Stimulants and a fib

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Attending1985

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Have a 50 year old patient who was diagnosed with a fib after it was found on an ekg done in the ed when he had kidney stones. Rate controlled with no symptoms. Son was recently diagnosed with adhd and wife and patient report he has same symptoms all his life and want same treatment as son which is concerta. He’s tried Effexor and Wellbutrin with limited benefit. Cardiology has said not ideal but ok to use stimulants if it’s impairing your life. Has anyone used stimulants in a fib history? Even with the cardiology ok I’m hesitant.
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I have, but I don't think they were already prescribed when patient was diagnosed with a fib and cardiology was fine with continuing Ritalin LA 10 mg or whatever the low dose was. If it's legit ADHD that's causing impairments and you've done a thorough eval/work-up and patient understands the risks, then I don't think a low dose trial is unreasonable. Recent JAMA article about this below:

jamanetwork.com

Methylphenidate and Short-Term Cardiovascular Risk

This cohort study examines the risks of cardiovascular disease after 6 months of methylphenidate treatment in individuals with attention-deficit/hyperactivity disorder.
jamanetwork.com jamanetwork.com

Also, not like atomoxetine doesn't have cardiac risks either, so imo really going to be patient specific.
 
I’m I’m
Stagg737 said:
I have, but I don't think they were already prescribed when patient was diagnosed with a fib and cardiology was fine with continuing Ritalin LA 10 mg or whatever the low dose was. If it's legit ADHD that's causing impairments and you've done a thorough eval/work-up and patient understands the risks, then I don't think a low dose trial is unreasonable. Recent JAMA article about this below:

jamanetwork.com

Methylphenidate and Short-Term Cardiovascular Risk

This cohort study examines the risks of cardiovascular disease after 6 months of methylphenidate treatment in individuals with attention-deficit/hyperactivity disorder.
jamanetwork.com jamanetwork.com

Also, not like atomoxetine doesn't have cardiac risks either, so imo really going to be patient specific.
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I’m wondering if I need to do testing? Although I don’t find it clinically useful at all maybe in this case it’s due diligence. He and his wife are endorsing the symptoms and he’s failed treatments of depression and anxiety, several ssris, snri, Wellbutrin and buspar.
Cardiologist specifically said strattera is not lower risk.
 
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Attending1985 said:
I’m I’m

I’m wondering if I need to do testing? Although I don’t find it clinically useful at all maybe in this case it’s due diligence. He and his wife are endorsing the symptoms and he’s failed treatments of depression and anxiety, several ssris, snri, Wellbutrin and buspar.
Cardiologist specifically said strattera is not lower risk.
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I find ADHD testing to be a mix. I have a psychologist I work directly with who is very good and I trust his assessments. I now defer straight ADHD evals to him. If I had time I'd just do them myself though, as I've found my ADHD assessments are actually more thorough than some of the psychologist assessments I've seen. So really just depends on your comfort with making the diagnosis and the availability of clinicians who actually do solid evals.
 
Stagg737 said:
I find ADHD testing to be a mix. I have a psychologist I work directly with who is very good and I trust his assessments. I now defer straight ADHD evals to him. If I had time I'd just do them myself though, as I've found my ADHD assessments are actually more thorough than some of the psychologist assessments I've seen. So really just depends on your comfort with making the diagnosis and the availability of clinicians who actually do solid evals
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Do you use any formal test, or just a thorough assessment?
 
50 y.o. M, new A-fib, depression/anxiety with many failed med trials... but all he and his wife care about is attention (and presumably getting stimulants, cardiac/stroke risks be damned)? Sounds about right.

Neuropsych testing isn't going to fulfill "due diligence" when it comes to malpractice, which is what I assume you mean. You alone decide to prescribe stimulants to someone with A-fib. What proof of serious impairment are you trying to overcome with stimulants? The serious risk of stroke must be outweighed. Sprinkle some Concerta, and his wife will 100% come back and say (and you document) that he pays better attention when she speaks. But no, that won't cut it.

Also, numerous failed med trials for anxiety/depression is likely pathognomonic for personality issues, coupled with being a 50 y.o. man who needs to bring his wife to his appointment. Is she present when he gets his prostate or colon checked, given the importance of those exams? When an adult brings someone into their psych appointment, especially in the context of controlled substances, it can be a form of aggression/pressure they are trying to apply to their psychiatrist.

