The issue of Ritalin / Stimulant medication with ADHD and functionality

[ghost dog]

Hey folks,

I'd like to run a recent scenario by you peeps with a patient who is taking Ritalin 15 mg BID for ADHD (diagnosed by Psychiatry , for which I have the note - Ritalin started by Psych, which he has been on x 5-6 years). This 34 year old man informs me that this medication allows for increased concentration and focus, and denies related side effects with this medication. He denies alcohol or other substance abuse. A recent urine drug screen was positive for Ritalin and negative for recreational drugs.

However, he has not been working for the past 6-8 months, and was working as a full time security guard x 1 - 2 years previously prior to this period. He states that he did not " feel like " renewing his security license in regards to working in this field.

On review of systems, he endorsed depressive symptoms x years, but did not meet the DSM IV criteria for a major depressive episode. He scored 15 points on the PHQ-9. He was previously prescribed Zoloft for these symptoms in the past by Psych and endorsed benefit; he strongly requested this medication at the most recent visit, and I therefore restarted this anti-depressant.

The patient was recently assessed by psychiatry and diagnosed with Asperger's syndrome, and will be reassessed in the near future.

My question is as follows: after the patient has received an adequate trial of Zoloft ( i.e. to ensure that his depressive symptoms are not causing the diminished function - which I doubt ) , should consideration be made to stop the Ritalin ?

After all, isn't the rationale for Ritalin increased function ?

I strongly suspect that his intial diagnosis of ADHD was incorrect.

Continuation of original post: I saw this pt in f/u today. He informs me he is feeling better, and his PH-Q 9 score is now 3. The Zoloft certainly seems to be helping his dysthmia.

However, he is yet to obtain gainful employment, although he tells me he has been looking over the past few weeks for a part - time job (which I take as a good sign).

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[nitemagi]

Hey folks,

I'd like to run a recent scenario by you peeps with a patient who is taking Ritalin 15 mg BID for ADHD (diagnosed by Pyschiatry - Ritalin started by Psych, which he has been on x 5-6 years). This 34 year old man informs me that this medication allows for increased concentration and focus, and denies related side effects with this medication. He denies alcohol or other substance abuse. A recent urine drug screen was positive for Ritalin and negative for recreational drugs.

However, he has not been working for the past 6-8 months, and was working as a full time security guard x 1 - 2 years previously prior to this period. He states that he did not " feel like " renewing his security license in regards to working in this field.

On review of systems, he endorsed depressive symptoms x years, but did not meet the DSM IV criteria for a major depressive episode. He scored 15 points on the PHQ-9. He was previously prescribed Zoloft for these symptoms in the past by Psych and endorsed benefit; he strongly requested this medication at the most recent visit, and I therefore restarted this anti-depressant.

The patient was recently assessed by psychiatry and diagnosed with Asperger's syndrome, and will be reassessed in the near future.

My question is as follows: after the patient has received an adequate trial of Zoloft ( i.e. to ensure that his depressive symptoms are not causing the diminished function - which I doubt ) , should consideration be made to stop the Ritalin ?

After all, isn't the rationale for Ritalin increased function ?

IMO someone who isn't working and isn't in school doesn't need a stimulant. The gray area is when you can make a case that someone their attention problems are keeping them from getting a job. But they'd show some serious objective evidence to justify that.

 

[OldPsychDoc]

Just to play devil's advocate, "improved function" isn't just about work and school. You're saying he may have Asperger's--the methylphenidate may be boosting what limited social skills the guy has such that he's not totally dependent on family members. It might be reducing his risk of motor vehicle accidents. It might be helping him keep his ADLs organized. It's appalling to me that an attending would say "Oh he doesn't have ADHD, he has depression, so sertraline will be enough". Look at the guy's life--likely there are components of depression/dysthymia, social phobia, and inattention. You're not committing a crime by keeping someone on a low-moderate dose of methylphenidate!

