The issue of Ritalin / Stimulant medication with ADHD and functionality

[Fastball32]

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383[/url]

I wanted to clarify about the age requirements.

Symptoms (and not age criteria) have to be present by age 12, which increases the pool of ADHD patients.
Actual minimum age requirement does not change and you can still prescribe Amphetamine to 3 year olds with the approval from the FDA.

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[ghost dog]

I am not a troll, it is comments like the one above that incite passionate responses against psychiatry. As a diagnosis of personality disorder could severely handicap a person going into any professional career requiring you to fill out one of those sheets that asks "if you've ever been diagnosed with a mental illness".

As a pilot I know completely normal people's lives severely burdened if not ruined by Psychiatry.

There was a court case in 2006 of a poor fellow who couldn't get his pilot license because he faked symptoms of Schizophrenia to get attention as a teenager, btw, other Psychiatrists undiagnosed this and agreed but that is how strong the label is. These are the kind of cases that really grind my gears about Psychiatry.

I have a suspicion kids who've been diagnosed with ADD don't have the easiest time getting a pilot license as it is a disqualifying condition under the FARs. Which is completely unfair, since everyone from high school I've ever known with 'ADD' was a completely normal person fully capable of flying an airplane. There really isn't that much thinking that goes into it guys. Up, down, left, right.

Perhaps Psychiatrists should change their treatments to cures, so when the issue is no longer a problem for the patient, they don't have to be burdened with the handicap of the diagnosis? This of course is logic and considering how much subjectivity is involved in any diagnosis it would only be reasonable.

I don't know if this poster is serious or not: flying isn't that hard? " Up, down, left, right."

How old are you ?

Airplanes don't have erasers on them.

 

[billypilgrim37]

I wanted to clarify about the age requirements.

Symptoms (and not age criteria) have to be present by age 12, which increases the pool of ADHD patients.
Actual minimum age requirement does not change and you can still prescribe Amphetamine to 3 year olds with the approval from the FDA.

I know, don't you just HATE it when the FDA does rigorous research to determine the appropriateness of treatment following intensive psychosocial intervention for severely impaired children? Gosh, if they'd just let these kids suffer in peace, we'd all be better off. I hate it when kids get appropriate treatment!

 

[whopper]

I actually agree with Fastball on some of his comments.

ADHD is already too easily diagnosable IMHO based on the DSM criteria. The DSM V criteria will make it even easier to diagnose.

I do believe ADHD does really exist but the standards that are used: a self report, a symptom checklist where you can get dx'd based on symptoms that literally everyone has had (e.g. not wanting to sit in a classroom), lazy clinicians, and meds that treat the disorder but area also abusable make this a very bad combination.

I do not blame doctors that will not give out stimulants at all. IMHO no one should ever give out one without scrutiny.

I do give out stimulants, and I'm repeating what I've written in other threads. I only do so when 1) the patient has a TOVA test verifying they have ADHD (and it has a symptom exaggeration scale to weed-out malingers) 2) the patient must try at least 1 non-stimulant such as Wellbutrin with no success...I'm talking pushing to the max dosage and being on it for at least one month and 3) an EKG

While on a stimulant, at least in the state I'm in, I can put the patients name in a state computer check that tells me every single prescription med the patient ever filled out.

I even sympathize with him on the anti-psychiatry comments because I've seen several bad psychiatrists out there and seen patients burned by them. I understand why a person would be so against psychiatry if someone they knew, or they themselves were mistreated by one. I do, however, believe that psychiatry is a real field, but given the subjectiveness, we psychiatrists need to hold ourselves to high standards.

 

[billypilgrim37]

ADHD is already too easily diagnosable IMHO based on the DSM criteria. The DSM V criteria will make it even easier to diagnose.

This brings up something I've been thinking about a lot. I think we do a really bad job talking about diagnosis and severity as two different things. I think this also fuels a lot of the discussions about misdiagnosis of bipolar disorder in youth.

We as psychiatrists make the decision about the diagnosis, and so whether we call someone ADHD or Bipolar Disorder or MonkeyBrained NOS is our attempt to be able to talk about our patients in consistent ways. These diagnoses also inform us regarding how we should treat. They do not necessarily completely inform us about how we should treat.