Anyway, sorry lady, your husband needs to get depression/anxiety controlled before ADHD can be considered, he needs to do XYZ (i.e., therapy); after all that, if he has ADHD, we can consider guanfacine because I'm not risking your husband getting a stroke and turning into a drooling vegetable.
 
Candidate2017 said:
50 y.o. M, new A-fib, depression/anxiety with many failed med trials... but all he and his wife care about is attention (and presumably getting stimulants, cardiac/stroke risks be damned)? Sounds about right.

Neuropsych testing isn't going to fulfill "due diligence" when it comes to malpractice, which is what I assume you mean. You alone decide to prescribe stimulants to someone with A-fib. What proof of serious impairment are you trying to overcome with stimulants? The serious risk of stroke must be outweighed. Sprinkle some Concerta, and his wife will 100% come back and say (and you document) that he pays better attention when she speaks. But no, that won't cut it.

Also, numerous failed med trials for anxiety/depression is likely pathognomonic for personality issues, coupled with being a 50 y.o. man who needs to bring his wife to his appointment. Is she present when he gets his prostate or colon checked, given the importance of those exams? When an adult brings someone into their psych appointment, especially in the context of controlled substances, it can be a form of aggression/pressure they are trying to apply to their psychiatrist.

Anyway, sorry lady, your husband needs to get depression/anxiety controlled before ADHD can be considered, he needs to do XYZ (i.e., therapy); after all that, if he has ADHD, we can consider guanfacine because I'm not risking your husband getting a stroke and turning into a drooling vegetable.
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Interestingly, cardiology has said they didn’t recommend guanfacine as an alternative. Felt it was also harmful with little benefit.
Appreciate the input.
Gonna likely say no. His only option appears to be effexor plus behavioral treatment. Will have to deal with the hassle of impending rage of wife and complaint but better than causing a stroke.
 
If I get one more of the "my 1st degree relative got diagnosed with this so I need the same thing now" I am not going to make it through the day. I am well aware of the r coefficient in ADHD but you made it to 50 and are asking now after an a fib diagnosis?
 
Merovinge said:
If I get one more of the "my 1st degree relative got diagnosed with this so I need the same thing now" I am not going to make it through the day. I am well aware of the r coefficient in ADHD but you made it to 50 and are asking now after an a fib diagnosis?
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Didn't you know ADHD has a autosomal dominant and recessive transmission with 100% penetration unlike any other psychiatric diagnoses?
 
littlefred said:
Didn't you know ADHD has a autosomal dominant and recessive transmission with 100% penetration unlike any other psychiatric diagnoses?
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I know you're at least half-joking, but isn't ADHD one of the most directly heritable conditions we treat?
 
ObsequiousAplomb said:
I know you're at least half-joking, but isn't ADHD one of the most directly heritable conditions we treat?
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At this point I'm even doubting the validity of the diagnosis, so jaded with it already.

Wishfully hoping the DEA just allow stimulants to be OTC and remove us from the transaction.
 
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littlefred said:
At this point I'm even doubting the validity of the diagnosis, so jaded with it already.

Wishfully hoping the DEA just allow stimulants to be OTC and remove use from the transaction.
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it's not like ADHD is dissociative identity disorder, where a psychiatrist can doubt the diagnosis and it won't effect society or treatment much. Are you sure you're not just so upset with people who don't have ADHD that you're throwing the baby out with the bathwater here?

Maybe I'm naive, maybe I'm oblivious to some signs that bother other people, but I just don't have very many clearly faking people who come to me for an ADHD evaluation. Everyone at least has the common decency to describe symptoms from early childhood that continue in multiple settings into adulthood. And the ones who avoided treatment until they were adults always end up doing well with non-stimulants or stimulants at such low doses that they don't arouse any clinically significant suspicion within me. I feel bad for doctors who have to deal with all the frustrating ADHD evals, and at the same time very happy that my patients haven't been too upsetting to me about it. When people do show obvious signs of abuse, we have a discussion and they are either very reasonable or terminate care with me. Either way, nothing to make me feel all that upset.
 
