinks they have ADHD. I work for a community service board and we only prescribe stimulants to children/adolescents. Adults only if they transferred from our child clinic. This is part of why I love my setting as I don’t have to argue multiple times daily about the stimulant issue.

It’s tough because certainly ADHD could have been missed for adults coming in fresh looking for treatment. However, by definition, the symptoms needed to have emerged in childhood. Addiction is my passion and stimulants are addicting! They are snorted, injected, and not to mention diverted. I’m not against prescribing them as obviously they can be beneficial but I agree that the soft cases need to be weeded out and are burdensome.

In residency, we required most adults to undergo neuropsych testing if we could not gather collateral that supported the childhood diagnosis. Those who truly had a problem, waited the 6 months for that testing and returned to our clinic. That really helped me feel more comfortable with the vague cases.

At the risk of being a complete broken record, neuropsych testing for ADHD, unless you are doing it specifically to exclude a specific learning or intellectual disability, is clinically useless. This is a case of insurance refusing to pay for something and being more than justified, frankly. If you don't want to prescribe it, just say no, don't make them jump through worthless hoops.

 

[comp1]

Definitely agree that neuropsych testing is not helpful. I do like the idea of requiring a clean UDS to prescribe. THC is a potential major cause of concentration issues. I haven't seen a UDS without THC in a long time.

 

[Merovinge]

At the risk of being a complete broken record, neuropsych testing for ADHD, unless you are doing it specifically to exclude a specific learning or intellectual disability, is clinically useless. This is a case of insurance refusing to pay for something and being more than justified, frankly. If you don't want to prescribe it, just say no, don't make them jump through worthless hoops.

I feel really torn on this. There will certainly be cases where things like effort/validity testing are very helpful as well as identification of overall IQ or SLD that better explain symptoms that you just cannot get by clinical interview. It may also identify specific cognitive profiles that are helpful to understand from a behavioral/support and just how-to-structure-your-life perspective. Also, I know the realities of most OP psychiatric practices and you farming off hours of collecting collateral and records from childhood to a psychologist can actually make sense.

On the other hand doing a good clinical evaluation is certainly the real gold standard and being a steward of all health care resources is important. People in my geography are starting to think that neuropsych testing is the only way to determine if someone has ADHD and that psychiatric evaluation is meaningless which is a really scary trend.

This is absolutely an area in current mental health where I think reasonable people can disagree.

 

[whopper]

This is my opinion without checking to see if the studies have backed this up yet. I also wrote about this in prior posts. IMHO ADHD is skyrocketing due to a number of factors.

1) Increased use of screentime by children increases ADHD. Now all almost children have excessive screen-time.
2) We've entered a new societal zone of increased technology to the point where so many jobs are much more tech driven and require higher attention spans making more people request treatment for ADHD that might've been able to get away without treatment. Someone working as a milkman had a job that was low-attention span, plus had to engage in labor everyday that increased this person's dopamine via physical activity. So many jobs now require high attention span but also have diminished physical activity.

Add to the problem ADHD diagnosis can often times be highly subjective, even with improvement with the medication that doesn't prove they have ADHD cause they improve attention in people without ADHD, and just WTF is ADHD if someone could get away without being diagnosed with a low attention span job, but suffers from ADHD with a high attention span job? We're trained to think a person has or doesn't have a disorder not dependent on the tasks they are supposed to do.

I presented this before. If 100 heterosexual young ADHD diagnosed men were given the task of having to stare at attractive nude young women, and palpate their breasts, I doubt any of them would have problems doing the task. If these same men were then told do their taxes, yes I believe the majority of them would now have ADHD problems.

I have ADHD, and was able to get away without treating it up until medical school. I didn't treat it in medical school, but should've in hindsight. My high IQ compensated. Again the problem can be relative based on the type and difficulty of the work involved.

 

[clozareal]

Shut down tele prescribing of CII, this will solve itself

You mean when all the people on CIIs are now going to flood into our physical office spaces demanding to be continued on the med that they say they've been doing well on?

 

[Merovinge]

This is my opinion without checking to see if the studies have backed this up yet. I also wrote about this in prior posts. IMHO ADHD is skyrocketing due to a number of factors.

