interesting articles on adult ADHD

[randomdoc1]

Hi everyone. I was reading this month's edition of the American Journal of Psychiatry and found a couple of interesting articles and also found an older article in another journal about this hot topic.

The two articles below already state what we've been discussing (e.g. need for a thorough evaluation, etc.).

Sibley, M. H., Rohde, L. A., Swanson, J. M., Hechtman, L. T., Molina, B. S., Mitchell, J. T., ... & Stehli, A. (2017). Late-onset ADHD reconsidered with comprehensive repeated assessments between ages 10 and 25. American Journal of Psychiatry, appi-ajp.

Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.

But what do you all think of this third article which argues there is validity literally in adult onset ADHD? It says even when assessing for comorbidity (e.g. AODA, mood disorders, anxiety disorders, etc.) there seems to actually be ADHD that starts as an adult. I find it interesting and wonder if this is more of a cultural phenomena (e.g. partially a byproduct of heavy marketing as well as the fact that we are now having to work harder and are in more direct competition with other countries). It would interesting to see if other countries are reporting similar prevalences of adult onset ADHD or this is specific to the US. As you may have guessed, I am skeptical until more literature comes out that supports this.

"Growing Up: Evolving Concepts of Adult Attention Deficit Hyperactivity Disorder." American Journal of Psychiatry, 175(2), pp. 95–96

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[AcronymAllergy]

Will check out the articles, but my initial thoughts are you'd probably need a more thorough review of why there wasn't a childhood diagnosis of ADHD. We know it's not uncommon for the condition to go undiagnosed in childhood, particularly if the person is intellectually high-functioning, otherwise able to compensate, in an impoverished school district, overshadowed by "worse" kiddos/siblings, etc. Wouldn't surprise me at all that there are cases where it first comes to a head in the tumultuousness of adolescence, although I'd still be surprised if there weren't symptoms of it in childhood (based on our current understanding of the developmental etiology).

And I could've mis-read based on my initial cursory summary, but I didn't get the feel that either of the first two articles was purporting an actual adult-onset ADHD. Per the first article, "There was no evidence for adult-onset ADHD independent of a complex psychiatric history." Which to me says, "the cluster of symptoms known as ADHD sometimes shows up in adulthood, but it's being caused by things that aren't really ADHD."

 

[randomdoc1]

Will check out the articles, but my initial thoughts are you'd probably need a more thorough review of why there wasn't a childhood diagnosis of ADHD. We know it's not uncommon for the condition to go undiagnosed in childhood, particularly if the person is intellectually high-functioning, otherwise able to compensate, in an impoverished school district, overshadowed by "worse" kiddos/siblings, etc. Wouldn't surprise me at all that there are cases where it first comes to a head in the tumultuousness of adolescence, although I'd still be surprised if there weren't symptoms of it in childhood (based on our current understanding of the developmental etiology).

And I could've mis-read based on my initial cursory summary, but I didn't get the feel that either of the first two articles was purporting an actual adult-onset ADHD. Per the first article, "There was no evidence for adult-onset ADHD independent of a complex psychiatric history." Which to me says, "the cluster of symptoms known as ADHD sometimes shows up in adulthood, but it's being caused by things that aren't really ADHD."

You’re right. It’s only the third article that says there seems to be adult onset ADHD. I am a skeptic of what the third article has to say. The first two I’m very on board with.

 

[DD214_DOC]

I really hate this, "adult-onset ADHD" nonsense. There is no such thing. Dysfunction or impairment from symptoms may not manifest until early adulthood, if someone has the intellectual ability to compensate. However, independent of dysfunction, there should exist the presence of symptoms during childhood. This is pretty clear in the DSM criteria, which literally states that symptoms should have been present prior to the age of 12. Notice that the criteria states that symptoms must be present before this age -- not dysfunction or impairment.

As mentioned above, there can certainly be something else that presents in adulthood with symptoms very similar to ADHD, but this would be diagnosed as the, "something else", and not ADHD.

 

[MacDonaldTriad]

Adult ADHD is a justification for giving patients stimulants. Everyone knows this is better handled with medicinal marijuana.

 

[Jules A]

Dysfunction or impairment from symptoms may not manifest until early adulthood, if someone has the intellectual ability to compensate.

That must be it, my intellectual ability buffered me from the need for a stimulant secondary to ADD related dysfunction until middle age coinciding with when my ass started getting wider and my stamina was reduced.

 

[MacDonaldTriad]

That must be it, my intellectual ability buffered me from the need for a stimulant secondary to ADD related dysfunction until middle age coinciding with when my ass started getting wider and my stamina was reduced.

Intellectualization and rationalization can let us believe about anything. God D*** the pusher man, blood sweat and tears.

 

[WingedOx]

Adult ADHD: When you have to tell the patient that their 5 hours of sleep isn't doing the job

 

[thoffen]

I don't believe there is such a thing as adult-onset ADHD. I do believe there are plenty of people who go to adulthood undiagnosed whose absolute success would not indicate dysfunction earlier in life. However, a clear indication of at least significant relative dysfunction ought to be easy to find. Such a thing is not a specific finding, so that shouldn't lead to an ADHD diagnosis necessarily either.

Could there be someone whose illness manifests entirely in adulthood? Or someone whose environment is so attuned that they face no relative dysfunction in childhood but do when getting to the adult world? I don't believe in that.

 

[nitemagi]

To be devil's advocate, maybe we should just lean into what everyone really wants these for: "cognitive enhancers"

http://people.psych.ucsb.edu/gazzan... cognitive enhancing drugs by the healthy.pdf

 

[randomdoc1]

This whole stimulant thing is so out of control and unfortunate. Still very much a skeptic of this whole adult onset ADHD thing. Even if it turns out to be legitimate, does it really require stimulants? Just like how all diabetics don't get put on an insulin pump right away, treating psychiatric disorders should not be a one size fits all either. Just the other day, a patient called looking for a new psychiatrist. I recognized her name, I saw her as a resident. She's nearly 60 years old and I had several years of records on her. She has no ADHD but guess what, someone started her on Adderall . I wish there was a way I could send a message to the world, stimulants only treat actual ADHD (and sleep disorders and some cases of TRD). They do not:
1) Make you smarter
2) Increase your income
3) Bring world peace
4) etc...

To be devil's advocate, maybe we should just lean into what everyone really wants these for: "cognitive enhancers"

http://people.psych.ucsb.edu/gazzaniga/PDF/towards responsible use of cognitive enhancing drugs by the healthy.pdf

And what the F***? I can't believe they are actually serious. That it would "benefit society"? No one has even looked at the longterm effects of these medications...

 

[clausewitz2]

This whole stimulant thing is so out of control and unfortunate. Still very much a skeptic of this whole adult onset ADHD thing. Even if it turns out to be legitimate, does it really require stimulants? Just like how all diabetics don't get put on an insulin pump right away, treating psychiatric disorders should not be a one size fits all either. Just the other day, a patient called looking for a new psychiatrist. I recognized her name, I saw her as a resident. She's nearly 60 years old and I had several years of records on her. She has no ADHD but guess what, someone started her on Adderall . I wish there was a way I could send a message to the world, stimulants only treat actual ADHD (and sleep disorders and some cases of TRD). They do not:
1) Make you smarter
2) Increase your income
3) Bring world peace
4) etc...


And what the F***? I can't believe they are actually serious. That it would "benefit society"? No one has even looked at the longterm effects of these medications...

I mean, if by smarter we mean "better and more consistently able to effectively implement your goals in the world and sustain purposeful activity in service of those goals", which strikes me as one of the few kinds of smart worth having, stimulants absolutely do do this for a lot of people. Whether it's a good idea in the long-term is an orthogonal question, but denying that they do seem to be helpful for some people even in the absence of a pathology we can diagnose is to succumb to a bull-headed refusal to engage with reality. Sure, some people use them to deliberately get high, fine. But I don't think this is actually how the vast majority of people knocking down your door these days for Adderall are going to be using them.

 

[Shikima]

I'd like to throw a curve ball to help me better understand, what if an adult, who did have symptoms in childhood but parents were neglectful and was somewhat successful in starting some kind of a career but then as the career advanced was demonstrating worsening performance absent of insomnia, sleep disorders, mood/anxiety disorder, etc

 

[thoffen]

I'd like to throw a curve ball to help me better understand, what if an adult, who did have symptoms in childhood but parents were neglectful and was somewhat successful in starting some kind of a career but then as the career advanced was demonstrating worsening performance absent of insomnia, sleep disorders, mood/anxiety disorder, etc

This can be a legitimate illness presentation. There are plenty of people whose combinations of environment, compensatory talents, and caregiver neglect make this diagnosis missed even in the setting of academic and personal success. But it requires careful evaluation.

