Where to learn more about adult ADHD?

[tr]

Depends on the population you're referring to. College kids? I haven't seen them being prescribed Adderall for cognitive enhancement in non-ADHD people. The ones taking it without ADHD seem to get them illegally. Older patients with dementia? That was a thing even when I was in med school. These aren't new narratives.

I don't know, I did a rotation at the university mental health center when I was in residency (lo these many years ago now) and we routinely had undergraduates with no psych history and stellar academic records come through with the report of being "unable to focus," clearly expecting that they would be quickly prescribed amphetamines on the basis of this complaint, without much further investigation.

They were invariably quite surprised when I pulled out the Conners-parent, leading me to believe that many of their peers had had little difficulty procuring stimulants by legal means.

---

Members don't see this ad.

 

[tr]

I have been trying to figure out how to get a good self-report scale for teenagers though to track treatment response, as I've noticed that's a large gap in assessment (if they're 17-18yo I'll end up using the BAARS to try to track sx over time).

I agree this is a gap. I use ASRS for symptom tracking but it's not so great, just the only thing I've found that's brief, widely available, and at least semiquantifiable.

 

[calvnandhobbs68]

Like I said, you know who WILL do all the stuff you require? The drug seekers. You know who won't? People with legitimate illness.

I think we're kind of arguing past each other here. There is not a huge sudden influx of people losing jobs or bombing out of college who are coming for ADHD assessments recently in my experience. We're talking about the huge margin of people on the edge who apparently every psychiatrist except you has gotten referrals for that are suddenly "unable to focus" this past year and can nail every DSM 5 box and definitely had a lot of problems paying attention as a kid that nobody ever noticed.

For instance, this issue got so bad recently at my fellowship program where the psych department was literally getting bombarded with "ADHD" referrals in the past year by primary care, that they developed an entire committee (that I was on btw) to try to figure out a way to standardize assessments. I assure you, this wasn't because there were hordes of people in the past 2 years suddenly failing out of college or getting fired from their jobs because of ADHD.

I agree you can abuse those other drugs. You can abuse almost any drug if you really want to try. We work in terms of relative risk of abuse/diversion.

Again, some of this is a philosophical argument on where exactly we draw the line for a diagnosis. From my end, there's both a concern for diversion but also this general loosening of criteria (similar for example "bipolar disorder" criteria). As per DSM anyway, "Adult recall of childhood symptoms tends to be unreliable and it is beneficial to obtain ancillary information".

I think some people get entranced though by the fact that they put people on stimulants and wow doc I can suddenly focus so much better. Without operating under the understanding that many neurocognitively "normal" people will also focus better on a stimulant EVEN IF THEY'RE NOT ABUSING the medication. That's fine but recognize that at the margins it's highly likely that's what's happening here...similar to plastic surgery for cosmetic vs reconstructive reasons. I don't have anything against cosmetic surgeons but gotta recognize that you're doing cosmetic surgery.

 

[calvnandhobbs68]

So if you don't suspect it, then it must not be there. Got it.

Uh also, yeah, that's kinda how diagnosis works. If I don't think it's there, I'm not making the diagnosis. Like literally every other diagnosis in medicine without objective markers.

 

[tr]

That's fine but recognize that at the margins it's highly likely that's what's happening here...similar to plastic surgery for cosmetic vs reconstructive reasons. I don't have anything against cosmetic surgeons but gotta recognize that you're doing cosmetic surgery.

This. I'm not philosophically opposed to neurocognitive enhancement (although I do have social-justice concerns about unequal access to such enhancements).

I do resent being put in the position of gatekeeper where the patient is expecting me to make the "medical diagnosis" required to bestow legitimacy on their use of amphetamines to boost their function past the entirely normal range where they currently operate.

 

[singasongofjoy]

For some of the newer faux-terminology, Google may be your best bet with how quickly some of it probably changes/develops. I don't have good recommendations beyond that.

In your own practice, if you want to assess for it but are hoping to cut down on some of the BS, you could require that all potential patients provide you multiple collateral contacts to interview, including someone who knows them well currently and someone who knew them well in childhood, the latter particularly if they're unable to provide school records and/or other evidence of clinically-significant multi-domain distress or impairment while they were growing up.

As for scales and other measures, I would second the recommendation for the DIVA-5, with the downside being that it can take a little while to get through (and it's no longer free, although the fee is nominal). The Barkley Adult ADHD Rating Scale is ok but face-valid. The Barkley Deficits in Executive Functioning Scale is more wide-ranging than just ADHD, but also comes with short- and long-forms as well as an informant version (sort of like the Connors scales for kiddos). The Clinical Assessment of Attention Deficit-Adult (CAT-A) is also decent and has current and retrospective report sections; I like the retrospective portion on it better than the Wender-Utah (WURS), but the latter is also an option.

Do you have thoughts on how the Barkley Exec Fx Scale compares to the various age-specific versions of the BRIEF? I"m not familiar w the Barkley; we often give the BRIEF as part of our standard packet for ASD evals. I eval more adolescents and adults so curious if you think that might be a preferable choice or not

 

[AcronymAllergy]

Do you have thoughts on how the Barkley Exec Fx Scale compares to the various age-specific versions of the BRIEF? I"m not familiar w the Barkley; we often give the BRIEF as part of our standard packet for ASD evals. I eval more adolescents and adults so curious if you think that might be a preferable choice or not

Unfortunately, I don't have much direct experience with the BRIEF. I suspect they likely tap many of the same skills, although I don't know that the BDEFS (Barkley's scale) gets as much into metacognition distinctly.

 

[Mass Effect]

I think we're kind of arguing past each other here. There is not a huge sudden influx of people losing jobs or bombing out of college who are coming for ADHD assessments recently in my experience. We're talking about the huge margin of people on the edge who apparently every psychiatrist except you has gotten referrals for that are suddenly "unable to focus" this past year and can nail every DSM 5 box and definitely had a lot of problems paying attention as a kid that nobody ever noticed.

Don't mischaracterize what I said. I didn't say I don't get referrals for these people. I said assumptions that these people make up the vast majority of ADHD referrals is inaccurate and harmful as many residents and med students read these forums and the takeaway is that the default is med seeker when someone comes in for an ADHD eval. I'm replying to comments like "In residency, I had a lot of new evals for "attention". 90% were stimulant seekers". 90%? Really?