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Candidate2017 said:
Neuropsych testing isn't going to fulfill "due diligence" when it comes to malpractice, which is what I assume you mean. You alone decide to prescribe stimulants to someone with A-fib. What proof of serious impairment are you trying to overcome with stimulants? The serious risk of stroke must be outweighed. Sprinkle some Concerta, and his wife will 100% come back and say (and you document) that he pays better attention when she speaks. But no, that won't cut it.
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I 100% agree with you but the neuropsych testing COULD be CYA if they show documented impairment with more "objective" testing...so you could use it to support your argument that he has impairment that needs to be treated if one was really gung ho about starting this 50yo who suddenly must have stimulants in his life.
 
littlefred said:
At this point I'm even doubting the validity of the diagnosis, so jaded with it already.
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I've said this before but ADHD is actually one of the most reliable diagnoses we deal with...however this is in the context of the vast majority of ADHD diagnoses in trials and in clinical practice being done on children with multiple collateral sources using standardized scales and interviews. It's not that the diagnosis isn't valid, consistency has just really not been looked at in depth with the situation many of you are dealing with now....an adult comes for a now basically retrospective "ADHD" evaluation who now has an adult's worth of baggage and a possible incentive to start stimulants for some reason or another.

I don't get many 12 year olds rolling in here begging to be started on stimulants.
 
thelastpsych said:
Do you use any formal test, or just a thorough assessment?
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Thorough assessment, in the past if I wanted to be really thorough I'd use the ACE+ as my outline. The psychologist I work with uses the DIVA in combination with his clinical interview. I just don't have the time to spend 2+ hours on an assessment just for ADHD to figure out how dysfunctional an adult has been over the past 10-20 years.

ObsequiousAplomb said:
I know you're at least half-joking, but isn't ADHD one of the most directly heritable conditions we treat?
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It is, but there's obviously varying severities and just because a kid has out of control symptoms doesn't mean their parent whose been mostly functional and just has mildly bothersome symptoms needs to be started on Concerta like their kids were.
 
Attending1985 said:
Have a 50 year old patient who was diagnosed with a fib after it was found on an ekg done in the ed when he had kidney stones. Rate controlled with no symptoms. Son was recently diagnosed with adhd and wife and patient report he has same symptoms all his life and want same treatment as son which is concerta. He’s tried Effexor and Wellbutrin with limited benefit. Cardiology has said not ideal but ok to use stimulants if it’s impairing your life. Has anyone used stimulants in a fib history? Even with the cardiology ok I’m hesitant.
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Have had a few ADHD patients with past infarcts/stents etc. If the cardiologist is ok with it, and the patient is receiving regular medical followup I'm not adverse to trialing a stimulant at the lowest dose, but the they have to stop immediately if they experience any re-emergence of cardiac symptoms. If you felt it was outside your comfort zone, a second opinion would be worth exploring.

ObsequiousAplomb said:
it's not like ADHD is dissociative identity disorder, where a psychiatrist can doubt the diagnosis and it won't effect society or treatment much. Are you sure you're not just so upset with people who don't have ADHD that you're throwing the baby out with the bathwater here?

Maybe I'm naive, maybe I'm oblivious to some signs that bother other people, but I just don't have very many clearly faking people who come to me for an ADHD evaluation. Everyone at least has the common decency to describe symptoms from early childhood that continue in multiple settings into adulthood. And the ones who avoided treatment until they were adults always end up doing well with non-stimulants or stimulants at such low doses that they don't arouse any clinically significant suspicion within me. I feel bad for doctors who have to deal with all the frustrating ADHD evals, and at the same time very happy that my patients haven't been too upsetting to me about it. When people do show obvious signs of abuse, we have a discussion and they are either very reasonable or terminate care with me. Either way, nothing to make me feel all that upset.
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Also have a similar patient population who is largely compliant and doesn’t require massive doses of medications.

I think having a long wait list tends to weed out those looking for a quick fix. In the past those patients would probably get their stimulants in other ways, although I suspect the recent trend for those who can’t wait is the expensive but quick telehealth diagnosis.
 
Merovinge said:
If I get one more of the "my 1st degree relative got diagnosed with this so I need the same thing now" I am not going to make it through the day. I am well aware of the r coefficient in ADHD but you made it to 50 and are asking now after an a fib diagnosis?
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I agree in general, but I do know of someone in their mid-50s who was a missed ADHD diagnosis despite having the most textbook list of inattentive symptoms I’ve ever seen and having sought therapy for the symptoms on and off for decades (with mid-level therapists, FWIW). They are extremely intelligent and in a profession where productivity is measured yearly, so they managed to be very successful on paper but were really distressed by the fact that they had entire days or weeks where they couldn’t focus enough to do any work and then ended up having a cram weeks of work into a few days.
 