 

[nitemagi]

Just to play devil's advocate, "improved function" isn't just about work and school. You're saying he may have Asperger's--the methylphenidate may be boosting what limited social skills the guy has such that he's not totally dependent on family members. It might be reducing his risk of motor vehicle accidents. It might be helping him keep his ADLs organized. It's appalling to me that an attending would say "Oh he doesn't have ADHD, he has depression, so sertraline will be enough". Look at the guy's life--likely there are components of depression/dysthymia, social phobia, and inattention. You're not committing a crime by keeping someone on a low-moderate dose of methylphenidate!

No offense OPD, but I think that's crap. No, it's not a crime, but is it really benefitting him. Since on the ritalin he has actually stopped working and even stopped pursuing work. So something's not working. And show me any data or study Anywhere that stimulants help improve social skills in autism spectrum people.

 

[ghost dog]

No offense OPD, but I think that's crap. No, it's not a crime, but is it really benefitting him. Since on the ritalin he has actually stopped working and even stopped pursuing work. So something's not working. And show me any data or study Anywhere that stimulants help improve social skills in autism spectrum people.

To be fair, this guy is unusual.

He actually finished a masters degree in economics a few years ago. His career achievement certainly is not commensurate with his educational level, that is for damn sure.

How about the argument that the Ritalin is acting as an antidepressant agent, and where he not on this, he may have met the criteria for a MDE? The only way to find this out would be to slowly and humanely taper off and reassess. Obviously this med is not a first line agent for this condition.

 

[ghost dog]

Just to play devil's advocate, "improved function" isn't just about work and school. You're saying he may have Asperger's--the methylphenidate may be boosting what limited social skills the guy has such that he's not totally dependent on family members. It might be reducing his risk of motor vehicle accidents. It might be helping him keep his ADLs organized. It's appalling to me that an attending would say "Oh he doesn't have ADHD, he has depression, so sertraline will be enough". Look at the guy's life--likely there are components of depression/dysthymia, social phobia, and inattention. You're not committing a crime by keeping someone on a low-moderate dose of methylphenidate!

The $ 64,000 question: why can't this guy go back to work with his ritalin ?

 

[dl2dp2]

The $ 64,000 question: why can't this guy go back to work with his ritalin ?

There are lots of possibilities, and the only way to figure this out is to ask him. If he's anxious, you can do med/therapy. If he lacks social skills, there's training for that.

But, from the brief story that you told, perhaps you would consider a personality disorder NOS diagnosis? Is it...gasp...time for long term psychoanalytically oriented psychotherapy? If this is the case, NO DRUG is going to make him better.

 

[OldPsychDoc]

No offense OPD, but I think that's crap. No, it's not a crime, but is it really benefitting him. Since on the ritalin he has actually stopped working and even stopped pursuing work. So something's not working. And show me any data or study Anywhere that stimulants help improve social skills in autism spectrum people.

Lots of ASD guys have attentional difficulties. We don't know from this vignette whether or not it's benefitting him, and I'm saying that you can't take from the fact that he quit his job that it is NOT benefitting him in some other way. I doubt that the work issue is merely an ADHD vs depression issue. The guy's got a masters in econ, and he's working as a security guard? I know it's a bad economy, but...

I'm not saying to keep the ritalin on because it's "fixing" him. Frankly the Zoloft isn't going to fix him either. But the meds might be a hook that keep him in therapy, help him get into and through some appropriate social skills training and/or vocational rehab. I think it's very short-sighted to take a guy this complex and pull him out of the "ADHD box" where he's getting ritalin, and stick him into a "depression box" where he gets zoloft and we applaud ourselves for diagnosing and treating him correctly as though that's all there is to it.

I'd really like to hear more from the OP about what this guy is like.

And yeah, it's just a single case, but you said "any data anywhere"--http://www.ncbi.nlm.nih.gov/pubmed/?term=aspergers%20stimulants

 

[billypilgrim37]

A bunch of adult psychiatrists debating ADHD is so cute. It's like y'all think you have a clue what you're talking about.

(and shame on you if you get mad for this one!)