Again, some of this is a philosophical argument on where exactly we draw the line for a diagnosis. From my end, there's both a concern for diversion but also this general loosening of criteria (similar for example "bipolar disorder" criteria). As per DSM anyway, "Adult recall of childhood symptoms tends to be unreliable and it is beneficial to obtain ancillary information".

Beneficial sure. No one argued otherwise. I even said if they have collateral great. But I don't think patients should be penalized for not providing collateral as there are a multitude of reasons someone would be unable to do so. Yes there's concern for diversion, but that doesn't mean preemptively assuming that's what's happening if someone meets criteria.

I think some people get entranced though by the fact that they put people on stimulants and wow doc I can suddenly focus so much better. Without operating under the understanding that many neurocognitively "normal" people will also focus better on a stimulant EVEN IF THEY'RE NOT ABUSING the medication. That's fine but recognize that at the margins it's highly likely that's what's happening here...similar to plastic surgery for cosmetic vs reconstructive reasons. I don't have anything against cosmetic surgeons but gotta recognize that you're doing cosmetic surgery.

I disagree with your assertion. You're basically saying that people are treating people who don't have ADHD with a stimulant for the praise of hearing they're doing better if I'm understanding you correctly? That's bull if that's what you're saying.

 

[Mass Effect]

Uh also, yeah, that's kinda how diagnosis works. If I don't think it's there, I'm not making the diagnosis. Like literally every other diagnosis in medicine without objective markers.

Except you said "Are there exceptions? Sure, but they're generally people I'm suspecting myself may have ADHD..."

That statement implies that the ones with ADHD are the ones you suspected all along had ADHD, as if scenarios in which a patient has ADHD without you suspecting it is impossible. You have to be open to the fact that there are undiagnosed ADHD patients out there. They are undiagnosed for a variety of reasons, including failure to get treatment but also, failure by their psychiatrist to accurately diagnose.

 

[Mass Effect]

This. I'm not philosophically opposed to neurocognitive enhancement (although I do have social-justice concerns about unequal access to such enhancements).

I do resent being put in the position of gatekeeper where the patient is expecting me to make the "medical diagnosis" required to bestow legitimacy on their use of amphetamines to boost their function past the entirely normal range where they currently operate.

I mean, I don't think we should be giving stimulants to anyone who doesn't have a legitimate disorder. There are people who operate at a "normal range" in grade school, meaning they're making average grades. That doesn't mean they don't have ADHD. Their symptoms are just not severe enough to impair them as a child. May be a different story as an adult. Same for other illnesses that can affect cognition, like MS.

 

[Candidate2017]

If only that were so. Though there were comments on report cards from teachers about my "daydreaming", behavioral problems, lack of effort, poor attendance etc, I sailed through school with good grades.

Exactly my point. ADHD is a neurodevelopmental issue that presents in childhood and attention issues rarely escape notice by parents/authority figures.

 

[tr]

I mean, I don't think we should be giving stimulants to anyone who doesn't have a legitimate disorder. There are people who operate at a "normal range" in grade school, meaning they're making average grades. That doesn't mean they don't have ADHD. Their symptoms are just not severe enough to impair them as a child. May be a different story as an adult. Same for other illnesses that can affect cognition, like MS.

Do you not see people who did quite well in school, all the way through, including graduate school, were started on stimulants in college, continued to use them through graduate school and into their high-demand professional jobs, and as adults absolutely require them to continue functioning in their big-deal careers? (But have no problem with more basic functions that can be impaired by AD/HD, like safe driving.)

Is the inability to do a high-powered big-law job without pharmacological assistance, like, a disorder? The majority of Joe Sixpacks out there don't have the cognitive capacity to do the big-law job either (or at least wouldn't have been able to rack up the academic record to obtain the job in the first place), do they all have a neurodevelopmental disorder?

AD/HD by definition requires a childhood history of inattentiveness and/or impulsivity. I often see adults who have been on stimulants for years who deny any such childhood history when I ask them, and are quite surprised when I tell them that it is a diagnostic sine qua non for AD/HD.

 

[Mass Effect]

Exactly my point. ADHD is a neurodevelopmental issue that presents in childhood and attention issues rarely escape notice by parents/authority figures.

The evidence shows exactly the opposite. It very commonly escapes notice especially if the child is not hyperactive and is intelligent enough to get by. As an intern, I thought the same as you. But it's just not factually correct. I don't understand how as physicians we can give in to our own biases rather than looking at the evidence. Even the DSM changed some of its criteria based on this research. Yet we continue to overlook it and hold onto old schools docs who try to convince us that if it isn't detected in childhood, it doesn't exist. Just not true.

This is hardly the only study that shows it is underdiagnosed, but it's one I could find very easily. After work, I'll find more if you're interested.

Underdiagnosis of Attention-Deficit/Hyperactivity Disorder in Adult Patients: A Review of the Literature

Objective: To raise awareness of attention-deficit/hyperactivity disorder (ADHD) as an underdiagnosed, undertreated, often comorbid, and debilitating condition in adults.Data Sources: PubMed was searched using combinations of keywords, including ADHD, ...

www.ncbi.nlm.nih.gov

We are headed toward a crisis of overdiagnosis thanks to the pill mills online but if more psychiatrists would get comfortable with doing accurate evals and treating appropriately, we could curb that. It's just become easy for psychiatrists to believe false information and shrug and not want to deal with it at all than to challenge themselves to do a proper assessment.

When you leave a gap open, others will fill it and with a much worse outcome.

 

[Mass Effect]

Do you not see people who did quite well in school, all the way through, including graduate school, were started on stimulants in college, continued to use them through graduate school and into their high-demand professional jobs, and as adults absolutely require them to continue functioning in their big-deal careers? (But have no problem with more basic functions that can be impaired by AD/HD, like safe driving.)

Yes but that doesn't mean they don't have ADHD. You don't have to have a history of accidents to meet criteria. Now if they don't meet criteria, then they shouldn't be on stimulants. And yes, I will admit I have seen a few of those patients. But the patients I've seen who don't meet criteria yet are on a stimulant are far less than the ones who do.

