Where to learn more about adult ADHD?

[Mad Jack]

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.

I was typing a brief response on my lunch break and really don't have time to dig into all of the nuances. I go by the criteria stipulated in the DSM. I can retype it for you if you would like. With regard to other factors, as the DSM states: the symptoms are not better explained by another mental disorder. Symptoms interfere with or reduce quality of social, work, or school functioning. Symptoms are present in two or more settings, including work, school, home, with friends or relatives, or in other activities. There is a lot of lattitude in all of that, but I am conservative when it comes to ADHD treatment, because the line between condition treatment and performance enhancement is very fine. They must have six or more very clear symptoms in one or both areas in two or more settings that cause enough impairment to a degree that is legitimately concerning in both in the absence of substantial assistance. There are certain symptoms no amount of private school or helicopter parenting will mask, and those are key in differentiating things at times. Ruling out other mental illness or causes of neurocognitive impairment is also critical. The questions are very tailored to my patient's particular circumstances, however, which makes it hard to generalize an assessment aside from the criteria above.

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[randomdoc1]

Well, and not just the cognitive enhancement with absence of actual ADHD. I've worked with cases of ADHD and I agree they can be very rewarding and often times, they don't come in on their own initiative nor do they seem all that crazy about their stimulants. The cases of ADHD I've had were primarily very responsible with their stimulants and at reasonable doses. However, those who don't have ADHD seem to more easily fall down that slippery slope. They take stim, perceive only a little if any benefit (no surprise, it's because they don't have ADHD, how earth shattering is that?!), they conclude they must need more, they get someone to prescribe them more, they continue to escalate the high daily dosage and next thing you know, they build up a tolerance and physiologic dependence to a point where they are even less functional on days without the stimulant than they ever were (entrenching their conclusion that they must have ADHD because look at how bad things are without the stim!). Not only that, it derails the patient from pursuing what is the actual underlying issue (e.g. sleep hygiene, substance use, other comorbid psychiatric disorders--both Axis I and II, better habits and routines even). I've heard a lot of people calling and trying to get into my clinic urgently because they are on 90mg Adderall a day, their last prescriber fired them because they still kept missing appointments, and they know they will be out of Adderall in less than two weeks and know the amphetamine crash is coming. Really unfortunate.

 

[sloh]

even less functional on days without the stimulant than they ever were

How common would you say this is for those without ADHD that take Adderall and decide to discontinue later? And how long would you say it generally lasts?

 

[Mad Jack]

Well, and not just the cognitive enhancement with absence of actual ADHD. I've worked with cases of ADHD and I agree they can be very rewarding and often times, they don't come in on their own initiative nor do they seem all that crazy about their stimulants. The cases of ADHD I've had were primarily very responsible with their stimulants and at reasonable doses. However, those who don't have ADHD seem to more easily fall down that slippery slope. They take stim, perceive only a little if any benefit (no surprise, it's because they don't have ADHD, how earth shattering is that?!), they conclude they must need more, they get someone to prescribe them more, they continue to escalate the high daily dosage and next thing you know, they build up a tolerance and physiologic dependence to a point where they are even less functional on days without the stimulant than they ever were (entrenching their conclusion that they must have ADHD because look at how bad things are without the stim!). Not only that, it derails the patient from pursuing what is the actual underlying issue (e.g. sleep hygiene, substance use, other comorbid psychiatric disorders--both Axis I and II, better habits and routines even). I've heard a lot of people calling and trying to get into my clinic urgently because they are on 90mg Adderall a day, their last prescriber fired them because they still kept missing appointments, and they know they will be out of Adderall in less than two weeks and know the amphetamine crash is coming. Really unfortunate.

I once had a patient like this that was on 120 mg of XR and 30 mg of IR Adderall a day because "I just don't respond to less than 90 mg a day and even that isn't doing it for me anymore." Reason for presentation? Crisis in the setting of screaming dowm the streets for reasons not even he could discern. No childhood signs or symptoms of ADHD, diagnosed as an adult after starting a very high pressure job that demanded 80-100 hour weeks. On bringing up that his high dose of stimulants may be the cause of his symptoms and erratic mood, his response was "that's what you people always ****ing say, it's the Adderall. I need this, I can't function without it." My response was simply, "and you think you are functioning well with it?"

 

[randomdoc1]

How common would you say this is for those without ADHD that take Adderall and decide to discontinue later? And how long would you say it generally lasts?