 

[Chimed]

Just to play devil's advocate, "improved function" isn't just about work and school. You're saying he may have Asperger's--the methylphenidate may be boosting what limited social skills the guy has such that he's not totally dependent on family members. It might be reducing his risk of motor vehicle accidents. It might be helping him keep his ADLs organized. It's appalling to me that an attending would say "Oh he doesn't have ADHD, he has depression, so sertraline will be enough". Look at the guy's life--likely there are components of depression/dysthymia, social phobia, and inattention. You're not committing a crime by keeping someone on a low-moderate dose of methylphenidate!

I couldn't agree more. It is a fallacy to think that the only problem with ADHD are attention issues. It's so much more. I'm too lazy to pull up the articles for you, but studies suggest that the biggest impairment in ADHD is not the attentional issues, but rather the social deficits and other problems that result from ADHD. Also, folks with ADHD have markedly increased rates of divorce, problems with the law, school drop out, fired from jobs, accidents...In addition, even though there are a lot of ADHD patients that do very well in academically, ADHD has been linked with executive functioning deficits that go beyond attention. Substance abuse is also higher in ADHD. HOWEVER, the most recent evidence has shown that treating with stimulants does not increase substance abuse and, in fact, may actually be protective.

 

[whopper]

Just because someone gets an improvement with a stimulant doesn't mean they have ADHD. Anyone, ADHD or not could get improvements with focus when given that medication.

IMHO a stimulant should not be given unless the person truly has ADHD and they actually need the medication. If for example someone with ADHD was working as a carpenter, they're happy with their job, nor problems with functioning, but they can't sit through reading War and Peace, nor do they care to, there's no reason to give a stimulant.

If you really want to find out if the person has ADHD, in addition to the DSM criteria (that I find bogus--everyone has ADHD per it's guidelines), you could do a TOVA test. It's not perfect but it's the best test I've seen to test for ADHD and it does have a symptom exaggeration scale to weed out malingerers. Unfortunately few people have the training needed to administer the test.

 

[OldPsychDoc]

A bunch of adult psychiatrists debating ADHD is so cute. It's like y'all think you have a clue what you're talking about.

(and shame on you if you get mad for this one!)

Like y'all have their ADHD and ASD totally fixed when they turn 18...
You're cute too.

 

[F0nzie]

Hey folks,

However, he has not been working for the past 6-8 months, and was working as a full time security guard x 1 - 2 years previously prior to this period. He states that he did not " feel like " renewing his security license in regards to working in this field.

If he doesn't meet criteria for anything, isn't it fair to just say he lacks discipline? Seems to fit with his unwillingness to be productive. Since he has a masters degree and clearly has a skill set maybe we can call it Lack of Discipline NOS- acute onset.

 

[F0nzie]

Or how about Lack of Discipline NOS- acute on chronic. (we never get to use acute on chronic in Psychiatry)...

 

[billypilgrim37]

You're cute too.

*blushes*

 

[IAmAUser]

.

 

[Therapist4Chnge]

A bunch of adult psychiatrists debating ADHD is so cute. It's like y'all think you have a clue what you're talking about.

Because everyone knows that ADHD cures itself once the person reaches adulthood.

I couldn't agree more. It is a fallacy to think that the only problem with ADHD are attention issues. It's so much more. I'm too lazy to pull up the articles for you, but studies suggest that the biggest impairment in ADHD is not the attentional issues, but rather the social deficits and other problems that result from ADHD. Also, folks with ADHD have markedly increased rates of divorce, problems with the law, school drop out, fired from jobs, accidents...In addition, even though there are a lot of ADHD patients that do very well in academically, ADHD has been linked with executive functioning deficits that go beyond attention. Substance abuse is also higher in ADHD. HOWEVER, the most recent evidence has shown that treating with stimulants does not increase substance abuse and, in fact, may actually be protective.

I'd argue that the heterogeneity of symptoms and how they impact each person is the most problematic aspect of ADHD. I think the DSM-IV-TR does a piss-poor job of quantifying the actual symptoms of ADHD. To further complicate matters, the symptoms and subsequence problems related to adult ADHD are lesser understood, and they often present differently.

There have been some good papers that have been published in the last few years about the role of executive function/dysfunction in ADHD (I can dig up some of the references if people are interested). One of the most interesting things to come from these papers involved how executive dysfunction is being quantified and evaluated in adults with ADHD, particularly in regard to traditional neuropsychological assessment. Performance on higher-level executive functioning tasks during a neuropsychological assessment may be aided by the inherent structure of the assessment setting: quiet, controlled environment, single task focus, etc.