Is the inability to do a high-powered big-law job without pharmacological assistance, like, a disorder?

It can be, though it doesn't mean it is. The criteria for ADHD is impairment in two settings that began in childhood. So to answer your question, no it doesn't necessarily mean ADHD. It could just be their own limitation. I had a law student come to me for an ADHD eval because she struggled so much in law school and was about to be expelled. Guess what, she didn't have ADHD. So instead, I worked with her on behavioral changes and organization. She barely passed her finals, but she passed. Then she stopped coming. I don't know if she ended up seeing someone to prescribe stimulants or if she just decided she didn't need my help. My point is, I don't give stimulants out freely. I do the evaluation. I just get fed up with psychiatrists who make broad assumptions or say things like "90%" of ADHD evals are med seeking. =

The majority of Joe Sixpacks out there don't have the cognitive capacity to do the big-law job either (or at least wouldn't have been able to rack up the academic record to obtain the job in the first place), do they all have a neurodevelopmental disorder?

No of course not. That's why the criteria is specific about impairment in two settings so that people who are in a career or school they can't hack don't get wrongly diagnosed. If you do a proper evaluation, you will catch the ones who don't have the disorder. But you shouldn't just dismiss every adult who comes to you because it wasn't picked up as a kid and now that they have this big shot career or demanding academic schedule is when they can't compensate. The latter does exist. Quite a lot among the ADHD population actually.

AD/HD by definition requires a childhood history of inattentiveness and/or impulsivity. I often see adults who have been on stimulants for years who deny any such childhood history when I ask them, and are quite surprised when I tell them that it is a diagnostic sine qua non for AD/HD.

Those patients should never been started on stimulants. No argument there.

 

[FlowRate]

It would be much easier to be on the side of the "ADHD is underdiagnosed and undertreated" crusade as it would justify the easy route with all of the numerous gray-area patients I've seen in the past two years. And whenever I say that on various forums people assume I don't treat ADHD. 15% of my 700 patients are on stimulants thank-you-very-much. I give the benefit of the doubt despite my extreme misgivings about the situation.

Where I have changed my practice recently is that I insist most new-dx pts try bupropion and/or atomoxetine before I consider a stimulant. "Most" because there are about 10% of pts with obvious severe ADHD who I want to have a robust, immediate response. But in terms of actual literature there are a number of concerns with stimulants in terms of lacking evidence for long-term efficacy, open question of potential neurotoxicity (and dependence), and compelling evidence for non-stimulant options with better safety profile. (Also see: retracted Cochrane review for mph products due to bias/quality issues.)

I am also becoming increasingly strict about having a no-THC policy. I'm tired of treating the side-effects of marijuana use.

I have to say I specifically tire of procrastination-only complaints. No other signs of ADHD other than "can't get stuff done until the last minute." And also "can't stay off my phone" disorder. The mobile app designers and algorithms do a great job capturing your attention, it's a feature not a diagnosis. A little meta that you watched a bunch of tiktoks about ADHD and are now convinced you have ADHD because you can't stop watching videos about ADHD on tiktok.

As a side-note, docs who do "ADHD" treatment as an easy cash grab a jerks. Patients on a stable medication regimen don't need to see you once every 4 weeks and some of those patients might actually have ADHD and are cruelly forced to waste their time and money on unnecessarily frequent visits. On the flip side, treating ADHD as a doc who doesn't do it as a cash grab sucks. It takes 30-60 seconds (load time dependent) to refill an automated controlled substance request and if I want to check PDMP it's more like 2 minutes+. That's 6-24+ minutes of uncompensated time per year per patient if I'm doing annual follow-ups.

Maybe pts should be able to get a medical stimulants card where they can go to a stimulant dispensary without needing a new Rx from me every month? (kidding)

 

[Stagg737]

No I think this gets into the point of are we selling cognitive enhancement with stimulants or treating a illness causing actual significant impairment. Seriously, I'd be pretty hard pressed saying that giving someone Concerta to get them from a B to an A in their college classes is "appropriately diagnosing ADHD". This is the same language that the "ADHD centers" use....everyone has ADHD and everyone could use a little cognitive enhancement. I mean yeah, sure, in the same way I could probably use a nose job or liposuction cause I suffer from an "attractiveness deficiency", I think a lot of this really comes down to your philosophical stance on this issue.

Those students could very well have ADHD, but I'm still not giving them a stimulant based on just their grades if there's not a significant impairment. Obviously, this is why it's important to be thorough about other domains of their life and functioning.

But in situations where the potential causal factors of that impairment are unclear, the person is a less-than-great historian, or the impairment itself is iffy, I don't think it's ridiculous or overreaching at all to ask the patient if you can have a 15-20 minute conversation with a parent to get information about early-life symptoms, and/or a spouse or friend or partner to get someone else's perspective on how they are currently outside your office. Especially because those conversations may give you additional information as to other contributing factors (even if there's also ADHD) and/or treatment recommendations.

Obviously we need to rule out other causes and having collateral from someone close can be extremely helpful, but I've met plenty of people with ADHD who I just couldn't get collateral for. They're not all on stimulants, but I'm not going to withhold treatment that is indicated just because I can't get collateral.

For instance, this issue got so bad recently at my fellowship program where the psych department was literally getting bombarded with "ADHD" referrals in the past year by primary care, that they developed an entire committee (that I was on btw) to try to figure out a way to standardize assessments.

And this was unexpected? We've been in a pandemic where rates of depression, anxiety, and isolation have soared. Of course everyone is going to be getting bored and having a harder time functioning. I don't really see the problem here as most of those individuals probably do have some psychiatric concern that could be addressed. I've actually found that a lot of my patients who came in for an ADHD eval and left with an SSRI were actually pretty happy about it at f/up. I don't think the situation above is really different than anything other than increased volume unless you truly had a sudden influx of drug seekers, which I think is probably unlikely.

I do resent being put in the position of gatekeeper where the patient is expecting me to make the "medical diagnosis" required to bestow legitimacy on their use of amphetamines to boost their function past the entirely normal range where they currently operate.

