What would you say?

[randomdoc1]

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My private practice is just getting established and someone (who's insurance I unfortunately do not accept) asked if I see patients with ADHD because their PCP recommended they get treatment for ADHD. Although I know I won't be able to see this patient for logistical reasons, ADHD is a topic I feel strongly about. Obviously, it needs to be treated. But I also see a lot of people getting incorrectly diagnosed with ADHD. For example, many who are depressed, have PTSD, personality disorders, sleep disorders, even psychotic disorders, or have an anxiety spectrum disorder get incorrectly diagnosed. I find ADHD can be particularly hard even as a psychiatrist to diagnose without a good thorough history that includes collateral and preferably some neuropsych testing (e.g. CPT). I am tempted to advise this person to get a thorough evaluation before putting all his eggs in a basket by looking for someone who specializes in ADHD to evaluate for other possible disorders that may either be co-morbid or not ADHD at all. Although I would hope someone who claims they are well informed in treating ADHD would be able to see what is versus is not ADHD, I also see many attendings over diagnose ADHD and put patients on stimulants when on the contrary my impression (along with other psychiatrists) is that it is another disorder affecting their concentration. On the other hand, I feel awkward advising him to seek a thorough evaluation preferably with formal testing if I've never even seen this person but feel it would be in his best interest. Do you think it would be appropriate even though I haven't formally evaluated him? I just kind of feel like it would be benign psychoeducation, that what looks like ADHD could be ADHD or there could be other disorders involved and I'm just advising to be careful and ensure to get a thorough evaluation. It would be completely different if I just said to him to find a provider to trial an SSRI first...that would be obviously inappropriate.

 

[slappy]

No.

 

[WisNeuro]

Just going to throw it out there, I'm all about drumming up referrals, but neuropsych testing is not diagnostic for ADHD. It may help to identify cognitive strengths and weaknesses, or rule out other possiblities (e.g., LD). But, if it's a simple question of ADHD or no, we neuropsychologists are not needed. It's a clinical history diagnosis at this point in time. There are no reliable biomarkers or neuro profiles for this.

 

[randomdoc1]

Just going to throw it out there, I'm all about drumming up referrals, but neuropsych testing is not diagnostic for ADHD. It may help to identify cognitive strengths and weaknesses, or rule out other possiblities (e.g., LD). But, if it's a simple question of ADHD or no, we neuropsychologists are not needed. It's a clinical history diagnosis at this point in time. There are no reliable biomarkers or neuro profiles for this.

Appreciated. I also agree it is helpful if there are other disorders to consider in the differential the testing can help with. But when I practice, I certainly don't use the testing as the pivotal point in determining whether or not to I diagnose ADHD. The history is important, especially a thorough one, collateral, and ongoing gathering history as you get to know the patient. For example, patient complains of concentration problems and you notice a pattern of it being associated with disputes, chaotic relationships, anger versus someone who is chronically late, struggles with their medications, reveals a history of academic struggles dating back into grade school, etc. I also find other batteries like the MMPI and MCMI helpful as well. I've seen a number of patients come in fixated that they must have ADHD (and demanding stimulants) that the personal history they give is incomplete or skewed. Not necessarily intentionally (although sometimes it is because some fear their complaints won't be taken seriously) but they are so worried about their attention that other batteries also help provide a little more history (especially in cases where collateral is not available). I have seen people who minimize (consciously or not) their other psychiatric symptoms (both to psychiatrists and other specialists) and when the MMPI or MCMI comes out, they score sky high on symptoms of depressive and anxiety spectrum disorders. Any thoughts about the original question?

 

[WisNeuro]

Well, I am firmly in the camp that someone should be formally evaluated, in some capacity, before being given any medication. ADHD is even more problematic in this regard, if not simply because many people view having better attention/concentration on a stimulant as diagnostic of having the disorder, without the knowledge that the medications will have this effect in most people, disorder or not. In the end, the evaluation, in a broad sense (not just neuro) is essential to accurately identify the symptoms that are being addressed and where they are coming from. Far too often I see people on maintenance sleep aids for years, when a few simple tweaks to their sleep hygiene would likely produce profound results. "Are you telling me that a cigarette and a cup of coffee before bed are making my sleep worse?!?"