I'm curious if the patient in question is struggling with the lack of structure that may be inherent to many jobs requiring a master's degree, which is why he took a far less mentally taxing job. Completing a Master's degree is not a walk in the park, but there is typically more structure imposed on pursuing a degree than would be found "out in the real world". With that being said, I definitely think effort needs to be formally evaluated, axis-II features explored, and secondary gains considered.

If you really want to find out if the person has ADHD, in addition to the DSM criteria (that I find bogus--everyone has ADHD per it's guidelines), you could do a TOVA test. It's not perfect but it's the best test I've seen to test for ADHD and it does have a symptom exaggeration scale to weed out malingerers. Unfortunately few people have the training needed to administer the test.

The TOVA is a great start, but I agree…there is far more training and expertise needed to tease out legitimate cases of ADHD. My personal batteries for child v. adult ADHD can vary quite a bit, partly due to some of the things I mentioned above.

 

[billypilgrim37]

Because everyone knows that ADHD cures itself once the person reaches adulthood.

Well, some ADHD does get quite a bit better in adulthood!

It's baffling that adult psychiatrists get so little training in ADHD but are now expected to treat it and have intelligent opinions about it. Our adult ADHD clinic was started by and is run by child psychiatrists. I have never met an adult psychiatrist who seemed comfortable with ADHD. I've met adult psychiatrists who are excessively conservative because they don't feel comfortable with their own assessment skills (but are usually pretty unaware that's why they're so uncomfortable). I've met adult psychiatrists who don't "believe" in ADHD, like ADHD is Santa Claus or something like that. And I've met adult psychiatrists who want to hand out stimulants to people like they're handing out french fries in the McDonald's drive-through. All three of these approaches leave something to be desired.

If the most effective treatment for ADHD weren't a highly abused and divertable and even dangerous substance, the debates would be entirely different. You might not be talking about "legitimate cases of ADHD" any more than you'd be talking about "legitimate cases of MDD" or "legitimate cases of schizoaffective disorder." Would Whopper be sending patients for a TOVA if the first line treatment for ADHD was clonidine or bupropion? I doubt it. He's probably sending everybody for a TOVA because the risk of treatment with a stimulant is high. Is it a reasonable thing to do? Sure. Is it something he would do if he did a child fellowship? Probably not. And the reason wouldn't be because child psychiatrists are cowboys. And it's not because he isn't a really good psychiatrist.

 

[sunlioness]

Or how about Lack of Discipline NOS- acute on chronic. (we never get to use acute on chronic in Psychiatry)...

I always thought MDD + Dysthymia was our version of acute on chronic.

Yeah, and I'm not overly comfortable with ADHD. Yet I get patients with the diagnosis or thinking they have the diagnosis all the time. I would love to learn more about it and how to administer the TOVA. Because ideally while I would like to refer people to testing, there are only so many neuropsychologists and access overall to our department just plain sucks. So I've only been referring when I'm really worried they're full of crap.

 

[Suedehead]

cool debate. essentially it's the old 'I only treat diseases' vs 'I'm ok with cognitive enhancement' debate. a good one. still raging. not sure if there's an answer until psychiatry is able to make more sense of itself...

 

[billypilgrim37]

cool debate. essentially it's the old 'I only treat diseases' vs 'I'm ok with cognitive enhancement' debate. a good one. still raging. not sure if there's an answer until psychiatry is able to make more sense of itself...

Well if you put it that way, I'm gonna go play with Whopper and NiteMagi!

 

[AcronymAllergy]

Because everyone knows that ADHD cures itself once the person reaches adulthood.


I’d argue that the heterogeneity of symptoms and how they impact each person is the most problematic aspect of ADHD. I think the DSM-IV-TR does a piss-poor job of quantifying the actual symptoms of ADHD. To further complicate matters, the symptoms and subsequence problems related to adult ADHD are lesser understood, and they often present differently.