1) Increased use of screentime by children increases ADHD. Now all almost children have excessive screen-time.
2) We've entered a new societal zone of increased technology to the point where so many jobs are much more tech driven and require higher attention spans making more people request treatment for ADHD that might've been able to get away without treatment. Someone working as a milkman had a job that was low-attention span, plus had to engage in labor everyday that increased this person's dopamine via physical activity. So many jobs now require high attention span but also have diminished physical activity.

Add to the problem ADHD diagnosis can often times be highly subjective, even with improvement with the medication that doesn't prove they have ADHD cause they improve attention in people without ADHD, and just WTF is ADHD if someone could get away without being diagnosed with a low attention span job, but suffers from ADHD with a high attention span job? We're trained to think a person has or doesn't have a disorder not dependent on the tasks they are supposed to do.

I presented this before. If 100 heterosexual young ADHD diagnosed men were given the task of having to stare at attractive nude young women, and palpate their breasts, I doubt any of them would have problems doing the task. If these same men were then told do their taxes, yes I believe the majority of them would now have ADHD problems.

I have ADHD, and was able to get away without treating it up until medical school. I didn't treat it in medical school, but should've in hindsight. My high IQ compensated. Again the problem can be relative based on the type and difficulty of the work involved.

This is not a good argument for task dependency because ADHD, by it's very neurobiologic basis, is a dysfunctional/hypoactive dopaminergic pay-attention system. No one is arguing that people with ADHD cannot focus on things that by their very nature generate large amounts of dopamine. The classic presentation of "he can play video games for hours paying attention to every little detail but can't complete a basic math assignment" is exactly what one would predict from a hypoactive dopamine system. Clearly there is more nuance to ADHD, but certainly a core component of the disorder is inability to start and complete low dopamine generating tasks.

 

[clozareal]

"I don't prescribe stimulants unless you have a clean urine toxicology" should clear out most of them. The number of people that started smoking cannabis with legalization in my state and suddenly found themselves struggling with attention issues is a real headache. I would say 95% of my focus and attention patients use cannabis daily

This is another oversimplified policy. It may be in your patient population, but when you look at clinical samples half of ADHD adults have had no history of illicit substance use. Also, those who have ADHD are much more likely to be using cannabis which doesn't rule out that they have ADHD. Not everyone who uses cannabis also has a SUD. I know it's a state law for some states to get it though which can give you helpful clinical information.

For my practice in the context of SUD and ADHD and I want to consider treatment:

1. If less severe SUD (using cannabis recreationally a few times a week), I treat the ADHD concomitantly.
2. if more severe SUD, then I treat SUD before treating ADHD.
3. If the SUD is recalcitrant or I'm unable to address it, I'll use non-stimulants or extended-release stimulants that are less abusable like Vyvanse or Concerta (amusing article on three teens who tried to and failed to abuse Concerta).

Outside of cannabis, alcohol is actually the substance used/abused most by those with ADHD and I think worsens ADHD symptoms more than cannabis does.

 

[whopper]

Merovinge You state task-dependency-it's not a "good argument," but then you pretty much throw in proven things that backed up what I said.

• "he can play video games for hours paying attention to every little detail but can't complete a basic math assignment" is exactly what one would predict from a hypoactive dopamine system." Is exactly what I mean by task dependency on one's ability to keep attention.
• "but certainly a core component of the disorder is inability to start and complete low dopamine generating tasks."

You state "task dependency" is not a good argument, then show there indeed is task dependent activities that are a component. Edit-no disrespect meant. I think you're a hell of a doctor.

 

[clozareal]

This is my opinion without checking to see if the studies have backed this up yet. I also wrote about this in prior posts. IMHO ADHD is skyrocketing due to a number of factors.

1) Increased use of screentime by children increases ADHD. Now all almost children have excessive screen-time.

Screens are too addictive for children. It definitely worsens problems. I've been recommending a program for a digital detox for 3 weeks for parents who are all taken aback on whether they have the power to do that (they often feel helpless when their kid has a temper tantrum when the iPad is taken away) but then are surprised at how well it works. Many of these kids might go on to develop ADHD or other atypical sensory processing later on in life, although those who are at risk are probably more likely to use screens.