Ultimately comes down to sound clinical judgement. I had a patient a couple of years ago that had lots of issues with trauma, substance use, and depression. During a hospitalization he was “correctly diagnosed” with ADHD by an “amazing nurse practitioner” and responded so well to adderall that they increased the dose after he left. Was doing so well, that he stopped coming to therapy. He committed suicide a couple months later. Don’t be that provider.
 
"wife and patient reported he had the same symptoms all his life" is a statement that contains multitudes of possibilities that range from "patient doesn't have adhd, wife gets annoyed he doesn't remember to take the garbage out" to "attention span of a hyperactive goldfish, drives recklessly almost unintentionally, history of multiple avoidable car accidents, ping pongs off the walls if nothing to do and has since age 5 but parents didn't believe in mental health assessment back then". At the end of the day all cases hinge on specifics. Would I prescribe stimulants to a patient with afib if their cardiologist was OK with it? The answer is always maybe. Maybe, if in my professional opinion as a psychiatrist the stimulant has the potential to do more good than harm.

And why do people so often seem to approach these decisions as though they are permanant? If you trial the stimulant and it doesn't help, you can stop it. And that DOESN'T hinge entirely on the pts word. You can stop it if you see weight loss, if the pt appears more anxious/agitated in your office, if they can't identify specific ways that their symptoms improved on it, if their cardiac condition changes....These are medications we literally can only issue one month at a time. If the pt gets mad when you stop the med, who cares? They have the choice to leave your practice.
 
Yeah, I think the decision is going to be based on what the impairment and level of impairment is.

I got diagnosed as an adult (mid-late 20's) in medical school. I hate taking the meds but function significantly better in both life and work during the periods where I decide to take them consistently. Turns out I had a shrink family member that told my parents I should get worked up when I was in middle school, but they refused because they didn't believe in it. Given how life altering it was for me to be medicated in medical school... I was kinda pissed at my mom for a second there. 🤣
 
clausewitz2 said:
With appropriate caveats about caution, low dosing, and diagnostic clarity aside, if cardiology says it's okay, why don't you trust their assessment of the relevant cardiac risk?
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cardiology gave a murky answer. I would prefer if you didn’t use them but it you’re really impaired by symptoms I can understand making an exception.
 
Celexa said:
"wife and patient reported he had the same symptoms all his life" is a statement that contains multitudes of possibilities that range from "patient doesn't have adhd, wife gets annoyed he doesn't remember to take the garbage out" to "attention span of a hyperactive goldfish, drives recklessly almost unintentionally, history of multiple avoidable car accidents, ping pongs off the walls if nothing to do and has since age 5 but parents didn't believe in mental health assessment back then". At the end of the day all cases hinge on specifics. Would I prescribe stimulants to a patient with afib if their cardiologist was OK with it? The answer is always maybe. Maybe, if in my professional opinion as a psychiatrist the stimulant has the potential to do more good than harm.

And why do people so often seem to approach these decisions as though they are permanant? If you trial the stimulant and it doesn't help, you can stop it. And that DOESN'T hinge entirely on the pts word. You can stop it if you see weight loss, if the pt appears more anxious/agitated in your office, if they can't identify specific ways that their symptoms improved on it, if their cardiac condition changes....These are medications we literally can only issue one month at a time. If the pt gets mad when you stop the med, who cares? They have the choice to leave your practice.
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His wife will give specific examples that endorse adhd but she’s well versed in this. Just like anyone will who feels they have adhd and wants treatment. That’s why, for me at least, it’s a really difficult territory to navigate these days.
 
clausewitz2 said:
With appropriate caveats about caution, low dosing, and diagnostic clarity aside, if cardiology says it's okay, why don't you trust their assessment of the relevant cardiac risk?
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Because the cardiologist isn't the one prescribing, so he won't be carrying the medicolegal liability.

Celexa said:
And why do people so often seem to approach these decisions as though they are permanant? If you trial the stimulant and it doesn't help, you can stop it. And that DOESN'T hinge entirely on the pts word. You can stop it if you see weight loss, if the pt appears more anxious/agitated in your office, if they can't identify specific ways that their symptoms improved on it, if their cardiac condition changes....These are medications we literally can only issue one month at a time. If the pt gets mad when you stop the med, who cares? They have the choice to leave your practice.
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Fair, but it's *such* a headache to have to pry people's stimulants away from them. It's just a draining conversation to keep having to have.
The desperation around stimulant refills is really dispiriting. The barest hint of a risk/benefit/tolerance conversation around the precious Adderall is enough to elicit instantaneous rolling of eyes and gnashing of teeth.