 

[Shikima]

This can be a legitimate illness presentation. There are plenty of people whose combinations of environment, compensatory talents, and caregiver neglect make this diagnosis missed even in the setting of academic and personal success. But it requires careful evaluation.

I've seen it only a couple of times and it took multiple sessions to get a proper history to determine the diagnosis.

 

[randomdoc1]

I mean, if by smarter we mean "better and more consistently able to effectively implement your goals in the world and sustain purposeful activity in service of those goals", which strikes me as one of the few kinds of smart worth having, stimulants absolutely do do this for a lot of people. Whether it's a good idea in the long-term is an orthogonal question, but denying that they do seem to be helpful for some people even in the absence of a pathology we can diagnose is to succumb to a bull-headed refusal to engage with reality. Sure, some people use them to deliberately get high, fine. But I don't think this is actually how the vast majority of people knocking down your door these days for Adderall are going to be using them.

Oh no, I'm not talking about that. I'm talking about people who actually don't have ADHD but have IQs of 70 or below and/or have unrealistic expectations. What I mean to say is, they will not increase your IQ. I have seen some people who got tested, turned out they had a below average IQ and were in highly intellectually demanding jobs or were trying to pursue something exceptionally prestigious in college. The stimulant is not going to fix their problem.

 

[nitemagi]

Oh no, I'm not talking about that. I'm talking about people who actually don't have ADHD but have IQs of 70 or below and/or have unrealistic expectations. What I mean to say is, they will not increase your IQ. I have seen some people who got tested, turned out they had a below average IQ and were in highly intellectually demanding jobs or were trying to pursue something exceptionally prestigious in college. The stimulant is not going to fix their problem.

Valid point, though recognizing that IQ testing itself very controversial, prone to plenty of environmental/cultural biases. Plus would want to be testing for learning disorders/processing problems, before writing someone off as just "low IQ."

 

[randomdoc1]

Valid point, though recognizing that IQ testing itself very controversial, prone to plenty of environmental/cultural biases. Plus would want to be testing for learning disorders/processing problems, before writing someone off as just "low IQ."

Agreed, which I have. I've served in the neuropsych department at the VA while a resident and we find a share of learning disorders too. We refer them to the appropriate resources.

 

[675015]

And what the F***? I can't believe they are actually serious. That it would "benefit society"? No one has even looked at the longterm effects of these medications...

Is it that much more unreasonable than the nations reliance on caffeine as a cognitive enhancer. How many people can't make it through a morning without their necessary coffee... and that addiction is a $20 billion global industry.

 

[randomdoc1]

Is it that much more unreasonable than the nations reliance on caffeine as a cognitive enhancer. How many people can't make it through a morning without their necessary coffee... and that addiction is a $20 billion global industry.

It doesn’t mean we should give into the path to least resistance. The fact that so many people drink coffee does not make the amphetamine problem any less significant. My friend who works at the dea says it’s becoming an increasing concern. In my area there are actual cardiovascular related deaths due to prescribed stimulants and it’s still on the rise, all adults. My perinatal psychiatrist friend is now seeing dozens of pregnant women opting to continue them even after an in depth discussion when it used to be rare to see a pregnant woman on a stimulant. Many had questionable diagnoses but they just decided to see someone who would continue stimulants for them. Not to mention the hypertensive urgencies and emergencies. So no, the fact that people drink coffee does not make this any less significant of an issue.

 

[erg923]

Is it that much more unreasonable than the nations reliance on caffeine as a cognitive enhancer. How many people can't make it through a morning without their necessary coffee... and that addiction is a $20 billion global industry.

Yea, if this wasn't so bunk...right? This is what people saaaaay. But its validity is preposterous.

I have 3 children, have gotten very little sleep some nights, as I'm sure most of you have experienced, and have never had an energy drink or "relied" of caffeine too function for a normal day of activities. Humans are strong and resilient.

Not necessary. Step up, folks!

Psychiatry is the last of the specialties that needs to step up the cosmetic plate!

 

[randomdoc1]

Yea, if this wasn't so bunk...right? This is what people saaaaay. But its validity is preposterous.

I have 3 children, have gotten very little sleep some nights, as I'm sure most of you have experienced, and have never had an energy drink or "relied" of caffeine too function for a normal day of activities. Humans are strong and resilient.

Not necessary. Step up, folks!

Psychiatry is the last of the specialties that needs to step up the cosmetic plate!

Don’t worry, we’ll just put in some clonazepam to take the edge off and Xanax for breakthrough. Although in my experience zyprexa may work out even better and then we’ll include vyvanse for the binge eating...

xD

 

[Ceke2002]

stimulants only treat actual ADHD (and sleep disorders and some cases of TRD).

And then of course there's also the idea that whilst stimulants certainly treat ADHD they're also not the miracle panacea for all patients everywhere that some would have you believe. There is something to be said for the management of symptoms without the use of medication, which for some patients can actually be preferable and have a better long term outcome than just relying on meds to deal with everything.

Btw, you seem interested (if that's the right word) in Adult ADHD in general - or at least you appear to have a lot of questions about it. I can only answer stuff as an individual patient, but I'd be open to asking some questions if you'd like to ask me some stuff.

 

[Trismegistus4]

It doesn’t mean we should give into the path to least resistance. The fact that so many people drink coffee does not make the amphetamine problem any less significant. My friend who works at the dea says it’s becoming an increasing concern. In my area there are actual cardiovascular related deaths due to prescribed stimulants and it’s still on the rise, all adults. My perinatal psychiatrist friend is now seeing dozens of pregnant women opting to continue them even after an in depth discussion when it used to be rare to see a pregnant woman on a stimulant. Many had questionable diagnoses but they just decided to see someone who would continue stimulants for them. Not to mention the hypertensive urgencies and emergencies. So no, the fact that people drink coffee does not make this any less significant of an issue.

Ah, adult ADHD rears its ugly head again, not only on this board, but also in real life: I saw a follow-up today who had elected to remain on her stimulant while pregnant, and is now breastfeeding while taking it. And I caved and started someone else on a stimulant today. It seems, as you say, that this issue is not going away and is only getting worse.

I really hate this, "adult-onset ADHD" nonsense. There is no such thing. Dysfunction or impairment from symptoms may not manifest until early adulthood, if someone has the intellectual ability to compensate. However, independent of dysfunction, there should exist the presence of symptoms during childhood. This is pretty clear in the DSM criteria, which literally states that symptoms should have been present prior to the age of 12. Notice that the criteria states that symptoms must be present before this age -- not dysfunction or impairment.

As mentioned above, there can certainly be something else that presents in adulthood with symptoms very similar to ADHD, but this would be diagnosed as the, "something else", and not ADHD.

The problem is, what do you do as a psychiatrist, what do you do diagnostically, what do you tell the patient and how do you treat them, when you have searched every nook and cranny and there is no "something else" identifiable, yet they insist until they are blue in the face that they cannot concentrate, yet are severely functionally impaired? The patient I started on a stimulant today, I had demurred on for a long time. She had a history of anxiety, but was not experiencing any clinically significant anxiety, nor depression, nor any other of what we used to call an "Axis I" diagnosis, during the time I have been seeing her. She didn't have a childhood history, though of course she attested to symptoms before the age of 12, with the classic explanation that she did OK in school because she worked extra hard to compensate and had enough innate intelligence to do so. Yet she state she recently got let go from her job, and while she passed last semester's grad school classes, did poorly enough not to qualify for financial aid, all because of impaired concentration. We have a psychologist in our organization who has recently started doing "testing" for ADHD, and while I know the psychologists on this board have said this is not diagnostic, we've been told by the powers that be in our organization that this is what we are going to do, so I felt my hands were tied; in fact, IIRC, it was her therapist, and not I, who referred her for the testing. The psychologist is someone I trust, who also did not find any other diagnosis, and, while of course, hedging her bets in her report, wrote that ADHD "should be considered." Then the patient comes back to see me. What can I do? At that point, it's either 1) prescribe a stimulant, or 2) say "sorry, it seems this is beyond my ability to help you. I suggest you see a different psychiatrist." Is the latter what everyone is doing? Frankly, we had the fear of lawsuits so drilled into us in residency that I'm afraid to do that.

Oh no, I'm not talking about that. I'm talking about people who actually don't have ADHD but have IQs of 70 or below and/or have unrealistic expectations. What I mean to say is, they will not increase your IQ. I have seen some people who got tested, turned out they had a below average IQ and were in highly intellectually demanding jobs or were trying to pursue something exceptionally prestigious in college. The stimulant is not going to fix their problem.