There have been some good papers that have been published in the last few years about the role of executive function/dysfunction in ADHD (I can dig up some of the references if people are interested). One of the most interesting things to come from these papers involved how executive dysfunction is being quantified and evaluated in adults with ADHD, particularly in regard to traditional neuropsychological assessment. Performance on higher-level executive functioning tasks during a neuropsychological assessment may be aided by the inherent structure of the assessment setting: quiet, controlled environment, single task focus, etc.

I’m curious if the patient in question is struggling with the lack of structure that may be inherent to many jobs requiring a master’s degree, which is why he took a far less mentally taxing job. Completing a Master’s degree is not a walk in the park, but there is typically more structure imposed on pursuing a degree than would be found “out in the real world”. With that being said, I definitely think effort needs to be formally evaluated, axis-II features explored, and secondary gains considered.


The TOVA is a great start, but I agree…there is far more training and expertise needed to tease out legitimate cases of ADHD. My personal batteries for child v. adult ADHD can vary quite a bit, partly due to some of the things I mentioned above.

Some great points, particularly with respect to how ADHD can be exhibited significantly differently in adults vs. children. Executive functioning deficits as central to ADHD is one of the current theories being academically "kicked around" (read pretty much anything published by Barkley over the past two decades to get a general overview, or by Quay for an even earlier take), as are theories on short, frequent attentional mini-lapses due to dysfunction in frontostriatal and frontoparietal networks (particularly the Default Mode Network) ala Sonuga-Barke and Castellanos; frontostriatal network dysfunction potentially owing to/resulting in catecholaminergic disruption leading to faulty conditioning/extinction ala Sagvolden; and disrupted energetic states ala Sergeant. Plus, there's also the idea that the predominantly inattentive type, in the lifelong absence of hyperactivity, may reflect an entirely distinct disorder.

While I'm not a physician, I tend to agree with others in the thread who've essentially said that if the patient's ADHD (or particularly if it isn't ADHD to begin with) isn't causing significant functional impairment, he probably shouldn't be receiving Ritalin for it.

 

[billypilgrim37]

While I'm not a physician, I tend to agree with others in the thread who've essentially said that if the patient's ADHD (or particularly if it isn't ADHD to begin with) isn't causing significant functional impairment, he probably shouldn't be receiving Ritalin for it.

I don't think many of us would disagree with that statement for most psychiatric medications, not just MPH.

 

[whopper]

I would love to learn more about it and how to administer the TOVA

I was purely lucky in working in a practice where we have a psychologist who does this, in fact I've learned some things I never knew before in terms of practice. E.g. I've had a few patients coming in not complaining of ADHD and only sx of anxiety that I thought were purely just an anxiety disorder but TOVA testing showed they had ADHD, SSRIs or SNRIs didn't work and then, beyond my expectation, and only because they had a TOVA test that was (+), I tried a stimulant and their anxiety went away. These people never once tried to get a diagnosis of ADHD and never wanted a stimulant until they tried it and the anxiety went away.

This brought in to question the language of diagnosis. E.g. several patients with generalized anxiety disorder mention "racing thoughts" that can make a clinician automatically think bipolar disorder. Excessive anxiety indeed could be described as racing thoughts. I thought to myself that if someone had ADHD and couldn't focus, they could be describing their problem in a manner that sounds simply like anxiety. E.g. if someone had the hyperactivity component of ADHD and spent most of their time just trying to sit still, that could cause anxiety. Several of the DSM criteria for GAD I've seen in ADHD patients even though they are or aren't on the diagnostic list such as poor sleep (several ADHD patients I've seen tell me they can't sleep because their mind is "all over the place"), or distractability and poor concentration.

If I ever form my own private practice, and it's something I may do down the road if I choose to not permanently work with the university (by the way I'm taking up their job offer, becoming an assistant professor and I'll be working with the residency program and forensic fellowship), I'm definitely going to learn TOVA testing or hire someone who can do it for me. It's been one of the only ways I have some means to truly believe the person had ADHD other than their claims.

