When will ADHD medication shortage end?

[MacDonaldTriad]

This is a joke right?

Educate us, what makes you say this?

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[VA Hopeful Dr]

Yes, because children are products of their environment. Typically poor sleep, poor discipline, poor parenting and poor academic environments are quick to label ADHD rather than modify and change the area which they live in.

If you have someone who is profound unable to "Focus and Concentrate", more than likely you have an underdiagnosed, under-realized OSA and MR. Just because we have more impulse control and conduct disorders popping up, doesn't make it ADHD.

So you've got some evidence to back this up I presume.

 

[Shikima]

So you've got some evidence to back this up I presume.

So, let's look at it from this perspective. What evidence is there really? We have a documented issue with piss-poor research occurring in science. Very poor reliability, validity and repeatability. Assuming this perspective, we cannot trust any research. Further, we also have very poor Inter-rater Reliability scores when it comes to diagnosing. This is a top-down mandate that suggests we react the same because those on the lofty panels often are taking the approach of "this is how I do it" and it then becomes an unwritten rule.

But to your point, there is plenty of evidence something as simple as OSA is under-recognized and underdiagnosed, I think the last number I heard was 80% of sleep related disorders are undiagnosed.

 

[MacDonaldTriad]

I don't believe there are any reasonable numbers about the over and under diagnosis of ADHD, but ironically, both are happening at alarming rates. What is safe to say is that the treatment of college age adults has exploded.

 

[VA Hopeful Dr]

So, let's look at it from this perspective. What evidence is there really? We have a documented issue with piss-poor research occurring in science. Very poor reliability, validity and repeatability. Assuming this perspective, we cannot trust any research. Further, we also have very poor Inter-rater Reliability scores when it comes to diagnosing. This is a top-down mandate that suggests we react the same because those on the lofty panels often are taking the approach of "this is how I do it" and it then becomes an unwritten rule.

But to your point, there is plenty of evidence something as simple as OSA is under-recognized and underdiagnosed, I think the last number I heard was 80% of sleep related disorders are undiagnosed.

Is this in adults or children?

There definitely is a good bit in the "other things can cause attention issues" line of thinking, but to say that ADHD as a diagnosis shouldn't exist at all seems a bit much.

 

[Merovinge]

So, let's look at it from this perspective. What evidence is there really? We have a documented issue with piss-poor research occurring in science. Very poor reliability, validity and repeatability. Assuming this perspective, we cannot trust any research. Further, we also have very poor Inter-rater Reliability scores when it comes to diagnosing. This is a top-down mandate that suggests we react the same because those on the lofty panels often are taking the approach of "this is how I do it" and it then becomes an unwritten rule.

But to your point, there is plenty of evidence something as simple as OSA is under-recognized and underdiagnosed, I think the last number I heard was 80% of sleep related disorders are undiagnosed.

Ah yes the repeated longitudinal studies in multiple countries showing lower rates of SUD, lower rates of incarceration, lower automobile accident rates, and higher graduation rates from early psychostimulant intervention in 5 year olds (who by the way have high interrater reliability even across countries) is an ivory tower made up nonsense to push stimulants that cost a few cents/pill.

The reality is that the evidence basis behind ADHD and the treatment of it in children is leaps and bounds better than 95% of the conditions we treat in psychiatry. This really reads like an adult psychiatrist who has not spend their time going through the childhood ADHD literature base who is frustrated with adult ADHD (and here I would absolutely agree) and then is overgeneralizing this to kids.

 

[forchinet121]

Educate us, what makes you say this?

What makes me say that ADHD as an entity exists? I don’t know where to start..

 

[comp1]

ADHD is one of the great success stories of psychiatry. There is immense literature supporting its inter-rater reliability and specificity. This includes parents, teachers and clinicians. There is also immense literature supporting the short and long term benefits of psychostimulants, possibly more than any other class of medications. All I can guess about why people would think otherwise is a kind of feeling they might have that all degrees of inattention are essentially normal and acceptable. However, you could make this argument for literally any psychiatric condition. You could say that all degrees of hallucinating or delusions are normal or all degrees of sadness or euphoria. It's an argument, sure, but it's not a world I want to live in. And yes, 2% of kids have OSA. They should absolutely be treated for that, probably before trying stimulants. The same goes for adults before hypnotics. However, the VAST majority of children with ADHD do not have OSA.

 

[calvnandhobbs68]

We have a documented issue with piss-poor research occurring in science. Very poor reliability, validity and repeatability. Assuming this perspective, we cannot trust any research.

Okay what? You're just going down a rabbit hole at this point. If you're looking for a field with a ton of research with those characteristics, you probably picked the wrong one in general.

 

[Merovinge]

ADHD is one of the great success stories of psychiatry. There is immense literature supporting its inter-rater reliability and specificity. This includes parents, teachers and clinicians. There is also immense literature supporting the short and long term benefits of psychostimulants, possibly more than any other class of medications. All I can guess about why people would think otherwise is a kind of feeling they might have that all degrees of inattention are essentially normal and acceptable. However, you could make this argument for literally any psychiatric condition. You could say that all degrees of hallucinating or delusions are normal or all degrees of sadness or euphoria. It's an argument, sure, but it's not a world I want to live in. And yes, 2% of kids have OSA. They should absolutely be treated for that, probably before trying stimulants. The same goes for adults before hypnotics. However, the VAST majority of children with ADHD do not OSA.

It's very gratifying getting the T+A done and having life improve, every CAP worth anything is well aware of this medical condition, but I still have only seen ADHD sx entirely disappear following surgery on a handful of occasions across my entire career. Which is to say I complete agree.

 

[clausewitz2]

Okay what? You're just going down a rabbit hole at this point. If you're looking for a field with a ton of research with those characteristics, you probably picked the wrong one in general.

ADHD is actually one of the most heritable of any of the conditions we study, really only beat out by schizophrenia. Neither is actually a natural kind or anything but there is way more support for ADHD being a discrete entity than, say, MDD.

