ADHD

[Therapist4Chnge]

Would it be boring if we found the means to treat autism successfully?

The news/media is in the business of getting eyeballs and clicks…and this is best done through sensationalism (warranted or not). Sure, if someone found a "cure" for autism, that would get news. It doesn't hurt that Autism is one of the best funded Dx's in the country/world. Sadly, if an orphan disease was "cured", it probably wouldn't get much press because 99.9% of the world has no idea that it existed and the news/media wouldn't be very compelled to share that info.

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[Par4thecourse]

I am glad that the medication works so well for you and I have seen it work well for many patients. Unfortunately, my experience has been that they seem to be the minority of my patients. For any psychotropic medication, it seems there are always a few patients who benefit tremendously, but many more who are in the "it might be helping a little" category.

Your post also points out the confounds of environmental factors and the resultant internalized messages. For you, the medication had sufficient benefit to override or mitigate those factors, but when the effects of medication are minimal then they are stuck with the other factors plus one more.

Hallowell and others find that medication makes a significant improvement in 80 percent of ADHDers. Maybe the patients you see don't really have ADHD, you know? I don't know. Just a thought.

"For you, the medication had sufficient benefit to override or mitigate those factors..." Spending most of my life in a personal holocaust has not been mitigated by the medication, let me assure you. My scars are deep, painful and many. I am convinced, however, that the agony I and many have gone through is eased by proper medical intervention in most cases. Just being assured that others have been likewise tortured as the result of these undiagnosed and treatable traits brings comfort. We are not alone and it is not our fault, after all. We, you and I, are no longer just a bad dream.

 

[thoffen]

The nature of stimulants is that they possess activity on the reward pathway and also provide short-term cognitive enhancement in attention in people without ADHD. It is also difficult to isolate these symptoms to one specific clinical entity. And further to isolate those symptoms to the awareness of potential malingerers so that you can reliably objectively measure stimulant benefit. This is not to discount the efficacy of stimulants for ADHD to other psychiatric medications for other psychiatric indications -- and to state that, like all interventions, it provides a range of benefit from drastic to detriment even when the illness is diagnosed and symptoms measured to the best of our knowledge.

 

[Par4thecourse]

The nature of stimulants is that they possess activity on the reward pathway and also provide short-term cognitive enhancement in attention in people without ADHD. It is also difficult to isolate these symptoms to one specific clinical entity. And further to isolate those symptoms to the awareness of potential malingerers so that you can reliably objectively measure stimulant benefit. This is not to discount the efficacy of stimulants for ADHD to other psychiatric medications for other psychiatric indications -- and to state that, like all interventions, it provides a range of benefit from drastic to detriment even when the illness is diagnosed and symptoms measured to the best of our knowledge.

Got ya and I realize there are good reasons that complicate this whole issue. I understand that. It is not as simple as a broken leg. I've studied it-thanks to the drugs I take for it. Without them, I could not read the contents of this forum nor respond in writing. I couldn't do a whole host of things. That speaks to the tragedy for those of us who've been relegated to hell, to return only to be scorned, doubted and patronized continuously. It is time for us to make clear to anyone interested that these ADHD traits are real. They baffle us, too, but they do respond, often, to an accurate analysis/diagnosis and proper medical intervention. We can function. We can live with our heads held high, regardless how we are misunderstood.

 

[Par4thecourse]

"The news/media is in the business of getting eyeballs and clicks…and this is best done through sensationalism (warranted or not)." Therapist4Chnge

True. Which is one of the reasons it is obvious that ADHD isn't taken as seriously as it deserves. What scientists and doctors have accomplished for many afflicted with these traits is nothing short of sensational. To be given your "sight" after having been practically blind is an incredible achievement. More of us need to stand up and be counted. We need to make our voices heard. Wounded children, teens and adults may never find the treatment they need if we sit on the sidelines preoccupied with other things. Maybe we just assume they, or their loved ones on their behalf, will seek medical attention; that they won't be discouraged or too confused to move ahead to find out what plagues their progress in life. Sometimes, when people are beaten down long enough, and severely enough, they give up hope. I never, ever, not even once, not for a split second, considered the possibility that I had ADHD.

 

[Ceke2002]

That's why I want this brave, relentless and downtrodden band of bruised warriors to begin to rally, to organize and to demand respectful recognition.

Just picture me visualising an organised rally of ADHD patients looking something like this...

 

[Par4thecourse]

CNS Drugs. 2005;19(8):643-55.
"Substance abuse in patients with attention-deficit hyperactivity disorder : therapeutic implications." Schubiner H
(Department of Internal Medicine, Providence Hospital, Southfield, Michigan 48075, USA. [email protected])
Therefore, research has been directed towards determining if the treatment of ADHD with stimulant medications can be safe and effective for the individual with active SUD and concomitant ADHD. An initial trial of methylphenidate in a population of adults with active cocaine dependence and ADHD indicates that this is the case.

 

[Jules A]

How often do you C&A docs suspect that stimulants for a kid are getting diverted? And if so, what can you do?

It would be really easy to manipulate a UDS by having the kid take it the day before, and that wouldn't identify the cases where a parent is cutting the dose and keeping the rest for themselves.

I guess you could insist that they keep and dispense the med at school, but those still must be very difficult conversations to have.

At the community clinics where I have worked the whole family's business is usually well known so it doesn't require Dick Tracy to figure out which parent is likely to divert their kids meds. In most of these cases I will attempt the less sought after meds first and discuss this with the parents up front. If I absolutely have to prescribe a stimulant I write for them to be given at school. There are forms the schools require and my office manager will touch base with the school nurse when she faxes the forms which helps ensure the parent actually brings the meds in or we get a call back from the nurse. I personally don't find these conversations difficult, just matter of fact, and in most cases the parents who aren't looking to scam or those who know they probably can't be trusted with these meds in their homes are ok with it.

 

[Par4thecourse]

I don't think there are any shortcuts here man. You still need a standard psychiatric evaluation examining symptoms, ruling out other medical or psychiatric causes for inattention, childhood hx, collateral info, ASRS screening tool, drug testing, referring out for neuropsych testing and TOVA, monitoring state pharmacy for abuse or diversion, etc... In the end it's a clinical diagnosis and you need to trust that the patient is not taking it as a performance enhancer or to get high.

You are correct, with the personal history the most important piece of information. A well established and lengthy series or pattern of disabling cognitive examples featuring numerous past failures and struggles across at least 2 major life functions should accompany a proper diagnosis. Grades, teacher's input, parental feedback, siblings, coaches, bosses, may all contribute to an accurate DX. No shortcuts, particularly with college students who are achieving at rates comparable to their peers. One group which should be monitored with skepticism is athletes, especially those on scholarship. They often receive a wink and a handshake on their academics.

 

[FreudianAutocorrect]

I was thinking about this the other day. Part of the problem (if you could call it that) is that the NNT of stimulants is very low, even in people without ADHD.

And on some level I think if some reasonably high functioning, low risk (for abuse, diversion etc) has gone out of their way to scam me for a performance enhancer I'm not sure I'd lose too much sleep over that. I think in coming decades we're going to see more and more of this, and it's possible it might morph in to legitimate cosmetic psychiatry (particularly with less abusable meds like modafinil).

 

[randomdoc1]

I was thinking about this the other day. Part of the problem (if you could call it that) is that the NNT of stimulants is very low, even in people without ADHD.

And on some level I think if some reasonably high functioning, low risk (for abuse, diversion etc) has gone out of their way to scam me for a performance enhancer I'm not sure I'd lose too much sleep over that. I think in coming decades we're going to see more and more of this, and it's possible it might morph in to legitimate cosmetic psychiatry (particularly with less abusable meds like modafinil).