Until then, and I'm falling into my own trap of being the psychiatrist calling for more research while not doing it myself in this area, better diagnostic measures should be used but clinicians should do better than simply use a self-report scale that could be easily faked. Another treatment I haven't seen people use is a form of EEG-feedback for ADHD that reduces or eliminates the need for medication called Play Attention. I've read about it but never got the training in it.

 

[Suedehead]

This brought in to question the language of diagnosis. E.g. several patients with generalized anxiety disorder mention "racing thoughts" that can make a clinician automatically think bipolar disorder. Excessive anxiety indeed could be described as racing thoughts. I thought to myself that if someone had ADHD and couldn't focus, they could be describing their problem in a manner that sounds simply like anxiety. E.g. if someone had the hyperactivity component of ADHD and spent most of their time just trying to sit still, that could cause anxiety. Several of the DSM criteria for GAD I've seen in ADHD patients even though they are or aren't on the diagnostic list such as poor sleep (several ADHD patients I've seen tell me they can't sleep because their mind is "all over the place"), or distractability and poor concentration.

This is well said. Our nosology just isn't enough to differentiate these complicated human experiences.

But even good nosology wouldn't answer the problem of risk/benefit analysis. E.g., just yesterday I saw for the first time a 24 yo white male with borderline intellectual functioning (maybe an IQ of 70-75) with autistic features who was dx'd with adhd at age 13 and has been on stimulants on and off since then. Mom says the stimulants may help a 'little bit' like by increasing his motivation and focus, like it 'turns on a little light in his brain.' without the stimulant he's his same old self, just a little less so. risk/benefit? Does he have problems with focus? Yes. Does the stimulant help? Sure, a little. Does he have ADHD. Well, no, not exactly, but he definitely has cognitive impairment. Are we treating a 'disease' (whatever that is)? not really. Is the stimulant providing cognitive enhancement? likely. Am I okay with this? not totally... but sigh.

I stopped the stimulant. will see in a few weeks.

 

[ghost dog]

This is well said. Our nosology just isn't enough to differentiate these complicated human experiences.

But even good nosology wouldn't answer the problem of risk/benefit analysis. E.g., just yesterday I saw for the first time a 24 yo white male with borderline intellectual functioning (maybe an IQ of 70-75) with autistic features who was dx'd with adhd at age 13 and has been on stimulants on and off since then. Mom says the stimulants may help a 'little bit' like by increasing his motivation and focus, like it 'turns on a little light in his brain.' without the stimulant he's his same old self, just a little less so. risk/benefit? Does he have problems with focus? Yes. Does the stimulant help? Sure, a little. Does he have ADHD. Well, no, not exactly, but he definitely has cognitive impairment. Are we treating a 'disease' (whatever that is)? not really. Is the stimulant providing cognitive enhancement? likely. Am I okay with this? not totally... but sigh.

I stopped the stimulant. will see in a few weeks.

The plot thickens.....

I didn't want to give too much information at once, but this patient also presented with atrial flutter which eventually required elective cardioversion to correct it. Could Ritalin have been a contributing factor to this problem ? Possibly. The risk / benefit balance to this medication has just changed.

The cardiologist mentioned it as an afterthought (i.e. Ritalin wasn't contraindicated in this situation, but he did question it's use).

What do you think now?

 

[billypilgrim37]

The plot thickens.....

I didn't want to give too much information at once, but this patient also presented with atrial flutter which eventually required elective cardioversion to correct it. Could Ritalin have been a contributing factor to this problem ? Possibly. The risk / benefit balance to this medication has just changed.

The cardiologist mentioned it as an afterthought (i.e. Ritalin wasn't contraindicated in this situation, but he did question it's use).

What do you think now?

Agreed, the risk/benefit calculus is heavily tipped. I wouldn't touch a stimulant in that situation unless there was a fantastic reason for it, and I can't even imagine a fantastic enough reason.

 

[nitemagi]

The plot thickens.....

I didn't want to give too much information at once, but this patient also presented with atrial flutter which eventually required elective cardioversion to correct it. Could Ritalin have been a contributing factor to this problem ? Possibly. The risk / benefit balance to this medication has just changed.

The cardiologist mentioned it as an afterthought (i.e. Ritalin wasn't contraindicated in this situation, but he did question it's use).