Is the bolded part really true? I can't find any references right now, but I could swear I heard somewhere once that there have been studies showing that people do score several points higher on the IQ scale with a stimulant in their system. But it's true, for more than a generation now our society has had this idea that everyone is a special and unique snowflake, and the world is like Lake Wobegon where "all the children are above average," and lay people consider IQ "controversial," (which, no offense, @nitemagi, as I understand it is incorrect; IQ is one of the most heavily validated concepts in psychology,) so we believe that anyone should be able to accomplish anything and are extremely uncomfortable with the idea that some--many, in fact-- people are simply not intelligent enough for advanced study in certain fields or employment in cognitively demanding professions. And that these people who can't maintain employment at a full-time job with abstract cognitive demands while taking 3 grad classes at night don't have a disorder, but rather lack the innate ability to pull such a task off.

I wish I knew what the solution to all this is. I know I sound like a broken record because I've said this in other threads, but the mere concept of adult ADHD was something we received zero exposure to, whether didactically or experientally, in residency, and thus I was totally blindsided when I started my first private outpatient job and began getting bombarded by all these referrals. Unfortunately I'm just a cog in a machine right now, working for a big organization where there is no mechanism for me to screen and decline referrals. The adult ADHD thing is one of several reasons I plan on fleeing back to the world of inpatient, but if wanted to continue doing outpatient, I would either 1) start my own private practice, where I could screen and decline referrals myself, or 2) bring up the adult ADHD issue during the interview process for a new job, making it explicitly clear that I do not want to see such patients, and getting the power to screen and decline referrals spelled out in my contract.

 

[smalltownpsych]

Ah, adult ADHD rears its ugly head again, not only on this board, but also in real life: I saw a follow-up today who had elected to remain on her stimulant while pregnant, and is now breastfeeding while taking it. And I caved and started someone else on a stimulant today. It seems, as you say, that this issue is not going away and is only getting worse.


The problem is, what do you do as a psychiatrist, what do you do diagnostically, what do you tell the patient and how do you treat them, when you have searched every nook and cranny and there is no "something else" identifiable, yet they insist until they are blue in the face that they cannot concentrate, yet are severely functionally impaired? The patient I started on a stimulant today, I had demurred on for a long time. She had a history of anxiety, but was not experiencing any clinically significant anxiety, nor depression, nor any other of what we used to call an "Axis I" diagnosis, during the time I have been seeing her. She didn't have a childhood history, though of course she attested to symptoms before the age of 12, with the classic explanation that she did OK in school because she worked extra hard to compensate and had enough innate intelligence to do so. Yet she state she recently got let go from her job, and while she passed last semester's grad school classes, did poorly enough not to qualify for financial aid, all because of impaired concentration. We have a psychologist in our organization who has recently started doing "testing" for ADHD, and while I know the psychologists on this board have said this is not diagnostic, we've been told by the powers that be in our organization that this is what we are going to do, so I felt my hands were tied; in fact, IIRC, it was her therapist, and not I, who referred her for the testing. The psychologist is someone I trust, who also did not find any other diagnosis, and, while of course, hedging her bets in her report, wrote that ADHD "should be considered." Then the patient comes back to see me. What can I do? At that point, it's either 1) prescribe a stimulant, or 2) say "sorry, it seems this is beyond my ability to help you. I suggest you see a different psychiatrist." Is the latter what everyone is doing? Frankly, we had the fear of lawsuits so drilled into us in residency that I'm afraid to do that.



Is the bolded part really true? I can't find any references right now, but I could swear I heard somewhere once that there have been studies showing that people do score several points higher on the IQ scale with a stimulant in their system. But it's true, for more than a generation now our society has had this idea that everyone is a special and unique snowflake, and the world is like Lake Wobegon where "all the children are above average," and lay people consider IQ "controversial," (which, no offense, @nitemagi, as I understand it is incorrect; IQ is one of the most heavily validated concepts in psychology,) so we believe that anyone should be able to accomplish anything and are extremely uncomfortable with the idea that some--many, in fact-- people are simply not intelligent enough for advanced study in certain fields or employment in cognitively demanding professions. And that these people who can't maintain employment at a full-time job with abstract cognitive demands while taking 3 grad classes at night don't have a disorder, but rather lack the innate ability to pull such a task off.

I wish I knew what the solution to all this is. I know I sound like a broken record because I've said this in other threads, but the mere concept of adult ADHD was something we received zero exposure to, whether didactically or experientally, in residency, and thus I was totally blindsided when I started my first private outpatient job and began getting bombarded by all these referrals. Unfortunately I'm just a cog in a machine right now, working for a big organization where there is no mechanism for me to screen and decline referrals. The adult ADHD thing is one of several reasons I plan on fleeing back to the world of inpatient, but if wanted to continue doing outpatient, I would either 1) start my own private practice, where I could screen and decline referrals myself, or 2) bring up the adult ADHD issue during the interview process for a new job, making it explicitly clear that I do not want to see such patients, and getting the power to screen and decline referrals spelled out in my contract.

An intelligence test that yields an IQ can be a very useful and accurate instrument when interpreted correctly taking into account concepts such as subtlest scatter, soicioeconomic factors and ethnocultural factors. Most of the criticisms that I have seen are related to misuse or misunderstanding of the constructs that are being measured.

 

[Jules A]

What can I do? At that point, it's either 1) prescribe a stimulant, or 2) say "sorry, it seems this is beyond my ability to help you. I suggest you see a different psychiatrist." Is the latter what everyone is doing? Frankly, we had the fear of lawsuits so drilled into us in residency that I'm afraid to do that.
.

This sounds distressing. Why would you be at risk of a lawsuit for refusing to prescribe something you aren't comfortable with and referring a patient elsewhere? I'm quite comfortable with "It seems I'm not going to be a good fit for you due to our difference of opinion on your treatment. My secretary will be happy to give you a list of local providers to contact". As for your organization's support that is definitely something to address up front next time. I always lay out my philosophy on benzos, bup and stimulants. There are practices that will allow you the autonomy to prescribe as you see fit.

 

[splik]

say "sorry, it seems this is beyond my ability to help you. I suggest you see a different psychiatrist." Is the latter what everyone is doing? Frankly, we had the fear of lawsuits so drilled into us in residency that I'm afraid to do that.

this is america. anyone can sue anyone for anything. over a 40 yr career a psychiatrist has an average of a 100% chance of being sued. however it is exceedingly difficult to be successfully sued as an outpatient psychiatrist. if you truly do not feel it is in your professional competence/scope to treat ADHD you either need to get training in it or not treat it. we are not supposed to practice outside our scope of practice so you would be well within your rights not to see someone and refer them on. if they cant find anyone else, well that's not your problem. now you could argue that as a psychiatrist you should know how to treat ADHD but this is definitely something that is very poorly covered in many residency programs.

I don't treat ADHD. or anxiety disorders for the matter. I have no interest in doing so. I don't want to work with such patients. It is a waste of my time for me to see patients with such diagnoses when anyone can do so. We have the right to not see anyone for any reason you like (although you probably do not want to give a racist/sexist/homophobic etc reason however even if that were the case, physicians have the right to treat whomever the hell we want and we dont have to give a reason). the exception of course is your employer may require you see these patients.

 

[Trismegistus4]

Thought of this thread again because before I left today, I got an email from a patient I recently saw for the first time whom I didn't think met ADHD criteria--in fact, that wasn't even the main reason he came in--with all kinds of anxiety issues, cluster C personality traits, tons of work and marital conflict, but is now emailing and vaguely demanding that prescribe an ADHD med for him; not explicitly threatening, not even quite implicitly threatening, but sort of implying that I am being neglectful in not treating him for ADHD and that if I don't all these terrible things are going to go wrong in his life and it will be my fault. Oh, and on Thursday I have a new patient on my schedule who just moved from out of town, or maybe is just new to our system, saw a new PCP, and "has a history of ADHD, was on meds before, and would like to get them again." (Another of my favorite kind of referrals; the kind where I'm just a dispensary, expected to take at face value their attestation to a history of ADHD, prescribe their stimulant, and send them on their merry way. This is another diagnostic conundrum for me. Even if a person has documentation of a childhood history, how am I supposed to know whether their current symptoms are anywhere near as impairing as they claim they are, especially since they've apparently survived fine without meds for years?)