*shudders*
I'm all for treating legitimate cases of ADHD and all. But as a psychiatrist who does some private practice, my negative countertransferance to cases who are calling in asking for an ADHD eval with no pediatric history is pretty high. Especially when they say they tried their friend's Adderall (who probably does not have ADHD either) and they found it helped so it sealed the diagnosis in their mind already and leave upset I did not prescribe it. Residency has not prepared me at all for this potential issue and as another poster mentioned, this kind of caught me by surprise when I first got out. I am grateful I currently have a way to deter some of these referrals (without looking like I am blowing it off) thank you to the excellent ideas posted on some of these boards. I tell my receptionist to inform callers that I require (but it is not limited to):
1)Random UDS
2)Me to be able to get collateral from someone else who can give me some good developmental history (e.g. parents)
3)No controlled substances the first visit
I think this is all very fair considering we are talking potentially prescribing stimulants which have high habit forming potential as well as various other potential adverse effects. THANK GOD it dramatically decreased these referrals who make it into my door. Let's see how long it lasts.

 

[Jules A]

I tell my receptionist to inform callers that I require (but it is not limited to):
1)Random UDS
2)Me to be able to get collateral from someone else who can give me some good developmental history (e.g. parents)
3)No controlled substances the first visit
I think this is all very fair considering we are talking potentially prescribing stimulants which have high habit forming potential as well as various other potential adverse effects. THANK GOD it dramatically decreased these referrals who make it into my door. Let's see how long it lasts.

Word will get out in the community that you aren't playing which should also cut down on those who are looking for a quick fix. I personally feel there are very few adults who are unable to function without treating their ADD or ADHD symptoms with a stimulant so I rarely prescribe them to adults. In my anecdotal experience those who truly do need a medication and aren't angling for a stimulant seem to respond fairly well to Strattera or Wellbutrin.

 

[randomdoc1]

Word will get out in the community that you aren't playing which should also cut down on those who are looking for a quick fix. I personally feel there are very few adults who are unable to function without treating their ADD or ADHD symptoms with a stimulant so I rarely prescribe them to adults. In my anecdotal experience those who truly do need a medication and aren't angling for a stimulant seem to respond fairly well to Strattera or Wellbutrin.

This reminds me of a funny story. I don't know why when I first got out so many people called my private office looking for stimulants (never prescribed them much as a resident either). But at the clinic I work at, I work with someone who used to be my supervisor when I was a resident and we have an excellent working relationship. One day she was answering the phone calls when the receptionist had to take leave and someone called specifically asking for me because he wanted Xanax AND Adderall. She asked him why he was so interested in me specifically and he said "because she's asian and asians tend to prescribe more, I also like that she recently graduated, I need someone cutting edge." My former supervisor was SO mad. She told that guy off and said "Dr. ____ is an excellent physician and she doesn't freely handout pills to drug seeking *&$%^^% like you..." etc. etc. Then she hung up on him. He called back wanting to file a complaint so my former supervisor literally spent at least 15 minutes on the phone with him, first she apologized then she helped him find a psychiatrist to make sure that guy doesn't come back. Maybe the community has the impression that younger docs would be easier to manipulate? As for the whole asian physician generalization, maybe it was just him, but who knows...

 

[FreudianAutocorrect]

*shudders*
I'm all for treating legitimate cases of ADHD and all. But as a psychiatrist who does some private practice, my negative countertransferance to cases who are calling in asking for an ADHD eval with no pediatric history is pretty high. Especially when they say they tried their friend's Adderall (who probably does not have ADHD either) and they found it helped so it sealed the diagnosis in their mind already and leave upset I did not prescribe it. Residency has not prepared me at all for this potential issue and as another poster mentioned, this kind of caught me by surprise when I first got out. I am grateful I currently have a way to deter some of these referrals (without looking like I am blowing it off) thank you to the excellent ideas posted on some of these boards. I tell my receptionist to inform callers that I require (but it is not limited to):
1)Random UDS
2)Me to be able to get collateral from someone else who can give me some good developmental history (e.g. parents)
3)No controlled substances the first visit
I think this is all very fair considering we are talking potentially prescribing stimulants which have high habit forming potential as well as various other potential adverse effects. THANK GOD it dramatically decreased these referrals who make it into my door. Let's see how long it lasts.

I was half asleep writing that reply. Obviously you still need clear evidence of an onset of symptoms at a young age, and that means collateral.
I just mean that if someone meets criteria for diagnosis but you're not 100% they're not inflating the symptoms (or coaching their collateral or whatever), as long as they're not the kind of person to start insufflating their Ritalin then it's not really the end of the world. Methylphenidate in particular is quite safe when used as directed.

 

[Trismegistus4]

*shudders*
I'm all for treating legitimate cases of ADHD and all. But as a psychiatrist who does some private practice, my negative countertransferance to cases who are calling in asking for an ADHD eval with no pediatric history is pretty high. Especially when they say they tried their friend's Adderall (who probably does not have ADHD either) and they found it helped so it sealed the diagnosis in their mind already and leave upset I did not prescribe it. Residency has not prepared me at all for this potential issue and as another poster mentioned, this kind of caught me by surprise when I first got out. I am grateful I currently have a way to deter some of these referrals (without looking like I am blowing it off) thank you to the excellent ideas posted on some of these boards. I tell my receptionist to inform callers that I require (but it is not limited to):
1)Random UDS
2)Me to be able to get collateral from someone else who can give me some good developmental history (e.g. parents)
3)No controlled substances the first visit
I think this is all very fair considering we are talking potentially prescribing stimulants which have high habit forming potential as well as various other potential adverse effects. THANK GOD it dramatically decreased these referrals who make it into my door. Let's see how long it lasts.

Randomdoc1, I started a thread about this issue last fall and still haven't come up with a good solution. I identify with what you're saying, especially about residency not preparing me for this issue. PGY3 year we had one day a week of community mental health clinic, and one day in that clinic, I saw one patient who was there because she took some of her granddaughter's Adderall, thought she had ADHD, and wanted treatment with a stimulant herself. I knew my attending wouldn't want me to give it to her, so I didn't, she got mad at me, I had supervision with my attending immediately afterward and he agreed with me. I had never thought about the issue before, and except for the required child rotations, never thought about ADHD again in residency.

I was blindsided by this after starting my current job. It's quieted down a bit now, but last fall there was a period when I literally had an average of one new patient every day whose reason for presenting was wanting to get diagnosed with ADHD for the first time as an adult. I still don't know quite what the best way to handle these people is, but I like your ideas.

Is your office equipped to get a random UDS right then and there? I ask because ours isn't, so we'd have to send them to a lab. Are you looking mainly for confirmation that they're taking the med, or proof that they're not using other drugs? If the former, and we sent them elsewhere, they'd have time to take the med.

I recently asked a child psychiatrist who just joined my organization, and she said she tells people "you've got to prove it to me." She suggests making them bring in report cards/transcripts, and insisting on talking to parents. She also refers for neuropsych testing, but we've got WisNeuro here and others who say that neuropsych testing is not diagnostic for ADHD. Supposedly the best thing is a structured clinical interview, but frankly, I don't really believe in this anyway, and would prefer not to deal with these people at all, so I'm not motivated to learn how to do such an interview and put in the extra time it might require. So I'm still left wondering just what I should tell these people.