I never see that with antidepressants/mood stabilizers, despite so many people being much more impaired without them *and* there's a very unpleasant discontinuation syndrome associated with SS/SNRIs. But people who run out of their S/NRI will often just grit their teeth through it or figure they had the flu or something, and don't even bother to contact me. Vs when their last Adderall "rolled under the couch and they can't find it" they are all up in my grill MyCharting me q 2 hours looking for an early refill.
 
tr said:
Because the cardiologist isn't the one prescribing, so he won't be carrying the medicolegal liability.



Fair, but it's *such* a headache to have to pry people's stimulants away from them. It's just a draining conversation to keep having to have.
The desperation around stimulant refills is really dispiriting. The barest hint of a risk/benefit/tolerance conversation around the precious Adderall is enough to elicit instantaneous rolling of eyes and gnashing of teeth.

I never see that with antidepressants/mood stabilizers, despite so many people being much more impaired without them *and* there's a very unpleasant discontinuation syndrome associated with SS/SNRIs. But people who run out of their S/NRI will often just grit their teeth through it or figure they had the flu or something, and don't even bother to contact me. Vs when their last Adderall "rolled under the couch and they can't find it" they are all up in my grill MyCharting me q 2 hours looking for an early refill.
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A few counter points:

- possibly it's the CL in me, but I'm just not that scared about prescribing stimulants to someone with afib. I play with much hotter medical fires on a daily basis when on the inpt service. I just also have a really hard time seeing a lawsuit on that being successful if documentation is good. Maybe that's also from seeing an endless parade of grim events on the CL service, including regularly horrendous mistakes made by psychiatrists and non psychiatrists alike (if you have heart failure, for the love of God seek out an actual heart failure center), with zero consequences for incompetence on all levels. It's not that I've lost my caution but stimulants on a guy with a mild cardiac hx whose cardiologist is on board? Meh. What I would insist on is reviewing the cards records myself. I'm def not gonna take a patients word 'my cardiologist said it's OK'. And the pt better do the leg work of getting me those records.

- some of the most dispiriting and frustrating conversations I've ever had to try and get a patient off meds were about.... Seroquel. Seroquel is also the only non controlled substance I've had people leave screaming messages about or flip out on the inpt service when it wasn't continued.

I've had lots of dispiriting conversations with people already on Adderall prescribed by someone else. But...

- I never start stimulants on the first visit. If I am starting stimulants it is always something long acting and never Adderall. The patient will have met with me multple times already. And I give them the talk. This medication can be very helpful but it is not life preserving. It is not an emergency to go a day or two or three without it. All prescriptions are tracked and I check the database every time. UDS must result prior to start. It is your responsibility to send me a reminder message a few days before you run out. If you bombard me with messages, if you hound my staff, that is unacceptable and an indication we have a problem that the stimulants are either not fixing or are making worse. I will not continue to prescribe in those cases.

Is it my favorite type of visit? Definitely not, that's obviously the bipolar 2 who I correctly diagnosed who has been treated with the wrong things for years and finally feels better on Lamictal and thinks I'm a wizard. But it's all part of the job. And if I'm confident in my ability to maintain boundaries, then id rather treat people if I think it's indicated and have a chance of helping them, then be avoidant of the issue and lump all adults who wonder if they have ADHD into the same bucket.
 
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Attending1985 said:
Even with the cardiology ok I’m hesitant.
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Attending1985 said:
Gonna likely say no. His only option appears to be effexor plus behavioral treatment. Will have to deal with the hassle of impending rage of wife and complaint but better than causing a stroke.
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Your intuition feels his wife will rage if he does not get stimulants. That's an abnormal and strong reaction. Psychodynamically, we must always ask, "Why?" when we have an intuition or hesitancy, or when a patient has an abnormal/strong reaction. My intuition wonders whether little Johnny Jr. is getting all his Concerta and what mom's UDS looks like.

clausewitz2 said:
With appropriate caveats about caution, low dosing, and diagnostic clarity aside, if cardiology says it's okay, why don't you trust their assessment of the relevant cardiac risk?
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Cards did not say stims are ok. They said, "Meh, YOUR judgment on benefits/risks." Second, what clinical judgment did cards use? Does cards prescribe stims/psychotropics to cardiac patients? Nope, we do. All cards does is order a stat psych consult to the telemetry floor when they DC Lexapro 10 mg.