I mean, I'm just straightforward with them that unless they provide records with testing and/or extensive treatment of stimulants for ADHD that I'll be doing my own eval and testing and won't be continuing stimulants unless I feel they legitimately have ADHD. If you're employed, I'd definitely be talking to the bosses or clinic managers to ensure incoming patients understand this before the appointment.

 

[Stagg737]

Warning, long personal experience below:

Exactly my point. ADHD is a neurodevelopmental issue that presents in childhood and attention issues rarely escape notice by parents/authority figures.

"Rarely escaping notice" and getting treatment or even believing something is wrong are very different things. I joked about it when I was younger, but never really thought about actually having it until near the end of undergrad. Yes, behavioral stuff (especially in the classroom) was noted, but was never a major issue because I'm one of the weirdos who actually really enjoys taking tests and quizzes and finds them to be genuinely fun. It was present at home, but mostly the inattentive symptoms because I was in so many activities to burn off energy and oftentimes was literally playing 3 different sports per season. The biggest area it affected was socialization, and looking back I wonder what my childhood could have been like if I had been treated.

It didn't become an ongoing issue for me until med school, as there was always enough time to get work done. Stuff like worksheets would get done quickly and bigger projects took 2-3x as long but always got done. M1 year was fine because of the way our curriculum was set up. I'd already seen almost all the information at least 3-4 times in previous classes, so it was mostly just a review year. M2 crushed me. I was studying 14+ hours per day just to pass, and it was so inefficient d/t distractions and having to read things over and over that it was probably only 4-5 hours of actual studying. I didn't actually take a (non-stimulant) med for ADHD until residency and pretty quickly noted that it was helpful. I didn't realize how helpful it was until this fall when I couldn't get it filled on time and did a trial without it for a couple of weeks, which turned out to be a terrible idea as I was staying at the hospital finishing notes until 7-8pm most nights when I was previously easily finishing work on that rotation by noon or 1.

Maybe it's just because actually having ADHD and looking back on my functioning, but I feel like there are things I pick up on and look for that just get overlooked a lot of times. I've been surprised in residency how often I've come across undiagnosed/untreated ADHD in adults. I don't always jump straight to stimulants (unless the ADHD is obvious), but I've had plenty of patient I started with SSRIs or trying to treat other conditions that didn't get better until we addressed their ADHD.

 

[sloh]

open question of potential neurotoxicity (and dependence)

Can you comment more on this or do you have references? I’ve heard some some cognitive psychologists mention this as a potential concern wrt stimulants.

 

[WisNeuro]

Exactly my point. ADHD is a neurodevelopmental issue that presents in childhood and attention issues rarely escape notice by parents/authority figures.

Anecdotally, way back when I was an evaluator on a very large ADHD grant. Full clinical interviews, blood work, genetics, neuropsych testing. Our site was specifically to boost recruitment of minority and low SES samples. ADHD gets missed in these populations by parents and low quality school systems quite often, for a variety of reasons.

 

[FlowRate]

Can you comment more on this or do you have references? I’ve heard some some cognitive psychologists mention this as a potential concern wrt stimulants.

I need to get in the habit of using my citation trackers more consistently when I do literature review. This review does a pretty good job of summarizing. The TL;DR is that there are inconsistent findings between various animal models regarding potential effects whether at typical human-used doses or very-high doses (common to animal safety studies.)

 

[littlefred]

We are headed toward a crisis of overdiagnosis thanks to the pill mills online but if more psychiatrists would get comfortable with doing accurate evals and treating appropriately, we could curb that. It's just become easy for psychiatrists to believe false information and shrug and not want to deal with it at all than to challenge themselves to do a proper assessment.

Hear me out on this one.... do you think the over diagnosis of pill mills, is just that? Over diagnosis due to financial gain (for the mill) and medication-seeking people?

I follow the same logic for benzodiazepines and opiates. Do they work? Yes. Would everyone benefit from them or feel an effect from them? Yes.
Does everyone need them? No.

We just have to learn to say no to patients that do not need the medication. But when we say no, they turn to the pill mill operations you refer to.

Look at the opioid epidemic we have now due to philosophical approaches like yours.

If you follow their logic the prevalence of ADHD would reach x%, where x is the amount of patients they can handle in their practice compared to those who don't have access to it.

 

[FlowRate]

If you follow their logic the prevalence of ADHD would reach x%, where x is the amount of patients they can handle in their practice compared to those who don't have access to it.

This is basically the issue at hand. Where on the "attention"/"executive function" curve are we setting the cutoff for "ADHD" and how do we reliably determine that a patient meets that criteria? It's an issue with the demand for ADHD diagnoses/medications outpacing relevant research, guidelines, and standards setting by the field as a whole. Per capita stimulant prescribing in the US continues to increase in children and adults, contrary to some other countries like the UK (where ADHD may actually be undertreated, in part due to cultural factors and not being prioritized over other MH disorders in the public healthcare system.) Depending on which source you look at, childhood/adolescent prevalence of an ADHD diagnosis is now >10%. (Historical prevalence being as low as 2-3% decades ago.)

 

[Mass Effect]

Hear me out on this one.... do you think the over diagnosis of pill mills, is just that? Over diagnosis due to financial gain (for the mill) and medication-seeking people?

Yes.

I follow the same logic for benzodiazepines and opiates. Do they work? Yes. Would everyone benefit from them or feel an effect from them? Yes.
Does everyone need them? No.

Very different meds and not a good argument since no one is arguing that everyone should get stimulants. We're talking about people who really have ADHD, not any person walking in off the street. Benzos and opiates are more addictive with worse side effect profiles, not to mention they actually make things worse long-term. We know stimulants work. We know they work well. We know they can literally change the trajectory of one's life if their ADHD is debilitating enough. We know they can work long-term. We know that few who are prescribed these meds for legitimate reasons actually get addicted. There is literally no reason to prescribe a benzo for daily long-term use. None. There is very, very good reason to prescribe Ritalin if someone has ADHD.

We just have to learn to say no to patients that do not need the medication.

I'm confused. Who on this thread do you think is not doing this?

Look at the opioid epidemic we have now due to philosophical approaches like yours.

Oh give me a break. The opioid epidemic was about liars and money-grubbing corrupt individuals who belong under a jail cell and the doctors who blindly followed, not philosophical approaches like mine, whatever that means. What exactly about my "philosophical" approach would you like to change and what would you change it to?