Especially since I'm fairly non-confrontational by nature, and can be a bit of a pushover, and some of these people are very insistent. When it becomes clear in the first 30 seconds of the interview that they're there to get a stimulant, and they freely admit that they graduated from high school on time, went to college, and got B's (i.e., had no impairment in childhood,) how do you spend the remaining 59 minutes and 30 seconds of the interview? Especially if they ask "OK, let's say I don't have true ADHD proper... so what, I'm still having these problems! I'm going to get fired from my job because I just can't make myself concentrate! What am I supposed to do, doc? HELP ME!"

Unfortunately, in my organization, patients aren't referred to nor call and ask for an appointment with me specifically. They see their PCP, who puts in a psychiatry referral; schedulers then get the referral, call the patient, and schedule them with a psychiatrist--any psychiatrist, whichever one of us has an appointment available. So any reputation I might get for being stingy with controlled substances wouldn't solve the problem. Still, it might theoretically be possible to have the schedulers tell the patients I have requirements like yours. I might try asking, but it could be tough to get such a thing implemented as official policy, because of the bureaucracy.

Plus, I have to sheepishly admit, I'm not sure I have such a reputation so far. Most people, I've managed to stall with a combination of psychological testing referrals, Strattera, Wellbutrin, or Intuniv, and treating their anxiety or depression first. But there are a couple who have scored stimulants off me, I'm ashamed to say, because I just didn't feel like arguing that day or in that case.

The thing is, while I know reviewing report cards and transcripts, and talking to parents, are the right thing to do, I don't really want to put in the effort to spend time outside of appointments, or have appointments run long, to do those things. I really just want these people to GTFO and not come back.

Plus, not all of these cases are created equal. We have:

1. People who do, in fact, have a solid, documented diagnosis from childhood, and just have never stopped stimulants, or want to go back on them because they're going back to school, or have 3 toddlers and can't keep everything straight at home, or whatever. While I don't really like this, if I can confirm that they're not abusing or diverting, giving them what they want in this case is easier than eternal arguing.
2. People who have no childhood diagnosis, and in fact freely admit, as above, that they did not have impairment in childhood, but think they have ADHD now.
3. People who had no diagnosis or impairment in childhood, but were "diagnosed" with ADHD as adults in a non-rigorous manner (e.g., a 5 minute PCP visit,) and have been treated with stimulants for years (and this can be confirmed with the state pharmacy reporting database) by their PCP or another psychiatrist, but who are just coming to me now because they moved here from out of town, or their PCP isn't comfortable treating their comorbid anxiety or depression, or something.

The last kind is actually the most difficult to deal with for me. What do we do with these people? Should I be telling them I need proof of impairment in childhood? They're going to get pretty mad if I refuse to continue their stimulant, as they've been getting it for years and in their mind, definitely have ADHD.

What about these people who come in having been "diagnosed" at one of the centers of these "famous" docs like Edward Hallowell, or Daniel Amen, but again with no evidence of childhood impairment? They were subject to what were at least some time-intensive, formal tests, but I have no idea whether they were valid.

How do you deal with people who are extremely ornery and adamant about the matter, saying that their concentration and focus are so bad that they're going to get fired from their job, begging and pleading for you to DO SOMETHING, and vaguely implying they'd consider suing you because they're suffering damages from this condition and you're not treating it?

I mean, if someone is having insomnia, but doesn't meet diagnostic criteria for any DSM condition of which insomnia is a known symptom, I can still help them. I can discuss sleep hygiene, recommend cutting back on caffeine, screen for signs of sleep apnea, and/or prescribe trazodone or doxepin or recommend melatonin. A small percentage of such people wind up being unhappy that I won't start with Ambien, but most are perfectly happy to try the aforementioned things, and for most, they work. What do you do for people who don't meet criteria for ADHD, but feel they can't concentrate or focus?

I really would like to grow a pair and tell people, right off the bat, "look, I'm skeptical of ADHD in general. I have an EXTREMELY high threshold for diagnosing or treating adults for it. If you can't PROVE to me that you had SIGNIFICANT impairment before the age of twelve, I will not be diagnosing you with ADHD or prescribing stimulants, period." But then, as I said, I wouldn't know what to do with the remainder of a 60 minute appointment, with what would then likely be an irate patient across the desk from me.

If I were in private practice, I would put on my website "Dr. Trismegistus4 does not diagnose or treat attention deficit-hyperactivity disorder in adults." God, I wish these people would just go away.

 

[randomdoc1]

Is your office equipped to get a random UDS right then and there? I ask because ours isn't, so we'd have to send them to a lab. Are you looking mainly for confirmation that they're taking the med, or proof that they're not using other drugs? If the former, and we sent them elsewhere, they'd have time to take the med.

Unfortunately, we are not equipped at the clinic site itself to get the UDS then and there. But there is a lab very close by. I am looking for both confirmation they are taking the med and proof they are not using other drugs. I've found that asking for the UDS before even prescribing the med already dropped off many of these referrals from actually coming in.

Supposedly the best thing is a structured clinical interview, but frankly, I don't really believe in this anyway, and would prefer not to deal with these people at all, so I'm not motivated to learn how to do such an interview and put in the extra time it might require.

I certainly feel your angst when thinking of how exactly to perform a well structured interview assessing for possible ADHD. Like you said in your thread last fall, of course people are going to say "yes" to everything. I sort of try to be clever as possible with how I word my questions like ask where they are from, where they went to school, how work is going, etc. I leave my questions as open ended as possible. Often times patients dig their own graves when it turns out work is just fine, or they brag about how well they did in grade school, etc. I try to make it sound like me just trying to get to know them. Truth is, ADHD will show in the history regardless of how the question is set up, so I don't feel guilty about it. But some people just come in determined to get the diagnosis and are obviously exaggerating/inflating symptoms. Something else I am starting to get prepared to administer in my history gathering is the Barkley, I can email you the manual and battery itself. It has questions about adulthood and childhood as well as a set of questions you can ask collateral. Although not diagnostic, it can be helpful to point out that "hey, your symptoms where absent/minimal as a kid but said to be worse as an adult, that is very inconsistent with ADHD which tends to be more pronounced in the pediatric years and improved with time."

how do you spend the remaining 59 minutes and 30 seconds of the interview?

I tell them that as part of the standard psychiatric assessment, I have to ask questions about other potential disorders that have symptoms which can overlap with ADHD and proceed asking about things like depression, anxiety, trauma, etc. That tends to burn up a fair amount of time and often reveals other potential diagnoses.

Still, it might theoretically be possible to have the schedulers tell the patients I have requirements like yours. I might try asking, but it could be tough to get such a thing implemented as official policy, because of the bureaucracy.

I can imagine it can be tough. I work part time at the VA, so they are already very stingy about stimulants which is awesome and the other time is in private practice where the autonomy is great. It might not be a bad idea to meet with someone higher up to discuss this issue. You can probably find some literature showing the rise in prescription of stimulants in adults, which (someone correct me if I am wrong) is rising faster in adults than children. This is just not right. You can talk about the risk of addiction and other adverse effects. And overall, I am sure you're bureaucracy is well aware of the rise of abuse of prescribed substances lately. Like was discussed, having requirements like the ones I have, I feel it's very fair considering what is at stake is prescribing a drug with potential to cause a lot of long term problems in the wrong person.

The thing is, while I know reviewing report cards and transcripts, and talking to parents, are the right thing to do, I don't really want to put in the effort to spend time outside of appointments, or have appointments run long, to do those things. I really just want these people to GTFO and not come back.

