Influx of adult ADHD referrals in outpatient

[carparker]

Good thread with lots of great responses so far.

For what it’s worth, I rarely see patients referred out (by PCP or midlevels) for testing who don’t ultimately make their way to me with a “diagnosis” of ADHD. Easily 9 out of every 10 referrals comes back with a seal of approval that they indeed have ADHD. So except in those rare cases where some other learning disorder is discovered, this is largely useless data for me.

Ultimately I think the surge in demand is related to psychiatry once again being used to solve societal problems, namely that the work most of us do in a service-based economy is boring, unfulfilling, and sedentary (aka “bull**** jobs”).

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[nexus73]

I think the surge in demand is almost 100% due to two things:

1. Many people without ADHD want stimulants because they do help energy and focus and are pretty good appetite suppressants. This demand has always been present but was mitigated because you had to see a family doc or psychiatrist who would do a thoughtful eval and didn't want to inappropriately prescribe controlled meds to patients because they are ethical and didn't want to build up a candyman practice.
2. Telehealth companies have hired an army of midlevels, giving ASRS screeners, doing ultra brief evals, and doling out boat loads of stimulants to everyone who pays the cash rate.

Telepsychiatry has been bastardized in the name of "improving access to mental health services", but unfortunately what's happening is tons of ignorant (and/or unethical) healthcare providers, mostly np's, are providing garbage care. I assume these telepsych companies have created streamlined processes which make it very normal and easy for an NP to land on a diagnosis of ADHD and justify prescribing stimulants, which means happy patients and repeat business. I would be shocked if anyone is doing a 60 minute intakes, taking good history about childhood symptoms, and trying to gather collateral to support the ADHD diagnosis. It would just take too much time.

Of course the DEA has investigated a couple of the worse offenders (Cerebral and Done), but many others are still flying under the radar for whatever reason.

 

[psycho-matic]

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.

Thanks for the information. I will take closer look at the DIVA. Regarding neuropsych testing not being necessary, I recently had this conversation with a young adult who came to me with a full neuropsych eval stating they had ADHD. Sincere, wanting treatment, not med seeking. Legitimate cognitive deficits, trouble with attention, etc. They had sought the diagnosis for accommodation at school. The report mentions that the symptoms started in 11th grade after a very prolonged ICU stay due to Covid19 and multi-organ inflammation. No childhood history of symptoms, no academic trouble before 11th grade. By definition not ADHD. Doesn't take a rocket scientist to know that hypoxia, being on a vent, organ inflammation can cause neurological sequela. The fact that a PhD neuropsychologist could go on to give the patient such a diagnosis makes me wonder if some of them can be bought. It certainly makes me not take neurospych test results at face value.

 

[calvnandhobbs68]

Thanks for the information. I will take closer look at the DIVA. Regarding neuropsych testing not being necessary, I recently had this conversation with a young adult who came to me with a full neuropsych eval stating they had ADHD. Sincere, wanting treatment, not med seeking. Legitimate cognitive deficits, trouble with attention, etc. They had sought the diagnosis for accommodation at school. The report mentions that the symptoms started in 11th grade after a very prolonged ICU stay due to Covid19 and multi-organ inflammation. No childhood history of symptoms, no academic trouble before 11th grade. By definition not ADHD. Doesn't take a rocket scientist to know that hypoxia, being on a vent, organ inflammation can cause neurological sequela. The fact that a PhD neuropsychologist could go on to give the patient such a diagnosis makes me wonder if some of them can be bought. It certainly makes me not take neurospych test results at face value.

Yeah I get some seriously sus reports from neuropsychologists too...quality varies quite a bit. Recently reviewed a report (I didn't recommend doing) diagnosing a grade school kid with Level 2 ASD with a negative ADOS, normal NEPSY II, normal SCQ and barely positive ASSQ (which is a questionable thing to be doing anyway, as it's a screener and you're doing the actual diagnostic eval for ASD but whatever...) but basically said "oh he compensates for all his "autism" symptoms because he's pretty smart".