2) We've entered a new societal zone of increased technology to the point where so many jobs are much more tech driven and require higher attention spans making more people request treatment for ADHD that might've been able to get away without treatment. Someone working as a milkman had a job that was low-attention span, plus had to engage in labor everyday that increased this person's dopamine via physical activity. So many jobs now require high attention span but also have diminished physical activity.

Manual labor had it's flaws (injuries) but also it's benefits.

Add to the problem ADHD diagnosis can often times be highly subjective, even with improvement with the medication that doesn't prove they have ADHD cause they improve attention in people without ADHD, and just WTF is ADHD if someone could get away without being diagnosed with a low attention span job, but suffers from ADHD with a high attention span job? We're trained to think a person has or doesn't have a disorder not dependent on the tasks they are supposed to do.

ADHD is not a stimulant-deficiency disorder. Almost everyone will feel like they have more motivation on stimulants although it's debatable whether they actually are more efficient or not. It most likely doesn't compensate for poor sleep.

I presented this before. If 100 heterosexual young ADHD diagnosed men were given the task of having to stare at attractive nude young women, and palpate their breasts, I doubt any of them would have problems doing the task. If these same men were then told do their taxes, yes I believe the majority of them would now have ADHD problems.

It's all about motivation and non-preferred activities. I would say staring at a screen for 8 hours a day expected to push out numbers or code or sit in boring meetings is a non-preferred activity for most people. There's much more health benefit to delivering milk to 100 different houses and getting exercise, sunlight, social interaction, etc. For adults, therapy does work or a lot of ADHD. Finding a way to make a task interesting, novel, or urgent is one way to build motivation for those with ADHD.

I have ADHD, and was able to get away without treating it up until medical school. I didn't treat it in medical school, but should've in hindsight. My high IQ compensated. Again the problem can be relative based on the type and difficulty of the work involved.

This is the tough part. People get missed because of compensation, immigrant status, lack of parental attention, or all other kids of reasons.

 

[AcronymAllergy]

I feel really torn on this. There will certainly be cases where things like effort/validity testing are very helpful as well as identification of overall IQ or SLD that better explain symptoms that you just cannot get by clinical interview. It may also identify specific cognitive profiles that are helpful to understand from a behavioral/support and just how-to-structure-your-life perspective. Also, I know the realities of most OP psychiatric practices and you farming off hours of collecting collateral and records from childhood to a psychologist can actually make sense.

On the other hand doing a good clinical evaluation is certainly the real gold standard and being a steward of all health care resources is important. People in my geography are starting to think that neuropsych testing is the only way to determine if someone has ADHD and that psychiatric evaluation is meaningless which is a really scary trend.

This is absolutely an area in current mental health where I think reasonable people can disagree.

Maybe this would explain why I started getting a significant uptick of ADHD referrals a few months ago. I've since stopped accepting them, largely because I already have too much clinical work handling dementia/MCI and related evals. Semi-related, but I also started seeing a huge uptick in adult autism evaluation requests.

I would say that from my end, if the referring psychiatrist had already done an excellent interview, it would make accepting the referral much more appealing.

Even when I was taking the evals, I hardly ever included full-on neuropsych testing. Usually it was just a thorough interview (ideally with patient and a collateral) and selected self-report scales. That type of setup could then allow the psychologist to see a couple/few of these per day, hopefully cutting down on wait times. And that also means it doesn't need to be a neuropsychologist doing the eval. Unfortunately, not as many psychologists nowadays have a strong background in assessment. But still, it opens things up a bit.

The cognitive testing portion would usually only come in if there was "other stuff" going on, or (again, if I did them) if the person needed a psychoeducational evaluation, such as for academic or testing accommodations. In which case, it'd likely be private pay.

 

[shibamomm]

At the risk of being a complete broken record, neuropsych testing for ADHD, unless you are doing it specifically to exclude a specific learning or intellectual disability, is clinically useless. This is a case of insurance refusing to pay for something and being more than justified, frankly. If you don't want to prescribe it, just say no, don't make them jump through worthless hoops.