 

[erg923]

ADHD is one of the great success stories of psychiatry. There is immense literature supporting its inter-rater reliability and specificity. This includes parents, teachers and clinicians. There is also immense literature supporting the short and long term benefits of psychostimulants, possibly more than any other class of medications. All I can guess about why people would think otherwise is a kind of feeling they might have that all degrees of inattention are essentially normal and acceptable. However, you could make this argument for literally any psychiatric condition. You could say that all degrees of hallucinating or delusions are normal or all degrees of sadness or euphoria. It's an argument, sure, but it's not a world I want to live in. And yes, 2% of kids have OSA. They should absolutely be treated for that, probably before trying stimulants. The same goes for adults before hypnotics. However, the VAST majority of children with ADHD do not have OSA.

One of the "great success stories?' Settle down.

While I don't agree that that there is NOT an entity that exists that is close to what is known as ADHD, I think what he is urging us to consider is worthy of consideration.

We know medical and psychiatric research is far from perfect, has biases, likes to extend its "neuroscience" evidence, etc. I hope we aren't so naïve to actually think otherwise? I think his point is that ADHD is soooooo jumped to as a principle diagnosis (even when applying formal DSM criteria) and as a catch-all for behavior problems, hyperactivity, and/or inattention in Medicaid youth populations, as just one example, that it is more than ridiculous. Both statistically and clinically.

Excessive screen-time/videogames, lack of discipline, lack of focus on persistence/distress tolerance, and psychosocial dysfunction.... any kid could essentially have what appears to be ADHD. And yet time and time again, these are the very very fuzzy conditions in which the diagnosis is made and carried over by PCPs and Psychiatrists. I'm pretty sure this is what @Shikima is getting at?

 

[Shikima]

One of the "great success stories?' Settle down.

While I don't agree that that there is NOT an entity that exists that is close to what is known as ADHD, I think what he is urging us to consider is worthy of consideration.

We know medical and psychiatric research is far from perfect, has biases, likes to extend its "neuroscience" evidence, etc. I hope we aren't so naïve to actually think otherwise? I think his point is that ADHD is soooooo jumped to as a principle diagnosis (even when applying formal DSM criteria) and as a catch-all for behavior problems, hyperactivity, and/or inattention in Medicaid youth populations, as just one example, that it is more than ridiculous. Both statistically and clinically.

Excessive screen-time/videogames, lack of discipline, lack of focus on persistence/distress tolerance, and psychosocial dysfunction.... any kid could essentially have what appears to be ADHD. And yet time and time again, these are the very very fuzzy conditions in which the diagnosis is made and carried over by PCPs and Psychiatrists. I'm pretty sure this is what @Shikima is getting at?

As always, you are far more articulate than I could ever be.

 

[smalltownpsych]

Ah yes the repeated longitudinal studies in multiple countries showing lower rates of SUD, lower rates of incarceration, lower automobile accident rates, and higher graduation rates from early psychostimulant intervention in 5 year olds (who by the way have high interrater reliability even across countries) is an ivory tower made up nonsense to push stimulants that cost a few cents/pill.

The reality is that the evidence basis behind ADHD and the treatment of it in children is leaps and bounds better than 95% of the conditions we treat in psychiatry. This really reads like an adult psychiatrist who has not spend their time going through the childhood ADHD literature base who is frustrated with adult ADHD (and here I would absolutely agree) and then is overgeneralizing this to kids.

Better long term outcomes for kids who get stimulants at age five than for the kids who don’t get them, maybe we should put it in the water then. I am not familiar with this research base and I do believe there are kids with some neurological patterns that we call ADHD and that benefit from stimulants, but am very skeptical in the vast majority of cases. Just off the top of my head, this research is confounded by the effects of intervention vs no intervention. Sometimes just having an adult pay a little attention to what’s going on with a kid can make a difference.

 

[Stagg737]

One of the "great success stories?' Settle down.

While I don't agree that that there is NOT an entity that exists that is close to what is known as ADHD, I think what he is urging us to consider is worthy of consideration.

We know medical and psychiatric research is far from perfect, has biases, likes to extend its "neuroscience" evidence, etc. I hope we aren't so naïve to actually think otherwise? I think his point is that ADHD is soooooo jumped to as a principle diagnosis (even when applying formal DSM criteria) and as a catch-all for behavior problems, hyperactivity, and/or inattention in Medicaid youth populations, as just one example, that it is more than ridiculous. Both statistically and clinically.

Excessive screen-time/videogames, lack of discipline, lack of focus on persistence/distress tolerance, and psychosocial dysfunction.... any kid could essentially have what appears to be ADHD. And yet time and time again, these are the very very fuzzy conditions in which the diagnosis is made and carried over by PCPs and Psychiatrists. I'm pretty sure this is what @Shikima is getting at?

Everything you're describing sounds more like an argument for why we should be thorough with our diagnostic interviews and assessments and addressing social factors instead of an argument against actual ADHD. I don't think anyone will argue that a lot of patients are improperly diagnosed or that people just want to medicate away their problems with stimulants attention/executive dysfunction being the latest pop-psychology craze. That doesn't change the fact that stimulants for legit ADHD are by far the most effective treatment for any psychiatric condition we recognize today and that no amount of addressing social factors is going to help many of these patients who clearly benefit immensely from stimulants.

If one is going to argue about the validity of ADHD as a diagnosis, then frankly they should be questioning every diagnosis in the DSM or any other psychologic/psychiatric nosology manual.

Better long term outcomes for kids who get stimulants at age five than for the kids who don’t get them, maybe we should put it in the water then. I am not familiar with this research base and I do believe there are kids with some neurological patterns that we call ADHD and that benefit from stimulants, but am very skeptical in the vast majority of cases. Just off the top of my head, this research is confounded by the effects of intervention vs no intervention. Sometimes just having an adult pay a little attention to what’s going on with a kid can make a difference.

You seem to be ignoring that there is a severity spectrum in ADHD just like with other disorders, even if it's not part of the diagnostic specifiers. Some people will have more mild ADHD, which imo is the far more difficult diagnosis and warrants a lot more work-up and treatment of other primary conditions before considering medicating it with stimulants. Not everyone with ADHD requires a stimulant to function (points at self), just like not everyone with depressive or anxiety disorders need meds for them and you could say the bolded about many psychiatric conditions for patients at any age. Can we just stop prescribing antidepressants to those with depression and anxiety and "just pay a little attention to what's going on?"