So yeah, this psychologist clearly has no idea what ASD, Level 2 even means (totally just ignore the fact that he probably doesn't have ASD at all). For anyone who's confused by this, pull up DSM and look up the autism levels and it'll make more sense why the explanation above is literally incompatible.

 

[AcronymAllergy]

Thanks for the information. I will take closer look at the DIVA. Regarding neuropsych testing not being necessary, I recently had this conversation with a young adult who came to me with a full neuropsych eval stating they had ADHD. Sincere, wanting treatment, not med seeking. Legitimate cognitive deficits, trouble with attention, etc. They had sought the diagnosis for accommodation at school. The report mentions that the symptoms started in 11th grade after a very prolonged ICU stay due to Covid19 and multi-organ inflammation. No childhood history of symptoms, no academic trouble before 11th grade. By definition not ADHD. Doesn't take a rocket scientist to know that hypoxia, being on a vent, organ inflammation can cause neurological sequela. The fact that a PhD neuropsychologist could go on to give the patient such a diagnosis makes me wonder if some of them can be bought. It certainly makes me not take neurospych test results at face value.

There are a fair number of "neuropsychologists" who perform testing but have questionable training and knowledge to do so. There's also, among numerous healthcare professionals, a significant misunderstanding of what ADHD actually is, even among folks who probably should know better. Or just a willful hubris/disregard of a century's worth of literature (e.g., "well, I know they say ADHD starts in childhood, but I don't believe all that"). Or folks who look at it in terms of it potentially being treated the same way regardless, or an ADHD eval opening various doors that another diagnosis might not (in their minds). And in the end, some providers also aren't as good at managing the effects of diagnostic pressure from patients/families/referral sources.

Your case actually sounds like one where neuropsych testing should have been beneficial. Like for in ruling out ADHD, identifying the presence of objective cognitive impairments, and discussing what caused those impairments (read: not ADHD).

If you're wanting to identify a quality (or at least competent) neuropsychologist: I'd suggest starting by identifying folks who are board-certified; still has the potential for variability, but generally not as much. Although there are still quality neuropsychologists who aren't boarded, so if not, identify if they at least completed a formal two-year fellowship (e.g., at an AMC, VA hospital, etc.). Or if they're a known quantity recommended by colleagues. And just like you probably would with physician colleagues, if the first few patient encounters you refer to them are crap, move on.

Unfortunately, as is not uncommonly the case throughout healthcare, the people willing to easily assign all manner of diagnoses are the last ones who should be doing so.

 

[clausewitz2]

Yeah I get some seriously sus reports from neuropsychologists too...quality varies quite a bit. Recently reviewed a report (I didn't recommend doing) diagnosing a grade school kid with Level 2 ASD with a negative ADOS, normal NEPSY II, normal SCQ and barely positive ASSQ (which is a questionable thing to be doing anyway, as it's a screener and you're doing the actual diagnostic eval for ASD but whatever...) but basically said "oh he compensates for all his "autism" symptoms because he's pretty smart".

So yeah, this psychologist clearly has no idea what ASD, Level 2 even means (totally just ignore the fact that he probably doesn't have ASD at all). For anyone who's confused by this, pull up DSM and look up the autism levels and it'll make more sense why the explanation above is literally incompatible.

As anyone who has hung out with mathematicians and physicists can tell you, you can be plenty smart without it compensating all that much for autism.

 

[SeniorWrangler]

As anyone who has hung out with mathematicians and physicists can tell you, you can be plenty smart without it compensating all that much for autism.

As someone who’s hung out in math clubs, yup. You just need to find your people.

 

[psycho-matic]

There are a fair number of "neuropsychologists" who perform testing but have questionable training and knowledge to do so. There's also, among numerous healthcare professionals, a significant misunderstanding of what ADHD actually is, even among folks who probably should know better. Or just a willful hubris/disregard of a century's worth of literature (e.g., "well, I know they say ADHD starts in childhood, but I don't believe all that"). Or folks who look at it in terms of it potentially being treated the same way regardless, or an ADHD eval opening various doors that another diagnosis might not (in their minds). And in the end, some providers also aren't as good at managing the effects of diagnostic pressure from patients/families/referral sources.