And I think that's where severity comes in as a different argument. It really isn't important (or, it doesn't have to be important clinically--it's clearly important on some level, but not in the way that's being implied here) how "easy" or "hard" it is to diagnose ADHD. The important thing should still be the level of dysfunction and suffering. An adult might "have ADHD," but that doesn't mean you HAVE to prescribe a stimulant (OR ANYTHING) if in your clinical judgment severity does not warrant it. It may be useful in identifying difficulties they are having, and it might reinforce their need for psychosocial interventions, even if that's just buying a planner to keep up with appointments.

I think that's where we've tripped up with bipolar disorder in kids (a very real, disabling illness) in that some assign the diagnosis in the absence of discrete periods of manic symptoms which are a distinct change from baseline. Otherwise, those children would probably get diagnoses of ADHD, ODD, MDD, maybe PTSD. Now those kids might get a diagnosis of DMDD, which is another argument I don't want to get into here. They didn't become different kids just because the alphabet soup on Axis 1 changed. I'm pretty sure the reason why the bipolar diagnosis gets assigned is because clinicians treat it as an indicator of severity. "This kid can't possibly have just MDD, ODD, and ADHD! He's way more impaired than that! He must have bipolar disorder! He needs Risperdal!" But really, maybe he just has severe MDD, ODD (or CD), ADHD, anxiety, PTSD, etc. And Risperdal may be an entirely appropriate intervention in severe cases, regardless of whether there are discrete periods of manic symptoms which are a distinct change from baseline or not.

So, my argument would be that none of our clinical practices will change much, because our patients' level of suffering isn't going to change one way or another just because the APA puts out a new book/website. No parent is going to come into my office and say in 2014, "Well, doc, Johnny stares out the window and forgets his homework and can't sit still and the teacher says he had ADHD, but I didn't come see you because nobody really noticed it until he was 8 years old because he was in a Montessori school before, and I knew you couldn't treat him for ADHD until DSM5 came out." It just doesn't work that way.

So, it makes really good sense to condemn lazy, sloppy, unthoughtful practice. It makes good sense to condemn handing out scheduled substances like candy without proper risk/benefit calculus.

But it doesn't make sense to generically condemn adjusting criteria to better reflect currently available research. It doesn't make sense to generically condemn prescribing psychotropics to young children (obviously, this should be an incredibly rare thing, but many of us work at tertiary or quarternary care centers, where there are simply going to be some rare cases severe enough to warrant interventions that, if commonplace, would sound ludicrous).

 

[whopper]

Agree.

I am, however, thoroughly disappointed with the quality of care I've seen in several areas including 5 states. There are good doctors out there but bad doctors are not exceedingly rare.

In my current area, I know of a psychiatrist that gave all his patients rectal exams. When confronted by the law, he even proudly admitted to doing it saying it's a norm in psychiatric practice. The guy eventually lost his license, after years of doing this type of practice,...only to move 10 miles and setup practice in a different state. Whoopdee do! I know of a psychiatrist that openly calls his patients losers to their face and then discharges them even when they are still suicidal. I know one that gives out Xanax and stimulants, as much as the patients want, with little to no scrutiny. I know another that only writes progress notes once every few months in the state hospital when they are supposed to write it at least weekly. Needless to say his care is quite awful.

It's upsetting. In each of these cases, when one of the patients that had one of these doctors told me what happens, I tell them to inform the state medical board, and tell them how to do so. In some of the cases, I've witnessed the doctor actually doing the act. In others, I've seen enough patients, who don't know the others, each tell me the same story happened to them. When one person complains Dr. X called them a "loser" so be it. When 10 do it, none of them know the other, and the context was very similar, I start to think there has to be at least something to it.

You figure the field is so difficult in the training that regulation of practice in the real world would be much better. Like a professor told me, it's next to impossible to get your license, but once you got it, it's next to impossible to lose it no matter how bad you are.

 

[billypilgrim37]

In my current area, I know of a psychiatrist that gave all his patients rectal exams. When confronted by the law, he even proudly admitted to doing it saying it's a norm in psychiatric practice. The guy eventually lost his license, after years of doing this type of practice,...only to move 10 miles and setup practice in a different state. Whoopdee do! I know of a psychiatrist that openly calls his patients losers to their face and then discharges them even when they are still suicidal. I know one that gives out Xanax and stimulants, as much as the patients want, with little to no scrutiny.

It sounds like these psychiatrists may suffer from MonkeyBrained NOS.

 

[Fastball32]

Objectifying as many aspects of Psychiatry will help the field, particularly in society.

ADHD is the most biologically inherited Psychiatric Disorder, so I'm all for necessary treatment, even if it requires a pre-school child with impairing symptoms.