 

[Merovinge]

Better long term outcomes for kids who get stimulants at age five than for the kids who don’t get them, maybe we should put it in the water then. I am not familiar with this research base and I do believe there are kids with some neurological patterns that we call ADHD and that benefit from stimulants, but am very skeptical in the vast majority of cases. Just off the top of my head, this research is confounded by the effects of intervention vs no intervention. Sometimes just having an adult pay a little attention to what’s going on with a kid can make a difference.

Wait so you are not familiar with the research base of some of the most fundamental and longitudinal studies of childhood psychopathology but you would like to opine about your skepticism? I do not understand how those sentences make any sense, either you practice and believe in empirical science or you just say whatever you want based on your n=1 life experience.

The seminal study randomized patients presenting at age 5 that meet criteria for ADHD to psychostimulants or watchful waiting and then added them on at age 8 in the second group and found all the benefits of treatment were magnified in patients who received treatment earlier. There are countless other studies using population based data from Egypt, Australia, and Europe to support the efficacy of the interventions. I assure you 15 min med checks every 3 months is not the basis behind why a kid doesn't get into a car crash 10 years later...

 

[calvnandhobbs68]

If one is going to argue about the validity of ADHD as a diagnosis, then frankly they should be questioning every diagnosis in the DSM or any other psychologic/psychiatric nosology manual.

100%. I'm all about calling out ADHD overdiagnosis but that doesn't mean the construct itself is any less valid than another other diagnosis. In fact, ADHD has a HIGHER inter-rater reliability than most of the DSM diagnoses. I mean, lets talk about the terrible replicability and consistency between diagnosis for most of the personality disorders...

https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2012.12091189

 

[clausewitz2]

100%. I'm all about calling out ADHD overdiagnosis but that doesn't mean the construct itself is any less valid than another other diagnosis. In fact, ADHD has a HIGHER inter-rater reliability than most of the DSM diagnoses. I mean, lets talk about the terrible replicability and consistency between diagnosis for most of the personality disorders...

https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2012.12091189

Or terrible consistency and replicability for non-personality disorders, the DSM-V field trials featured kappa's around 0.4 for MDD.

 

[whopper]

I find myself having to explain this to my patients and it can be over 10 minutes of discussion on this issue alone. Adding to the frustration is several of these meds such as generic Concerta allegedly are no longer produced. Wow. Its as if the Azstarys owner went to the generic manufacturer of Concerta and must've showed him pics of the guy doing illegal stuff with kids.

Vyvanse is going generic-so what that means in reality for clinicians and patients is the generic won't be available for months cause factories have to start making it, the pharmaceutical companies need FDA permission and this takes time, then they got to make deals with the pharmacies, but the second it goes generic insurance companies will refuse to pay for it. So patients will say "but if it's generic why does it take so long to hit the shelves," so I got to spend several minutes explaining this, and then they ask "if it doesn't hit the shelves for months why is my insurance company still not paying for the tradename," and I give them the proverbal-cause they don't give an eff about you.

Some of the only recent good ADHD news is I've seen several patients do very very very well on Qelbree and much better than Atomoxetine or Wellbutrin. Also it's cardiac side effect risks are low.

100%. I'm all about calling out ADHD overdiagnosis but that doesn't mean the construct itself is any less valid than another other diagnosis. In fact, ADHD has a HIGHER inter-rater reliability than most of the DSM diagnoses. I mean, lets talk about the terrible replicability and consistency between diagnosis for most of the personality disorders...

Completely agree here too. A problem with ADHD is there's so much room for misdiagnosis and bad agendas but the disorder does exist and some people need treatment for it.

 

[docksan]

I love Qelbree. Such a good medicine.

But echo everything else you said.

 

[FlowRate]

I don't believe there are any reasonable numbers about the over and under diagnosis of ADHD, but ironically, both are happening at alarming rates. What is safe to say is that the treatment of college age adults has exploded.

Not just college age... but also their 40-50 year-old parents, subsequently, as a result of "It's genetic and Sally feels better on stims so I realized I had ADHD too."

There is also immense literature supporting the short and long term benefits of psychostimulants, possibly more than any other class of medications.

Longer term data is probably better for the child->adolescent cohort. Longer term data for adults is lacking, at least as far as the last time I tried to do a deep dive on ADHD literature (which was a year or two ago so completely possible I missed or forgot something.)

All I can guess about why people would think otherwise is a kind of feeling they might have that all degrees of inattention are essentially normal and acceptable.

That doesn't change the fact that stimulants for legit ADHD are by far the most effective treatment for any psychiatric condition we recognize today and that no amount of addressing social factors is going to help many of these patients who clearly benefit immensely from stimulants.

I still think this is the most challenging thing right now. Maybe 5-10% of presenting "inattention" intakes that I get have real obvious/high confidence ADHD diagnoses. 10-30% have other compelling causes of inattention. The remainder are in a spectrum of subjective report of inattention that's difficult to parse once they've learned to read you the DSM criteria thanks to social media and "research."

ADHD is actually one of the most heritable of any of the conditions we study, really only beat out by schizophrenia. Neither is actually a natural kind or anything but there is way more support for ADHD being a discrete entity than, say, MDD.

Wanted to refresh myself on ADHD genetics and found this great nature paper, which actually talks about the above quite a bit, this paragraph especially:

Accumulating evidence from family, twin, and molecular genetic studies suggests that the disorder we know as ADHD is the extreme of a dimensional trait in the population. The dimensional nature of ADHD has wide-ranging implications. If we view ADHD as analogous to cholesterol levels, then diagnostic approaches should focus on defining the full continuum of “ADHD-traits” along with clinically meaningful thresholds for defining who does and does not need treatment and who has clinically subthreshold traits that call for careful monitoring. The dimensional nature of ADHD should also shift the debate about the increases in ADHD’s prevalence in recent years. Instead of assuming that misdiagnoses are the main explanation for the increased prevalence, perhaps researchers should explore to what extent the threshold for diagnosis has decreased over time and whether changes in the threshold are clinically sensible or not. A shift from categorical to dimensional constructs harmonizes with the Research Domain Criteria (RDoC) initiative of the National Institute of Mental Health [152]. RDoC seeks to define and validate dimensional constructs mediating psychopathology along with the neurobiological underpinnings of these constructs.