Your case actually sounds like one where neuropsych testing should have been beneficial. Like for in ruling out ADHD, identifying the presence of objective cognitive impairments, and discussing what caused those impairments (read: not ADHD).

If you're wanting to identify a quality (or at least competent) neuropsychologist: I'd suggest starting by identifying folks who are board-certified; still has the potential for variability, but generally not as much. Although there are still quality neuropsychologists who aren't boarded, so if not, identify if they at least completed a formal two-year fellowship (e.g., at an AMC, VA hospital, etc.). Or if they're a known quantity recommended by colleagues. And just like you probably would with physician colleagues, if the first few patient encounters you refer to them are crap, move on.

Unfortunately, as is not uncommonly the case throughout healthcare, the people willing to easily assign all manner of diagnoses are the last ones who should be doing so.

I'm a PMHNP, just for clarity, but we're not all cut from the same cloth. I actively read and look for different ways to advance my knowledge. It's worth noting I did my interview 4 days before I had the actual report and came to the conclusion it wasn't ADHD after my interview. I started an SSRI because he had GAD (one thing the report did get right) but also met criteria for MDD. The report discussed many depressive symptoms but didn't arrive at a depressive diagnosis.

This neurospychologist was from a large reputable practice in a major Texas city, so it was a bit surprising to me. I hope the patient didn't think I'm an idiot when I basically told him that 1. The general consensus is that neuropsych testing doesn't aid in ADHD diagnosis and 2. This report is basically bull*hit (I didn't say it like that of course). I hope they didn't waste a lot of money. From the patient's perspective, we have a PhD saying he has ADHD and a nurse practitioner saying he doesn't. Who's he supposed to believe? He probably could have got the same accommodation at school if the report said explained he had neuro cognitive defitics from COVID (whatever diagnosis that would actually be).

I do wonder if a stimulant would help in the same way for someone with my patient's issues. It's not a dopamine efficiency so I don't know if it they would help. I admit that's an area of knowledge that I lack.

To me the SSRI seemed a good place to start because depression could be causing cognitive deficits. Adding an NDRI might help in the future if focus remains a problem. I do wonder if therapy would teach him ways to adapt to the deficits. Open to any other suggestions.

 

[calvnandhobbs68]

As anyone who has hung out with mathematicians and physicists can tell you, you can be plenty smart without it compensating all that much for autism.

Absolutely, but by definition that’s a nonsensical thing to be saying about someone you’re saying has ASD Level 2 and is bizarre to put in a neuropsych report.

Level 2 ASD I should be able to figure out within about 5 minutes of meeting a patient.

 

[psycho-matic]

I think the surge in demand is almost 100% due to two things:

1. Many people without ADHD want stimulants because they do help energy and focus and are pretty good appetite suppressants. This demand has always been present but was mitigated because you had to see a family doc or psychiatrist who would do a thoughtful eval and didn't want to inappropriately prescribe controlled meds to patients because they are ethical and didn't want to build up a candyman practice.
2. Telehealth companies have hired an army of midlevels, giving ASRS screeners, doing ultra brief evals, and doling out boat loads of stimulants to everyone who pays the cash rate.

Telepsychiatry has been bastardized in the name of "improving access to mental health services", but unfortunately what's happening is tons of ignorant (and/or unethical) healthcare providers, mostly np's, are providing garbage care. I assume these telepsych companies have created streamlined processes which make it very normal and easy for an NP to land on a diagnosis of ADHD and justify prescribing stimulants, which means happy patients and repeat business. I would be shocked if anyone is doing a 60 minute intakes, taking good history about childhood symptoms, and trying to gather collateral to support the ADHD diagnosis. It would just take too much time.

Of course the DEA has investigated a couple of the worse offenders (Cerebral and Done), but many others are still flying under the radar for whatever reason.