What do you think now?

Meh. A little aflutter never killed anyone

 

[AcronymAllergy]

This brought in to question the language of diagnosis. E.g. several patients with generalized anxiety disorder mention "racing thoughts" that can make a clinician automatically think bipolar disorder. Excessive anxiety indeed could be described as racing thoughts. I thought to myself that if someone had ADHD and couldn't focus, they could be describing their problem in a manner that sounds simply like anxiety. E.g. if someone had the hyperactivity component of ADHD and spent most of their time just trying to sit still, that could cause anxiety. Several of the DSM criteria for GAD I've seen in ADHD patients even though they are or aren't on the diagnostic list such as poor sleep (several ADHD patients I've seen tell me they can't sleep because their mind is "all over the place"), or distractability and poor concentration.

Good points, which is why it's always important to inform your interpretation of a self-report personality/psychopathology inventory (e.g., PAI, MMPI) with information gathered via clinical interview. Individuals with ADHD can endorse items belonging to anxiety- and even psychoticism-loading scales (e.g., "there's something wrong with my thinking"). Also, as I'm sure most here are aware and have seen in their own clinical experiences, symptoms of untreated sleep apnea/chronic poor sleep habits can sometimes "masquerade" as ADHD. And yes, the symptom self-reports of individuals with anxiety disorders and attentional disorders in particular can often look amazingly similar, nevermind the relatively high base rate of some ADHD symptoms reported in the general population.

 

[whopper]

I got a guy now with two prior MIs, HTN, high cholesterol, he smokes, and I got him on a stimulant....

The guy's also got an eating disorder IMHO---not lack of eating but too much of it. For example, I suggested he carry a picture of a rat on a stick and that anytime he had a desire to eat he take a look at the picture. My intent would be it would ruin his appetite. He readily told me that if he saw a rat on a stick he'd want to eat it and that when he drives by roadkill he wants to pick up the dead animal and eat it. I'm not joking. He said he'll eat anything that's edible.

I allowed a stimulant only because his anxiety without it is through the roof, 4 SSRIs were tried and failed to treat the anxiety, Wellbutrin didn't work, Strattera wasn't tried because that too could cause cardiac side effects and we spent lengthy sessions with him and his wife present explaining the risks and benefits and he opted to take a stimulant with full knowledge that it could tip the scales with his health. His cardiologist was also informed.

Now since then, each time he's been to my office his BP was through the roof and he admitted forgetting to take his BP meds, yet he doesn't forget to take his stimulant. If this happens again, I'm thinking of terminating him as a patient.

The data that's recently come out suggests that stimulants are not connected with cardiac problems but only in children and young adults. A guy in his mid 50s with prior cardiac events, and nothing else seems to work, I hate cases like that. Damned if you do, damned if you don't and merely teriminating him because he's a hard patient isn't fair to him.

 

[F0nzie]

The guy's also got an eating disorder IMHO---not lack of eating but too much of it. For example, I suggested he carry a picture of a rat on a stick and that anytime he had a desire to eat he take a look at the picture. My intent would be it would ruin his appetite. He readily told me that if he saw a rat on a stick he'd want to eat it and that when he drives by roadkill he wants to pick up the dead animal and eat it. I'm not joking. He said he'll eat anything that's edible.

There is an increasing amount of evidence that indicates inflammation may play a significant role in the development of depression. There is also evidence that administering inflammatory agents may induce depressive symptoms in individuals. I like conceptualize eating burgers and fries as "inflammatory" foods vs. healthier fruits and vegetables as "anti-inflammatory" foods. I love fast food, don't get me wrong- but we all know it eventually makes us all feel like **** after a while (some people sooner than later). We also know obesity may be a risk factor for depression- from a biologic standpoint adipose tissue which contains alot of inflammatory factors may be a contributing factor. And not to discount the psychological impact of being obese with heart disease (poor self-esteem, poor self-image, guilt, lack of self-efficacy etc.) which may also contribute to depression/anxiety. These kinds of cases are difficult and disheartening- you can do all the education and support in the world but in the end you can take a horse to water but you can't make it drink.