I feel that pain too. I am trying to figure out if there is some way we can bill for the extra work that is put into this? If anyone has more input, I'd be plenty happy to hear. I will try to do the right thing if someone is still determined enough to see me. My hopes are that these cases are very rare for me so I don't have to worry about doing this all the time. At the very least, thanks to smalltownpsych, you can bill for batteries you administer. It pays very little, but it is something you can tack on. Also, if the patient says their attention issues are so severe, it may be able to push you into a 99205 depending on what else you find in the history and what other collateral/work up you decide to get (plus getting vital signs that visit). Someone correct me if I am wrong on that too. But if you work for a healthcare system, 90792 may be better since I hear it generates more RVUs. Are you able to charge for phone calls perhaps?

The last kind is actually the most difficult to deal with for me. What do we do with these people? Should I be telling them I need proof of impairment in childhood? They're going to get pretty mad if I refuse to continue their stimulant, as they've been getting it for years and in their mind, definitely have ADHD.

What about these people who come in having been "diagnosed" at one of the centers of these "famous" docs like Edward Hallowell, or Daniel Amen, but again with no evidence of childhood impairment? They were subject to what were at least some time-intensive, formal tests, but I have no idea whether they were valid.

I generally have just told these people that although I can't speak for what the PCP did or what their method was, that the standard of care if diagnosing ADHD is the manners we discussed already. I do tell them they are free to seek another opinion from someone else. For those diagnosed at a different center, I may just request records to see what exactly was administered and continue on with my interview. Often asking for the records takes time, and people often move on to someone else by then because they don't want to wait. If the records do come through, in my opinion, of the few cases I've seen, the history gathering wasn't all that rigorous and I got back to talking about the standard of care for diagnosis.

vaguely implying they'd consider suing you because they're suffering damages from this condition and you're not treating it?

Ouch! I'd do what they do for any case where we are concerned about litigation, document document document!

What do you do for people who don't meet criteria for ADHD, but feel they can't concentrate or focus?

There is therapy for ADHD too. At the VA we also have speech pathology we can refer people to for developing compensatory means.

During my interviews to take up time and hopefully give patients a better education so they can make a better informed decision (hopefully), I discuss:

1. As another poster said, poor concentration is analogous to the cough that is presented to a PCP. It is very nonspecific and there are many potential causes. It is my duty as a psychiatrist to do a thorough history.
2. Even if people feel better on a stimulant, that is very common and certainly not diagnostic of ADHD. I explain how stimulants work and why they may be having that experience. Just because you can perform better on one, does not mean we need to all be on them. Same reason we're not all on anabolic steroids so we can all play sports better. Yes, it can improve performance, but like steroids, stimulants also have down sides and are a serious medication. The high addiction potential, cardiovascular risk, worsening underlining psychiatric symptoms, etc.
3. Discuss other likely comorbidities. Many of these patients meet criteria for having a depressive disorder, anxiety disorder, PTSD, etc. Discussing how the standard of care is to address these first.
4. Educating people on the epidemiology of ADHD. The odds really are often not in their favor for the likelihood of them having adult ADHD.
5. I sheepishly admit, I do refer to neuropsych sometimes to assess for other things in the differential like a learning disorder, premorbid low IQ, etc.

With that, patients generally don't leave my office too terribly angry. I hope I conveyed the message to them that I am just trying to do my due diligence and that treating adult ADHD if it really is there, is a serious and very big deal. Legitimate cases if untreated can lead to bad outcomes, but we must first do no harm.

 

[erg923]

1. I sheepishly admit, I do refer to neuropsych sometimes to assess for other things in the differential like a learning disorder, premorbid low IQ, etc.

This is legitimate, although documenting medical necessity and the clinical reasoning/rationale is important because most commercial insurers will not authorize payment for a lengthy neuropsych battery/assessment if one simply submits with "suspected AHHD."

When there is strong suspicion of secondary gain, a formal CPT can help flush out exaggeration. I really think that's the only thing its truly good for since the presence of attention deficits is actually so flimsy and non-diagnostic of the actual disorder.

 

[Jules A]

I really would like to grow a pair and tell people, right off the bat, "look, I'm skeptical of ADHD in general. I have an EXTREMELY high threshold for diagnosing or treating adults for it. If you can't PROVE to me that you had SIGNIFICANT impairment before the age of twelve, I will not be diagnosing you with ADHD or prescribing stimulants, period." But then, as I said, I wouldn't know what to do with the remainder of a 60 minute appointment, with what would then likely be an irate patient across the desk from me.

If I were in private practice, I would put on my website "Dr. Trismegistus4 does not diagnose or treat attention deficit-hyperactivity disorder in adults." God, I wish these people would just go away.

You have a pair they just need to be bigger. I agree with you and have gotten to the point in my career wher I'm just not prescribing anything that makes me feel uncomfortable and if that pisses people off so be it. No one can tell you what to prescribe and if your employer attempts to perhaps its not the place you want to continue working.

During the intake interview I resist the overwhelming urge to redirect them at the 50th time they hit me up for a stimulant. At the end I will simply tell them that while it does sound like they are having organizational difficulties that I do not prescribe stimulants to adults so if they are convinced that is what they need then I'm not going to be a good fit for them. If they are interested in exploring non-stimulant medications and therapy I'd be happy to work with them and if not my receptionist can provide them with a list of other local providers. The key is not to spend too much time defending your philosophy other than say after consideration of risks vs benefits you believe there are other options shown to be effective and well tolerated. Definitely do not give them the impression that if they provide you with sufficient evidence of their long history of disorganization warranting an ADHD dx, try Strattera, Intuniv and Wellbutrin without effect or have an adverse reaction to every single one that they will be getting a stimulant from you.

If you are low key and don't waiver that you just don't prescribe stimulants to adults they will usually leave without too much protest and will direct their attention to working someone else for Adderall. The ideal outcome in my opinion is to have them decide at the initial evaluation that you are not the one for them or on a rare occasion you might be pleasantly surprised and have one stick with you and try alternative treatments with a positive effect.

 

[hamstergang]

What do you do for people who don't meet criteria for ADHD, but feel they can't concentrate or focus?

If they meet criteria for a psychiatric condition (any that impair their focus), treat that. If not, what is there for you as a psychiatrist to do? Send them to someone who teaches organizational and attention skills, I guess, but otherwise you can do nothing.

I know patients can be anxious for you to do something, but that's their anxiety, not yours unless you allow it to be. We don't have solutions for all of life's problems, and that's ok.

 

[WisNeuro]

When there is strong suspicion of secondary gain, a formal CPT can help flush out exaggeration. I really think that's the only thing its truly good for since the presence of attention deficits is actually so flimsy and non-diagnostic of the actual disorder.

It's not even moderately good at that. It should not be used as a PVT.

 

[Trismegistus4]

All right, guys, I'm embarrassed to admit I prescribed a stimulant to 2 new patients last week; I suppose I justified it to myself because they were already on them. But I felt really uncomfortable after the fact, so I've got to figure out what to do about this problem.

I generally have just told these people that although I can't speak for what the PCP did or what their method was, that the standard of care if diagnosing ADHD is the manners we discussed already. I do tell them they are free to seek another opinion from someone else. For those diagnosed at a different center, I may just request records to see what exactly was administered and continue on with my interview. Often asking for the records takes time, and people often move on to someone else by then because they don't want to wait. If the records do come through, in my opinion, of the few cases I've seen, the history gathering wasn't all that rigorous and I got back to talking about the standard of care for diagnosis.