 

[Fan_of_Meehl]

Not just college age... but also their 40-50 year-old parents, subsequently, as a result of "It's genetic and Sally feels better on stims so I realized I had ADHD too."

Longer term data is probably better for the child->adolescent cohort. Longer term data for adults is lacking, at least as far as the last time I tried to do a deep dive on ADHD literature (which was a year or two ago so completely possible I missed or forgot something.)


I still think this is the most challenging thing right now. Maybe 5-10% of presenting "inattention" intakes that I get have real obvious/high confidence ADHD diagnoses. 10-30% have other compelling causes of inattention. The remainder are in a spectrum of subjective report of inattention that's difficult to parse once they've learned to read you the DSM criteria thanks to social media and "research."

Wanted to refresh myself on ADHD genetics and found this great nature paper, which actually talks about the above quite a bit, this paragraph especially:

The continuum / dimensional model of ADHD is why I feel so strongly that it is the prescribers (or the medication treatment for the problem) who should primarily take responsibility for 'diagnosing' the problem and treating the problem. Since attentional difficulties lie on a continuum and since the decision to treat (at all) a certain level of that problem with medication lies with the prescriber then I think that the prescriber should be the one assessing/diagnosing the condition as well as continuously monitoring the efficacy (balanced against adverse effects) of the medication intervention. However, the current model implemented (at least in the VA system) is one of: (a) someone raises the possibility of 'ADHD' in the patient (most often the patient themselves) ---> (b) enter consult for 'psychological testing/ assessment' to rule in/out 'ADHD' ---> (c) rubber stamping of diagnosis by the resident pseudoneuropsychologist ---> (d) stimulant meds for adult psychiatric patient with comorbid severe PTSD, MDD, GAD, mTBI, OSA, SUD, etc. This results in: (1) diffusion of responsibility between professionals that results in very poor 'quality control' in terms of delivery of and accountability for clinical services, (2) a convenient (inconvenient?) 'label' for 'the problem' or etiological scapegoat for the issue of 'inattention' being 'ADHD' vs. a broad spectrum of other plausible (and treatable) causes or drivers of the 'inattention.' It's a mess.

 

[FlowRate]

The continuum / dimensional model of ADHD is why I feel so strongly that it is the prescribers (or the medication treatment for the problem) who should primarily take responsibility for 'diagnosing' the problem and treating the problem. Since attentional difficulties lie on a continuum and since the decision to treat (at all) a certain level of that problem with medication lies with the prescriber then I think that the prescriber should be the one assessing/diagnosing the condition as well as continuously monitoring the efficacy (balanced against adverse effects) of the medication intervention. However, the current model implemented (at least in the VA system) is one of: (a) someone raises the possibility of 'ADHD' in the patient (most often the patient themselves) ---> (b) enter consult for 'psychological testing/ assessment' to rule in/out 'ADHD' ---> (c) rubber stamping of diagnosis by the resident pseudoneuropsychologist ---> (d) stimulant meds for adult psychiatric patient with comorbid severe PTSD, MDD, GAD, mTBI, OSA, SUD, etc. This results in: (1) diffusion of responsibility between professionals that results in very poor 'quality control' in terms of delivery of and accountability for clinical services, (2) a convenient (inconvenient?) 'label' for 'the problem' or etiological scapegoat for the issue of 'inattention' being 'ADHD' vs. a broad spectrum of other plausible (and treatable) causes or drivers of the 'inattention.' It's a mess.

This is my main worry about our system's upcoming ADHD workflow. We're training the therapists and integrated care psychologists to do ADHD assessments (but decently well thought out assessments, at least) hoping that will lead to doing more behavioral strategies for ADHD (from the therapists) and PCP treatment of ADHD but in the latter case the PCP is even less familiar with treating adults with ADHD than we are so could end up similar to what you describe from the VA. The other challenge will be if they end shipping the pts off to us anyway because then we even have someone internal to the system who's already rubber stamped the diagnosis.

 

[smalltownpsych]

Wait so you are not familiar with the research base of some of the most fundamental and longitudinal studies of childhood psychopathology but you would like to opine about your skepticism? I do not understand how those sentences make any sense, either you practice and believe in empirical science or you just say whatever you want based on your n=1 life experience.

The seminal study randomized patients presenting at age 5 that meet criteria for ADHD to psychostimulants or watchful waiting and then added them on at age 8 in the second group and found all the benefits of treatment were magnified in patients who received treatment earlier. There are countless other studies using population based data from Egypt, Australia, and Europe to support the efficacy of the interventions. I assure you 15 min med checks every 3 months is not the basis behind why a kid doesn't get into a car crash 10 years later...

Skepticism is always my approach. I will try an d find some time to delve into this research further and I am opining based on other research that I have been more familiar with in the past as I have had less need as I haven’t been working with the younger population. I do think there is a population for which stimulant medication is of benefit, but most of my work the last ten years or so has been with adolescents and young adults that were misdiagnosed and had more severe problems so as you rightly call out my sample is skewed. I guess I wonder how we can see a high rate of over diagnosis in the community and yet have such high interrater reliability in studies. Or am I mistaken and we are not overdiagnosing? Some of why I ask these questions is because I don’t always have the time to be the expert in every area of our field and feedback from others can help me continue to learn.

 

[Stagg737]

I still think this is the most challenging thing right now. Maybe 5-10% of presenting "inattention" intakes that I get have real obvious/high confidence ADHD diagnoses. 10-30% have other compelling causes of inattention. The remainder are in a spectrum of subjective report of inattention that's difficult to parse once they've learned to read you the DSM criteria thanks to social media and "research."