Oof, that's a tough question to answer. lol. Since being out of residency and doing my own practice with a focus more on depression, anxiety, and PTSD, I run into this way less. But of the people I recall, almost everyone without ADHD fell into the temptation of taking the med every day and/or escalation of dose. They all grew tolerant of the effects and with continued use just experienced more side effects than benefit. For example, they'd say they have the same persistent symptoms in regards to cognition or that they are coming back. Insomnia is a common complaint too. In terms of how long this dynamic lasts, I'd say it depends on the frame of mind of that patient, like any stages of change are they in contemplation or precontemplation. Some get very attached to their stimulants and despite glaring evidence that all it does is keep them up at night, they start insisting on a benzo. Even when they get the benzo they say "it doesn't work" and they keep going down this path of asking meds to do everything for them. Some patients however start to realize that this stimulant path is really not achieving anything for them and on their own, they decide they've had enough. I've seen this course take anywhere from a few months to years.

 

[Mass Effect]

I was typing a brief response on my lunch break and really don't have time to dig into all of the nuances. I go by the criteria stipulated in the DSM. I can retype it for you if you would like.

No thanks, I'm good. My point was if you're clinging to the DSM without consideration of the nuances, that's a problem.

With regard to other factors, as the DSM states: the symptoms are not better explained by another mental disorder.

And? Much of what I stated isn't about another mental disorder.

There are certain symptoms no amount of private school or helicopter parenting will mask, and those are key in differentiating things at times.

I have a huge problem with this type of thinking especially when it comes to evaluating the childhood of an adult who is here for treatment because it's factually wrong.

 

[Mad Jack]

I have a huge problem with this type of thinking especially when it comes to evaluating the childhood of an adult who is here for treatment because it's factually wrong.

Factually wrong? If we have therapies and ways of altering a child's environment that can completely alleviate ADHD I would love to see the literature. I treat kids, it's literally all I do these days aside from the occasional weekend on an adult unit, and if there's some magic way of keeping them off of stimulants by which all their problems completely disappear I'd love to hear it.

 

[birchswing]

Factually wrong? If we have therapies and ways of altering a child's environment that can completely alleviate ADHD I would love to see the literature. I treat kids, it's literally all I do these days aside from the occasional weekend on an adult unit, and if there's some magic way of keeping them off of stimulants by which all their problems completely disappear I'd love to hear it.

What about an entirely different scenario, not in which a child is assisted but is ignored, or graduated through because it's easier, or they move to a country where they don't speak the language so everyone assumes their issues are due to a language barrier?

By the time I graduated high school—and I won't go into details of my case—but the vice principal sat down with me and said we need to come up with an excuse for all these absences. That was it. It was the easiest thing to do. People often do what is easiest, and it's easy to ignore problems.

You said that you treat kids, but what about the parents who would never bring their kids to you. The parents who don't believe in mental health help or who are neglecting their children for other reasons. There are a lot of ways to slip through the cracks.

 

[calvnandhobbs68]

Factually wrong? If we have therapies and ways of altering a child's environment that can completely alleviate ADHD I would love to see the literature. I treat kids, it's literally all I do these days aside from the occasional weekend on an adult unit, and if there's some magic way of keeping them off of stimulants by which all their problems completely disappear I'd love to hear it.

@Mass Effect how many kids are you routinely seeing right now?

 

[Mass Effect]

Factually wrong? If we have therapies and ways of altering a child's environment that can completely alleviate ADHD I would love to see the literature. I treat kids, it's literally all I do these days aside from the occasional weekend on an adult unit, and if there's some magic way of keeping them off of stimulants by which all their problems completely disappear I'd love to hear it.

Yes factually wrong. I didn't say their problems completely disappear by any means. That's kind of the point.

You said "There are certain symptoms no amount of private school or helicopter parenting will mask, "

And I'm telling you that this is inaccurate, both based on experience and based on the evidence that some circumstances can mask ADHD symptoms especially in mild but still legitimate symptoms. Kids with helicopter parents are the perfect example. That kid isn't organized on their own, but are organized thanks to Mom and Dad's tendencies to have every moment of the day planned out, have the kids room cleaned daily, remind the kid 100 times about the book report due and maybe even "over"help him finish because of their own tendency to helicopter, drive the kid to and from sports where their daydreaming isn't noticeable except when he misses the ball and the other kids just think he's lame or in Sunday school or church where they get in trouble for talking but no major infraction because Mom and Dad intervene. This kid could quite easily be a mess in college when he's managing his own life, his own schedule, his own obligations, driving himself places and responsible for his own work.

I had a therapy patient very similar to the above as a PGY 4. He came to see me for CBT for anxiety. It took about 10 sessions before we peeled away enough of the junk to get at the diagnosis. In that particular case, it did take a conversation with Mom too because the kid was so over-scheduled and so over-managed on a daily basis, he couldn't even remember much of it.

 

[Mass Effect]

@Mass Effect how many kids are you routinely seeing right now?

Very few. I am seeing many adolescents age 16 and up.

 

[Mad Jack]

What about an entirely different scenario, not in which a child is assisted but is ignored, or graduated through because it's easier, or they move to a country where they don't speak the language so everyone assumes their issues are due to a language barrier?