Another frustrating aspect of this I've faced lately is that I've now gotten several referrals from PCPs who saw the patient (who, again, had no childhood ADHD history) and started them on a stimulant "until they could see psychiatry." So then by the time they come to me, they've been on the stimulant for 4 months. As far as they're concerned, it's "my Adderall" now. And they're in the middle of a semester at the local community college, and feel they absolutely, positively need it, or they'll fail out of school!

Even if people feel better on a stimulant, that is very common and certainly not diagnostic of ADHD. I explain how stimulants work and why they may be having that experience. Just because you can perform better on one, does not mean we need to all be on them. Same reason we're not all on anabolic steroids so we can all play sports better. Yes, it can improve performance, but like steroids, stimulants also have down sides and are a serious medication. The high addiction potential, cardiovascular risk, worsening underlining psychiatric symptoms, etc.

I've considered starting to actually say to people who say they tried their friend's and it "worked": "Look, androstenedione 'worked' for Mark McGwire. It allowed him to hit more home runs than he otherwise would have been able to. Does that mean he had a disorder that required treatment with steroids?" I really think that with many of these people we're seeing the Peter principle inaction. They've been promoted to a new job and they can't handle all the responsibilities. Oh well, maybe you're just not cut out for that job!

I notice you've used the phrase "standard of care" several times--do you have a good source on this, beyond the DSM criteria for diagnosis? As I alluded to in the other thread, part of my problem is that in residency I just kept my head down in my child rotations, because I had enough trouble believing it was a legitimate disorder even in children and never thought I'd be seeing complaints pertaining to it again. I think part of the reason I find it hard to stand up against this is that I don't feel I have any authoritative sources to rely on. It's almost like "well, this person is telling me they're having tons of awful symptoms... who am I to judge?"

You have a pair they just need to be bigger. I agree with you and have gotten to the point in my career wher I'm just not prescribing anything that makes me feel uncomfortable and if that pisses people off so be it. No one can tell you what to prescribe and if your employer attempts to perhaps its not the place you want to continue working.

During the intake interview I resist the overwhelming urge to redirect them at the 50th time they hit me up for a stimulant. At the end I will simply tell them that while it does sound like they are having organizational difficulties that I do not prescribe stimulants to adults so if they are convinced that is what they need then I'm not going to be a good fit for them. If they are interested in exploring non-stimulant medications and therapy I'd be happy to work with them and if not my receptionist can provide them with a list of other local providers. The key is not to spend too much time defending your philosophy other than say after consideration of risks vs benefits you believe there are other options shown to be effective and well tolerated. Definitely do not give them the impression that if they provide you with sufficient evidence of their long history of disorganization warranting an ADHD dx, try Strattera, Intuniv and Wellbutrin without effect or have an adverse reaction to every single one that they will be getting a stimulant from you.

If you are low key and don't waiver that you just don't prescribe stimulants to adults they will usually leave without too much protest and will direct their attention to working someone else for Adderall. The ideal outcome in my opinion is to have them decide at the initial evaluation that you are not the one for them or on a rare occasion you might be pleasantly surprised and have one stick with you and try alternative treatments with a positive effect.

I would love to just tell people I don't prescribe stimulants to adults, but I'm not sure I can get away with that. And I do mean I'm not totally sure my higher-ups would support it. But beyond that, as I mentioned above, the new patients I'm seeing now were referred in January. Many of them are on stimulants prescribed by their PCP, who has told them "I'll continue to prescribe this until May 1st when you have your appointment with the psychiatrist." So they come to me with very high hopes and if I just say "I don't prescribe stimulants to adults," that's going to lead to a LOT of VERY difficult patient interactions, complaints from patients, and maybe even complaints from PCPs, since it takes months to get in with a psychiatrist around here, so now, in the patient's mind, they're back to square one and have to wait another 4 months to see someone else. It seems like more often than not, I wind up giving in rather than getting into a big argument.

Are your patients told you don't prescribe stimulants when they schedule? That is how I'd prefer to handle things, but I doubt that could be done given the logistics of referrals and scheduling in my organization.

 

[Jules A]

Another frustrating aspect of this I've faced lately is that I've now gotten several referrals from PCPs who saw the patient (who, again, had no childhood ADHD history) and started them on a stimulant "until they could see psychiatry." So then by the time they come to me, they've been on the stimulant for 4 months. As far as they're concerned, it's "my Adderall" now. And they're in the middle of a semester at the local community college, and feel they absolutely, positively need it, or they'll fail out of school! .

I'd definitely get in touch and discuss with the PCPs who are starting the stimulant that it would be preferable to trial Wellbutrin or Strattera while they are waiting for your appointment. In my experience most are appreciative of any guidance offered and not just for ADHD. If you can get them on board it will make your life much easier especially regarding benzos also.

I've considered starting to actually say to people who say they tried their friend's and it "worked": "Look, androstenedione 'worked' for Mark McGwire. It allowed him to hit more home runs than he otherwise would have been able to. Does that mean he had a disorder that required treatment with steroids?" I really think that with many of these people we're seeing the Peter principle inaction.

I offer analogies like that often and on a rare occasion have mentioned that taking someone else's controlled substance is unwise as well as illegal when I educate them that a positive response doesn't confirm dx. Regardless I'm not as interested in meeting the diagnostic criteria as an indication of impairment to the extent they need a stimulant.

While I do believe in the disorder I also believe that by adulthood a majority are able to function without a stimulant. I suppose I might be missing the rare someone in their 60s with ADHD and understand it wasn't diagnosed years ago but regardless I'm skeptical that many are significantly impaired.

I would love to just tell people I don't prescribe stimulants to adults, but I'm not sure I can get away with that. And I do mean I'm not totally sure my higher-ups would support it. But beyond that, as I mentioned above, the new patients I'm seeing now were referred in January. Many of them are on stimulants prescribed by their PCP, who has told them "I'll continue to prescribe this until May 1st when you have your appointment with the psychiatrist." So they come to me with very high hopes and if I just say "I don't prescribe stimulants to adults," that's going to lead to a LOT of VERY difficult patient interactions, complaints from patients, and maybe even complaints from PCPs, since it takes months to get in with a psychiatrist around here, so now, in the patient's mind, they're back to square one and have to wait another 4 months to see someone else. It seems like more often than not, I wind up giving in rather than getting into a big argument.

Are your patients told you don't prescribe stimulants when they schedule? That is how I'd prefer to handle things, but I doubt that could be done given the logistics of referrals and scheduling in my organization.

My schedulers generally don't know why people are coming to see me so unless they specifically ask they aren't informed that I am very conservative with stimulants and benzos. The truth is I will prescribe stimulants in some instances most often as you described when someone is gainfully employed or in school and comes to me on them. In those cases, especially with school, I am often willing to continue at least on a short term basis. Word will get out that you are stingy with the stimulants and that will reduce some of the encounters which also works the other way if the word on the street is that you are free and loose. I personally feel it is problematic when I offer alternate options and a patient escalates. I am probably fortunate that my employer understands there are plenty of patients to fill our practice so losing some who aren't on board with our philosophy is to be expected. If someone goes off when told they won't be getting a stimulant it is a huge red flag similar to when I tell someone I'm concerned about their benzo regimen and they start to cry. Unless they are willing to work with what I feel is prudent and safe I have no problem not accepting them as a patient. It is complicated if you like your present job but for future reference it is something I always discuss prior to accepting an outpatient position because I'm not willing to have someone else dictate what I prescribe.

 

[SeniorWrangler]

I think the conversation goes better when you emphasize that it's not about who "deserves" Adderall, it's about risk vs benefit. Of course some people won't be happy unless they leave with a script in hand.