This sounds distressing. Why would you be at risk of a lawsuit for refusing to prescribe something you aren't comfortable with and referring a patient elsewhere? I'm quite comfortable with "It seems I'm not going to be a good fit for you due to our difference of opinion on your treatment. My secretary will be happy to give you a list of local providers to contact". As for your organization's support that is definitely something to address up front next time. I always lay out my philosophy on benzos, bup and stimulants. There are practices that will allow you the autonomy to prescribe as you see fit.

As I've said elsewhere, I'm kind of a pushover and don't do well with confrontation. Maybe that is something I need to get over. But:

1. Our organization's website says we treat ADHD (and remember, this wasn't something I even thought to ask about or contest during the interview process, as I had no idea this could be such a big issue)
2. We have no way of screening referrals (PCP puts in a psych referral, it goes into the queue, scheduler calls the patient to offer them a psych appointment, asks which of our locations is most convenient, says "let's see, Dr. Trismegistus4 has a 10:00 available on February 22nd," patient says "OK," and gets scheduled, period. There's no way for the scheduler to stop and check and say "wait a minute, this referral is for ADHD and Dr. Trismegistus4 has a policy of not treating that")
3. We're booked out solid. The patient has been waiting 3 months to see the big expert psychiatrist; their big day is finally here to come in and receive the diagnosis of ADHD which they're certain is the fundamental key to everything that's ever gone wrong in their life... only to get here and be told "sorry, I don't do ADHD?" This last point is where maybe I should stop being a pushover. Maybe I should tell these people that. But I have a feeling my organization would not support that.

this is america. anyone can sue anyone for anything. over a 40 yr career a psychiatrist has an average of a 100% chance of being sued. however it is exceedingly difficult to be successfully sued as an outpatient psychiatrist. if you truly do not feel it is in your professional competence/scope to treat ADHD you either need to get training in it or not treat it. we are not supposed to practice outside our scope of practice so you would be well within your rights not to see someone and refer them on. if they cant find anyone else, well that's not your problem. now you could argue that as a psychiatrist you should know how to treat ADHD but this is definitely something that is very poorly covered in many residency programs.

Well, I think most of us have a rough idea of how to treat ADHD: by prescribing a stimulant. It's being asked to diagnose it that's the problem. Specifically, feeling confident in my ability to rule the diagnosis in our out, given the large number of possible confounding factors, comorbidities, the fact that the drugs used to treat it are drugs of abuse, have a street value, and, most importantly, are felt to be very beneficial even by many people who do not meet diagnostic criteria for ADHD or any other psychiatric condition for that matter.

But wait... what am I saying? Although I learned nothing about evaluating adults for ADHD in residency, since I started this job, my beloved patients have taught me. In medical school, they taught us we learn the most from our patients, and nowhere else is this more true. After conducting a psychiatric interview, probing for all the various inattentive and hyperactivity symptoms, and determining, to the best of your ability, that they don't meet diagnostic criteria for ADHD, you start by gently reassuring them that "trouble focusing" can occur in many other psychiatric conditions, like depression, anxiety, PTSD, OCD, etc. You inform them that they meet diagnostic criteria for one or more of the above, and you believe this needs to be treated first. You get buy-in from them, and prescribe an SSRI. They come back and tell you it didn't work, or made them nauseated. You prescribe a different SSRI. They come back and tell you that didn't work either. You prescribe an SNRI and oh, by the way, therapy is very effective too, and have they considered seeing a therapist? You get them referred to a therapist. They come back, the SNRI didn't work, they like the therapist and plan to continue with them, but still can't concentrate. Oh, and you know what, they don't really think they have depression, anxiety, PTSD, OCD, or various other conditions after all, and hey, they've brought in this printout from the intarwebz listing the symptoms of ADHD, and they have all of them! And they showed the list to their mom, and she said "OMG, that describes you to a T!" But, you still think they do meet criteria for whatever else you had in mind, so you get buy-in this one last time to, maybe, add Wellbutrin, or augment with an atypical antipsychotic, depending on the condition. They come back again and of course it didn't work. So, you tell them about Strattera. They're skeptical, because they googled it and learned it didn't work right away, or read a lot of reviews from people saying it didn't work at all, but they reluctantly agree to try it. They come back, and wouldn't you know it, it didn't work, or it made them drowsy, or it was too expensive. (Because how can you expect someone who is about to get fired from their [white collar, professional] job for inability to concentrate, to spend some of the money they earn at that job on a medicine to alleviate the symptoms which are allegedly about to get them fired?) So, at your wits end, with no idea what else you could possibly tell this person, and since it's 4PM on Friday and you just want to go home, you groan inwardly as a huge wave of sheepish defeat washes over you, and as one more little piece of you dies inside, while you try to pretend this isn't happening, you sign the prescription for a stimulant. They come back, and... it worked! Congratulations, doctor! You have mastered the gold standard test for ADHD--getting the patient to shut up and leave you alone! You have solved the mystery and made the diagnosis! You are an ADHD expert!

Ahh, I'm gonna go fix myself a mixed drink and enjoy an hour or 2 on the couch before going to bed and enjoying yet another day of my fulfilling, supremely self-actualizing job of being begged for stimulants.

 

[WisNeuro]

Is the bolded part really true? I can't find any references right now, but I could swear I heard somewhere once that there have been studies showing that people do score several points higher on the IQ scale with a stimulant in their system.

Studies are somewhat inconsistent, with questionable methodology. But, there are some that show ~.3SD difference in scores on group means. May be a different effect for people with ADHD vs controls. That was my read of the lit as of like 8 years ago. I don't do any actual ADHD "testing" anymore.

 

[PsyDr]

I'll remind everyone that there is about 1-2 decades of research that indicates that:

1) ADHD has an observable difference from normal controls on structural MRI
2) The structural imaging research indicates that the structural differences between ADHD and normal controls resolve.
3) The MTA study shows limited benefit of continued medication after 3 years.
4) MANY DSM5 diagnoses have a criteria for subjective complaints of attention/concentration impairment (e.g., GAD, MDD)
5) The DSM5 requires that the symptoms are present before 12 years of age.
6) Sleep Apnea, both central and obstructive, show a neuropsychological pattern of impairments which include attention impairments.
7) Substance abuse, in many forms, impairs attention.
8) There is consistent research which indicates that people overestimate their past abilities and performance.
9) The DSM5 indicates that while cognitive testing is not required in ADHD, it is recommended in neurocognitive disorders.

Valid point, though recognizing that IQ testing itself very controversial, prone to plenty of environmental/cultural biases. Plus would want to be testing for learning disorders/processing problems, before writing someone off as just "low IQ."

That's not how IQ tests work.

 

[randomdoc1]

ADHD Prescriptions Skyrocket Among Young Women

The potential perinatal risks of taking stimulants is a very valid concern. The healthcare provider discussion about this topic under the article is interesting (you have to log in to see it). What I also find interesting is this polarized response to the upsoar of stimulant prescriptions. Some people are very concerned about it (like myself) others applaud it saying it is finally being diagnosed and treated properly. imho, it is headed down a very slippery slope.

@Trismegistus4
I'd just run. I'd go crazy if I were in your shoes, it's not fun to work with patients when they are not on board with your expert opinion and have their minds already made up. Same thing with people who insist only Xanax works for them. I explain why I don't prescribe it and feel so fortunate that I can just give them a list of other physicians if they don't agree. I totally feel your pain. People on this forum probably remember the patient I treated who is morbidly obese, untreated sleep apnea, and raging etoh use disorder who wanted ADHD meds because she's been on them before. I'd only seen her a few months, she's continuing to ease up her drinking but she says she still can't concentrate. Her depression got much better. She's demanding amphetamines because she had some old doses at home, tried one recently and said she had so much energy and was not hungry. I told her these are not the indications for amphetamines (also when recovering from addiction it is not uncommon to have residual sx and the best you can do is focus on lifestyle changes). Stimulants are for: TRD, sleep disorders, and ADHD. She has none of those. She keeps begging, saying she feels so much better when she takes a stimulant. I explained to her what an amphetamine is, what it does, and the high risk for tolerance and dependence. I offered her numbers to other psychiatrists but interestingly, she still wants to see me. I set the boundaries that I'm not going to give her amphetamines purely for cosmetic purposes, it's not good medicine. Have a feeling she'll eventually trail off...but I'm not going to be an Adderall mill.

So, at your wits end, with no idea what else you could possibly tell this person, and since it's 4PM on Friday and you just want to go home, you groan inwardly as a huge wave of sheepish defeat washes over you, and as one more little piece of you dies inside, while you try to pretend this isn't happening, you sign the prescription for a stimulant. They come back, and... it worked! Congratulations, doctor! You have mastered the gold standard test for ADHD--getting the patient to shut up and leave you alone! You have solved the mystery and made the diagnosis! You are an ADHD expert!