Third, the primary clinician is medicolegally responsible. There is this weird thinking that if we add more specialists to a rickety boat, it will be ok when it sinks because we can point fingers at each other. Again, we are the experts on stims/psychotropics, so we do the risk/benefit calculation. "Tee hee, I'm just a psychiatrist, cards/medicine said it was ok, and the patient consented" is not a great defense even though this is how the average psychiatrist thinks.

More importantly, this discussion is not about stimulants or A-fib. I feel as if OP posted because they wanted explore the dynamics of the situation.

Doctor Eliza said:
Did anyone else read this thread title as stimulants and a small lie? I was thinking your stimulant patient was having issues with honesty. 😂
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Wow, there you have it. Freudian stuff rolling around OP's head, the answer has been there all along.
 
Candidate2017 said:
Your intuition feels his wife will rage if he does not get stimulants. That's an abnormal and strong reaction. Psychodynamically, we must always ask, "Why?" when we have an intuition or hesitancy, or when a patient has an abnormal/strong reaction. My intuition wonders whether little Johnny Jr. is getting all his Concerta and what mom's UDS looks like.



Cards did not say stims are ok. They said, "Meh, YOUR judgment on benefits/risks." Second, what clinical judgment did cards use? Does cards prescribe stims/psychotropics to cardiac patients? Nope, we do. All cards does is order a stat psych consult to the telemetry floor when they DC Lexapro 10 mg.

Third, the primary clinician is medicolegally responsible. There is this weird thinking that if we add more specialists to a rickety boat, it will be ok when it sinks because we can point fingers at each other. Again, we are the experts on stims/psychotropics, so we do the risk/benefit calculation. "Tee hee, I'm just a psychiatrist, cards/medicine said it was ok, and the patient consented" is not a great defense even though this is how the average psychiatrist thinks.

More importantly, this discussion is not about stimulants or A-fib. I feel as if OP posted because they wanted explore the dynamics of the situation.



Wow, there you have it. Freudian stuff rolling around OP's head, the answer has been there all along.
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I agree that the dynamics are the main reason to pause here, not the afib. Would be curious to know if OP has spoken to the pt by himself.

I might prescribe stimulants to someone with afib. I definitely would NOT to someone if I think the main motivator is coming from the spouse--although I'd suspect other troubles in the marriage one person has decided to blame on ADHD would be more likely than diversion. Unless the spouse is reeeaally insistent that the prescription needs to be ADDERALL ONLY ADDERALL NOTHING ELSE WILL WORK.
 
Celexa said:
I agree that the dynamics are the main reason to pause here, not the afib. Would be curious to know if OP has spoken to the pt by himself.

I might prescribe stimulants to someone with afib. I definitely would NOT to someone if I think the main motivator is coming from the spouse--although I'd suspect other troubles in the marriage one person has decided to blame on ADHD would be more likely than diversion. Unless the spouse is reeeaally insistent that the prescription needs to be ADDERALL ONLY ADDERALL NOTHING ELSE WILL WORK.
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I have spoken to the patient by himself but the adhd symptoms are driven by the spouse. My feeling is she’s extremely exasperated with various aspects of his behavior and is desperate for someone or something to change him. I don’t have concerns for diversion. Maybe part of his issue is untreated adhd. It’s definitely not clear to me l. I’m just not comfortable with experimenting with stimulants with the a fib.
 
As I reread this, it sounds to me that the mom is just hearing that the treatment really helped son and is likely to help the dad. She is probably just frustrated with why the medical folk don’t see this as a no brainer. Our perception can get skewed by all the patients that shouldn’t be on stimulants and we start to miss the ones that truly benefit.
 
Attending1985 said:
I have spoken to the patient by himself but the adhd symptoms are driven by the spouse. My feeling is she’s extremely exasperated with various aspects of his behavior and is desperate for someone or something to change him. I don’t have concerns for diversion. Maybe part of his issue is untreated adhd. It’s definitely not clear to me l. I’m just not comfortable with experimenting with stimulants with the a fib.
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Sounds like you need to have a family session actually talking about the marital discord and have a conversation about what stimulants will/won't do to help things.

If hubby takes his addy and starts tootling around doing something that bothers wife, there's a decent chance he's going to have a harder time breaking away from that behavior and task switching if he doesn't actually need the stimulant. There are non stimulant options as well. Can always consider those first as well.

The dude is 50 and there seems to be little issue in his professional life from this (unless you haven't explored this). It's not like he's a kid about to get kicked out of school because he can't sit still in class and keeps being the subject of the teacher's ire.
 