If you follow their logic the prevalence of ADHD would reach x%, where x is the amount of patients they can handle in their practice compared to those who don't have access to it.

Again your insistence on comparing this to opiates shows a profound lack of understanding of the opioid epidemic.

 

[FlowRate]

We're talking about people who really have ADHD.

See my point above, unless you're arguing that 10% of kids being dx with ADHD is just us "catching up" to some "true prevalence" which you'd be estimating at like 15%?

We know stimulants work. We know they work well.

Actually, especially in adults, very limited and poor quality data for this. Ample clinical and, as always in these threads, personal experiences, but limited data.

We know they can work long-term.

Again, mixed and limited evidence for this statement, as well. Saying "we know" implies high certainty on a subject on which there is ample debate and lacking rigorous study.

Have a bunch of errands to run this morning but will try to pull a few references when I have time later today.

 

[Candidate2017]

Anecdotally, way back when I was an evaluator on a very large ADHD grant. Full clinical interviews, blood work, genetics, neuropsych testing. Our site was specifically to boost recruitment of minority and low SES samples. ADHD gets missed in these populations by parents and low quality school systems quite often, for a variety of reasons.

ADHD is a neurodevelopmental disorder so it's hard to go undiagnosed or escape the attention of parent, teacher or authority figures. The trickiest case is where a patient grows up in an unstable environment without authority figures

I agree.

 

[Candidate2017]

As a side-note, docs who do "ADHD" treatment as an easy cash grab a jerks. Patients on a stable medication regimen don't need to see you once every 4 weeks and some of those patients might actually have ADHD and are cruelly forced to waste their time and money on unnecessarily frequent visits. On the flip side, treating ADHD as a doc who doesn't do it as a cash grab sucks. It takes 30-60 seconds (load time dependent) to refill an automated controlled substance request and if I want to check PDMP it's more like 2 minutes+. That's 6-24+ minutes of uncompensated time per year per patient if I'm doing annual follow-ups.

Maybe pts should be able to get a medical stimulants card where they can go to a stimulant dispensary without needing a new Rx from me every month? (kidding)

Anecdotally, it seems a large percentage of patients at large private practices (e.g., highly profitable clinics for the owners) are on stimulants and/or chronic benzodiazepines.

There is so much of this going on that I'm not sure whether private practice psychiatry has become or is only about dispensing controlled substances, or whether stimulants and benzodiazepines are highly effective for treating the worried well. Arguably, stimulants plus benzos are the de facto standard of care if the majority of psychiatrists are doing it, at least in my community.

Also, the argument that these psychiatrists are doing a cash grab is legitimized by the fact that many of these patients are stable and only come for stimulant refills (regardless that 90833 "supportive" is coded). Other specialties would have sent refill only patients back to PCP. For example, cardiologists aren't seeing stable patients (who have very, very serious cardiac issues) q1-3 months to refill their b-blockers.

 

[Mass Effect]

See my point above, unless you're arguing that 10% of kids being dx with ADHD is just us "catching up" to some "true prevalence" which you'd be estimating at like 15%?

Those are separate conversations. I was talking about people who have ADHD, not arguing the over/underdiagnosis in that statement. I can argue the over/underdiagnosis, but that wasn't what I was saying.

Actually, especially in adults, very limited and poor quality data for this. Ample clinical and, as always in these threads, personal experiences, but limited data.

No there isn't. There's actually a lot of data on the utility of stimulants. I don't know what you consider limited and poor quality since that's definitely not what I see.

Again, mixed and limited evidence for this statement, as well. Saying "we know" implies high certainty on a subject on which there is ample debate and lacking rigorous study.

Have a bunch of errands to run this morning but will try to pull a few references when I have time later today.

I would like to see your references because I wholeheartedly disagree with this statement. We do know that stimulants can work longterm. Do they always? No, but no drug always works.

 

[FlowRate]

No there isn't. There's actually a lot of data on the utility of stimulants. I don't know what you consider limited and poor quality since that's definitely not what I see.

I would like to see your references because I wholeheartedly disagree with this statement. We do know that stimulants can work longterm. Do they always? No, but no drug always works.

There's a lot of published studies on short term effectiveness.

The majority of studies on stimulant meds are considered very low quality evidence and high risk of bias by cochrane reviewers (and other reviewers as well.)

Limited apparent benefit of stimulant medications in naturalistic long-term cohort study:

Error - Cookies Turned Off

acamh.onlinelibrary.wiley.com

Amphetamines in children review:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009996.pub2/full

Amphetamines in adults review:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007813.pub3/full

More concerns regarding adverse effects and even less quality evidence for MPH in both groups so I'll skip linking those reviews.

 

[Mass Effect]

There's a lot of published studies on short term effectiveness.

The majority of studies on stimulant meds are considered very low quality evidence and high risk of bias by cochrane reviewers (and other reviewers as well.)

Limited apparent benefit of stimulant medications in naturalistic long-term cohort study:

Error - Cookies Turned Off

acamh.onlinelibrary.wiley.com

Going to need to see this whole thing which I can't until I'm back at my work computer on Tuesday. Need more info on what they're using to monitor symptom severity. As for side effects, of course there are side effects so that part isn't surprising at all. But I'm curious about ongoing symptom severity with the use of stimulants, if that's what it's really saying.

Amphetamines in children review:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009996.pub2/full

Amphetamines in adults review:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007813.pub3/full

So these studies say that stimulants do reduce ADHD symptoms as monitored by patients themselves, parents, and teachers. But there is chance of bias. But when you read over and tbh, I only skimmed because it's 107 pages, they call out potential bias for any number of reasons. This could apply to any research. I will need to really dig into it to see their sources of bias and whether or not it's responsible to point out "potential" bias without actual evidence of bias for reasons that could pertain to any number of studies, including SSRIs, TCAs, antipsychotics, and even therapy modalities. I could see if studies contradicted themselves, but when you have a slew of studies all showing the same evidence, to red flag all the potential bias requires further explanation. I have bookmarked it and will read it when I get a chance.

In the meantime, are you saying you don't believe stimulants work for ADHD or that the risks outweigh the benefits? I'm trying to understand where you're coming from.