The only thing I'm concerned about with the proposed revisions are that some clinicians who only have 15 minutes for a med check, may resort to a symptom checklist. Although sensitivity will increase, so will false positives.

 

[nitemagi]

The only thing I'm concerned about with the proposed revisions are that some clinicians who only have 15 minutes for a med check, may resort to a symptom checklist. Although sensitivity will increase, so will false positives.

That is a problem that extends far beyond ADHD. Understanding a pt. phenomenologically has gone out the window, leading to a heckuva lotta false positives (psychosis, bipolar). What's sad is that just by sitting and asking a few extra questions these things can be teased out.

 

[Fastball32]

That is a problem that extends far beyond ADHD. Understanding a pt. phenomenologically has gone out the window, leading to a heckuva lotta false positives (psychosis, bipolar). What's sad is that just by sitting and asking a few extra questions these things can be teased out.

Agreed. Thankfully as a whole, I think Psychiatrists are very good at using their judgment to tease out what is true pathology.

 

[whopper]

A problem with psychiatry and ADHD is that most of the help psychiatrists offer is based simply on the patient's self-report. In most disorders, patients do not have an incentive unless in a truly terrible or otherwise rare situation (e.g homelessness, extreme drug withdrawal, factitious disorder) to fake or exaggerate symptoms.

In ADHD, as well as in disability, lawsuits, forensic, and the extreme cases, patients are in a position where malingering actually can suit them. In ADHD, the usual treatments are meds of abuse with a street value. In these situations, a clinician should not simply use the patient's own subjective reports. They should actively pursue malingering testing and evaluation.

Then here is the problem. Most psychiatrists are not taught to do this. They simply are taught to treat based on the patient's subjective complaints. I can tell you that I only knew of one doctor in my general residency training that competently knew how to look for malingering and he left that program, so I figure now they got no one.

The problem is to the degree that several medical doctors are under the erroneous belief that due to the "Do no harm" motto, they are not allowed to consider malingering because calling their patient a liar could do harm. It's pathetic.

Psychiatry, of all medical fields, requires heightened scrutiny in diagnosis due to the relatively lower use of labs and other objective verifications for illness.

 

[nitemagi]

I've always had an interest in malingering, and over time have gotten more interested in polytheoretical (I know that isn't a word, but have been struggling to find an appropriate one) approach to all clinical interviews. Sx checklists can be a piece of the picture, a phenomenological approach with in-depth questioning can add a lot (like teasing out the difference between just "voices" and hallucinations, collateral. I think it's further important to incorporate malingering questions into the clinical interview, rather than only using screening tests. Standardized tests can be learned and beaten. A good clinical interview can involve building an alliance then asking probing questions that might really elucidate secondary gain or the real depth of their concerns. This can also be done during an interview once the pt. feels you are taking them seriously (and they feel less pressure to convince you of something to get what they want), potentially lessening an symptom inflation seen in those malingering or just exaggerating.

 

[ghost dog]

That is a problem that extends far beyond ADHD. Understanding a pt. phenomenologically has gone out the window, leading to a heckuva lotta false positives (psychosis, bipolar). What's sad is that just by sitting and asking a few extra questions these things can be teased out.

What really pisses me off ?

Some ( read : a lot ) of psychiatrists now do consult medicine in ambulatory practice, and simply won't follow patients. They will see the patient once, provide recommendations, and out the door they go. Admittedly, I often see this from a third party perspective as a pain consultant (and I do follow my patients !! ).

An example I saw recently : a 49 yr old woman who I thought had MDE who seemed to deny any manic symptoms. However, she had recently been assessed by a psychiatrist and diagnosed with "bipolar disorder", and given depakote (only) and then discharged from his care.

Can anyone comment on this ?

She was seen once by this guy. She denied any Hx of hospitiliz'ns, but did have contact with a different psych in the past ( no plan for psych follow up, apart from her family MD). I personally would not be comfortable adjusting bipolar meds.

Note: I practice in Canadia.

 

[Therapist4Chnge]

Standardized tests can be learned and beaten. A good clinical interview can involve building an alliance then asking probing questions that might really elucidate secondary gain or the real depth of their concerns. This can also be done during an interview once the pt. feels you are taking them seriously (and they feel less pressure to convince you of something to get what they want), potentially lessening an symptom inflation seen in those malingering or just exaggerating.