I'd argue there is a huge placebo effect from stimulants too (for some patients it probably just gave them a confidence boost which can be accomplished without stimulants). In my anecdotal experience more than antidepressants. Is there any data about this? Plus, it is such a self reinforcing drug given the way it affects the nucleus accumbens. I sometimes find explaining the pathway of amphetamines to patients helpful. But as we see a lot in psychiatry, how the patient perceives the treatment also greatly affects how they perceive the efficacy (e.g. "only xanax works, antidepressants never work for me.").

 

[MacDonaldTriad]

This is only a diagnostic conundrum if you drink the kool aid and participate in this rationalized form of being a drug dealer. Learn to say no, or else word will get out and you will make you or someone a lot of money at the cost of your dignity. This isn't complicated at all. If in your heart you believe that adult ADHD is real, it isn't like there aren't tons of other providers who have flawed ethics to supply this demand. Personally, this dwarfs Bandini mountain in my eyes. This isn't the level of do no harm, this only reaches don't purposely and knowingly do more harm than good.
Before all of you stimulant prescribers jump on me, look at Trismegus4's description of his patient's demands. If you argue that your patients report feeling better, who wouldn't like stimulants? Yes, not all ADHD evaporates at age 18, but it doesn't triple in incidence either.

 

[Jules A]

Ahh, I'm gonna go fix myself a mixed drink and enjoy an hour or 2 on the couch before going to bed and enjoying yet another day of my fulfilling, supremely self-actualizing job of being begged for stimulants.

Have you discussed this with leadership? Are you looking at other jobs? This sounds miserable. In the patients' defense however you are sending mixed message that you will prescribe a stimulant if they try other things first.

I attempt to educate my adult ADHD stimulant seeking patients about my concerns and also inform them I will not be prescribing a stimulant for them, period. If we find their attention isn't improved by addressing possible comorbidities there are non-stimulant options. I always inform them they are under no obligation to continue with my services if our philosophies are incongruent. Most won't come back but I have had several who did well on alternatives and also a couple, literally two, I started on stimulants after legitimate trials of the other options. I also discharge patients who make threats which includes that they can't hold a job because I won't prescribe a stimulant or will relapse on whatever substances they used if I don't prescribe benzos.

 

[erg923]

Thought of this thread again because before I left today, I got an email from a patient I recently saw for the first time whom I didn't think met ADHD criteria--in fact, that wasn't even the main reason he came in--with all kinds of anxiety issues, cluster C personality traits, tons of work and marital conflict, but is now emailing and vaguely demanding that prescribe an ADHD med for him; not explicitly threatening, not even quite implicitly threatening, but sort of implying that I am being neglectful in not treating him for ADHD and that if I don't all these terrible things are going to go wrong in his life and it will be my fault. Oh, and on Thursday I have a new patient on my schedule who just moved from out of town, or maybe is just new to our system, saw a new PCP, and "has a history of ADHD, was on meds before, and would like to get them again." (Another of my favorite kind of referrals; the kind where I'm just a dispensary, expected to take at face value their attestation to a history of ADHD, prescribe their stimulant, and send them on their merry way. This is another diagnostic conundrum for me. Even if a person has documentation of a childhood history, how am I supposed to know whether their current symptoms are anywhere near as impairing as they claim they are, especially since they've apparently survived fine without meds for years?)


As I've said elsewhere, I'm kind of a pushover and don't do well with confrontation. Maybe that is something I need to get over. But:

1. Our organization's website says we treat ADHD (and remember, this wasn't something I even thought to ask about or contest during the interview process, as I had no idea this could be such a big issue)
2. We have no way of screening referrals (PCP puts in a psych referral, it goes into the queue, scheduler calls the patient to offer them a psych appointment, asks which of our locations is most convenient, says "let's see, Dr. Trismegistus4 has a 10:00 available on February 22nd," patient says "OK," and gets scheduled, period. There's no way for the scheduler to stop and check and say "wait a minute, this referral is for ADHD and Dr. Trismegistus4 has a policy of not treating that")
3. We're booked out solid. The patient has been waiting 3 months to see the big expert psychiatrist; their big day is finally here to come in and receive the diagnosis of ADHD which they're certain is the fundamental key to everything that's ever gone wrong in their life... only to get here and be told "sorry, I don't do ADHD?" This last point is where maybe I should stop being a pushover. Maybe I should tell these people that. But I have a feeling my organization would not support that.


Well, I think most of us have a rough idea of how to treat ADHD: by prescribing a stimulant. It's being asked to diagnose it that's the problem. Specifically, feeling confident in my ability to rule the diagnosis in our out, given the large number of possible confounding factors, comorbidities, the fact that the drugs used to treat it are drugs of abuse, have a street value, and, most importantly, are felt to be very beneficial even by many people who do not meet diagnostic criteria for ADHD or any other psychiatric condition for that matter.

But wait... what am I saying? Although I learned nothing about evaluating adults for ADHD in residency, since I started this job, my beloved patients have taught me. In medical school, they taught us we learn the most from our patients, and nowhere else is this more true. After conducting a psychiatric interview, probing for all the various inattentive and hyperactivity symptoms, and determining, to the best of your ability, that they don't meet diagnostic criteria for ADHD, you start by gently reassuring them that "trouble focusing" can occur in many other psychiatric conditions, like depression, anxiety, PTSD, OCD, etc. You inform them that they meet diagnostic criteria for one or more of the above, and you believe this needs to be treated first. You get buy-in from them, and prescribe an SSRI. They come back and tell you it didn't work, or made them nauseated. You prescribe a different SSRI. They come back and tell you that didn't work either. You prescribe an SNRI and oh, by the way, therapy is very effective too, and have they considered seeing a therapist? You get them referred to a therapist. They come back, the SNRI didn't work, they like the therapist and plan to continue with them, but still can't concentrate. Oh, and you know what, they don't really think they have depression, anxiety, PTSD, OCD, or various other conditions after all, and hey, they've brought in this printout from the intarwebz listing the symptoms of ADHD, and they have all of them! And they showed the list to their mom, and she said "OMG, that describes you to a T!" But, you still think they do meet criteria for whatever else you had in mind, so you get buy-in this one last time to, maybe, add Wellbutrin, or augment with an atypical antipsychotic, depending on the condition. They come back again and of course it didn't work. So, you tell them about Strattera. They're skeptical, because they googled it and learned it didn't work right away, or read a lot of reviews from people saying it didn't work at all, but they reluctantly agree to try it. They come back, and wouldn't you know it, it didn't work, or it made them drowsy, or it was too expensive. (Because how can you expect someone who is about to get fired from their [white collar, professional] job for inability to concentrate, to spend some of the money they earn at that job on a medicine to alleviate the symptoms which are allegedly about to get them fired?) So, at your wits end, with no idea what else you could possibly tell this person, and since it's 4PM on Friday and you just want to go home, you groan inwardly as a huge wave of sheepish defeat washes over you, and as one more little piece of you dies inside, while you try to pretend this isn't happening, you sign the prescription for a stimulant. They come back, and... it worked! Congratulations, doctor! You have mastered the gold standard test for ADHD--getting the patient to shut up and leave you alone! You have solved the mystery and made the diagnosis! You are an ADHD expert!

Ahh, I'm gonna go fix myself a mixed drink and enjoy an hour or 2 on the couch before going to bed and enjoying yet another day of my fulfilling, supremely self-actualizing job of being begged for stimulants.

1. No one is saying this isn't an issue or problem. I think we all agree.

2. Your work setting/environment sounds like it sucks, and it is much if the reason why I deferred interest in clinical psychiatry when I was still in undergrad 15 years ago.
I was lucky enough not to get a romanticized notion about what psychiatry was facing in this day and age, and it what it would actually consist of on regular basis.....not just this issue, but the monotony of "med checks" and such...unless I was in private practice or an AMC (in which case you are often underpaid).

3. There are many other ways to market your degree and skill set.

4. Looking back, it's hard to imagine how persons with that degree of education and training can stand working within a such a rigorous schedule of OP appt times.
Personally, I chose higher education in this field (clinical psychology) to have actualization, but also to avoid working a menial and inflexible 9-5.

 

[Trismegistus4]

8) There is consistent research which indicates that people overestimate their past abilities and performance.

May I ask what you mean by this? I would think if people overestimate their past abilities and performance, that would lend credence to undiagnosed childhood ADHD--"I think I actually did have ADHD as a kid, but I was able to compensate for it because I was really smart and just worked extra hard!" is a very common refrain.