That's probably because ADHD and "inattention" are not the same thing at all despite one of the sub-types being labeled as "inattentive type". Even within that sub-type, it's so much more than that. ADHD isn't even in the top 2-3 thoughts of my differential when a chief complaint is just "inattention", I'm ruling out depression, anxiety, sleep issues, and trauma-related disorders before I even start asking about ADHD. If it's just inattention, they won't meet criteria anyway. As I'll say below, I try to focus less on the patient's perception of the problem and more on how it's affecting their functioning. If they can't give me actual examples of how it negatively impacts them, they can list off all the criteria they want, they're still not getting stims from me.

Skepticism is always my approach. I will try an d find some time to delve into this research further and I am opining based on other research that I have been more familiar with in the past as I have had less need as I haven’t been working with the younger population. I do think there is a population for which stimulant medication is of benefit, but most of my work the last ten years or so has been with adolescents and young adults that were misdiagnosed and had more severe problems so as you rightly call out my sample is skewed. I guess I wonder how we can see a high rate of over diagnosis in the community and yet have such high interrater reliability in studies. Or am I mistaken and we are not overdiagnosing? Some of why I ask these questions is because I don’t always have the time to be the expert in every area of our field and feedback from others can help me continue to learn.

The bolded is likely because interrater reliability in studies are almost certainly based on clinicians who are doing full evals (or at least going through full criteria) for ADHD and those studies don't include all the pill mills and the 5 minute diagnoses made by docs/NPs/therapists running churn and burn clinics.

There's also a difference between overdiagnosis and overprescribing. Like I mentioned above, not everyone with a disorder needs meds, and ADHD and stimulants aren't an exception. Plenty of people with mild to moderate symptoms do fine wtihout them. It just so happens that patients like stimulants because they can immediately FEEL the effects unlike most other meds and they have a perceived benefit. Same reason patients love benzos. Imagine how much more often people would be coming in demanding Prozac or Zoloft if they could feel it working hours after starting it.

Clausewitz brings it up frequently, but it's why I like to focus on tangible effects and functioning rather than how patients feel. How many hours are patients spending on work or chores before/after meds? Are they still losing/forgetting things? Have their co-workers and bosses, family, or friends noticed a difference? I don't prescribe meds just so patients can feel better (though it's nice when they do), I prescribe so they actually function better.

 

[calvnandhobbs68]

Skepticism is always my approach. I will try an d find some time to delve into this research further and I am opining based on other research that I have been more familiar with in the past as I have had less need as I haven’t been working with the younger population. I do think there is a population for which stimulant medication is of benefit, but most of my work the last ten years or so has been with adolescents and young adults that were misdiagnosed and had more severe problems so as you rightly call out my sample is skewed. I guess I wonder how we can see a high rate of over diagnosis in the community and yet have such high interrater reliability in studies. Or am I mistaken and we are not overdiagnosing? Some of why I ask these questions is because I don’t always have the time to be the expert in every area of our field and feedback from others can help me continue to learn.

So it's also because DSM field trials (as far as I can tell) aren't including the whole "adult ADHD evaluation" component of it. Trying to evaluate people for undiagnosed ADHD as adults wasn't even really a thing until relatively recently and (this has been discussed before) there's pretty poor standardization of assessments for first time diagnosis as an adult.

However, there are a number of standardized assessments available we'll use for kids/teenagers both self report, parent report and teacher report which probably contribute to a higher level of reliability between assessors...they're getting data from multiple collateral sources which likely all tends to agree with each other if we're seeing actual ADHD. Those assessments also screen for other possible explanatory problems (anxiety disorders, depressive disorders, disruptive behaviors).

That's probably why the ASD diagnosis reliability is so high as well, typically there is a lot of collateral information gathered (SRS, CARS2, ADI-R), along with usually an actual standardized assessment for an ASD diagnosis.

 

[Merovinge]

Skepticism is always my approach. I will try an d find some time to delve into this research further and I am opining based on other research that I have been more familiar with in the past as I have had less need as I haven’t been working with the younger population. I do think there is a population for which stimulant medication is of benefit, but most of my work the last ten years or so has been with adolescents and young adults that were misdiagnosed and had more severe problems so as you rightly call out my sample is skewed. I guess I wonder how we can see a high rate of over diagnosis in the community and yet have such high interrater reliability in studies. Or am I mistaken and we are not overdiagnosing? Some of why I ask these questions is because I don’t always have the time to be the expert in every area of our field and feedback from others can help me continue to learn.

I'm not sure where your referral base is from but this is what I expect to see. ADHD "diagnosis" by the NP who sees the patient for 15 minutes, sees elevated scores on a Vanderbilt and parent that wants their kids on stimulants, wham bam thank you mam. The majority of pediatric stimulants are NOT prescribed by child/adolescent psychiatrists and the majority of ADHD diagnosis are NOT by CAP or pediatric neuropsychologists.

There are so many instances of misdiagnosis in medicine generally and psychiatry in particular, but Joe Shmoes 15 minute tip-top shop existing does not decrease the validity of having multiple different blinded child/adolescent psychiatrists assessing the same patient and then seeing how reliable the diagnosis is.

 

[FlowRate]

That's probably because ADHD and "inattention" are not the same thing at all despite one of the sub-types being labeled as "inattentive type". Even within that sub-type, it's so much more than that. ADHD isn't even in the top 2-3 thoughts of my differential when a chief complaint is just "inattention", I'm ruling out depression, anxiety, sleep issues, and trauma-related disorders before I even start asking about ADHD. If it's just inattention, they won't meet criteria anyway. As I'll say below, I try to focus less on the patient's perception of the problem and more on how it's affecting their functioning. If they can't give me actual examples of how it negatively impacts them, they can list off all the criteria they want, they're still not getting stims from me.


The bolded is likely because interrater reliability in studies are almost certainly based on clinicians who are doing full evals (or at least going through full criteria) for ADHD and those studies don't include all the pill mills and the 5 minute diagnoses made by docs/NPs/therapists running churn and burn clinics.