By the time I graduated high school—and I won't go into details of my case—but the vice principal sat down with me and said we need to come up with an excuse for all these absences. That was it. It was the easiest thing to do. People often do what is easiest, and it's easy to ignore problems.

You said that you treat kids, but what about the parents who would never bring their kids to you. The parents who don't believe in mental health help or who are neglecting their children for other reasons. There are a lot of ways to slip through the cracks.

Those ones generally are the ones I ended up treating as adults. Because even if they didn't get the treatment they needed when they were younger, they checked all the boxes for treatment. Not getting treatment doesn't mean not having clinically significant symptoms.

Yes factually wrong. I didn't say their problems completely disappear by any means. That's kind of the point.

You said "There are certain symptoms no amount of private school or helicopter parenting will mask, "

And I'm telling you that this is inaccurate, both based on experience and based on the evidence that some circumstances can mask ADHD symptoms especially in mild but still legitimate symptoms. Kids with helicopter parents are the perfect example. That kid isn't organized on their own, but are organized thanks to Mom and Dad's tendencies to have every moment of the day planned out, have the kids room cleaned daily, remind the kid 100 times about the book report due and maybe even "over"help him finish because of their own tendency to helicopter, drive the kid to and from sports where their daydreaming isn't noticeable except when he misses the ball and the other kids just think he's lame or in Sunday school or church where they get in trouble for talking but no major infraction because Mom and Dad intervene. This kid could quite easily be a mess in college when he's managing his own life, his own schedule, his own obligations, driving himself places and responsible for his own work.

I had a therapy patient very similar to the above as a PGY 4. He came to see me for CBT for anxiety. It took about 10 sessions before we peeled away enough of the junk to get at the diagnosis. In that particular case, it did take a conversation with Mom too because the kid was so over-scheduled and so over-managed on a daily basis, he couldn't even remember much of it.

You simply strengthen my point. None of your examples made the symptoms of ADHD go away, they were still present. I interview patients, primarily, not football acquaintances and teachers from Sunday school. If a person is really struggling with enough symptoms regularly, that's meaningful even if it didn't impact grades or whatever. Do you know how many cases of ADHD and autism I see that are missed because a patient was in a class of 5 at a private school and their parents were either in denial or didn't believe in treatment until it became a major issue? Their problems *never went away.* Requiring 100 reminders a day clearly demonstrates the inabikity to organize tasks. Avoiding trouble because you have a teacher that provides you with half of their attention does not mean you aren't having issues in class due to your hyperactivity, inattention, or impulsiveness. So, again, it comes down to clinical interview and degree of impairment. One could be impaired but get good grades, just as one could be unimpaired and fail. Grades and performance do not equal impairment. "How did you do in school" is not a question that I limit to grades, but rather emotional, social, familial, and academic domains and the perceived degree of function and distress in each. Same goes for other environments.

 

[erg923]

I would like to think the DSM and ALL its criteria exist for a, ya know... a reason? Lest we think Harvard and the MTA study is now clown college stuff? Lets use. it. The hemming and hawing about this diagnosis amongst practionerss drives me crazy!

 

[Mass Effect]

You simply strengthen my point. None of your examples made the symptoms of ADHD go away, they were still present.

I think where you're misunderstanding me is that you're thinking I'm saying the ADHD symptoms are cured or something. I said it would mask them. His mother reminding him 10 times the week his book report was due masked the fact that the kid didn't remember it. His mother finishing the book report with him masked the fact that the kid, if left alone, wouldn't have. His mother organizing his room every other day masked his habit of losing things. Masking something and making it go away aren't the same thing.

I interview patients, primarily, not football acquaintances and teachers from Sunday school.

Ok... I don't know why this line is included but ok.

If a person is really struggling with enough symptoms regularly, that's meaningful even if it didn't impact grades or whatever. Do you know how many cases of ADHD and autism I see that are missed because a patient was in a class of 5 at a private school and their parents were either in denial or didn't believe in treatment until it became a major issue? Their problems *never went away.*

I never said the problems went away. You said that and I corrected you in the post before this one. Don't misrepresent what I'm saying to argue against it.

Requiring 100 reminders a day clearly demonstrates the inabikity to organize tasks.

Except no one knew he "required 100 reminders a day". That's the point. Mom did the same with his sibling who didn't struggle when leaving home. Mom had control issues and frankly, I thought she was OCPD but I never evaluated her.

Avoiding trouble because you have a teacher that provides you with half of their attention does not mean you aren't having issues in class due to your hyperactivity, inattention, or impulsiveness. So, again, it comes down to clinical interview and degree of impairment. One could be impaired but get good grades, just as one could be unimpaired and fail. Grades and performance do not equal impairment. "How did you do in school" is not a question that I limit to grades, but rather emotional, social, familial, and academic domains and the perceived degree of function and distress in each. Same goes for other environments.