I think you are over-estimating the diagnostic accuracy of a clinical interview and under-estimating the value of standardized assessment. There are built in measures for objective assessments, there are also independant measures to help tease out malingering. In a clinical interview you are limited by what the patient chooses to tell you. It is far harder to beat an assessment with imbedded measures than it is a single clinician.

 

[cara susanna]

I think it's important to remember motivation for ADHD tests, though. I mean, I could probably do well on a CPT, but would I want to put effort into it? They are super boring. I give them a lot and I always feel so badly for the kids.

I remember reading somewhere on here about how basically ADHD has become what you give any kid who has trouble sitting through class. I know that real ADHD exists, but it's hard to tease out.

 

[AcronymAllergy]

I think it's important to remember motivation for ADHD tests, though. I mean, I could probably do well on a CPT, but would I want to put effort into it? They are super boring. I give them a lot and I always feel so badly for the kids.

I remember reading somewhere on here about how basically ADHD has become what you give any kid who has trouble sitting through class. I know that real ADHD exists, but it's hard to tease out.

In the case of children, I think this is why collateral report from multiple sources (e.g., at least parent and teacher), combined with classroom observation, are particularly important. Especially given the potential biases of the reporters themselves, even if their earnest intention is to help the child.

When it comes to adults, collateral report and/or historical data are often limited, and thus cognitive testing (IMO) becomes more important. That, and because many of the hyperactive symptoms typically associated with ADHD become "internalized" with age. The biggest problem currently is that we're still trying to do a good job of developing tests and/or patterns of performance that are specific to ADHD. Also, yes, effort/malingering assessment in ADHD evaluations with adults is a must (as is the case with any cognitive testing) in light of the myriad potential secondary gains.

Self-report and collateral-report in adults must also be tailored to the types of symptoms that most typically occur in adult populations with ADHD, which are not necessarily consistent with the DSM-IV criteria that were developed for use with children. I haven't looked at the DSM-V ADHD criteria yet, so I'm not sure how those "stack up" for use in adults.

 

[ghost dog]

Hey folks,

I'd like to run a recent scenario by you peeps with a patient who is taking Ritalin 15 mg BID for ADHD (diagnosed by Psychiatry , for which I have the note - Ritalin started by Psych, which he has been on x 5-6 years). This 34 year old man informs me that this medication allows for increased concentration and focus, and denies related side effects with this medication. He denies alcohol or other substance abuse. A recent urine drug screen was positive for Ritalin and negative for recreational drugs.

However, he has not been working for the past 6-8 months, and was working as a full time security guard x 1 - 2 years previously prior to this period. He states that he did not " feel like " renewing his security license in regards to working in this field.

On review of systems, he endorsed depressive symptoms x years, but did not meet the DSM IV criteria for a major depressive episode. He scored 15 points on the PHQ-9. He was previously prescribed Zoloft for these symptoms in the past by Psych and endorsed benefit; he strongly requested this medication at the most recent visit, and I therefore restarted this anti-depressant.

The patient was recently assessed by psychiatry and diagnosed with Asperger's syndrome, and will be reassessed in the near future.

My question is as follows: after the patient has received an adequate trial of Zoloft ( i.e. to ensure that his depressive symptoms are not causing the diminished function - which I doubt ) , should consideration be made to stop the Ritalin ?

After all, isn't the rationale for Ritalin increased function ?

I strongly suspect that his intial diagnosis of ADHD was incorrect.

QUOTE]

Continuation of original post: I saw this pt in f/u today. He informs me he is feeling better, and his PH-Q 9 score is now 3 ( versus the originalscore of 15 points ) . The Zoloft certainly seems to be helping his dysthmia.

However, he is yet to obtain gainful employment, although he tells me he has been looking over the past few weeks for a part - time job (which I take as a good sign).

 

[ShrunkenHeads]

I've personally had issues with having ritalin being prescribed to me when it shouldn't have been (the doc should have known, the facts were presented clearly before him). What ensued was a very, very dark period which I hope to never see again in my life.

 

[whopper]

Your comments are a reason why I never continue a diagnosis simply because someone else started it. I just had a guy come in to the hospital yesterday and I don't think he's mentally ill at all.

He was reported by the jail to be "responding to internal stimuli." He told me he is a poet and was reciting his poetry because he was bored while in solitary. The jail claims he's "delusional" because he believes he has connections with the FBI. He told me his college roommate joined the FBI and that's it. He has no "special" connection as he describes it and maintains a friendship with that person. The jail alleges he threatened other inmates. He told me that he has no tolerance for drug dealers and gang members and would tell them up to their face he thought they were scum if they harassed him. Yes, not exactly good judgement but that's not proof positive of mental illness. THat's also why he was in solitary--because the staff wanted to make sure he was safe from other inmates.