There's also a difference between overdiagnosis and overprescribing. Like I mentioned above, not everyone with a disorder needs meds, and ADHD and stimulants aren't an exception. Plenty of people with mild to moderate symptoms do fine wtihout them. It just so happens that patients like stimulants because they can immediately FEEL the effects unlike most other meds and they have a perceived benefit. Same reason patients love benzos. Imagine how much more often people would be coming in demanding Prozac or Zoloft if they could feel it working hours after starting it.

Clausewitz brings it up frequently, but it's why I like to focus on tangible effects and functioning rather than how patients feel. How many hours are patients spending on work or chores before/after meds? Are they still losing/forgetting things? Have their co-workers and bosses, family, or friends noticed a difference? I don't prescribe meds just so patients can feel better (though it's nice when they do), I prescribe so they actually function better.

I agree, about half of the time I spend in these evaluations is ruling out anything else potentially causative. I've caught a bunch of severe OSA, several narcolepsy/IH, and the full spectrum of patients with/without insight into anxiety/depression/insomnia as the cause of their inattention. That's not even touching all of the heavy THC use.

To be clear, these patients usually aren't just saying the dsm criteria. I always ask for examples. There's a gut feeling and descriptive difference between compelling severe ADHD in that their examples are specific, personal, unique, and have more emotional weight. The most compelling ADHD patients give examples like: literally always having to have their coworker remind them that it's time to head out for a standing daily work meeting or they just won't make it, or screwing up the relatively straightforward materials order every. single. time. at a construction job, or any patient who is truly actually impulsive/hyperactive in the interview, or failing the hazmat (basic) test 4x for the fire department and requiring weeks of intensive dedicated remediation to pass (almost everyone passes the first time), or multiple car accidents from just not attending to the road.

Most of the marginal feeling patients give the exact same semi-vague examples (the most common ones you'll see on social media/websites devoted to patient facing info on ADHD): Everyone says they start loading the dishwasher and then start cleaning the counter and then start doing the laundry and don't get any of that done as quickly as they'd like because they get sidetracked. They procrastinate (which is not specific to ADHD) things a lot. They feel it takes them so much longer than other people to get things done (but are still successful in their JD/MD/PhD program / software dev job / promoted through three managerial levels in 5 years). These examples may be true and they may be common because they're actually common baseline manifestations of ADHD but they also sound like a script coming from patients along a wide spectrum of proxy indicators of function (educational attainment, workplace promotions for high performance, successful relationships.) And good luck nailing these people down on "often" or "impairing" beyond "I could be so much more effective/efficient/have better work life balance." So where do you draw the line? If you take too skeptical an approach, you're probably missing people who could genuinely benefit from medical help.

 

[Stagg737]

I agree, about half of the time I spend in these evaluations is ruling out anything else potentially causative. I've caught a bunch of severe OSA, several narcolepsy/IH, and the full spectrum of patients with/without insight into anxiety/depression/insomnia as the cause of their inattention. That's not even touching all of the heavy THC use.

To be clear, these patients usually aren't just saying the dsm criteria. I always ask for examples. There's a gut feeling and descriptive difference between compelling severe ADHD in that their examples are specific, personal, unique, and have more emotional weight. The most compelling ADHD patients give examples like: literally always having to have their coworker remind them that it's time to head out for a standing daily work meeting or they just won't make it, or screwing up the relatively straightforward materials order every. single. time. at a construction job, or any patient who is truly actually impulsive/hyperactive in the interview, or failing the hazmat (basic) test 4x for the fire department and requiring weeks of intensive dedicated remediation to pass (almost everyone passes the first time), or multiple car accidents from just not attending to the road.

Most of the marginal feeling patients give the exact same semi-vague examples (the most common ones you'll see on social media/websites devoted to patient facing info on ADHD): Everyone says they start loading the dishwasher and then start cleaning the counter and then start doing the laundry and don't get any of that done as quickly as they'd like because they get sidetracked. They procrastinate (which is not specific to ADHD) things a lot. They feel it takes them so much longer than other people to get things done (but are still successful in their JD/MD/PhD program / software dev job / promoted through three managerial levels in 5 years). These examples may be true and they may be common because they're actually common baseline manifestations of ADHD but they also sound like a script coming from patients along a wide spectrum of proxy indicators of function (educational attainment, workplace promotions for high performance, successful relationships.) And good luck nailing these people down on "often" or "impairing" beyond "I could be so much more effective/efficient/have better work life balance." So where do you draw the line? If you take too skeptical an approach, you're probably missing people who could genuinely benefit from medical help.

I'm stricter with stimulants, but fortunately there are non-stimulant options for suspected ADHD. I have a relatively low threshold to start Wellbutrin if I suspect ADHD but am unsure and will give patients instructions on things to monitor and document. This is where I like the dimensional model better in terms of nosology and I'll give Criteria A for PDs in the alternative model as an example below:

In this model, a person is considered to have a personality disorder if they score a 2 or higher in severity in at least 2/4 of the above areas of functioning (identity, self-direction, empathy, intimacy). I realize we don't have a uniform, well-validated scale of functioning with scoring like this for ADHD, but there are plenty of tools that can help and we can use a general model like this to guage the severity of impairment that each symptom causes. The nice thing about ADHD is that when symptoms are severe, they're pretty easy to pick up in 5 or 10 minutes on initial intake unless the patient is a great actor. It can be tough if it's not obvious, that's where the specifics mentioned comes in though. If they're giving vague responses about functional impairment, we can trial Wellbutrin or Strattera and instruct them to monitor specific tasks or metrics (for example: how many times do you have to read 2-3 sentences before it sticks?) before considering stimulants.

One thing I like to ask about that helps me is hyperfocus. Even with inattentive type, patients can have periods of diving down rabbit holes for hours (I've seen it last days and look like mania a few times) and being unable to remove themselves from a topic that prevents them from doing relevant tasks. If that's not present, especially if patients adamantly deny that, it's a red flag for me that either something else is going on or they're seeking stims. And maybe surprisingly, patients with legit ADHD almost uniformly have told me that the hyperfocus and inability to pull themselves out of the rabbit hole improves after they start the right treatment; usually that med is a stimulant, but some patients (and me, lol) have also told me non-stims improved this as well.