I disagree with this. Psychological testing can and does look for other diagnoses that can be mistaken for ADHD (some of which you mentioned such as specific learning disabilities). There is also information to be gained from
a structured and standardized assessment. ADHD is a clinical diagnosis of course but when the childhood window has passed it becomes a lot harder to diagnose. Jumping through hoops for diagnostic clarity for a neurodevelopmental issue that is allegedly presenting itself in adulthood is not unreasonable, in my opinion. But that’s why practicing medicine is an art! Perhaps there should be better guidelines on this issue.

 

[clausewitz2]

I disagree with this. Psychological testing can and does look for other diagnoses that can be mistaken for ADHD (some of which you mentioned such as specific learning disabilities). There is also information to be gained from
a structured and standardized assessment. ADHD is a clinical diagnosis of course but when the childhood window has passed it becomes a lot harder to diagnose. Jumping through hoops for diagnostic clarity for a neurodevelopmental issue that is allegedly presenting itself in adulthood is not unreasonable, in my opinion. But that’s why practicing medicine is an art! Perhaps there should be better guidelines on this issue.

An editorial from one of the most prominent ADHD researchers of all time:

https://guilfordjournals.com/doi/abs/10.1521/adhd.2019.27.2.1

AAP guidelines, saying neuropsych testing doesn't improve diagnostic accuracy and generally discouraging it:

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for...

publications.aap.org

Why not just do a structured interview focused on ADHD?

 

[comp1]

I am pretty strongly opposed to neuropsych testing as some sort of criteria for diagnosing ADHD in adults. I absolutely adore psychometric testing in general, but there is nothing special or unique about ADHD that justifies a higher prevalence of requesting neuropsych testing for it than for any other condition. It's actually the opposite; there's good evidence it's not helpful. You are likely to get vastly more useful information if you refer for testing in patients where you're concerned about a Cluster B personality disorder, PTSD and/or bipolar disorder than for ADHD. The extremely justified concern about schedule II controlled substances being the primary treatment for a condition unfortunately doesn't magically make neuropsych testing helpful.

 

[ObsequiousAplomb]

This is an interesting topic. I haven't had a flood of consultation requests for ADHD. In fact, I haven't had any. Everyone I've treated for ADHD in private practice came to me because they moved to the area and brought records to the first appointment. They were taking modest doses and I agreed with the diagnosis.

It's odd, because I don't say anything to dissuade these people on my website. I'm much more frequently seeing people who have treatment resistant mood disorders or for niche things like palliative cases that take up a lot more emotional energy. I'd rather have some simple "no you have track marks I'm not prescribing you Adderall 30 QID" or "yeah I guess we can start Vyvanse 30 or Jornay or Strattera if you really do think you also had problems in grade school but you could compensate until now" consults to sprinkle in the day.

 

[AcronymAllergy]

An editorial from one of the most prominent ADHD researchers of all time:

https://guilfordjournals.com/doi/abs/10.1521/adhd.2019.27.2.1

AAP guidelines, saying neuropsych testing doesn't improve diagnostic accuracy and generally discouraging it:

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for...

publications.aap.org

Why not just do a structured interview focused on ADHD?

If anyone needs a decent example of a structured ADHD interview, there's the DIVA. Nothing magical about it, but it provides some decent follow-up questions and behavioral anchors, and tries to help in establishing not just the presence of symptoms, but also the presence of associated impairment.

As for neuropsych testing, unsurprisingly, the World Federation of ADHD agrees with Barkley (and AAP). Neuropsych testing isn't necessary: https://www.sciencedirect.com/science/article/pii/S014976342100049X

There are differences in neuropsych testing between samples of people with ADHD vs. not. Part of my dissertation focused on that. But those differences aren't diagnostically useful. I'm pretty sure the major neuropsych ADHD researchers (e.g., Joel Nigg) would agree. The neuropsychologists I see in practice who push for neuropsych testing to diagnose ADHD seem to fall into the camp of folks who aren't aware of, or aren't current on research (or have a lack of critical understanding of research in general), and/or who overestimate the importance of test data more globally.

 

[Ceke2002]

There is definitely an uptick. My deterrents
1. High fees. Much cheaper to get from pcp
2. 4-8 week min wait time for new appt. There are ways to get stimulants faster
3. I tell prospective patients that the vast majority adult onset attention issues are related to sleep, mood/anxiety and substance use. I say that we will have to address all of these areas before we can properly consider a primary attention disorder

Patients looking to feel and function better are generally ok with the above approach. Patients who just want stimulants now realize that I’m not a good fit for them and move on

Slightly off topic, but I just misread the bolded line as "High fees. Much cheaper to get pcp" and now I can't stop giggling like a loon about it.