ADHD Prescriptions Skyrocket Among Young Women

The potential perinatal risks of taking stimulants is a very valid concern. The healthcare provider discussion about this topic under the article is interesting (you have to log in to see it). What I also find interesting is this polarized response to the upsoar of stimulant prescriptions. Some people are very concerned about it (like myself) others applaud it saying it is finally being diagnosed and treated properly. imho, it is headed down a very slippery slope.

Wow, yes the comments to that article are very interesting. I get the impression most of the pro-stimulant responses come from people who have been diagnosed with, or think they have, ADHD themselves. But yes, this has the potential to become the next opioid crisis. And when it does, make no mistake, doctors will be blamed. I participated in a debate on the opioid issue on another, non-medical message board, and the belief in patient accountability among the other posters was zero. It was all doctors' fault: "doctors pushed pain pills on patients, believing the pharmaceutical industry propaganda that timed-release formulations weren't addictive, they got hooked, switched to heroin, overdosed, and died! There's no excuse for this! Not giving people addictive drugs is basic medicine!" Believe me, there is no sympathy for the PCP reluctantly caving to the Percocet-demanding, chronic pain, disability, fibromyalgia, spinal stenosis patient because he just wants to get them out of his office so he can go home. So it will be with stimulants.

Incidentally, on that same message board, one poster remarked that the test for ADHD is to give a person a stimulant and see how they respond. And this was a very intelligent person, a physicist. There is a HUGE amount of misinformation out there.

I'd just run. I'd go crazy if I were in your shoes, it's not fun to work with patients when they are not on board with your expert opinion and have their minds already made up. Same thing with people who insist only Xanax works for them. I explain why I don't prescribe it and feel so fortunate that I can just give them a list of other physicians if they don't agree. I totally feel your pain. People on this forum probably remember the patient I treated who is morbidly obese, untreated sleep apnea, and raging etoh use disorder who wanted ADHD meds because she's been on them before. I'd only seen her a few months, she's continuing to ease up her drinking but she says she still can't concentrate. Her depression got much better. She's demanding amphetamines because she had some old doses at home, tried one recently and said she had so much energy and was not hungry. I told her these are not the indications for amphetamines (also when recovering from addiction it is not uncommon to have residual sx and the best you can do is focus on lifestyle changes). Stimulants are for: TRD, sleep disorders, and ADHD. She has none of those. She keeps begging, saying she feels so much better when she takes a stimulant. I explained to her what an amphetamine is, what it does, and the high risk for tolerance and dependence. I offered her numbers to other psychiatrists but interestingly, she still wants to see me. I set the boundaries that I'm not going to give her amphetamines purely for cosmetic purposes, it's not good medicine. Have a feeling she'll eventually trail off...but I'm not going to be an Adderall mill.

Yeah, I hope for your sake she doesn't come back. That is what I always hope these people will do, and in fact some do, but because of observer bias I remember the ones who don't more, the ones who just keep coming back over and over relentlessly until I give them what they want. Your patient reminds me of one of mine I eventually allowed to guilt-trip me into restarting a stimulant. He's in his mid-thirties and was diagnosed with ADHD in his teens, and given a stimulant. Finished school, went to live in another state, went to audio engineering school, was actually in a rock band that toured, and worked in a record store. Then he got fired from the record store job for too much oversleeping and missing work, and his life went downhill from there. Kind of a reverse failure-to-launch: he moved back in with his parents and started doing nothing with his life. Then a couple years ago the other psych clinic he was going to found THC in his UDS and announced they would no longer prescribe a stimulant. His main complaints were debilitating social anxiety and complete lack of motivation, which of course he felt a stimulant had fixed in the past. That's the sketchy thing: although he was diagnosed with ADHD subsequent to academic problems, and got fired from a job for disorganization and lack of time management, what he thinks he needs a stimulant for is motivation. Of course I tried to treat his social anxiety and depression first, but to no avail. And I do believe his anxiety is real. Before restarting the stimulant, his voice would be tremulous, and his hand which he extended to me to shake would be cold and clammy. One thing I have held the line on is his request, of course, to be on a benzo as well.

I'd argue there is a huge placebo effect from stimulants too (for some patients it probably just gave them a confidence boost which can be accomplished without stimulants). In my anecdotal experience more than antidepressants. Is there any data about this? Plus, it is such a self reinforcing drug given the way it affects the nucleus accumbens. I sometimes find explaining the pathway of amphetamines to patients helpful. But as we see a lot in psychiatry, how the patient perceives the treatment also greatly affects how they perceive the efficacy (e.g. "only xanax works, antidepressants never work for me.").

I think most of these people really believe that. That is their subjective experience. Most people aren't being calculating and saying to themselves "I want to party with Z-bars, so I'm going to go to my doctor and tell him Xanax is the only thing that works for me!" Rather, the first time they tried that controlled substance, it felt like it "worked" better than anything else they'd ever tried, and they can't understand why a doctor won't just prescribe what works! Once they've had whatever feeling it gave them, that is their new normal and they never feel the same without it again. Just like opioid addicts.

But yeah, people get hung up on the word "antidepressant." That's something I've heard numerous times: "I went to this other doctor, and he just kept prescribing antidepressants. I'm not depressed, I have anxiety! I need an anti-anxiety med!" However, I have found attempts to explain this, or anything else for that matter, to be of limited usefulness. Once someone knows what they want, what the doctor says, unless it involves giving it to them, goes in one ear and out the other.

This is only a diagnostic conundrum if you drink the kool aid and participate in this rationalized form of being a drug dealer. Learn to say no, or else word will get out and you will make you or someone a lot of money at the cost of your dignity. This isn't complicated at all. If in your heart you believe that adult ADHD is real, it isn't like there aren't tons of other providers who have flawed ethics to supply this demand. Personally, this dwarfs Bandini mountain in my eyes. This isn't the level of do no harm, this only reaches don't purposely and knowingly do more harm than good.
Before all of you stimulant prescribers jump on me, look at Trismegus4's description of his patient's demands. If you argue that your patients report feeling better, who wouldn't like stimulants? Yes, not all ADHD evaporates at age 18, but it doesn't triple in incidence either.

Ha ha. There actually is a pill mill ADHD specialty practice in my area, which I wish all these people would just go to. Some of them have in fact gone there first, but found that they didn't take their insurance, or couldn't fit them into their schedule, or they were too far away, or any other of a litany of objections.

Have you discussed this with leadership? Are you looking at other jobs? This sounds miserable. In the patients' defense however you are sending mixed message that you will prescribe a stimulant if they try other things first.

I attempt to educate my adult ADHD stimulant seeking patients about my concerns and also inform them I will not be prescribing a stimulant for them, period. If we find their attention isn't improved by addressing possible comorbidities there are non-stimulant options. I always inform them they are under no obligation to continue with my services if our philosophies are incongruent. Most won't come back but I have had several who did well on alternatives and also a couple, literally two, I started on stimulants after legitimate trials of the other options. I also discharge patients who make threats which includes that they can't hold a job because I won't prescribe a stimulant or will relapse on whatever substances they used if I don't prescribe benzos.

I haven't discussed this with leadership yet. I probably should, but I'm just so non-optimistic, and am planning on leaving in the next year or so, so yes, I am looking at other jobs. But I don't think I'm sending patients a mixed message; I'm not telling them I'll prescribe a stimulant if they try other things first. I try to redirect the discussion away from stimulants, and in fact away from ADHD at all if I don't think they meet criteria. But, as I said above, most of what I tell people goes in one ear and out the other--I in fact tried telling one patient flat out that I don't prescribe stimulants, and it didn't work. He kept coming back and requesting stimulants. This guy had been on stimulants before and had every red flag in the book, in his chart which fortunately I reviewed before the initial visit: doctor-shopping, pharmacy-shopping, overtaking, running out early and then asking his cousin for some of hers to hold him over, showing signs of mania, abusing other substances, you name it. Fortunately, I was able to fire him, for being rude and using profanity at staff. God knows if he ever would have given up if I hadn't.

4. Looking back, it's hard to imagine how persons with that degree of education and training can stand working within a such a rigorous schedule of OP appt times.
Personally, I chose higher education in this field (clinical psychology) to have actualization, but also to avoid working a menial and inflexible 9-5.

I have often had the same thought, though very intellectually-minded psychoanalysts see patients for appointments all day. At least those are an hour long. But yeah, after 8 years of med school and residency, in this job I feel like I'm back to being the defeated, crushed-down, soulless cubicle-drone I was before I went to med school. Back to locum tenens inpatient work it is for me!