 

[Trismegistus4]

I'd definitely get in touch and discuss with the PCPs who are starting the stimulant that it would be preferable to trial Wellbutrin or Strattera while they are waiting for your appointment. In my experience most are appreciative of any guidance offered and not just for ADHD. If you can get them on board it will make your life much easier especially regarding benzos also.

I may have to do that, though it might be of limited benefit. I've prescribed Strattera in some cases, only to receive a request for prior authorization, saying it's not approved unless the patient has tried and failed 2 stimulants.

My schedulers generally don't know why people are coming to see me so unless they specifically ask they aren't informed that I am very conservative with stimulants and benzos. The truth is I will prescribe stimulants in some instances most often as you described when someone is gainfully employed or in school and comes to me on them. In those cases, especially with school, I am often willing to continue at least on a short term basis. Word will get out that you are stingy with the stimulants and that will reduce some of the encounters which also works the other way if the word on the street is that you are free and loose.

I hope so, but I'm not optimistic about developing a reputation. We're a large health care system with a large patient base from out there in the private world. I doubt many of these people talk to each other. It's not like we're a community mental health agency where our patient base is largely one local community (e.g., a local homeless population.)

It is complicated if you like your present job but for future reference it is something I always discuss prior to accepting an outpatient position because I'm not willing to have someone else dictate what I prescribe.

I hate my current job, but I don't like working in general. But yes, I recently had the thought that if I had had any idea I would be getting adult ADHD referrals, I would have brought the issue up in the interview. If I ever interview for another outpatient job, I will be asking, well before I sign on the dotted line, if they would support one of the following, in order of preference:

1. Having these referrals screened out and never scheduled with me in the first place,
2. My having a blanket policy of not prescribing stimulants, or
3. Having the 3 requirements that randomdoc1 listed above, and having patients told this when they first make the appointment.

 

[cookymonster]

Sounds like it may be worth your while to spend half an hour typing up an FAQ for Stimulants and ADHD that you can hand out at these appointments, maybe get other clinicians in your group to adopt (and improve quality) and also send out to referring clinicians (which might help screen these out). It might be easier and faster to refer to a document rather than regurgitate your same side of the arguments over and over again. It will also send the message to your patients that this isn't your first rodeo.

Questions you can address:
Why make such a big deal about stimulants (i.e. what are the risks and side effects)?
If I can concentrate and focus better on a stimulant, does that mean I have ADHD?
According to the DSM I have it. Isn't that how psychiatrists diagnose everything?
Why else would I be struggling to focus and concentrate at work and school?
Wouldn't it be easier to just take a pill than do x,y,z?

As an inpatient doc this wouldn't be worth my while but I've thought about doing something like this to explain to patients why I'm tapering them off benzos, which usually results in repetitive 15-minute arguments. It would be nice to hand something like that out and say "I'm glad you brought that up... I addressed that in question 4."

 

[Merovinge]

All right, guys, I'm embarrassed to admit I prescribed a stimulant to 2 new patients last week; I suppose I justified it to myself because they were already on them. But I felt really uncomfortable after the fact, so I've got to figure out what to do about this problem.

Another frustrating aspect of this I've faced lately is that I've now gotten several referrals from PCPs who saw the patient (who, again, had no childhood ADHD history) and started them on a stimulant "until they could see psychiatry." So then by the time they come to me, they've been on the stimulant for 4 months. As far as they're concerned, it's "my Adderall" now. And they're in the middle of a semester at the local community college, and feel they absolutely, positively need it, or they'll fail out of school!

I've considered starting to actually say to people who say they tried their friend's and it "worked": "Look, androstenedione 'worked' for Mark McGwire. It allowed him to hit more home runs than he otherwise would have been able to. Does that mean he had a disorder that required treatment with steroids?" I really think that with many of these people we're seeing the Peter principle inaction. They've been promoted to a new job and they can't handle all the responsibilities. Oh well, maybe you're just not cut out for that job!

I notice you've used the phrase "standard of care" several times--do you have a good source on this, beyond the DSM criteria for diagnosis? As I alluded to in the other thread, part of my problem is that in residency I just kept my head down in my child rotations, because I had enough trouble believing it was a legitimate disorder even in children and never thought I'd be seeing complaints pertaining to it again. I think part of the reason I find it hard to stand up against this is that I don't feel I have any authoritative sources to rely on. It's almost like "well, this person is telling me they're having tons of awful symptoms... who am I to judge?"

I would love to just tell people I don't prescribe stimulants to adults, but I'm not sure I can get away with that. And I do mean I'm not totally sure my higher-ups would support it. But beyond that, as I mentioned above, the new patients I'm seeing now were referred in January. Many of them are on stimulants prescribed by their PCP, who has told them "I'll continue to prescribe this until May 1st when you have your appointment with the psychiatrist." So they come to me with very high hopes and if I just say "I don't prescribe stimulants to adults," that's going to lead to a LOT of VERY difficult patient interactions, complaints from patients, and maybe even complaints from PCPs, since it takes months to get in with a psychiatrist around here, so now, in the patient's mind, they're back to square one and have to wait another 4 months to see someone else. It seems like more often than not, I wind up giving in rather than getting into a big argument.

Are your patients told you don't prescribe stimulants when they schedule? That is how I'd prefer to handle things, but I doubt that could be done given the logistics of referrals and scheduling in my organization.

Honestly, I think part of this is your adult training was not exposing you to the right CAP world. If you did not get the impression ADHD is a legitimate disorder, someone really dropped the ball on your didactics and suggested readings. In order to even make the supposition that ADHD is not legitimate one would have to believe that despite every other developmental task occurring on a continuum (say fine motor skills, development of empathy or other social skills, language skills, etc.) executive function does not. One can conceptualize much of ADHD as developmentally delayed executive function. Some kids manifest this with inattention and poor organizational skills while others are impulsive and physically hyperactive. This conceptualization goes hand-in-hand with most pts no longer requiring medications by the time they reach full brain maturity (although there is clear evidence not everyone outgrows ADHD, just like not every kid with a language disorder can fix it even with good language therapy).

That said, for your problems in the adult world with folks trying to score stimulants, definitely craftily ask questions to elicit what their educational experience was like in childhood/college and their work history. Functional impairment is key to psychiatry, so getting a super through background on this will help the entire intake process and reveal a lot about potential ADHD. If the person clearly did not have a childhood onset, I would explain how attention problems are often related to sleep, anxiety, and mood and explore those further. If someone just wants the pill and clearly does not have ADHD, you are going to have to upsell the risks. Adderall is mechanistically cocaine in a pill. It can cause sudden cardiac death. People can become dependent on it. It can cause insomnia, n/v, and anorexia. Explain your oath to not do harm and weigh risks/benefits. Make sure they feel like you want to help them and keep that countertransference in check! If you are worried about lawsuits coming across as very caring and conservative in practice will do much better than feeling bothered/frustrated with a patient.

Lastly, if a patient does have good evidence of pediatric onset, has been trialed off stimulants recently and had a marked decline in function, well then I would feel pretty good about keeping their medication going after discussion of risks/benefits. These folks will let you feel comfortable working with stimulants without using them as performance enhancers. Try to stick with almost exclusively long-acting stimulants to lessen abuse potential.

 

[Trismegistus4]

When do you guys administer rating scales? The patient comes in, sits down, I ask them what brings them in, and they say "I have ADHD." At that point, I have 1 hour with them maximum, and have to do my full psych eval. Do I whip out the Wender Utah and have them sit there filling it out for 5 minutes in silence across the desk from me? That seems weird.