I'm an NP and do telehealth but smart enough to work for a company that doesn't do any controlled substances. I briefly worked for Done but quickly realized it was a level of badness I didn't want to deal with. The guy who started Done is a Stanford trained psychiatrist so on the face of it he's certainly not a quack. But the entire op is very disorganized, on-boarding was a mess and there's virtually no training on diagnosing ADHD, what to do with drug seeking patients etc. Your bonus is based almost completely on patient satisfaction so if you don't give out the candy of course you're going to get bad reviews, so there's certainly pressure to perform by prescribing stimulants even if it's not explicity stated. I didn't become an NP to be a drug dealer so I quit before ever seeing a single patient.

I do agree that companies like Done have hurt telehealth and created the expectation that people can go to telehalth to easily get CS. Where I work now, we don't do any CS and make it clear but some patients just don't pay attention and miss that important notice. Most are polite and understanding but I had one guy recently become livid after stating I couldn't (but wouldn't if I could) prescribe his diazepam. "You mean I paid $200 to get prescribed an SSRI and a blood pressure medicine." No, you paid for an evaluation and treatment recommendations. Scheduled propranolol is the most appropriate medication to treat your panic symptoms. Guy wouldn't hear it.

 

[AcronymAllergy]

I'm a PMHNP, just for clarity, but we're not all cut from the same cloth. I actively read and look for different ways to advance my knowledge. It's worth noting I did my interview 4 days before I had the actual report and came to the conclusion it wasn't ADHD after my interview. I started an SSRI because he had GAD (one thing the report did get right) but also met criteria for MDD. The report discussed many depressive symptoms but didn't arrive at a depressive diagnosis.

This neurospychologist was from a large reputable practice in a major Texas city, so it was a bit surprising to me. I hope the patient didn't think I'm an idiot when I basically told him that 1. The general consensus is that neuropsych testing doesn't aid in ADHD diagnosis and 2. This report is basically bull*hit (I didn't say it like that of course). I hope they didn't waste a lot of money. From the patient's perspective, we have a PhD saying he has ADHD and a nurse practitioner saying he doesn't. Who's he supposed to believe? He probably could have got the same accommodation at school if the report said explained he had neuro cognitive defitics from COVID (whatever diagnosis that would actually be).

I do wonder if a stimulant would help in the same way for someone with my patient's issues. It's not a dopamine efficiency so I don't know if it they would help. I admit that's an area of knowledge that I lack.

To me the SSRI seemed a good place to start because depression could be causing cognitive deficits. Adding an NDRI might help in the future if focus remains a problem. I do wonder if therapy would teach him ways to adapt to the deficits. Open to any other suggestions.

This, unfortunately, doesn't always mean a whole lot. Private practices can be pretty variable in their hiring. Even AMCs sometimes get some wonky providers. When I'm vetting a colleague (e.g., for a referral), the first things I check are where they trained and if they're boarded. As I mentioned, I don't automatically cross someone off if they aren't boarded, but I do look a bit more closely at their training, experience, research work, etc. None of this is foolproof, but it's a decent start. Although in this case, it's not like you had control over who they saw anyway.

Without seeing the report, I obviously can't speak to this specific case. But it certainly seems like a diagnostic "whiff" RE: the ADHD.

 

[mcatqueen]

I don't prescribe stimulants on the first visit with a pt and make sure they get labs first to rule everything else out first, which cuts down on some of the med-seeking.
Also, it can be helpful to have patients obtain copies of their elementary school report cards. Some of the teacher comments are very insightful in painting a picture of how they were as a kid (and sometimes comical lol). Yes, this is extra work and not all patients will do it, but it is super helpful and gives a more accurate comparison to how they were versus the other kids in school.

 

[Ahamis]

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 wonder what would change for an adult suddenly diagnosed with autism. What would significantly change in the life of an adult?

 

[Stagg737]

I wonder what would change for an adult suddenly diagnosed with autism. What would significantly change in the life of an adult?