Here we're in agreement. What I'm saying is that it's possible for impairment not to be evident in childhood if you have a parent picking up after you. It's just one of many reasons that impairment may not jump out at anyone, including the patient.

 

[Mad Jack]

I think where you're misunderstanding me is that you're thinking I'm saying the ADHD symptoms are cured or something. I said it would mask them. His mother reminding him 10 times the week his book report was due masked the fact that the kid didn't remember it. His mother finishing the book report with him masked the fact that the kid, if left alone, wouldn't have. His mother organizing his room every other day masked his habit of losing things. Masking something and making it go away aren't the same thing.




Ok... I don't know why this line is included but ok.




I never said the problems went away. You said that and I corrected you in the post before this one. Don't misrepresent what I'm saying to argue against it.



Except no one knew he "required 100 reminders a day". That's the point. Mom did the same with his sibling who didn't struggle when leaving home. Mom had control issues and frankly, I thought she was OCPD but I never evaluated her.



Here we're in agreement. What I'm saying is that it's possible for impairment not to be evident in childhood if you have a parent picking up after you. It's just one of many reasons that impairment may not jump out at anyone, including the patient.

I mean we're really splitting hairs here. You agree that there were symptoms present before age 12. That's my criteria, period. No symptoms before age 12, no ADHD. If someone else wants to diagnose someone that can't recall their symptoms because they were somehow sheltered from their own flaws for their entire childhood then they can do so, but I won't, because I feel that the risk of harm by prescribing unnecessary medication outweighs the benefit of possibly getting that one rarity that somehow was blissfully unaware of their own limitations throughout the entirety of childhood. The first rule of medicine is not to help, it is to do no harm. Doctors that err too far toward trying to help those that are "struggling with ADHD" but which do not have any childhood histories of ADHD often end up doing more harm than good, as demonstrated by any number of "ADHD" specialists whose patients have wound up at my door in the past after being given unnecessary stimulants and developing a problem with them. People with ADHD don't abuse stimulants, generally, so their abuse of them and subsequent firing from multiple practices is indicative of inappropriate initial diagnosis. These patients are common, and most of them initially present with stories similar to that which you advocate.

 

[Mass Effect]

I mean we're really splitting hairs here. You agree that there were symptoms present before age 12.

No I'm saying we don't know if he met criteria before age 12 because of Mom's hyper-organization. Only symptom as a child that wasn't in dispute was the inattention. But the impairment only became apparent when he moved out so it took a lot of teasing apart to figure out. I don't really think that's splitting hairs.

That's my criteria, period. No symptoms before age 12, no ADHD. If someone else wants to diagnose someone that can't recall their symptoms because they were somehow sheltered from their own flaws for their entire childhood then they can do so, but I won't, because I feel that the risk of harm by prescribing unnecessary medication outweighs the benefit of possibly getting that one rarity that somehow was blissfully unaware of their own limitations throughout the entirety of childhood. The first rule of medicine is not to help, it is to do no harm. Doctors that err too far toward trying to help those that are "struggling with ADHD" but which do not have any childhood histories of ADHD often end up doing more harm than good, as demonstrated by any number of "ADHD" specialists whose patients have wound up at my door in the past after being given unnecessary stimulants and developing a problem with them. People with ADHD don't abuse stimulants, generally, so their abuse of them and subsequent firing from multiple practices is indicative of inappropriate initial diagnosis. These patients are common, and most of them initially present with stories similar to that which you advocate.

That's flawed logic, an inaccurate interpretation of what I'm saying and definitely not how I practice. But this disagreement has run its course. You do you. Peace out.

 

[Mad Jack]

No I'm saying we don't know if he met criteria before age 12 because of Mom's hyper-organization. Only symptom as a child that wasn't in dispute was the inattention. But the impairment only became apparent when he moved out so it took a lot of teasing apart to figure out. I don't really think that's splitting hairs.



That's flawed logic, an inaccurate interpretation of what I'm saying and definitely not how I practice. But this disagreement has run its course. You do you. Peace out.

I apologize if I come off as antagonistic, I just have a lot of strong feelings in this area due to significant issues in the community I trained in with bad ADHD prescribing. I don't mean to displace any of that on to you, and I'm not saying you're practicing bad psychiatry or anything. Just that there are a couple of ways to see this issue and you're on one side erring toward treatment while I'm on the other erring toward caution. I've seen patients that turned to meth after they lost their ability to get amphetamines legally, or ones that got admitted for psychosis after getting unnecessary Adderall prescriptions in college that they proceeded to abuse. I never, ever want one of my patients to go down those roads. I prescribe stimulants with some frequency in kids these days, and am not against them in general, I'm just very- and possibly overly- judicious.