 

[PikminOC]

If only that were so. Though there were comments on report cards from teachers about my "daydreaming", behavioral problems, lack of effort, poor attendance etc, I sailed through school with good grades. Med school I totally couldn't cope. It was on ordeal. Adulting has been an ordeal for me. I've never been able to hand in assignments on time. I never make deadlines. I lose things all the time. I am pathologically incapable of being on time. I constantly get threatened with losing my credentialing because of being behind with notes (sometimes 6 months behind) even though my patient volume is embarrassingly low. Anyone who knows me superficially thinks I am "high functioning" but people who know me well are like "how can you live like this?"

I have seen quite a few physicians who are like me (and can spot it a mile away). it's not uncommon for intelligent people to compensate in childhood and struggle later in life.

Also not every illness requires meds....mild hypertension, high cholesterol that can be treated with diet and exercise. Mild depression. Same with ADHD. Not every case requires medicine.

 

[FlowRate]

Going to need to see this whole thing which I can't until I'm back at my work computer on Tuesday. Need more info on what they're using to monitor symptom severity. As for side effects, of course there are side effects so that part isn't surprising at all. But I'm curious about ongoing symptom severity with the use of stimulants, if that's what it's really saying.



So these studies say that stimulants do reduce ADHD symptoms as monitored by patients themselves, parents, and teachers. But there is chance of bias. But when you read over and tbh, I only skimmed because it's 107 pages, they call out potential bias for any number of reasons. This could apply to any research. I will need to really dig into it to see their sources of bias and whether or not it's responsible to point out "potential" bias without actual evidence of bias for reasons that could pertain to any number of studies, including SSRIs, TCAs, antipsychotics, and even therapy modalities. I could see if studies contradicted themselves, but when you have a slew of studies all showing the same evidence, to red flag all the potential bias requires further explanation. I have bookmarked it and will read it when I get a chance.

In the meantime, are you saying you don't believe stimulants work for ADHD or that the risks outweigh the benefits? I'm trying to understand where you're coming from.

I'm basically continuing the point that our conceptual framework and evidence base around diagnosis and treatment of ADHD in adults is severely lacking. There are ample open questions regarding stimulants in terms of long term safety, effectiveness, and also comparison to treatments that are emphasized a lot more in kids and adolescents than they are in adults (behavioral/therapy approaches, non-stimulant alternatives.) This isn't even necessarily unique to ADHD but I think the uncertainty is downplayed w/r/t ADHD.

 

[littlefred]

Again your insistence on comparing this to opiates shows a profound lack of understanding of the opioid epidemic.

I just happen to work at an OTP, but yeah...lol

I think your name suits you well.

 

[Mass Effect]

I just happen to work at an OTP, but yeah...lol

I think your name suits you well.

You can work at an OTP and still be ignorant to the underlying deception that caused the opioid crisis. It had very little to do with philosophy. The philosophy of all of us should be to treat patients to the best of our ability. The opioid crisis was allowed to happen due to corruption. If you want to argue a parallel trajectory, then that argument needs to be aimed at NP's and pill mills and not at psychiatrists who are providing the standard of care.

 

[Merovinge]

There's a lot of published studies on short term effectiveness.

The majority of studies on stimulant meds are considered very low quality evidence and high risk of bias by cochrane reviewers (and other reviewers as well.)

Limited apparent benefit of stimulant medications in naturalistic long-term cohort study:

Error - Cookies Turned Off

acamh.onlinelibrary.wiley.com

Amphetamines in children review:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009996.pub2/full

Amphetamines in adults review:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007813.pub3/full

More concerns regarding adverse effects and even less quality evidence for MPH in both groups so I'll skip linking those reviews.

These studies are looking at placebo controlled RCTs. Of course these types of studies are very hard to do over long periods of time due financial and best-practice concerns.

There is a huge amount of population data that compares children diagnosed with ADHD but started or not started on stimulants that use other naturalistic study designs to show numerous long-term benefits of stimulant treatment. This is marked contrast to most psychiatric disorders in which we do not have data to suggest a pharmacologic intervention alone has long-term benefit. These studies are largely not done in America due to lack of unified health care system, in contrast to the reviews you link above which are largely American studies.

I have absolutely nothing to say about adult ADHD management, but what you link above is a very disingenuous description of the state of ADHD tx in the pediatric population.

 

[FlowRate]

These studies are looking at placebo controlled RCTs. Of course these types of studies are very hard to do over long periods of time due financial and best-practice concerns.

There is a huge amount of population data that compares children diagnosed with ADHD but started or not started on stimulants that use other naturalistic study designs to show numerous long-term benefits of stimulant treatment. This is marked contrast to most psychiatric disorders in which we do not have data to suggest a pharmacologic intervention alone has long-term benefit. These studies are largely not done in America due to lack of unified health care system, in contrast to the reviews you link above which are largely American studies.

I have absolutely nothing to say about adult ADHD management, but what you link above is a very disingenuous description of the state of ADHD tx in the pediatric population.

I agree that looking at only rigorous placebo controlled RCT is a narrow view. The one study I linked is a naturalistic cohort study with no-meds, intermittent-meds, and consistent-meds groups. It seems to me like a quite well done study and one of the few that actually looks at long-term outcomes. There's definitely good evidence of benefit in relatively short studies for children and adults.

This seems like a thoughtful review/take on that study: ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge

The challenge ahead is therefore great. Even when stigma is overcome81 and an appropriate diagnosis is made—and evidence-based treatment initiated—far more remains to be done. Most saliently, the field needs to rethink the ways, beyond altering individual neurochemistry per se, in which families, schools, and peer groups must be included in the effort to foster self-regulation and age-appropriate competencies across the lifespan. Given the increasing evidence for long-range impairments in the clear majority of individuals with ADHD, such reconceptualization and renewed effort is of paramount importance.

 

[calvnandhobbs68]

These studies are looking at placebo controlled RCTs. Of course these types of studies are very hard to do over long periods of time due financial and best-practice concerns.