 

[PsyDr]

@Trismegistus4 since adhd is by definition a neuro developmental disorder, we are talking ability, not performance. Iirc, the DSM5 requires impairment in either all or most spheres of functioning.

In the hypothetical scenario you provided to me, I would say that the person demonstrates an adequate performance and this would not qualify for a diagnosis of adhd. Even if they did, the mta study shows that after 3 years stimulants do little in terms of symptoms for individuals with ADHD. Beyond that, the imaging research shows that the majority of individuals with ADHD normalize.

There are tasks that exceed people’s abilities.
Those that refuse to acknowledge this are narcissists.

 

[randomdoc1]

Even if they did, the mta study shows that after 3 years stimulants do little in terms of symptoms for individuals with ADHD. Beyond that, the imaging research shows that the majority of individuals with ADHD normalize.

There are tasks that exceed people’s abilities.
Those that refuse to acknowledge this are narcissists.

Just an innocent question, where can I find this information? I'd love to read the direct source, may be helpful for any patients I come across who insist on stimulants forever. I'm also no guru at appraising studies so I'm just wondering from your take of the data, is it saying after three years of stimulants it loses efficacy or that over time most people develop adequate compensatory mechanisms to just not need it? I presume this data is on children, is there a way to extrapolate this to adults? Also, when you say majority, what was the percentage that was given in this study? I'd love to know the number as well to discuss this with patients.

I believe someone else mentioned there was a new zealand study that showed adults presenting inquiring if they had ADHD, there was little overlap between them and people who were diagnosed as children. Suggesting that these are actually two very different populations and more likely than not, having different etiologies of their concentrational issues (i.e. the adults probably do not have ADHD to start with). But correct me if I am wrong and does anyone know exactly what study this is?

Fully agree with the need for impairment in multiple settings. Many of my adults presenting don't meet this criteria but still insist they need the stims. Unfortunately many health providers neglect looking for this piece too as well as evidence of the disorder present before age of 12 and ruling out substance use.

 

[PsyDr]

Just an innocent question, where can I find this information? I'd love to read the direct source, may be helpful for any patients I come across who insist on stimulants forever. I'm also no guru at appraising studies so I'm just wondering from your take of the data, is it saying after three years of stimulants it loses efficacy or that over time most people develop adequate compensatory mechanisms to just not need it? I presume this data is on children, is there a way to extrapolate this to adults? Also, when you say majority, what was the percentage that was given in this study? I'd love to know the number as well to discuss this with patients.

I believe someone else mentioned there was a new zealand study that showed adults presenting inquiring if they had ADHD, there was little overlap between them and people who were diagnosed as children. Suggesting that these are actually two very different populations and more likely than not, having different etiologies of their concentrational issues (i.e. the adults probably do not have ADHD to start with). But correct me if I am wrong and does anyone know exactly what study this is?

Fully agree with the need for impairment in multiple settings. Many of my adults presenting don't meet this criteria but still insist they need the stims. Unfortunately many health providers neglect looking for this piece too as well as evidence of the disorder present before age of 12 and ruling out substance use.

1) If you are treating ADHD pts, you should absolutely be very familiar with the NIMH's MTA study. Their outcome measures might have you disagree with my position. But it might not.

Jensen, P. S., Arnold, L. E., Swanson, J. M., Vitiello, B., Abikoff, H. B., Greenhill, L. L., . . . Hur, K. (2007). 3-year follow-up of the NIMH MTA study. J Am Acad Child Adolesc Psychiatry, 46(8), 989-1002. doi: 10.1097/CHI.0b013e3180686d48

2) I have quoted some of the MRI longitudinal stuff here before. This is a good one.

Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D., . . . Rapoport, J. L. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the National Academy of Sciences, 104(49), 19649-19654. doi: 10.1073/pnas.0707741104

 

[Trismegistus4]

All right, I brought this up with our medical director today. She said "we can't stop PCPs from sending us these referrals." So, the idea of screening referrals and not having supposed ADHD patients scheduled with me is a no-go, which means I can't get away with telling people "I don't treat ADHD." She said "if you really don't think they meet the diagnostic criteria for ADHD, you should feel comfortable telling them that, and that you don't think a stimulant is right for them." Which sounds nice, but doesn't really help me, because as I've experienced, that doesn't make these patients give up and go away. Time to dust off my locums recruiters' contact info...

I had 12 patients on my schedule today. 3 of them are on a stimulant. That's a 25% stimulant rate. Plus my one new one was there to see about getting back on a stimulant, after having been diagnosed in childhood but come off it later, because he's planning on taking another crack at college later this year. Fortunately, he wasn't too demanding. Actually, by his diction and vocabulary, he came across as just a not very intelligent person. He also described a lifetime history of difficulty learning math in particular. He was totally open to neuropsych testing to rule out a learning disability and find out his actual IQ. I actually felt a little bad for him. If he turns out just to have an 85 IQ, people like him are as much victims of our society's "college is for everyone" mentality as anything.

You know, thinking about the patient I described upthread, I realized something else my patients have taught me. In addition to teaching me valuable lessons about the high number of follow-up visits required to diagnose ADHD by having them try and fail every non-stimulant under the sun, they've also taught me a similar number of follow-ups are required to find the correct stimulant. You may not know this, because Big Pharma keeps falsifying peer-reviewed double-blinded placebo-controlled randomized clinical trials showing that multiple different meds work, but in reality, the only thing that works is immediate release Adderall. Of course, we docs, knowing that timed release formulations are less prone to abuse, must do our due diligence and have the patient try them first. So, after finally, relucantly agreeing to prescribe a stimulant as I described upthread, you prescribe Vyvanse. They come back for follow-up and tell you it didn't work. So you give them Concerta. They come back and tell you that didn't work either. Next on the list is Adderall XR. They give it their best shot, but wouldn't you know it, that didn't work either! Please, oh pretty please with sugar on top, can they try the immediate release Adderall their friend takes? They promise they'll only take the 2nd dose when they have afternoon classes or work and didn't sleep in that day. Finally, you consent to exercise the full gamut of your skills you spent years learning and perfecting in med school and residency, and do what really makes a doctor a doctor: give them the sacred only thing that works! You sign the Adderall IR prescription with a smile on your face, leave the office and walk to your car with a spring in your step, when you lie down in bed that night, you drift off to sleep in utter peace, knowing that today you have done your part to make the world a better place.

(You might think that even more follow-up visits are required, because if the starting dose of Vyvanse or Concerta didn't work, shouldn't they try a higher dose before moving on to another med? Come on, this is 2017--that's what phone calls and emails are for. In between each appointment, the patient has already called or emailed several times to tell you the med isn't working and asking for an increase, and being the empathic, patient-centered-care-oriented doctor you are, you've been more than happy to deal with these pressing concerns between seeing all the other patients on your schedule that day, and have willingly obliged.)

 

[OldPsychDoc]

"It takes 30 seconds to say Yes, and 30 minutes to say No."

 

[randomdoc1]

All right, I brought this up with our medical director today. She said "we can't stop PCPs from sending us these referrals." So, the idea of screening referrals and not having supposed ADHD patients scheduled with me is a no-go, which means I can't get away with telling people "I don't treat ADHD." She said "if you really don't think they meet the diagnostic criteria for ADHD, you should feel comfortable telling them that, and that you don't think a stimulant is right for them." Which sounds nice, but doesn't really help me, because as I've experienced, that doesn't make these patients give up and go away. Time to dust off my locums recruiters' contact info...

Hmm...I'd feel disheartened too if I were in your shoes. I may try to show them some of the studies like the MTA and New Zealand data. As well as some of the articles I originally posted. Also, I may think of showing the data about the concern of the upsoar of stimulant use in adults and potential for serious medical side effects. The data and admittedly some of my countertransferance is why I do not work with ADHD in adults. But the data also supports my reluctance and caution due to the slippery slope of overprescribing and just being a push over. That and many patients already have their minds made up anyways, it just goes in one ear and out the other in many cases. If this medical director is still not understanding and/or they get on your case about you appropriately saying no to patients, then it is not a good match. What state are you in? Maybe you can set up a gig like part time VA and part time PP. That's what I did. I LOVE it. The call is great, minimal and they have great retirement benefits, some with loan repayment. If you're nearby seriously maybe we can talk about you joining my gig. At least I know for sure you're not a pill mill. lol (partially kidding, partially serious)

You know, thinking about the patient I described upthread, I realized something else my patients have taught me. In addition to teaching me valuable lessons about the high number of follow-up visits required to diagnose ADHD by having them try and fail every non-stimulant under the sun, they've also taught me a similar number of follow-ups are required to find the correct stimulant. You may not know this, because Big Pharma keeps falsifying peer-reviewed double-blinded placebo-controlled randomized clinical trials showing that multiple different meds work, but in reality, the only thing that works is immediate release Adderall. Of course, we docs, knowing that timed release formulations are less prone to abuse, must do our due diligence and have the patient try them first. So, after finally, relucantly agreeing to prescribe a stimulant as I described upthread, you prescribe Vyvanse. They come back for follow-up and tell you it didn't work. So you give them Concerta. They come back and tell you that didn't work either. Next on the list is Adderall XR. They give it their best shot, but wouldn't you know it, that didn't work either! Please, oh pretty please with sugar on top, can they try the immediate release Adderall their friend takes? They promise they'll only take the 2nd dose when they have afternoon classes or work and didn't sleep in that day. Finally, you consent to exercise the full gamut of your skills you spent years learning and perfecting in med school and residency, and do what really makes a doctor a doctor: give them the sacred only thing that works! You sign the Adderall IR prescription with a smile on your face, leave the office and walk to your car with a spring in your step, when you lie down in bed that night, you drift off to sleep in utter peace, knowing that today you have done your part to make the world a better place.