 

[randomdoc1]

Well, I am firmly in the camp that someone should be formally evaluated, in some capacity, before being given any medication. ADHD is even more problematic in this regard, if not simply because many people view having better attention/concentration on a stimulant as diagnostic of having the disorder, without the knowledge that the medications will have this effect in most people, disorder or not. In the end, the evaluation, in a broad sense (not just neuro) is essential to accurately identify the symptoms that are being addressed and where they are coming from. Far too often I see people on maintenance sleep aids for years, when a few simple tweaks to their sleep hygiene would likely produce profound results. "Are you telling me that a cigarette and a cup of coffee before bed are making my sleep worse?!?"

I actually completely agree. I've heard so many patients say they felt better on benzos or stimulants and therefore it is diagnostic that it must be a necessity and psychiatrists make the same error. Stimulants can make people perform a little better, disorder or not indeed! Just like how having a beer might relax me a little, doesn't mean I have an anxiety disorder and need beer. I admit, the topic of ADHD does strike a bit of a cord with me. With stimulants, you give it to the wrong person you risk addiction and potentially worsening the symptoms. Many of these cases can be prevented by a good quality evaluation and I feel the disorder is made far too hastily in a lot of cases. The other part that made me a little worried is that he said it was his PCP that recommended he be on something for ADHD. Obviously, for all I know, the person may have a well established diagnosis (like a more classic case dating with a clear childhood history) but when I hear about this being brought up by another speciality and understand how busy their practices are, I wonder how much of a history was really obtained. I also admit I'm a bit jaded by my consult rotation experiences (e.g. consult for first break schizophrenia in an 85 year old who was delirious...ect.).

 

[MacDonaldTriad]

Our neuropsych service will not accept referrals to evaluate adult ADHD. I have heard respected faculty suggest that a stimulant trial is diagnostic, but I always lose respect for people who believe this.

 

[WisNeuro]

Our neuropsych service will not accept referrals to evaluate adult ADHD. I have heard respected faculty suggest that a stimulant trial is diagnostic, but I always lose respect for people who believe this.

Yeah, we decline these referrals in the VA. There's not much we can do, we can't get teacher ratings, parent ratings, old school records in the vast majority of cases. At that point it's all reported clinical history and ruling out more likely factors. And, I'm with you, each time I hear the "let's try a stimulant to see if they have ADHD" line, I just shake my head and make a mental note to keep my patients away from that person if I can.

 

[smalltownpsych]

Some patients sincerely want help and are responsive to identifying correct diagnosis and indicated treatment. Others just want a quick fix and are angry when you don't do what they want and then even angrier if you do what they want and it causes bigger problems for them. I am just glad that I don't have to spend too much time with the latter type and knowing that psychiatrists have to day after day makes me a little less envious of the extra bucks you guys make. 😀

 

[wolfvgang22]

Yeah, unfortunately most patients referred to me are the ones that just want a quick fix and complain when educated that is not the correct course.

 

[Jules A]

Yeah, unfortunately most patients referred to me are the ones that just want a quick fix and complain when educated that is not the correct course.

Agree and in my experience the PCP referral for ADHD is often code for "this person has been bugging the crap out of me for schedule II meds".

 

[randomdoc1]

Agree and in my experience the PCP referral for ADHD is often code for "this person has been bugging the crap out of me for schedule II meds".

Ditto.

 

[Shikima]

Well, I am firmly in the camp that someone should be formally evaluated, in some capacity, before being given any medication. ADHD is even more problematic in this regard, if not simply because many people view having better attention/concentration on a stimulant as diagnostic of having the disorder, without the knowledge that the medications will have this effect in most people, disorder or not. In the end, the evaluation, in a broad sense (not just neuro) is essential to accurately identify the symptoms that are being addressed and where they are coming from. Far too often I see people on maintenance sleep aids for years, when a few simple tweaks to their sleep hygiene would likely produce profound results. "Are you telling me that a cigarette and a cup of coffee before bed are making my sleep worse?!?"

This.