The existence of TikTok and other social media in people with post-COVID social anxiety/awkwardness and their need for a validating label that it's not their fault.

 

[SeniorWrangler]

“Suddenly it all makes sense”

 

[calvnandhobbs68]

“Suddenly it all makes sense”

The existence of TikTok and other social media in people with post-COVID social anxiety/awkwardness and their need for a validating label that it's not their fault.

This is basically what people tell me when I'm posing this question to 17-20 something year olds who suddenly tell me they want to be "evaluated for autism". Because my point to them often is that if their "autism" is so subtle that I haven't picked it up after a year or whatever of seeing them, it's not going to change anything from a treatment standpoint for me.

 

[psycho-matic]

I wonder what would change for an adult suddenly diagnosed with autism. What would significantly change in the life of an adult?

That's an excellent question. I had a similar discussion with a patient yesterday about this very thing. She's someone who probably does have autism but I told her that's something I didn't feel comfortable diagnosing, certainly not in the span of 30 minutes online. Told her if she wanted to explore that, she needed to find a lock center that does adult autism testing. I told her one may wait months for testing and it may be expensive. If she did have autism, she's certainly higher functioning, so she needed to consider what the diagnosis would change for her life if she obtains the testing.

 

[calvnandhobbs68]

That's an excellent question. I had a similar discussion with a patient yesterday about this very thing. She's someone who probably does have autism but I told her that's something I didn't feel comfortable diagnosing, certainly not in the span of 30 minutes online. Told her if she wanted to explore that, she needed to find a lock center that does adult autism testing. I told her one may wait months for testing and it may be expensive. If she did have autism, she's certainly higher functioning, so she needed to consider what the diagnosis would change for her life if she obtains the testing.

If I can comment on this specific point though, I’d love if everyone (including other psychiatrists but I see this most with therapists) would also stop referring to “autism testing”.

Just like ADHD, there is no “test” to diagnose autism. Like ADHD there are sets of standardized rating scales that multiple informants can fill out and structured clinical interview tools. Less like ADHD, there are also structured clinical observation tools which allow someone to evaluate for ASD symptoms in a more standardized setting. They aren’t really “tests” though as much as more formal ways to assess if someone meets DSM criteria.

 

[Ironspy]

That's an excellent question. I had a similar discussion with a patient yesterday about this very thing. She's someone who probably does have autism but I told her that's something I didn't feel comfortable diagnosing, certainly not in the span of 30 minutes online. Told her if she wanted to explore that, she needed to find a lock center that does adult autism testing. I told her one may wait months for testing and it may be expensive. If she did have autism, she's certainly higher functioning, so she needed to consider what the diagnosis would change for her life if she obtains the testing.

This is overkill. I’ve had patients do a 10 min questionnaire to get the autism diagnosis from an NP and it only cost 1k. It was life changing for them because they gained a supportive community on TikTok. /story is real but tone is sarcastic

 

[AcronymAllergy]

I wonder what would change for an adult suddenly diagnosed with autism. What would significantly change in the life of an adult?

Good question, and one that I think patients should be asked more often. Probably not much, but it could allow the patient to have more of an understanding of themselves. If there's a suspected co-occurring intellectual disability, then that can open some doors for additional resources, but it's also more likely that would've already been identified.

There's a thread in the Psychology forum about ASD assessment and this same topic came up there.

If I can comment on this specific point though, I’d love if everyone (including other psychiatrists but I see this most with therapists) would also stop referring to “autism testing”.

Just like ADHD, there is no “test” to diagnose autism. Like ADHD there are sets of standardized rating scales that multiple informants can fill out and structured clinical interview tools. Less like ADHD, there are also structured clinical observation tools which allow someone to evaluate for ASD symptoms in a more standardized setting. They aren’t really “tests” though as much as more formal ways to assess if someone meets DSM criteria.

And just to add--especially for adults. Primarily, much like ADHD, it ultimately comes down to the provider having experiencing with ASD. I've shied away from both ADHD and ASD evaluations in the past, but after seeing some of what passes in the/my community for "assessment" of these conditions, I've wondered at times if I should start taking on at least a few referrals.