I have nothing else to add apart from a lot of ADHD assessment clinics in Melbourne appear to also be closing their doors to new patients, I'm presuming due to an influx. So it might not just be a US thing.

 

[shibamomm]

An editorial from one of the most prominent ADHD researchers of all time:

https://guilfordjournals.com/doi/abs/10.1521/adhd.2019.27.2.1

AAP guidelines, saying neuropsych testing doesn't improve diagnostic accuracy and generally discouraging it:

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for...

publications.aap.org

Why not just do a structured interview focused on ADHD?

Thanks for the info. These guidelines still only pertain to children, I wish they published guidance for adults. Again, my practice setting does not allow for prescriptions of stimulants for adults unless they transferred from our child clinic. I like it that way and it’s part of my overall job satisfaction! Everyone thinks they need a stimulant so it’s a tough one overall and hats off to those dealing with this issue in practice daily.

 

[Mad Jack]

This is another oversimplified policy. It may be in your patient population, but when you look at clinical samples half of ADHD adults have had no history of illicit substance use. Also, those who have ADHD are much more likely to be using cannabis which doesn't rule out that they have ADHD. Not everyone who uses cannabis also has a SUD. I know it's a state law for some states to get it though which can give you helpful clinical information.

For my practice in the context of SUD and ADHD and I want to consider treatment:

1. If less severe SUD (using cannabis recreationally a few times a week), I treat the ADHD concomitantly.
2. if more severe SUD, then I treat SUD before treating ADHD.
3. If the SUD is recalcitrant or I'm unable to address it, I'll use non-stimulants or extended-release stimulants that are less abusable like Vyvanse or Concerta (amusing article on three teens who tried to and failed to abuse Concerta).

Outside of cannabis, alcohol is actually the substance used/abused most by those with ADHD and I think worsens ADHD symptoms more than cannabis does.

Of course, but it creates too much of a confounder for me to be certain unless they have some time sober. I had a couple of people that stopped smoking, and lo and behold their attention issues and depressive symptoms ameliorated, despite initial pushback. If they aren't willing to do that, well... I'm fine with them looking elsewhere, I'm sure plenty of people will treat them. That being said, I have done non-stimulants in those with positive UDS, and have prescribed stimulants in those with a clear childhood diagnosis that also use cannabis in very particular cases (generally in the hope that treatment of their ADHD will alleviate the symptoms causing their use in the first place).

 

[Stagg737]

I disagree with this. Psychological testing can and does look for other diagnoses that can be mistaken for ADHD (some of which you mentioned such as specific learning disabilities). There is also information to be gained from
a structured and standardized assessment. ADHD is a clinical diagnosis of course but when the childhood window has passed it becomes a lot harder to diagnose. Jumping through hoops for diagnostic clarity for a neurodevelopmental issue that is allegedly presenting itself in adulthood is not unreasonable, in my opinion. But that’s why practicing medicine is an art! Perhaps there should be better guidelines on this issue.

Psychological and neuropsych testing are NOT the same thing and should not be conflated. Psychological testing to have some perform a DIVA or ACE+ when a psychiatrist is not comfortable (or just too lazy) to do it themselves is one thing. Neuropsych testing is not helpful unless you’re concerned about other developmental or intelligence problems. I see lots of doctors (primary and psychiatrists alike) require “testing” when they don’t even know what tests they’re asking for though. I share an office with a psychologist who does testing and get to listen to him rant about it occasionally. If you’re going to require or recommend testing know what you’re specifically asking for. Don’t be “that doc” that just refers for CYA to prescribe stimulants.

I would say that from my end, if the referring psychiatrist had already done an excellent interview, it would make accepting the referral much more appealing.

Playing devils advocate, if the psychiatrist does an excellent interview then they shouldn’t need to refer to you for 99% of cases. The biggest benefits for me to refer to psych is typically so they can do the DIVA or ACE for me and they can use their billing codes (or cash price if it’s referred out) instead of me taking an extra hour+ to do testing that I basically won’t get paid for.