You know, I have learned alot about treating ADHD too. From what I gather from child and adolescent psychiatrists, they've told me in their experience the extended release formulations work better. That has been my experience. Which is why in legit ADHD, I prefer Concerta or Vyvanse, that and the decreased abuse potential. If they're only asking for Adderall IR, it sounds to me they are more looking to treat their fatigue. I had one patient who insisted only high dose IR works for her and she's pretty much a functioning single mom of 4...

 

[Jules A]

All right, I brought this up with our medical director today. She said "we can't stop PCPs from sending us these referrals." So, the idea of screening referrals and not having supposed ADHD patients scheduled with me is a no-go, which means I can't get away with telling people "I don't treat ADHD." She said "if you really don't think they meet the diagnostic criteria for ADHD, you should feel comfortable telling them that, and that you don't think a stimulant is right for them." Which sounds nice, but doesn't really help me, because as I've experienced, that doesn't make these patients give up and go away. Time to dust off my locums recruiters' contact info...

This is good news because although I'm sure they don't want you to lose business they have shown support that you are free to prescribe as you see fit. You aren't telling patients you don't treat ADHD more that you don't prescribe stimulants while reserving the right to make exceptions-do not tell this to patients. I will guarantee if you flat out say you do NOT prescribe stimulants the ones interested in only that will fade away. Also whats with all the phone calls and emails? My patients go through my admin staff and I rarely address anything other than adverse reactions outside of an appointment. If they want an increase or change they need to come in for a follow up.

The guy you described who isn't the sharpest knife in the drawer with childhood history is someone I'd actually consider a stimulant for.

 

[randomdoc1]

Just as a side story since we are talking about the misinformation out there about ADHD. There was a middle aged adult male I came across in residency, it turned out he was getting benzos from two different prescribers. Not surprisingly, he developed cognitive symptoms. His daughter, a pharmacist said he has "classic ADHD" while being completely in the dark about his benzo issue. So get this, she got stims from her work and had him sample some to see if it would help and next thing you know, he was out looking for stims. I support family being engaged in a pt's care, but that was ridiculous.

 

[WisNeuro]

Always be checking them PDMPs folks.

 

[Shikima]

ADHD and sleeplessness: A critical link?

 

[Shikima]

http://www.adhdnetwerk.nl/Content/MeetingAttachments/Kooij - ADHD and Circadian rhythm.pdf

 

[Trismegistus4]

"It takes 30 seconds to say Yes, and 30 minutes to say No."

This reminds me of an idea I've formulated recently. Not long after I started this job, I realized I prefer inpatient for many reasons, one of which is that the patient is a captive audience. That may sound paternalistic, but it's true, and it makes difficult patients, like borderlines or drug-seekers, more difficult to deal with and set limits with, at least for me. You can just say "no" and walk away. But what I recently realized is that in outpatient, the doctor is the captive audience. We've made a deal in which they get 25 minutes of face-to-face time with me, making it impossible to just say "no" and walk away.

Hmm...I'd feel disheartened too if I were in your shoes. I may try to show them some of the studies like the MTA and New Zealand data. As well as some of the articles I originally posted. Also, I may think of showing the data about the concern of the upsoar of stimulant use in adults and potential for serious medical side effects. The data and admittedly some of my countertransferance is why I do not work with ADHD in adults. But the data also supports my reluctance and caution due to the slippery slope of overprescribing and just being a push over. That and many patients already have their minds made up anyways, it just goes in one ear and out the other in many cases. If this medical director is still not understanding and/or they get on your case about you appropriately saying no to patients, then it is not a good match. What state are you in? Maybe you can set up a gig like part time VA and part time PP. That's what I did. I LOVE it. The call is great, minimal and they have great retirement benefits, some with loan repayment. If you're nearby seriously maybe we can talk about you joining my gig. At least I know for sure you're not a pill mill. lol (partially kidding, partially serious)

I may PM you, though I really think right now I want to go back to inpatient.

You know, I have learned alot about treating ADHD too. From what I gather from child and adolescent psychiatrists, they've told me in their experience the extended release formulations work better. That has been my experience. Which is why in legit ADHD, I prefer Concerta or Vyvanse, that and the decreased abuse potential. If they're only asking for Adderall IR, it sounds to me they are more looking to treat their fatigue. I had one patient who insisted only high dose IR works for her and she's pretty much a functioning single mom of 4...

Interesting. I have never particularly gotten the impression they are looking to treat fatigue. I just assumed that whatever "rush" the immediate release gives you, they interpret as the medicine "working." They're druggies getting their fix, but don't have the insight to realize it.

This is good news because although I'm sure they don't want you to lose business they have shown support that you are free to prescribe as you see fit. You aren't telling patients you don't treat ADHD more that you don't prescribe stimulants while reserving the right to make exceptions-do not tell this to patients. I will guarantee if you flat out say you do NOT prescribe stimulants the ones interested in only that will fade away. Also whats with all the phone calls and emails? My patients go through my admin staff and I rarely address anything other than adverse reactions outside of an appointment. If they want an increase or change they need to come in for a follow up.

Patients go through the admin staff with me, too, but for anything other than a routine med refill, I have to deal with it. I don't want to address anything other than adverse reactions outside of an appointment, but I'm loath to ask people to come in instead, because 1) I don't like seeing them anyway, and 2) some of these people are so needy they'd start coming to see me every week.

The guy you described who isn't the sharpest knife in the drawer with childhood history is someone I'd actually consider a stimulant for.

I actually agree. He's one of these people with whom the gestalt is, well, if a UDS is clear, and I'm checking the state PDMP, and there's no evidence of abuse, diversion, inappropriate prescribing, he's not running out early, etc., etc., then... whatever, just give it to him.

Just as a side story since we are talking about the misinformation out there about ADHD. There was a middle aged adult male I came across in residency, it turned out he was getting benzos from two different prescribers. Not surprisingly, he developed cognitive symptoms. His daughter, a pharmacist said he has "classic ADHD" while being completely in the dark about his benzo issue. So get this, she got stims from her work and had him sample some to see if it would help and next thing you know, he was out looking for stims. I support family being engaged in a pt's care, but that was ridiculous.

I've heard that if an old lady swallows a fly, first-line therapy is to swallow a spider...

 

[VA Hopeful Dr]

Patients go through the admin staff with me, too, but for anything other than a routine med refill, I have to deal with it. I don't want to address anything other than adverse reactions outside of an appointment, but I'm loath to ask people to come in instead, because 1) I don't like seeing them anyway, and 2) some of these people are so needy they'd start coming to see me every week.

If you're paid for production, then see them. Just keep telling yourself "Every visit with this person is $X".

If you're salaried, then yeah try to keep them out of the office.

 

[MacDonaldTriad]

It is true, IR Adderall is the only stimulant that works, if your definition of working is giving you a good high and providing the most street value.

 

[Trismegistus4]

If you're paid for production, then see them. Just keep telling yourself "Every visit with this person is $X".

If you're salaried, then yeah try to keep them out of the office.

I'm still in my first 2 years so I'm still on guaranteed salary, but while I could earn a bonus, I don't care. I'd rather make less money than see difficult patients. There are no values of X for which $X is worth it.

It is true, IR Adderall is the only stimulant that works, if your definition of working is giving you a good high and providing the most street value.

I have never tried any of these drugs, but I almost want to, just to find out why people who don't satisfy diagnostic criteria for ADHD become so convinced they "work," rather than just realizing they like the way they make them feel.