 

[Mass Effect]

I apologize if I come off as antagonistic, I just have a lot of strong feelings in this area due to significant issues in the community I trained in with bad ADHD prescribing. I don't mean to displace any of that on to you, and I'm not saying you're practicing bad psychiatry or anything. Just that there are a couple of ways to see this issue and you're on one side erring toward treatment while I'm on the other erring toward caution. I've seen patients that turned to meth after they lost their ability to get amphetamines legally, or ones that got admitted for psychosis after getting unnecessary Adderall prescriptions in college that they proceeded to abuse. I never, ever want one of my patients to go down those roads. I prescribe stimulants with some frequency in kids these days, and am not against them in general, I'm just very- and possibly overly- judicious.

We're good. Just different ways of practice. I apologize if I came across too strong as well.

 

[Mad Jack]

We're good. Just different ways of practice. I apologize if I came across too strong as well.

It's all good, and honestly I think it was worth discussing so others can see the legitimate concerns of both sides of the issue.

 

[avatarftw]

I'm curious what you guys think about this. I've been an attending for a while now but am getting a lot, about 20% of my patients on the schedule are for adult ADHD or bipolar. I haven't ramped up my patient panel yet at my current position so that is a contributing factor to the higher percentage of adult ADHD requesting stimulants but I hear that my area just has a lot of stimulant use also. We have a lot of opiate and controlled meds being prescribed in my area too.

I'm finding that a high percentage of the adult ADHD cases I see also have bipolar and I don't feel comfortable giving stimulants to these patients. A fair percentage are people who were diagnosed after age 35.

I usually tell these patients that I can switch them to a non stimulant ADHD med or refer them to psychiatry.

What do you think about PCP's that don't give stimulant meds in general, with rare exceptions such as a patient who has more classic ADHD sxs at an early age and who was diagnosed by neuropsychology?

 

[Merovinge]

What do you think about PCP's that don't give stimulant meds in general, with rare exceptions such as a patient who has more classic ADHD sxs at an early age and who was diagnosed by neuropsychology?

That you are a paragon of medicine willing to risk negative reviews for doing the right thing for both the person in front of you and the population as a whole (diversion). I would be happy to buy a beer for you if we ever meet.

 

[calvnandhobbs68]

What do you think about PCP's that don't give stimulant meds in general, with rare exceptions such as a patient who has more classic ADHD sxs at an early age and who was diagnosed by neuropsychology?

I wouldn't be afraid of stimulants if you're a PCP but yeah, don't go starting every positive ASRS on immediate release Adderall BID (as I've seen even some psychiatrists do). The thing that actually irks me is when a 23 year old goes to a new PCP, has been on Concerta since 12yo and the new PCP tells them they have to go to psychiatry for their ADHD...so then they have to wait months to get in with psychiatry just for us to tell them "yep you still have ADHD and yep we're gonna continue your concerta at the same dose". It happens.

 

[avatarftw]

I wouldn't be afraid of stimulants if you're a PCP but yeah, don't go starting every positive ASRS on immediate release Adderall BID (as I've seen even some psychiatrists do). The thing that actually irks me is when a 23 year old goes to a new PCP, has been on Concerta since 12yo and the new PCP tells them they have to go to psychiatry for their ADHD...so then they have to wait months to get in with psychiatry just for us to tell them "yep you still have ADHD and yep we're gonna continue your concerta at the same dose". It happens.

Thanks for your 2 cents.

Yeah there's just been cases where the pt is like 50 years old and been on stimulants for 2 years and the patient says that they have *not* been having any inattention or distractibility or any ADHD sxs until age 48 when their PCP started them on stimulants.

Edit: There's literally about 2-4x more controlled meds being given here than my previous jobs.

 

[Crayola227]

There was a national push to stop undertreating pain. Then we had an opiate epidemic and mandatory trainings to educate us on the use of opiates and CURES was developed. Stimulants will be the next mandatory training to tackle this stimulant epidemic.

reading this the first time, I thought you were making a joke that physicians would need stimulants to tackle the next mandatory training on stimulants lol

 

[Mass Effect]

I'm curious what you guys think about this. I've been an attending for a while now but am getting a lot, about 20% of my patients on the schedule are for adult ADHD or bipolar. I haven't ramped up my patient panel yet at my current position so that is a contributing factor to the higher percentage of adult ADHD requesting stimulants but I hear that my area just has a lot of stimulant use also. We have a lot of opiate and controlled meds being prescribed in my area too.

I'm finding that a high percentage of the adult ADHD cases I see also have bipolar and I don't feel comfortable giving stimulants to these patients. A fair percentage are people who were diagnosed after age 35.

I usually tell these patients that I can switch them to a non stimulant ADHD med or refer them to psychiatry.

What do you think about PCP's that don't give stimulant meds in general, with rare exceptions such as a patient who has more classic ADHD sxs at an early age and who was diagnosed by neuropsychology?