 

[psycho-matic]

This is overkill. I’ve had patients do a 10 min questionnaire to get the autism diagnosis from an NP and it only cost 1k. It was life changing for them because they gained a supportive community on TikTok. /story is real but tone is sarcastic

I'm just a humble PMHNP. Maybe this is a regional thing, I don't know. Minors in my area are referred to centers that specialize in autism evaluation. So even though a CAP psychiatrist (who also saw adults) was my mentor and I worked with numerous patients diagnosed with autism, our clinic didn't provide the autism diagnosis for these patients. I had a ton of exposure diagnosing and treating ADHD in kids and adults, but I was never exposed to autism diagnosis.

I would think it rare an adult with obvious autistic traits lives into their 20s without getting diagnosed. So in the span of 30 minutes with a new patient I've never met, which barely gives me time to address their depression, I don't think is the proper setting to also diagnose them with autism. Sure, I could go down a DMS-V checklist but there's still differentials to consider, and then there's the thing of knowing what you don't know.

If sending an adult to an autism testing center is overkill, I'm open to other feedback (I'm here to learn) of what to do. I just think that my lack experience diagnosing autism combined with the brevity of telehealth visits means that not something I should be trying to do in that setting.

 

[psycho-matic]

If I can comment on this specific point though, I’d love if everyone (including other psychiatrists but I see this most with therapists) would also stop referring to “autism testing”.

Just like ADHD, there is no “test” to diagnose autism. Like ADHD there are sets of standardized rating scales that multiple informants can fill out and structured clinical interview tools. Less like ADHD, there are also structured clinical observation tools which allow someone to evaluate for ASD symptoms in a more standardized setting. They aren’t really “tests” though as much as more formal ways to assess if someone meets DSM criteria.

I appreciate the feedback.

 

[FlowRate]

Almost all of the "want to be assessed for autism" patients who I've seen clearly do not meet criteria A for the diagnosis because they are very obviously normally socially related and integrate a full range of normal social behaviors, cues, and displays/responses to affect. Being (or feeling) a little weird and awkward does not make you autistic. Having "sensory issues" alone doesn't make you autistic.

 

[Stagg737]

I'm just a humble PMHNP. Maybe this is a regional thing, I don't know. Minors in my area are referred to centers that specialize in autism evaluation. So even though a CAP psychiatrist (who also saw adults) was my mentor and I worked with numerous patients diagnosed with autism, our clinic didn't provide the autism diagnosis for these patients. I had a ton of exposure diagnosing and treating ADHD in kids and adults, but I was never exposed to autism diagnosis.

I would think it rare an adult with obvious autistic traits lives into their 20s without getting diagnosed. So in the span of 30 minutes with a new patient I've never met, which barely gives me time to address their depression, I don't think is the proper setting to also diagnose them with autism. Sure, I could go down a DMS-V checklist but there's still differentials to consider, and then there's the thing of knowing what you don't know.

If sending an adult to an autism testing center is overkill, I'm open to other feedback (I'm here to learn) of what to do. I just think that my lack experience diagnosing autism combined with the brevity of telehealth visits means that not something I should be trying to do in that setting.

Frankly, 30 minute intakes barely give you time to really address any problems unless it's so obvious that the PCP should be handling it themselves. Imo if it's an adult with legit concerns for autism, they do need to be seen by someone well-versed in ASD. I don't think Ironspy was criticizing you, and you are correct that you absolutely should NOT be diagnosing ASD during a 30-minute intake.

Almost all of the "want to be assessed for autism" patients who I've seen clearly do not meet criteria A for the diagnosis because they are very obviously normally socially related and integrate a full range of normal social behaviors, cues, and displays/responses to affect. Being (or feeling) a little weird and awkward does not make you autistic. Having "sensory issues" alone doesn't make you autistic.