 

[FlowRate]

I'm stricter with stimulants, but fortunately there are non-stimulant options for suspected ADHD. I have a relatively low threshold to start Wellbutrin if I suspect ADHD but am unsure and will give patients instructions on things to monitor and document. This is where I like the dimensional model better in terms of nosology and I'll give Criteria A for PDs in the alternative model as an example below:


View attachment 369662


In this model, a person is considered to have a personality disorder if they score a 2 or higher in severity in at least 2/4 of the above areas of functioning (identity, self-direction, empathy, intimacy). I realize we don't have a uniform, well-validated scale of functioning with scoring like this for ADHD, but there are plenty of tools that can help and we can use a general model like this to guage the severity of impairment that each symptom causes. The nice thing about ADHD is that when symptoms are severe, they're pretty easy to pick up in 5 or 10 minutes on initial intake unless the patient is a great actor. It can be tough if it's not obvious, that's where the specifics mentioned comes in though. If they're giving vague responses about functional impairment, we can trial Wellbutrin or Strattera and instruct them to monitor specific tasks or metrics (for example: how many times do you have to read 2-3 sentences before it sticks?) before considering stimulants.

One thing I like to ask about that helps me is hyperfocus. Even with inattentive type, patients can have periods of diving down rabbit holes for hours (I've seen it last days and look like mania a few times) and being unable to remove themselves from a topic that prevents them from doing relevant tasks. If that's not present, especially if patients adamantly deny that, it's a red flag for me that either something else is going on or they're seeking stims. And maybe surprisingly, patients with legit ADHD almost uniformly have told me that the hyperfocus and inability to pull themselves out of the rabbit hole improves after they start the right treatment; usually that med is a stimulant, but some patients (and me, lol) have also told me non-stims improved this as well.

I agree--I similarly start most patients on nonstims except for more obvious/severe ADHD. There's roughly equivalent data for the non-stims as for the stims in adults (none of the data is great really), it's a safer place to start, and lots of people see benefit from those options. It is also a mild test for whether the pt will start heavily pushing for stims anyway.

 

[Stagg737]

I agree--I similarly start most patients on nonstims except for more obvious/severe ADHD. There's roughly equivalent data for the non-stims as for the stims in adults (none of the data is great really), it's a safer place to start, and lots of people see benefit from those options. It is also a mild test for whether the pt will start heavily pushing for stims anyway.

Yep, secondary metric for me is how badly does the patient want their symptoms to improve vs how badly do they just want a stimulant, lol.

 

[Fluidity of Movement]

What are thoughts on Adzenys or Cotempla due to shortages? They have a ton of vouchers to include a $50 max even for uncovered and non participating pharmacies. It seems almost too good to be true since the other vouchers are 0, 15, and 30 ish.

 

[calvnandhobbs68]

What are thoughts on Adzenys or Cotempla due to shortages? They have a ton of vouchers to include a $50 max even for uninsured and non participating pharmacies. It seems almost too good to be true since the other vouchers are 0, 15, and 30 ish.

I do it all the time right now because I haven't had a patient yet who can't get Adzenys or Cotempla. The branded manufacturers are probably making bank with the shortage because their production seems to have been fine....even Vyvanse I haven't run into any issues. Their coupons are actually that good too, if they go to particular pharmacies they only pay $35 even if their insurance rejects it and $0 if insurance accepts at all....I had one person who would have had a $100 copay at CVS and went to $0 at an AytuConnect pharmacy.

 

[Fluidity of Movement]

I do it all the time right now because I haven't had a patient yet who can't get Adzenys or Cotempla. The branded manufacturers are probably making bank with the shortage because their production seems to have been fine....even Vyvanse I haven't run into any issues. Their coupons are actually that good too, if they go to particular pharmacies they only pay $35 even if their insurance rejects it and $0 if insurance accepts at all....I had one person who would have had a $100 copay at CVS and went to $0 at an AytuConnect pharmacy.

Awesome!

They also have a thing where it's 50 max for ANY pharmacy even if not covered.

https://aytubio.com/downloads/AytuCoupon/Aytu-Retail-Coupon-Digital-Download.pdf

I'm guessing there isn't much concern for Cotempla for adults as off-label?

 

[calvnandhobbs68]

Awesome!

They also have a thing where it's 50 max for ANY pharmacy even uninsured.

https://aytubio.com/downloads/AytuCoupon/Aytu-Retail-Coupon-Digital-Download.pdf

I'm guessing there isn't much concern for Cotempla for adults as off-label?

Means insurance probably won't cover it but probably vary based on insurance plan. I see mostly kids so only have one adult on Cotempla, I have had to do a prior auth for her every year and the only way I get them to cover it was because she started it when <17yo. So may get stuck paying the $35/$50 copay.

 

[heartsink]

So where do you draw the line? If you take too skeptical an approach, you're probably missing people who could genuinely benefit from medical help.

This is the gray area where I struggle to understand the nuance of treatment.

At what point does treating pathology become just improving performance? What exactly is being defined as the pathology to treat? In the example of the fireman who repeatedly struggles to complete his haz mat test, does he need to get fired from his job for the threshold to be high enough to justify stimulants? At that point he might have bigger problems. What if he never gets fired and eventually hobbles his way through a Pass -- technically he never needed a medication to "advance his career", but stimulants may have helped -- would we have called that treatment, or performance enhancement?

The reason I ask is because it seems so subjective and arbitrary to call one patient's experience of inattention pathologic and "deserving" of medication, whereas another patients challenges are interpreted to be less persuasive by the clinician because the patient hasn't suffered enough dire consequences of their ADHD/Inattention symptoms (yet). I would think the goal is to change the trajectory of these patients before they hit those brick walls, rather than using their crash as reassurance to the physician that he/she is not overtreating.

 

[calvnandhobbs68]

This is the gray area where I struggle to understand the nuance of treatment.

At what point does treating pathology become just improving performance? What exactly is being defined as the pathology to treat? In the example of the fireman who repeatedly struggles to complete his haz mat test, does he need to get fired from his job for the threshold to be high enough to justify stimulants? At that point he might have bigger problems. What if he never gets fired and eventually hobbles his way through a Pass -- technically he never needed a medication to "advance his career", but stimulants may have helped -- would we have called that treatment, or performance enhancement?