 

[WisNeuro]

When do you guys administer rating scales? The patient comes in, sits down, I ask them what brings them in, and they say "I have ADHD." At that point, I have 1 hour with them maximum, and have to do my full psych eval. Do I whip out the Wender Utah and have them sit there filling it out for 5 minutes in silence across the desk from me? That seems weird.

At that point, just ask them questions regarding the symptoms. Probably saves you time and is just as face valid. Unless someone is going to do some sort of full eval, the questionnaires are usually pretty useless. People just say yes to everything most of the time and there is no symptom validity component to the vast majority of non-proprietary self-report scales.

 

[randomdoc1]

When do you guys administer rating scales? The patient comes in, sits down, I ask them what brings them in, and they say "I have ADHD." At that point, I have 1 hour with them maximum, and have to do my full psych eval. Do I whip out the Wender Utah and have them sit there filling it out for 5 minutes in silence across the desk from me? That seems weird.

I have them do it after the visit and review it later. I whip out the Barkley. If they are very early, I can have em do it before hand too. I think it may have better value getting it done before getting the history because during history gathering they may get more biased and you may get more false positives. Just my anecdotal experience. Anyone can feel free to correct me.

 

[PistolPete]

When do you guys administer rating scales? The patient comes in, sits down, I ask them what brings them in, and they say "I have ADHD." At that point, I have 1 hour with them maximum, and have to do my full psych eval. Do I whip out the Wender Utah and have them sit there filling it out for 5 minutes in silence across the desk from me? That seems weird.

You can have them fill it out afterwards and then tell them you won't prescribe them a stimulant until you get collateral from parents and see them for visit #2. But I agree with the above poster to try and have them fill it out beforehand if possible.

 

[cookymonster]

You can have them fill it out afterwards and then tell them you won't prescribe them a stimulant until you get collateral from parents and see them for visit #2. But I agree with the above poster to try and have them fill it out beforehand if possible.

Problem is, it's going to be pretty easy for them to just give you one of their friend's phone numbers with a non-descript voice mail. This happens all the time when I prescribe Suboxone, only to find out later that the patients relapse and were likely selling it.

 

[digitlnoize]

When do you guys administer rating scales? The patient comes in, sits down, I ask them what brings them in, and they say "I have ADHD." At that point, I have 1 hour with them maximum, and have to do my full psych eval. Do I whip out the Wender Utah and have them sit there filling it out for 5 minutes in silence across the desk from me? That seems weird.

Child psych here. We send Vanderbilt scales to every new Intake and have them fill it out before their appointment. Then at the visit, if I think they might have ADHD, I send them home with a stack of Vanderbilts to give to teachers.

There are a lot of subtle things you can see in the visit though. For example, did they leave a personal item (jacket, water bottle, etc) in your office or waiting room? Do they have trouble sitting still or fidgeting? Are they constantly looking at the clock or looking around the room in boredom? Were they on time or late for their appointments? If they had to find a pen, how disorganized were they? Lots of things.

 

[hamstergang]

There are a lot of subtle things you can see in the visit though. For example, did they leave a personal item (jacket, water bottle, etc) in your office or waiting room? Do they have trouble sitting still or fidgeting? Are they constantly looking at the clock or looking around the room in boredom? Were they on time or late for their appointments? If they had to find a pen, how disorganized were they? Lots of things.

I wonder if any of it has been validated. Coming to the doctor, being a not-so-usual thing, can change people's behaviors. They may put themselves together better and be able to muster the effort to be on time and organized (giving you a potential false-negative), or they may be so anxious they end up late and disorganized (giving you a potential false-positive). Plus, it is 1 data point on 1 day. Are you aware of any data on the utility of such observations?

 

[digitlnoize]

I wonder if any of it has been validated. Coming to the doctor, being a not-so-usual thing, can change people's behaviors. They may put themselves together better and be able to muster the effort to be on time and organized (giving you a potential false-negative), or they may be so anxious they end up late and disorganized (giving you a potential false-positive). Plus, it is 1 data point on 1 day. Are you aware of any data on the utility of such observations?

Of course not, but these are subtle clues you can see in addition to extensive data gathering which can further shore up your diagnosis. Obviously, none of these things are diagnostic. But if you have positive Vanderbilts from patient, parents, and old/current teachers, plus a reasonable report of symptoms and examples from the patient history, plus clinical evidence from these aspects of the mental status exam, I'd say you have pretty good evidence that they have ADHD, and probably aren't "faking it". And check your state prescription monitoring program if you have one.

Also, when it doubt, get a UDS and tell them you'll screen randomly. NEVER give more medication than they should have in a month (30 pills for 30 days only). NEVER replace lost prescriptions. When in doubt consider Vyvanse, which is difficult to abuse, or Strattera, which doesn't have any real abuse potential, but works very well for most people.

 

[Trismegistus4]

I have them do it after the visit and review it later. I whip out the Barkley. If they are very early, I can have em do it before hand too. I think it may have better value getting it done before getting the history because during history gathering they may get more biased and you may get more false positives. Just my anecdotal experience. Anyone can feel free to correct me.

I've had the same thought. But often I don't know why exactly why someone is coming in, or their chief complaint turns out to be different from what it looks like it would be based on the referral. I've seen patients who dropped the "ADHD" bomb on me despite there being no mention of it in their PCP's note or the referral, and I've had patients who looked based on their chart like they wanted to get diagnosed with ADHD and put on a stimulant turn out to be coming in for just depression. So I'd have a hard time deciding whom to give it to before the appointment.

Problem is, it's going to be pretty easy for them to just give you one of their friend's phone numbers with a non-descript voice mail. This happens all the time when I prescribe Suboxone, only to find out later that the patients relapse and were likely selling it.

Well, presumably, you'd decline to prescribe a stimulant until you actually got collateral from their parents, not just dialed a phone number and got a voicemail greeting.

There are a lot of subtle things you can see in the visit though. For example, did they leave a personal item (jacket, water bottle, etc) in your office or waiting room? Do they have trouble sitting still or fidgeting? Are they constantly looking at the clock or looking around the room in boredom? Were they on time or late for their appointments? If they had to find a pen, how disorganized were they? Lots of things.

I've had 2-3 patients who had such signs, but the vast majority have no discernable signs of inattention or hyperactivity on interview. Yet they have heart-rending sob stories about how they're about to fail out of college because they can't concentrate on their schoolwork.

Of course not, but these are subtle clues you can see in addition to extensive data gathering which can further shore up your diagnosis. Obviously, none of these things are diagnostic. But if you have positive Vanderbilts from patient, parents, and old/current teachers, plus a reasonable report of symptoms and examples from the patient history, plus clinical evidence from these aspects of the mental status exam, I'd say you have pretty good evidence that they have ADHD, and probably aren't "faking it". And check your state prescription monitoring program if you have one.

Also, when it doubt, get a UDS and tell them you'll screen randomly. NEVER give more medication than they should have in a month (30 pills for 30 days only). NEVER replace lost prescriptions. When in doubt consider Vyvanse, which is difficult to abuse, or Strattera, which doesn't have any real abuse potential, but works very well for most people.

Most of these people are full-fledged adults, so I'm not going to be getting anything from teachers.

None of the ones I've seen have liked Strattera. Of the once I can convince to try it, they all either say it doesn't work, or that they have intolerable side effects.

 

[hamstergang]

Of course not, but these are subtle clues you can see in addition to extensive data gathering which can further shore up your diagnosis.

Is argue that if these have not been actually studied, then you shouldn't use them to support or refute your diagnosis. It's certainly possible for such clues to be more misleading than helpful. How hard would it be for these to be studied anyway?