It's somewhat ironic that there's several diagnoses in our field that are frequently incorrect when I get a referral for it (ASD, ADHD, bipolar, OSA) but that I identify myself fairly often and sometimes confirm with testing (ASD and OSA) in other patients referred to me for basic "depression" or "anxiety" that the PCP can't figure out. I see a lot of people from the rural areas who were never diagnosed because they were labeled as just being "off" with their ASD or ADHD but would probably be obvious to any decent psychiatrist today.

 

[psycho-matic]

Frankly, 30 minute intakes barely give you time to really address any problems unless it's so obvious that the PCP should be handling it themselves. Imo if it's an adult with legit concerns for autism, they do need to be seen by someone well-versed in ASD. I don't think Ironspy was criticizing you, and you are correct that you absolutely should NOT be diagnosing ASD during a 30-minute intake.


It's somewhat ironic that there's several diagnoses in our field that are frequently incorrect when I get a referral for it (ASD, ADHD, bipolar, OSA) but that I identify myself fairly often and sometimes confirm with testing (ASD and OSA) in other patients referred to me for basic "depression" or "anxiety" that the PCP can't figure out. I see a lot of people from the rural areas who were never diagnosed because they were labeled as just being "off" with their ASD or ADHD but would probably be obvious to any decent psychiatrist today.

I didn't feel criticized by Ironspy, and you're right that 30 minutes is barely enough and sometimes it turns into 35 or 40 minutes. It's not ideal, but we also don't live in an ideal world. It helps that there are scales, questions about history, meds etc. already completed online. A lot of my patients are in rural areas where access is difficult, others are in urban areas but the wait to see a local psychiatrist is months. Some of these people can't wait months when they are able to lose their job, marriage etc. I also get patients that are stable but have moved to another state and need their meds filled.

And speaking of PCPs, some people that move to large cities where one would expect there to be an over-saturation of providers are waiting months for an initial appointment. I seem to hear about this the most in NC and VA. That blows my mind. I'm in a mid-size city in the south and there's very little wait to see a PCP. I could call my PCP and easily see him the next day under most circumstances (psych here is the opposite of that).

Access to care, and timely care, is part of the problem.

 

[aim-agm]

One situation when an adult evaluation for ASD in a generally well-functioning individual would be unexplained catatonia (particularly if recurrent), particularly in context of stress, both for purposes of workup and future management.

It could also be useful in context of evaluating worsening impairments. For example, a case of disproportionately profound impairment of verbal communication (compared to other impairments) which was assessed to be an early dementing process intersecting with functioning but tenuous/fragile verbal skills in previously undiagnosed (at least formally) ASD.

But for most patients, would it matter whether their interpersonal and intrapersonal impairments are the product of mild ASD, personality, or other factors? Would behavioral interventions, psychotherapy, and pharmacotherapy be materially different?

 

[Fan_of_Meehl]

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

It may be an unpopular opinion but I also think that the person doing the evaluating (and making the decision on the diagnosis) should be the same person prescribing, monitoring, adjusting the dosage, etc.

What I have observed--being in one of those systems where one person does the 'evaluation' and the other does the 'treatment'--is that this separation of responsibilities just makes it turn out to be the case that the 'assessor' pretty much 'rubber stamps' the ADHD diagnosis (says 'yes') and this simply provides, perhaps, 'plausible deniability' on the part of the prescriber (well, someone else made the diagnosis, so I don't have to think critically about it). There is almost no disincentive for these 'evaluators' to rubber stamp (yes, yes, yes!) everything and there is every disincentive to ever say 'no.' In my informal/anecdotal experience with how it operates in our system, I think maybe 3-5% of these 'evaluations for ADHD' (so they can get their stimulant meds prescribed to them) have ever come back 'negative' for the ADHD diagnosis. Considering the fact that the true rate of diagnostic error has to be above 5%, why even do the damn 'evaluation' to 'determine' yes/no status of ADHD diagnosis in the first place. It is, in effect, an empty (and expensive) ritual (and they're backed up like four to five months to even get the 'assessment').