As long as the social worker checks this out and tells me there is not strong evidence of psychosis, I'm discharging him and writing on the report that he is merely eccentric.

Pretty much every single patient I see, I will not continue a diagnosis unless I see signs of it myself, the patient tells me they believe they have it and give me enough data for a DSM IV diagnosis, or I see several well written records strongly supporting the patient has it. Otherwise, I'll write in my progress notes that I'm not sure, but will use my time with the patient to try to do an appopriate diagnosis.

 

[ShrunkenHeads]

Your comments are a reason why I never continue a diagnosis simply because someone else started it. I just had a guy come in to the hospital yesterday and I don't think he's mentally ill at all.

He was reported by the jail to be "responding to internal stimuli." He told me he is a poet and was reciting his poetry because he was bored while in solitary. The jail claims he's "delusional" because he believes he has connections with the FBI. He told me his college roommate joined the FBI and that's it. He has no "special" connection as he describes it and maintains a friendship with that person. The jail alleges he threatened other inmates. He told me that he has no tolerance for drug dealers and gang members and would tell them up to their face he thought they were scum if they harassed him. Yes, not exactly good judgement but that's not proof positive of mental illness. THat's also why he was in solitary--because the staff wanted to make sure he was safe from other inmates.

As long as the social worker checks this out and tells me there is not strong evidence of psychosis, I'm discharging him and writing on the report that he is merely eccentric.

Pretty much every single patient I see, I will not continue a diagnosis unless I see signs of it myself, the patient tells me they believe they have it and give me enough data for a DSM IV diagnosis, or I see several well written records strongly supporting the patient has it. Otherwise, I'll write in my progress notes that I'm not sure, but will use my time with the patient to try to do an appopriate diagnosis.

Unfortunately, it seems like other doctors don't have the same sense of integrity and responsibility that doc's like yourself do. It's very scary to think what happened with me is probably happening with millions of people right now.

It's a huge aspect of psychiatry which worries me, I don't doubt at all that stimulants or other meds are helpful to lots of people, but when there are giant screaming red flags, which after several years of training and decades of being on the job tell you NOT to give this person certain meds, it is negligent, nay, borderline criminal, to be giving this person precisely what they should not be given.

I never filed a report against him, but sometimes I wonder if I should.

 

[nitemagi]

Your comments are a reason why I never continue a diagnosis simply because someone else started it. I just had a guy come in to the hospital yesterday and I don't think he's mentally ill at all.

He was reported by the jail to be "responding to internal stimuli." He told me he is a poet and was reciting his poetry because he was bored while in solitary. The jail claims he's "delusional" because he believes he has connections with the FBI. He told me his college roommate joined the FBI and that's it. He has no "special" connection as he describes it and maintains a friendship with that person. The jail alleges he threatened other inmates. He told me that he has no tolerance for drug dealers and gang members and would tell them up to their face he thought they were scum if they harassed him. Yes, not exactly good judgement but that's not proof positive of mental illness. THat's also why he was in solitary--because the staff wanted to make sure he was safe from other inmates.

As long as the social worker checks this out and tells me there is not strong evidence of psychosis, I'm discharging him and writing on the report that he is merely eccentric.

Pretty much every single patient I see, I will not continue a diagnosis unless I see signs of it myself, the patient tells me they believe they have it and give me enough data for a DSM IV diagnosis, or I see several well written records strongly supporting the patient has it. Otherwise, I'll write in my progress notes that I'm not sure, but will use my time with the patient to try to do an appopriate diagnosis.

Good case. Though over the years I've gotten a little bit more cautious about dismissing psychosis diagnoses in patients who appear superficially linear. Every so often I meet relatively intelligent higher functioning individuals who are able to hold it together during an interview, but slowly unravel the longer they're observed (over days in an inpatient setting). I had 1 pt. with something in the schizo-obsessive realm who looked together but essentially had contamination fears and a delusional parasitosis (intestinal not morgellons) who could seem together but had collateral reports to RIS when at home. She got discharged several times because she seemed so together, then eventually she couldn't suppress it anymore and stripped off all her clothes in public d/t her delusions. She had the insight that her delusions were out of the norm, and was actively defensive to minimize sx's. I have to remind myself that I get so caught up thinking about malingering that it's easy to miss the other side of the coin.