There is a huge amount of population data that compares children diagnosed with ADHD but started or not started on stimulants that use other naturalistic study designs to show numerous long-term benefits of stimulant treatment. This is marked contrast to most psychiatric disorders in which we do not have data to suggest a pharmacologic intervention alone has long-term benefit. These studies are largely not done in America due to lack of unified health care system, in contrast to the reviews you link above which are largely American studies.

I have absolutely nothing to say about adult ADHD management, but what you link above is a very disingenuous description of the state of ADHD tx in the pediatric population.

The first study is based on the MTA group which is probably one of the best defined cohorts we have for ADHD longitudinally.

 

[hebel]

If only that were so. Though there were comments on report cards from teachers about my "daydreaming", behavioral problems, lack of effort, poor attendance etc, I sailed through school with good grades. Med school I totally couldn't cope. It was on ordeal. Adulting has been an ordeal for me. I've never been able to hand in assignments on time. I never make deadlines. I lose things all the time. I am pathologically incapable of being on time. I constantly get threatened with losing my credentialing because of being behind with notes (sometimes 6 months behind) even though my patient volume is embarrassingly low. Anyone who knows me superficially thinks I am "high functioning" but people who know me well are like "how can you live like this?"

I have seen quite a few physicians who are like me (and can spot it a mile away). it's not uncommon for intelligent people to compensate in childhood and struggle later in life.

How do you read so much splik?

Even without ADHD, I am terrible at getting through professional books or articles.

 

[clausewitz2]

How do you read so much splik?

Even without ADHD, I am terrible at getting through professional books or articles.

People with ADHD have no problems sinking many hours into things they find intrinsically stimulating/rewarding enough, often to the exclusion of all other concerns and to their detriment. Cf. the stereotype of the classic absent-minded professor who can barely function for not being able to pull their nose out of a book.

 

[Mad Jack]

I'm getting back into private practice (cash this time) in a new city with lots of college students. I will be explicitly stating that I DO NOT TREAT ADHD OR PRESCRIBE STIMULANTS. Just like that, in big capital letters on the top of my webpage. This will probably cost me 80% of new referrals, but will save me 98% of headaches. Absolutely worth it.

In my old insurance practice, people coming in for ADHD were: 60% definitely didn't have it, 10% definitely did, and 29% were in a probably-don't-but-maybe gray zone. About 1% presented acutely high out of their minds. No idea what else they had.

The only ADHD patients who were satisfying to treat were the ones who didn't come in for ADHD. They came in for anxiety or depression, and over multiple sessions showed obvious signs of actual ADHD, and responded like a miracle when treated. The couple of those I had were in fact my favorite patients of all.

In conclusion, I formally invite the OP to join me in flexing some PP autonomy and just avoiding the whole charade.

Also, one anecdote for anyone doubting the big market push : my spouse, an internist, was looking for telemed work last year, and applied to an advertised spot for supposedly doing urgent care visits in a "new exciting tech company platform", also cofounded in partnership with Big Name University. Spouse was asked point blank if willing to prescribe stimulants, and on replying negatively, was told "thanks for talking with us we'll keep your CV on file." I checked out their website, and the big button next to "urgent care telemed" or whatever was "Get your ADHD treatment online!!!"

I've seen numerous ads on Facebook for getting ADHD "diagnosed and treated online" from various companies. It's shameful, and most of the comments are people talking about how great it is because it's been so hard to get a diagnosis. The struggle with everyone I would get in the office when I was doing adult treatment was explaining to the vast majority of them that they had done well in multiple environments for most of their life and that ADHD is a neurodevelopmental disease, not something that just creeps up in adulthood. The idea that their issues with focus and attention could be anything other than ADHD is always met with skepticism to outright rejection, and often they'll have stories of using Adderall that "I got once from a friend and it worked great." Nevermind the fact that stimulants are inherently performance enhancing and virtually everyone will have increased performance on them.

Rare is the patient that just had missed ADHD, but they do happen. More often I would get people with previously good performance that have subsequently had declines which they attribute to ADHD rather than depression, substance use (often marijuana), or other issues. Neurodiagnostic testing is often a double-edged sword, as things like TOVA are often used rather than proper structured clinical interviews and these seem to give a lot of false positives (even their own data shows 30% false positivity). Due to this I generally just rely on a thorough history and clinical interview for diagnosis, personally, plus or minus collateral if it is available.

 

[calvnandhobbs68]

Rare is the patient that just had missed ADHD, but they do happen. More often I would get people with previously good performance that have subsequently had declines which they attribute to ADHD rather than depression, substance use (often marijuana), or other issues. Neurodiagnostic testing is often a double-edged sword, as things like TOVA are often used rather than proper structured clinical interviews and these seem to give a lot of false positives (even their own data shows 30% false positivity). Due to this I generally just rely on a thorough history and clinical interview for diagnosis, personally, plus or minus collateral if it is available.

Yeah so TOVA or CPT can be helpful in the right circumstance...like huh I have some suspicion for ADHD (esp inattentive) but I'm not sure, let me see if I can get some more supporting info. But all the continuous performance tests tell you is does someone have current attention problems relative to normative samples. Doesn't tell you anything about WHY they have attention problems, which is what you're getting at. If you have the capability to do TOVAs over time, can also be helpful to see response to stimulants in people you have diagnosed with ADHD.

Also people aren't great at weeding out faked results, they tend to just go "TOVA abnormal-> ADHD". There are papers that have looked at subjects where they had them intentionally "fake" results on testing and what happens is that their testing is so abnormal that they look even worse than the people who actually have ADHD. So you have to know how to interpret the data too.

 

[FlowRate]

The struggle with everyone I would get in the office when I was doing adult treatment was explaining to the vast majority of them that they had done well in multiple environments for most of their life and that ADHD is a neurodevelopmental disease, not something that just creeps up in adulthood.

The hard part is stories like a couple of people ITT where the "smart and compensated well until truly taxed" explanation is given. It's certainly helpful when there are other details that are convincing of multiple domain impairment. I think there's a wide spectrum of opinion when it comes to whether impairment requires more "objective" signs of "failure," if you will (poor grades, losing jobs, etc.)

CPT can be helpful

IMO it's most helpful at detecting malingering, although it's hard to fully validate it for that purpose. Controls and p/w ADHD test almost exactly the same on CPT but students instructed to malinger on the CPT do notably worse.