So first of all, if someone comes to you on a stimulant, I would not tell them you're going to switch them. Just refer them to psych and tell them it's outside your scope of practice. Same with anyone with a bipolar diagnosis. I hate when PCP's change meds because they're afraid of a class of meds and the patient actually needs the medication. It's wrong and can be malpractice just as easily as anything else. If you don't feel comfortable with stimulants and patient comes in on them, refer out or tell patient your rule and they can choose a different PCP if they want.

Neuropsych testing for ADHD diagnosis is a waste of resources like 90% of cases.

 

[Mass Effect]

I wouldn't be afraid of stimulants if you're a PCP but yeah, don't go starting every positive ASRS on immediate release Adderall BID (as I've seen even some psychiatrists do). The thing that actually irks me is when a 23 year old goes to a new PCP, has been on Concerta since 12yo and the new PCP tells them they have to go to psychiatry for their ADHD...so then they have to wait months to get in with psychiatry just for us to tell them "yep you still have ADHD and yep we're gonna continue your concerta at the same dose". It happens.

I agree but the poster was saying they switch them to something else because they don't feel comfortable with stimulants. I'd much rather they refer to psych than switch a patient that's already on a stimulant. I've seen it happen. Most recent case was a 40 something stay at home mom whose ex-PCP stopped her Ritalin that she'd been on since she was a teenager. She has legit severe ADHD but PCP refused to prescribe stimulant because she's a stay at home mom. PCP is in our system so I read the records and this was his reasoning. There was no hint of diversion, just a PCP who refused to prescribe. Trialed her on Wellbutrin and Strattera with no luck and instead of going back to the stimulant, gave her Celexa with no mention of depression and anxiety before he d/c'd the stim. Only after when she came in complaining that she's struggling with distraction. He didn't even refer to psych. Poor woman finally called herself to get in.

 

[FlowRate]

reading this the first time, I thought you were making a joke that physicians would need stimulants to tackle the next mandatory training on stimulants lol

To be honest, this seems to be the prevailing cultural winds as well as the opinion of a lot of referring therapists. "It's terrible for patients to experience any degree of subjective difficulty attending to 'things they're not interested in' and so you must 'get comfortable' treating with Rx meth. It's totally safe and non-addictive when used for legitimate medical purposes like 'sometimes I forget what I was going to do when I walk into the other room.'"

Edit: realized I also took it in the opposite direction of what you originally meant, my thought being we haven't quite yet hit the "inattention as a vital sign" stage.

 

[PikminOC]

I don't consider social media influencers to be a "movement", certainly not one comparable to big pharma and their influence over the opioid epidemic. If there are doctors just handing out scripts for stimulants because this person or that person saw a SM on it, they should have their license yanked. But I'm not seeing a lot of this. I'm seeing the same irresponsible prescribing patterns of NPs and some MDs but no different than the ones prescribing benzos or even lamictal to everyone with a pulse. But the key difference is the national movement based on doctors being deceived and manipulated into prescribing.

If you have data on changes in prescribing patterns with stimulants, I'd like to see it. I'll admit I'm wrong if you have data on it.

Big pharma pushes this narrative too. Vyvanse ain't gonna sell itself.

 

[PikminOC]

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?



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 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.

At the setting the poster describes I believe 90 percent wanted stimulants.
And the "praise" is easy follow ups and $$$

 

[PikminOC]

To be honest, this seems to be the prevailing cultural winds as well as the opinion of a lot of referring therapists. "It's terrible for patients to experience any degree of subjective difficulty attending to 'things they're not interested in' and so you must 'get comfortable' treating with Rx meth. It's totally safe and non-addictive when used for legitimate medical purposes like 'sometimes I forget what I was going to do when I walk into the other room.'"

Exactly what 💯

 

[Crayola227]

I agree but the poster was saying they switch them to something else because they don't feel comfortable with stimulants. I'd much rather they refer to psych than switch a patient that's already on a stimulant. I've seen it happen. Most recent case was a 40 something stay at home mom whose ex-PCP stopped her Ritalin that she'd been on since she was a teenager. She has legit severe ADHD but PCP refused to prescribe stimulant because she's a stay at home mom. PCP is in our system so I read the records and this was his reasoning. There was no hint of diversion, just a PCP who refused to prescribe. Trialed her on Wellbutrin and Strattera with no luck and instead of going back to the stimulant, gave her Celexa with no mention of depression and anxiety before he d/c'd the stim. Only after when she came in complaining that she's struggling with distraction. He didn't even refer to psych. Poor woman finally called herself to get in.

Jesus just tells me the guy doesn't spend enough time helping with childcare (if he has kids of his own) if he thinks a stay at home mom with ADHD isn't going to have a hard time running after kids and staying organized.

Honestly in so many ways my attention is the antithesis of ADHD, despite always forgetting stuff and being late and rambling (no, really, it isn't ADHD), and it's takes everything I've got to remember and organize everything this 2.5 mo of mine needs.