ObsequiousAplomb said:
it's not like ADHD is dissociative identity disorder, where a psychiatrist can doubt the diagnosis and it won't effect society or treatment much. Are you sure you're not just so upset with people who don't have ADHD that you're throwing the baby out with the bathwater here?

Maybe I'm naive, maybe I'm oblivious to some signs that bother other people, but I just don't have very many clearly faking people who come to me for an ADHD evaluation. Everyone at least has the common decency to describe symptoms from early childhood that continue in multiple settings into adulthood. And the ones who avoided treatment until they were adults always end up doing well with non-stimulants or stimulants at such low doses that they don't arouse any clinically significant suspicion within me. I feel bad for doctors who have to deal with all the frustrating ADHD evals, and at the same time very happy that my patients haven't been too upsetting to me about it. When people do show obvious signs of abuse, we have a discussion and they are either very reasonable or terminate care with me. Either way, nothing to make me feel all that upset.
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I get lots of the neurotic, OCPD-lite and/or avoidant-procrastinating types who've seen a relative decline in their level of performance in comparison to their prior extremely high baseline. Now they want to explain their inability to meet their high standards for themselves with an easy-to-treat stimulant deficiency. It doesn't help that a lot of these types do feel more productive and push through procrastination tendencies more easily once someone other than me starts them on a stimulant or they take their friend/sibling/child/parent's amphetamine a couple of times.

I think the reliability and heritability data, a lot of which came from studies 20+ years ago in much more rigorous and better-controlled settings, was more compelling. These days I'm shocked when someone doesn't tell me that two of their friends and one or two of their family members were recently diagnosed and have "the same issues." Those issues are mostly baseline difficulties of living as an adult that most people share.

I, of course, do get patients who give histories and present behaviorally in a way that's way more consistent with actual ADHD. Those patients are rare.
 
FlowRate said:
Those issues are mostly baseline difficulties of living as an adult that most people share.
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Completely agree on this, but also wonder what is really the solution when just existing in our hypercomplex, hyperdemanding society requires a level of executive functioning that is out of reach for a large percentage of the population.

Handing everyone a stimulant so they can keep up doesn't seem genius, but I guess transforming our society into something more navigable is a utopian pipe dream, and definitely out of my hands as an individual.
 
Had the conversation today. They were not happy with my caution against the stimulant and plan to get the opinion of a adult adhd specialty clinic in town. However after some discussion they were respectful and I believe earnestly want help. Decisions like these are really tough for me and I appreciate everyone’s input. I don’t think I was gonna feel good about the decision either way and don’t feel great right now.
 
Attending1985 said:
Had the conversation today. They were not happy with my caution against the stimulant and plan to get the opinion of a adult adhd specialty clinic in town. However after some discussion they were respectful and I believe earnestly want help. Decisions like these are really tough for me and I appreciate everyone’s input. I don’t think I was gonna feel good about the decision either way and don’t feel great right now.
Click to expand...

Ah yes the "ADHD specialty clinic" opinion. Right up there with the "Lyme disease clinic" and "Men's health clinic".

You have to make the decision you're comfortable with and if they don't like it they can certainly transfer his care to the ADHD clinic.
 
tr said:
Completely agree on this, but also wonder what is really the solution when just existing in our hypercomplex, hyperdemanding society requires a level of executive functioning that is out of reach for a large percentage of the population.
Click to expand...
So, are you for enhancement and where do you draw the line between pathology/enhancement?
 
sloh said:
So, are you for enhancement and where do you draw the line between pathology/enhancement?
Click to expand...
I don't think there's a bright line, and I don't have any ethical issues with neuroenhancement per se.

It is just unfortunate that most amphetamine derivatives carry the potential for tolerance, dependence, and abuse; and on a personal level I resent being placed in the position of gatekeeper.
 
tr said:
I don't think there's a bright line, and I don't have any ethical issues with neuroenhancement per se.

It is just unfortunate that most amphetamine derivatives carry the potential for tolerance, dependence, and abuse; and on a personal level I resent being placed in the position of gatekeeper.
Click to expand...
I know someone else already said it ITT, but we already have a model for monitored, behind-the-counter prescription stimulant-precursors (simplifying things) with pseudoephedrine. Adderall could totally be made into a BTC med with strict 1800mg per month (60mgx30days) limits. (Only half kidding, make it something harder to abuse, like Lisdexamfetamine, if you want.)
 