 

[Candidate2017]

Even without ADHD, I am terrible at getting through professional books or articles.

Clear cut case of Adderall deficiency.

 

[PikminOC]

I mean, that can be true. I did a "high risk" rotation during training in communities with low SES and exploding crime rates and of course lots of drugs. But there was a patient the attending and I diagnosed with severe ADHD that had likely been there since childhood but undiagnosed. It was literally life changing for this individual. We even did a presentation it. I don't want to reveal too much because something very specific happened that I can't say, but let's just say the whole family was so much better off that it should be a case report. I wonder what this person's life trajectory would have been if it had been diagnosed earlier. When you see severe ADHD you'll never forget the power of the diagnosis and treatment and the fact that it can affect not only your job but your ability to even get a job.

Why not write the case report? And that is not the run of the mill ADHD case that is seen in output practice.

 

[PikminOC]

Waiting any amount of time for a neuropsychological evaluation to arrive at a diagnosis of ADHD is unnecessary and empirically unsupported, unless you're trying to potentially rule-in/out other conditions for which a neuropsych could be helpful. That's not to say a neuropsych eval can't be helpful for informing recommendations, but it definitely shouldn't hold up a diagnosis.

I think there are a number of other diagnoses it could be. I have a good PhD neuropsych I refer to and she has found many other correct diagnoses. Only rarely is is ADHD and if it is it's with other comorbidities that need to be treated too.

 

[hebel]

People with ADHD have no problems sinking many hours into things they find intrinsically stimulating/rewarding enough, often to the exclusion of all other concerns and to their detriment. Cf. the stereotype of the classic absent-minded professor who can barely function for not being able to pull their nose out of a book.

True, I just rarely hear of anyone being lucky enough to find textbooks or journal articles that intrinsically stimulating.

Who knows what I could have amounted to if smart phones were never invented. 😄

 

[PikminOC]

Aside from the very good teaching and supervision I have gotten in residency, a really impactful part of my education in ADHD was marrying a spouse with ADHD and having a child with ADHD. I don't necessarily think this should be added to the ACGME competencies, but the degree to which my understanding of the subtle nuances of ADHD, the ways in which it can impact one's life and my empathy towards those who have it has evolved is substantial.

I completely agree with the idea that it is cruel to make people jump through hoops to be diagnosed. I inherited several patients where there was a question of ADHD and they had been waiting 6+ months to see a neurophyschologist before the previous psychiatrist would make a diagnosis and start treatment. It was pretty clear to me after a few visits that both did indeed have ADHD and both have had remarkable improvement in their lives since starting treatment. I'm not comfortable with preventing people from living satisfying lives because someone might misuse or sell their meds.

That's not to say that I am giving out stimulus to anyone who asks for them, but rather if my clinical impression is that they do have ADHD, I'm likely going to start treatment, just as I do with any other psychiatric disorder.

With the way medical boards are clamping down on controlled subs, makes sense to wait for Neuro testing. Just need to get them into another place sooner. And one that is good. Doesn't specialize in add.

 

[hebel]

Clear cut case of Adderall deficiency.

Have any space for new intakes? 😄

 

[Mad Jack]

The hard part is stories like a couple of people ITT where the "smart and compensated well until truly taxed" explanation is given. It's certainly helpful when there are other details that are convincing of multiple domain impairment. I think there's a wide spectrum of opinion when it comes to whether impairment requires more "objective" signs of "failure," if you will (poor grades, losing jobs, etc.)

IMO it's most helpful at detecting malingering, although it's hard to fully validate it for that purpose. Controls and p/w ADHD test almost exactly the same on CPT but students instructed to malinger on the CPT do notably worse.

I'm of the opinion that if one can compensate for the entirety of their life until they are an adult and in a high-pressure position that they do not have ADHD. You *have to,* by definition, have symptoms that reach the point of impairment in childhood. If "ADHD" presents in adulthood, it is more likely that someone has relatively normal levels of inattention and have exceeded their (within the range of normal) abilities to focus due to excess stressors/obligations, not that they are suffering from a neurodevelopmental disability. I think we live in a fast-paced and complex world that is beyond the ability of many developmentally normal brains to tolerate at all times, and that many people misinterpret this as ADHD. Life being hard isn't a reason to take amphetamines.

 

[birchswing]

I'm of the opinion that if one can compensate for the entirety of their life until they are an adult and in a high-pressure position that they do not have ADHD. You *have to,* by definition, have symptoms that reach the point of impairment in childhood. If "ADHD" presents in adulthood, it is more likely that someone has relatively normal levels of inattention and have exceeded their (within the range of normal) abilities to focus due to excess stressors/obligations, not that they are suffering from a neurodevelopmental disability. I think we live in a fast-paced and complex world that is beyond the ability of many developmentally normal brains to tolerate at all times, and that many people misinterpret this as ADHD. Life being hard isn't a reason to take amphetamines.

Wouldn't this depend on at least two variables: the intelligence of the person in question and the level of difficulty of the material/tasks they are presented with in childhood?

Other variables that come to mind would be the particular school environment, the amount of one-on-one assistance given by teachers, how much is compensated for by teachers in passing students through without regard to their mastery, etc.

 

[Mass Effect]

I'm of the opinion that if one can compensate for the entirety of their life until they are an adult and in a high-pressure position that they do not have ADHD. You *have to,* by definition, have symptoms that reach the point of impairment in childhood. If "ADHD" presents in adulthood, it is more likely that someone has relatively normal levels of inattention and have exceeded their (within the range of normal) abilities to focus due to excess stressors/obligations, not that they are suffering from a neurodevelopmental disability. I think we live in a fast-paced and complex world that is beyond the ability of many developmentally normal brains to tolerate at all times, and that many people misinterpret this as ADHD. Life being hard isn't a reason to take amphetamines.

This is very simplistic. Define impairment in childhood. Do you account for helicopter parents? Do you account for charter schools vs private schools vs home school vs public school vs private tutor? Do you account for sports vs boy scouts vs music vs art? Do you account for childhood neglect/trauma vs not? Do you account for SES in childhood? Sounds like you have a prototype of what an ADHD patient would look like without considering that there are many who don't fit the cookie cutter mold due to a variety of reasons.