Only slight hyperbole when I say it might be lucky this woman's kids even survived this

 

[VA Hopeful Dr]

I agree but the poster was saying they switch them to something else because they don't feel comfortable with stimulants. I'd much rather they refer to psych than switch a patient that's already on a stimulant. I've seen it happen. Most recent case was a 40 something stay at home mom whose ex-PCP stopped her Ritalin that she'd been on since she was a teenager. She has legit severe ADHD but PCP refused to prescribe stimulant because she's a stay at home mom. PCP is in our system so I read the records and this was his reasoning. There was no hint of diversion, just a PCP who refused to prescribe. Trialed her on Wellbutrin and Strattera with no luck and instead of going back to the stimulant, gave her Celexa with no mention of depression and anxiety before he d/c'd the stim. Only after when she came in complaining that she's struggling with distraction. He didn't even refer to psych. Poor woman finally called herself to get in.

I'm amazed the woman didn't get a new PCP. I've had patients transfer care for way less.

 

[WisNeuro]

Jesus just tells me the guy doesn't spend enough time helping with childcare (if he has kids of his own) if he thinks a stay at home mom with ADHD isn't going to have a hard time running after kids and staying organized.

Honestly in so many ways my attention is the antithesis of ADHD, despite always forgetting stuff and being late and rambling (no, really, it isn't ADHD), and it's takes everything I've got to remember and organize everything this 2.5 mo of mine needs.

Only slight hyperbole when I say it might be lucky this woman's kids even survived this

Yeah, that PCP is a *****. A day at home taking care of young children is way more taxing on my attention and EF than a day at the office dealing with patients or legal reports.

 

[Mass Effect]

I'm amazed the woman didn't get a new PCP. I've had patients transfer care for way less.

She did eventually. That's why I said her ex-PCP. She should have dropped him much earlier but she kept an open mind about Strattera and Wellbutrin until neither worked for her.

 

[Mass Effect]

At the setting the poster describes I believe 90 percent wanted stimulants.
And the "praise" is easy follow ups and $$$

Stimulant seekers implies to me they're not legit ADHD cases. I have a hard time believing there's a practice with 90% stimulant seekers outside a SUD practice, NP practice or pill mill. Some are med seeking in any practice, but 90% is not the norm from what I've seen and what I've read. I also haven't seen a practice with 90% ADHD dx outside an NP practice or an ADHD mill. Usually a regular adult psych will have a fair mix of ADHD, depression, anxiety, bipolar, psychotic disorders, insomnia, personality disorders, and on and on unless the practioner is specializing in ADHD or something.

 

[PikminOC]

Stimulant seekers implies to me they're not legit ADHD cases. I have a hard time believing there's a practice with 90% stimulant seekers outside a SUD practice, NP practice or pill mill. Some are med seeking in any practice, but 90% is not the norm from what I've seen and what I've read. I also haven't seen a practice with 90% ADHD dx outside an NP practice or an ADHD mill. Usually a regular adult psych will have a fair mix of ADHD, depression, anxiety, bipolar, psychotic disorders, insomnia, personality disorders, and on and on unless the practioner is specializing in ADHD or something.

That poster was talking about a college health service. Of course they all wanted stimulants

 

[Mass Effect]

That poster was talking about a college health service. Of course they all wanted stimulants

Where in that post did the poster say they were at a college health service?

And even if that's true, I spend two days a week in college mental health and also worked in college mental health in residency and have never had 90% stimulant seekers. I did have a much higher cohort of legitimate ADHD patients along with anxiety, and some drug seekers, but 90% drug seeking?

The only point I'm making is that every person who wants a stimulant is not someone trying to game the system. Stimulants are first line for legit ADHD and ADHD patients are sometimes undertreated or not treated at all because of our own biases about this class of medications and the patients who need them.

 

[PikminOC]

Where in that post did the poster say they were at a college health service?

And even if that's true, I spend two days a week in college mental health and also worked in college mental health in residency and have never had 90% stimulant seekers. I did have a much higher cohort of legitimate ADHD patients along with anxiety, and some drug seekers, but 90% drug seeking?

The only point I'm making is that every person who wants a stimulant is not someone trying to game the system. Stimulants are first line for legit ADHD and ADHD patients are sometimes undertreated or not treated at all because of our own biases about this class of medications and the patients who need them.

We will have to agree to disagree.

 

[WisNeuro]

Anecdotally, our graduate program did the ADHD/LD evals for the university for referrals and accommodations. Our rate of potential malingering/PVT/SVT failure generally hovered between 40-50%.

 

[splik]

Anecdotally, our graduate program did the ADHD/LD evals for the university for referrals and accommodations. Our rate of potential malingering/PVT/SVT failure generally hovered between 40-50%.

This is consistent with the data I've seen. malingering is in the 50% range for ADHD in college students. One point of confusion that some people don't understand is that some of these people also have ADHD. it is not mutually exclusive from malingering. It just means there is a subset of people who are grossly exaggerating their symptoms in order to get stimulants as evidenced by performance on PVT failures etc.