Some thoughts -

Cardiology recs: Seem to be saying significant potential risk, but not so much to outweigh potential benefits if there are significant functional impairments from ADHD. Contrast to what they might say if it was WPW or HOCM instead of a-fib: "Although functional impairment may be present due to ADHD, killing the patient would lead to no function at all. No stimulants."

Rate controlled a-fib: The only risk with a stimulant seems to be that HR will increase...which is the easiest vital sign to monitor. Stroke risk is due to potential for clots to form in the fibrillating atrium, which patient should be on anticoagulation for already and shouldn't be affected by stimulant.

Age: I think my personal record for first diagnosis of ADHD is late 60s, patient happened to be quite high functioning professionally. Chief complaint was basically weight gain. Why were they gaining weight? Because they were always chewing on something. Why were they always chewing? Because they felt restless. Why did they feel restless? Because they felt driven, as if by a motor. Interview fairly quickly pivoted to asking about their childhood. Symptoms resolved with bupropion 150.
Also, as patients start to experience cognitive decline, points of weakness (even if they were previously compensated for) will likely be the first point of failure, so mild, subsyndromal, or behaviorally ADHD can become symptomatic and require treatment.
 
aim-agm said:
Some thoughts -

Cardiology recs: Seem to be saying significant potential risk, but not so much to outweigh potential benefits if there are significant functional impairments from ADHD. Contrast to what they might say if it was WPW or HOCM instead of a-fib: "Although functional impairment may be present due to ADHD, killing the patient would lead to no function at all. No stimulants."

Rate controlled a-fib: The only risk with a stimulant seems to be that HR will increase...which is the easiest vital sign to monitor. Stroke risk is due to potential for clots to form in the fibrillating atrium, which patient should be on anticoagulation for already and shouldn't be affected by stimulant.

Age: I think my personal record for first diagnosis of ADHD is late 60s, patient happened to be quite high functioning professionally. Chief complaint was basically weight gain. Why were they gaining weight? Because they were always chewing on something. Why were they always chewing? Because they felt restless. Why did they feel restless? Because they felt driven, as if by a motor. Interview fairly quickly pivoted to asking about their childhood. Symptoms resolved with bupropion 150.
Also, as patients start to experience cognitive decline, points of weakness (even if they were previously compensated for) will likely be the first point of failure, so mild, subsyndromal, or behaviorally ADHD can become symptomatic and require treatment.
Click to expand...
Only risk with stimulant is not hr increase. They have effects on cardiac conduction. Patient is not an anticoagulant after weighing risks and benefits with cardiology.
 
tr said:
I don't think there's a bright line, and I don't have any ethical issues with neuroenhancement per se.

It is just unfortunate that most amphetamine derivatives carry the potential for tolerance, dependence, and abuse; and on a personal level I resent being placed in the position of gatekeeper.
Click to expand...

As an interesting aside, know it’s not an amphetamine derivative but the main component in Azstarys is actually schedule IV right now and if they can get approval for only serdexmethylphenidate would be the first schedule IV stimulant. It’s in trials right now for treatment of stimulant use disorder so hopefully something that’s much less reinforcing (although I know the DEA schedules are totally arbitrary and Xanax is also schedule IV lol…but it was a big deal for them to get it scheduled lower than the default for most stimulants, even Vyvanse is schedule II still).


 
Last edited:
calvnandhobbs68 said:
As an interesting aside, know it’s not an amphetamine derivative but the main component in Azstarys is actually schedule IV right now and if they can get approval for only serdexmethylphenidate would be the first schedule IV stimulant. It’s in trials right now for treatment of stimulant use disorder so hopefully something that’s much less reinforcing (although I know the DEA schedules are totally arbitrary and Xanax is also schedule IV lol…but it was a big deal for them to get it scheduled lower than the default for most stimulants, even Vyvanse is schedule II still).


Click to expand...
one of my older attendings in residency would prescribe phentermine for ADHD because he felt more comfortable prescribing schedule IV to some patients.
 
littlefred said:
I had one that probably owned stock on the manufacturer of Modafinil (he used it for ADHD as well).
Click to expand...
I had an attending in medical school who gave every single patient at least 2/3 of Cymbalta, Zyprexa, and Modafinil. I have to imagine he also owned stock in them.
 
ObsequiousAplomb said:
one of my older attendings in residency would prescribe phentermine for ADHD because he felt more comfortable prescribing schedule IV to some patients.
Click to expand...
Did it work? I've been curious about that but have had trouble finding literature.
 
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