The reason I ask is because it seems so subjective and arbitrary to call one patient's experience of inattention pathologic and "deserving" of medication, whereas another patients challenges are interpreted to be less persuasive by the clinician because the patient hasn't suffered enough dire consequences of their ADHD/Inattention symptoms (yet). I would think the goal is to change the trajectory of these patients before they hit those brick walls, rather than using their crash as reassurance to the physician that he/she is not overtreating.

This is literally almost any diagnosis or condition we treat. Crack open DSM and look at the last few criterion for most of the disorders in there, which is usually "the disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning". This criteria is there specifically to try to head off the idea that the field of psychiatry is "pathologizing" lots of variations of normal behavior.

This is obviously still a big debate back and forth though even among professionals around where you draw the line at variations of normal functioning and pathology on a continuum. It's like other continuous variables, like height/weight or high frequency discrete variables like blood pressure/pulse or even a lot of labs. Where's the cutoff for when I should do something about this? You have to try to put it somewhere.

 

[smalltownpsych]

I'm not sure where your referral base is from but this is what I expect to see. ADHD "diagnosis" by the NP who sees the patient for 15 minutes, sees elevated scores on a Vanderbilt and parent that wants their kids on stimulants, wham bam thank you mam. The majority of pediatric stimulants are NOT prescribed by child/adolescent psychiatrists and the majority of ADHD diagnosis are NOT by CAP or pediatric neuropsychologists.

There are so many instances of misdiagnosis in medicine generally and psychiatry in particular, but Joe Shmoes 15 minute tip-top shop existing does not decrease the validity of having multiple different blinded child/adolescent psychiatrists assessing the same patient and then seeing how reliable the diagnosis is.

I think you answered the question as to where the misdiagnoses come from and it is consistent with what I see as afar as less qualified providers more likely to misdiagnose.
To answer yours, my referral base tends to be the misdiagnosed as I work with the more severe cases. In my last job, long term residential for young adults, we wouldn’t accept anyone with just a diagnosis of ADHD. They always had psychosis or severe mood disorder or multiple comorbidities. When admissions would put a prospective resident up on the board, their prior diagnoses would be listed and every time I went there to see who was coming in and review their files, I would see ADHD on almost every single one. They would often list relevant symptoms as opposed to diagnosis such as self-harm, SI, or psychosis which actually is probably more useful at a glance than ADHD. We also didn’t admit substance abuse disorders without another severe mental health disorder. So substance use with ADHD wouldn’t count, but substance use with Bipolar I Disorder would. My current job is outpatient but a significant number of patients are coming from prior treatments so still skewing toward the more severe.

 

[Stagg737]

This is the gray area where I struggle to understand the nuance of treatment.

At what point does treating pathology become just improving performance? What exactly is being defined as the pathology to treat? In the example of the fireman who repeatedly struggles to complete his haz mat test, does he need to get fired from his job for the threshold to be high enough to justify stimulants? At that point he might have bigger problems. What if he never gets fired and eventually hobbles his way through a Pass -- technically he never needed a medication to "advance his career", but stimulants may have helped -- would we have called that treatment, or performance enhancement?

The reason I ask is because it seems so subjective and arbitrary to call one patient's experience of inattention pathologic and "deserving" of medication, whereas another patients challenges are interpreted to be less persuasive by the clinician because the patient hasn't suffered enough dire consequences of their ADHD/Inattention symptoms (yet). I would think the goal is to change the trajectory of these patients before they hit those brick walls, rather than using their crash as reassurance to the physician that he/she is not overtreating.

This is where clinical judgment comes in and where something like AI would be a disaster. In the fireman example, I'd actually be more likely to give a stimulant or medicate assuming there's not some other underlying concern like low IQ or another disorder as they're performing a high-risk job where the patient or those he's serving could be seriously hurt or killed by a mistake (we can debate whether they should even pursue a job like that in the first place, but that's more of an ethics question). Take the exact same person but say they're stay at home or work part-time at a convenient store and and stimulants probably aren't necessary at all.

We also compare them to what a reasonable person in their situation could do. If it takes someone 3 hours to do something that another average person in that situation could finish in 20 minutes, then it's probably worth addressing. Or in the above example, if that person is moderately intelligent and doesn't have something else going on, I agree that they should be able to pass a test like that easily (from my experience in my past life as an EMT).

You're right though, where we actually draw that line of who gets controlled substances vs who doesn't is somewhat subjective. The problem most of us who aren't child psych run into is that we're not going to be catching this early, we'll see the fallout. If we want to really make a difference we need to have more people in pediatrics with a robust knowledge of how to identify ADHD and parse it out from all the other developmental/social issues that occur at that age. However, given the massive shortage of competent prescribers in this population as well as our healthcare system's priority on treating emergencies vs preventing them, I'd say good luck with preventing patients from hitting those brick walls.

 

[randomdoc1]

Clausewitz brings it up frequently, but it's why I like to focus on tangible effects and functioning rather than how patients feel. How many hours are patients spending on work or chores before/after meds? Are they still losing/forgetting things? Have their co-workers and bosses, family, or friends noticed a difference? I don't prescribe meds just so patients can feel better (though it's nice when they do), I prescribe so they actually function better.

Love what you guys said. I am the same. I talk about the concept of medical necessity and risks versus benefits. Not every diabetic needs insulin. Do we always need to take a sledgehammer to a fly? For stimulants, I tell the patient, let's set up some tangible goals. How much time are you spending on work? How are your quarterly reviews? If you work say...in medical billing, has your collection rate gone up 5%? 10%? more? If there is no change in measurable outcomes, why are we continuing the take the medication? If there is change but we plateau at a dose, what's the point of increasing? Once we talked about tangible goals (which even is used in general therapy), people have gotten less pushy about stims for less well defined reasons. I find that it can commonly develop into a discussion about a patient wanting to feel "motivated" or "good." Which opens a good discussion about what is our reasoning for looking into these medications.