 

[WisNeuro]

This is consistent with the data I've seen. malingering is in the 50% range for ADHD in college students. One point of confusion that some people don't understand is that some of these people also have ADHD. it is not mutually exclusive from malingering. It just means there is a subset of people who are grossly exaggerating their symptoms in order to get stimulants as evidenced by performance on PVT failures etc.

It also tracks with PVT/SVT failures in many VA samples. As to the last point, I totally agree. There are generally three true outcomes we think about in these types of evals. They have the disorder in question/they don't have the disorder in question/they have the disorder, but are magnifying/overplaying symptoms. Unfortunately in that last group, I have no real way of telling what there symptom severity is, all I know is that they lied to me about some things.

 

[Mass Effect]

Anecdotally, our graduate program did the ADHD/LD evals for the university for referrals and accommodations. Our rate of potential malingering/PVT/SVT failure generally hovered between 40-50%.

This.

 

[PikminOC]

Where in that post did the poster say they were at a college health service?

And even if that's true, I spend two days a week in college mental health and also worked in college mental health in residency and have never had 90% stimulant seekers. I did have a much higher cohort of legitimate ADHD patients along with anxiety, and some drug seekers, but 90% drug seeking?

The only point I'm making is that every person who wants a stimulant is not someone trying to game the system. Stimulants are first line for legit ADHD and ADHD patients are sometimes undertreated or not treated at all because of our own biases about this class of medications and the patients who need them.

It's massively over diagnosed and treated with stimulants given all the stimulants sold at colleges etc. There's alot of diversion from people who don't really need it.

 

[PikminOC]

Anecdotally, our graduate program did the ADHD/LD evals for the university for referrals and accommodations. Our rate of potential malingering/PVT/SVT failure generally hovered between 40-50%.

What's pvt and svt? And the people who see you are at least willing to undergo testing. In physicians offices they just show up and want meds since they took their friends and obviously have add because the med worked so well.

 

[PikminOC]

Where in that post did the poster say they were at a college health service?

And even if that's true, I spend two days a week in college mental health and also worked in college mental health in residency and have never had 90% stimulant seekers. I did have a much higher cohort of legitimate ADHD patients along with anxiety, and some drug seekers, but 90% drug seeking?

The only point I'm making is that every person who wants a stimulant is not someone trying to game the system. Stimulants are first line for legit ADHD and ADHD patients are sometimes undertreated or not treated at all because of our own biases about this class of medications and the patients who need them.

Who needs doctors for these meds anymore? Bloomberg - Are you a robot?

ADHD Drugs Are Convenient To Get Online. Maybe Too Convenient​

 

[WisNeuro]

What's pvt and svt? And the people who see you are at least willing to undergo testing. In physicians offices they just show up and want meds since they took their friends and obviously have add because the med worked so well.

Performance and validity tests. And, for out university, at least back then, they required a comprehensive eval for accommodations. I'm sure things have changed sine then. But, we should still be cognizant of the people who need and will benefit greatly from treatment.

 

[Mass Effect]

Who needs doctors for these meds anymore? Bloomberg - Are you a robot?

ADHD Drugs Are Convenient To Get Online. Maybe Too Convenient​

You're preaching to the choir. I'm against online ADHD mills. But maybe they wouldn't exist if doctors weren't so judgmental about this class of legitimate treatment medications.

 

[PikminOC]

It's massively over diagnosed and treated with stimulants given all the stimulants sold at colleges etc. There's alot of diversion from people who don't really need it.

Nothing to say about this?

 

[PikminOC]

Performance and validity tests. And, for out university, at least back then, they required a comprehensive eval for accommodations. I'm sure things have changed sine then. But, we should still be cognizant of the people who need and will benefit greatly from treatment.

I agree that neuropsych testing is extremely helpful for this diagnosis and to rule in and out other diagnoses. The people who are stimulant seekers who come to my office rarely follow up with this testing. So the majority of the ones that do are motivated to find out what is really going on.

 

[WisNeuro]

I agree that neuropsych testing is extremely helpful for this diagnosis and to rule in and out other diagnoses. The people who are stimulant seekers who come to my office rarely follow up with this testing. So the majority of the ones that do are motivated to find out what is really going on.

Unfortunately, these kinds of comprehensive evaluations are not available to most if they are 18+. Our clinic only did the all day testing/questionnaire/record review eval as it was subsidized by the university and it was a way for 1st and 2nd years to get supervised testing experience. Insurances do not cover these types of evals. In the insurance world, you essentially get 90791 and the time to give a couple of questionnaires and write up a report. So, if a provider insists on testing, which we really don't need for the diagnosis, people have to pay quite a bit of out of pocket money after sitting in a waitlist for 6+ months. So, for some people, it may not be motivation as much as affordability and access.