 

[digitlnoize]

Most of these people are full-fledged adults, so I'm not going to be getting anything from teachers.

Why not? Adults never had a teacher who might remember them? They don't have school records? When I did adult during training, I definitely got hold of old teachers AND old school records on numerous occasions. Parents often have old report cards from elementary school saying "Johnny had trouble sitting still or keeping his hands to himself." College students have teachers. Even many adults take classes or lessons or sports or what have you. Adults also have bosses. Don't forget the diagnostic criteria say impairment in work functioning too. If patient is comfortable with it and gives you a release, you can totally get collateral about their productivity, procrastination, attention, and focus, from a boss. You can definitely get collateral for adults. I'd argue you can get more collateral than with most kids even
because they have a longer history.

If you can't find the evidence, they either don't have ADHD or you didn't look hard enough. For inattentive type at least, it's usually the later.

None of the ones I've seen have liked Strattera. Of the once I can convince to try it, they all either say it doesn't work, or that they have intolerable side effects.

Weird. Works great in kids. Either adults are different or you have a large population of malingerers...or both lol.

 

[cookymonster]

Well, presumably, you'd decline to prescribe a stimulant until you actually got collateral from their parents, not just dialed a phone number and got a voicemail greeting.

You mean you got collateral from someone who said that s/he was the patient's parent. If you're doing this over the phone, how do you know you're not talking to the patient's best friend, boss, significant other, or roommate's cousin?

 

[cookymonster]

Child psych here. We send Vanderbilt scales to every new Intake and have them fill it out before their appointment. Then at the visit, if I think they might have ADHD, I send them home with a stack of Vanderbilts to give to teachers.

Out of curiosity, do you typically see higher Vanderbilt scores from the teachers? I always wonder if their reports are biased since they probably want every kid on a stimulant. Same reason I think it's problematic to be getting collateral from a boss, though I suppose biased collateral can still be useful.

 

[cookymonster]

Why not? Adults never had a teacher who might remember them? They don't have school records? When I did adult during training, I definitely got hold of old teachers AND old school records on numerous occasions. Parents often have old report cards from elementary school saying "Johnny had trouble sitting still or keeping his hands to himself." College students have teachers. Even many adults take classes or lessons or sports or what have you. Adults also have bosses. Don't forget the diagnostic criteria say impairment in work functioning too. If patient is comfortable with it and gives you a release, you can totally get collateral about their productivity, procrastination, attention, and focus, from a boss. You can definitely get collateral for adults. I'd argue you can get more collateral than with most kids even
because they have a longer history.

If you can't find the evidence, they either don't have ADHD or you didn't look hard enough. For inattentive type at least, it's usually the later.

It's not that it's impossible; it's just that the last thing psychiatrists in the adult outpatient world want to do is spend an hour or more doing this uncompensated grunt work. It's a very different animal in CAP where parents can sit down with you face-to-face and teachers can just turn in reports that you can review during the allotted appointment time.

 

[hamstergang]

Out of curiosity, do you typically see higher Vanderbilt scores from the teachers? I always wonder if their reports are biased since they probably want every kid on a stimulant.

It's not the case at all that teachers want all their kids medicated. I have used teacher Vanderbilts to both support and refute ADHD diagnoses regularly enough. Many times it's more an issue of the kid not following rules at home and parents not have the skills to control their kid, so the parent circles 3s down the line but teachers see nothing wrong.

 

[digitlnoize]

It's not that it's impossible; it's just that the last thing psychiatrists in the adult outpatient world want to do is spend an hour or more doing this uncompensated grunt work. It's a very different animal in CAP where parents can sit down with you face-to-face and teachers can just turn in reports that you can review during the allotted appointment time.

It's not grunt work. It's called taking care of your patient. ADHD is a common and devastating neurodevelopmental illness. If there's a chance they have it, it's literally your job to figure that out. Leaving it untreated because you're afraid of stimulant abuse because you didn't get enough collateral to make you feel comfortable with your diagnosis is doing your patient and community a huge disservice.

There are just too many options for treatment today to make worrying about possible abuse a significant issue. You control the rx pad, so you give out exactly 30 pills for 30 days and see them every month. You only give medications that are difficult to abuse if you're paranoid about a possible issue. Vyvanse, Concerta, and Strattera are all very effective and have pretty low abuse potential. You monitor the state prescription monitoring program to ensure they're not filling prescriptions from other doctors. You get random UDSes.

Do you worry this much about a patient lying about depression or anxiety? Do you worry that the child of your elderly patient isn't actually their child?

The reality is that it is far easier and cheaper to score stimulants on the street or at college than paying for an appointment, filling out forms, sitting through a lengthy intake, trying to convince a doctor you have ADHD, filling out more forms, convincing a friend to impersonate your parents, training your friend on the life details you told the doctor so they can reliably impersonate your parents, hoping you're friend sounds like they are over 40 yo, then coming back to the doctor and getting prescribed Concerta, then breaking apart the capsule, attempting to extract the methylphenidate from the chamber, then snorting it and hating it because the binder in Concerta burns your nose all to hell.

Adderall is cheap and easily obtainable at many schools, so why go through all the above? Yes, it happens. Yes, you should watch for it. But if you take a reasonable history, obtain reasonable collateral, document well, check available resources (PMP), and prescribe conservative medicines, and with a tight control on quantity and frequency, there is zero reason to be this paranoid about treating patients who are suffering a debilitating psychiatric illness.

 

[cookymonster]

Whether you call it grunt work or patient care, what you can't argue with is that it's completely uncompensated and therefore most psychiatrists simply aren't going to take the time to do it at 6pm after doing 20 minute med checks all day.

I don't think that most of these patients are trying to get stimulants with the intent to abuse them. I also don't think many of them expect getting them from a doctor to be a major hassle. Once they're convinced they have it and that stimulants are the only thing that work they probably think it's as easy as getting Ambien. But once they put in the sunk cost of the appointment time, it makes sense to jump through all the hoops to getting the prescription.

Random UDS's are certainly helpful. I also worry about whether the patient could be selling the drug, which only random pill counts are really going to pick up. I have just been burned too many times by patients to whom I've prescribed controlled substances I guess, and I don't Like being a policeman. Of course I don't worry about this in depressed patients for whom I'm prescribing SSRI's, because there isn't so much obvious secondary gain to worry about. But at least with benzos it isn't so difficult to determine what it is I'm treating.

 

[Par4thecourse]

Whether you call it grunt work or patient care, what you can't argue with is that it's completely uncompensated and therefore most psychiatrists simply aren't going to take the time to do it at 6pm after doing 20 minute med checks all day.

I don't think that most of these patients are trying to get stimulants with the intent to abuse them. I also don't think many of them expect getting them from a doctor to be a major hassle. Once they're convinced they have it and that stimulants are the only thing that work they probably think it's as easy as getting Ambien. But once they put in the sunk cost of the appointment time, it makes sense to jump through all the hoops to getting the prescription.

Random UDS's are certainly helpful. I also worry about whether the patient could be selling the drug, which only random pill counts are really going to pick up. I have just been burned too many times by patients to whom I've prescribed controlled substances I guess, and I don't Like being a policeman. Of course I don't worry about this in depressed patients for whom I'm prescribing SSRI's, because there isn't so much obvious secondary gain to worry about. But at least with benzos it isn't so difficult to determine what it is I'm treating.

Taking the history is key. Doing a complete workup is critical, too. Prescribing stimulants to treat ADHD is acceptable medical practice. Prescribing them without a history and a thorough workup can be deadly. Prescribing them merely to enhance one's educational experience is immoral.