He readily told me that if he saw a rat on a stick he'd want to eat it and that when he drives by roadkill he wants to pick up the dead animal and eat it.

That is freaking sick...

 

[ghost dog]

I got a guy now with two prior MIs, HTN, high cholesterol, he smokes, and I got him on a stimulant....

The guy's also got an eating disorder IMHO---not lack of eating but too much of it. For example, I suggested he carry a picture of a rat on a stick and that anytime he had a desire to eat he take a look at the picture. My intent would be it would ruin his appetite. He readily told me that if he saw a rat on a stick he'd want to eat it and that when he drives by roadkill he wants to pick up the dead animal and eat it. I'm not joking. He said he'll eat anything that's edible.

I allowed a stimulant only because his anxiety without it is through the roof, 4 SSRIs were tried and failed to treat the anxiety, Wellbutrin didn't work, Strattera wasn't tried because that too could cause cardiac side effects and we spent lengthy sessions with him and his wife present explaining the risks and benefits and he opted to take a stimulant with full knowledge that it could tip the scales with his health. His cardiologist was also informed.

Now since then, each time he's been to my office his BP was through the roof and he admitted forgetting to take his BP meds, yet he doesn't forget to take his stimulant. If this happens again, I'm thinking of terminating him as a patient.

The data that's recently come out suggests that stimulants are not connected with cardiac problems but only in children and young adults. A guy in his mid 50s with prior cardiac events, and nothing else seems to work, I hate cases like that. Damned if you do, damned if you don't and merely teriminating him because he's a hard patient isn't fair to him.

Yes, but is this type of non-compliant crap fair to you as his treating physician ?

I think it is a reasonable expectation that patients comply with their other doctors recommendations (i.e. take their BP meds, and not die of sudden cardiac arrest).

I think this might put you in a potentially medicolegally unenviable position when your stimulant script is found in this patient's house should he expire from heart related causes. From your above description, it's not a matter of if, but when.

Notwithstanding what the current literature says on the subject of stimulant and CV death - a personal injury lawyer will see the adverse reactions / contradindications on the stimulant monograph and go nuts.

 

[IT514]

If he doesn't meet criteria for anything, isn't it fair to just say he lacks discipline? Seems to fit with his unwillingness to be productive. Since he has a masters degree and clearly has a skill set maybe we can call it Lack of Discipline NOS- acute onset.

Did you completely miss the diagnosed with Asperger's part? Yes he has a masters because he can function in an academic setting, but cant find a "real world" job in his field due to social skills deficits and social anxiety.

I would expect the SSRI to play a larger role in helping this guy if he does in fact have Aspergers, ideally coupled with therapy.

 

[OldPsychDoc]

I got a guy now with two prior MIs, HTN, high cholesterol, he smokes, and I got him on a stimulant....
...I allowed a stimulant only because his anxiety without it is through the roof, 4 SSRIs were tried and failed to treat the anxiety, Wellbutrin didn't work, Strattera wasn't tried because that too could cause cardiac side effects and we spent lengthy sessions with him and his wife present explaining the risks and benefits and he opted to take a stimulant with full knowledge that it could tip the scales with his health. His cardiologist was also informed.

Now since then, each time he's been to my office his BP was through the roof and he admitted forgetting to take his BP meds, yet he doesn't forget to take his stimulant. If this happens again, I'm thinking of terminating him as a patient.
.

You don't need to terminate him, but this is a guy I would totally stop prescribing stims to (and I'm really not averse to prescibing stims where I think they're called for, as you see above). Document that he's not compliant with recommended treatment and that you're no longer willing to accept the risk of him having an adverse event. Play up the BP meds for his anxiety. Also, is he drinking? My suspicions are "through the roof" too.

 

[whopper]

Agree with all the above.

I made him bring his wife and make her agree to give out his meds. I even used speech such as...

"I saw a Deniro movie and he told a guy he was planning to kill and said I'm talkig at a dead man. I don't want to kill you but unless you get your blood pressure under control you could realistically be a dead man in a few months if not years. I don't want to have contributed to that."

I did not feel it would be right to terminate him as a patient or his stims based on 1 or two times with his BP being high. Another time, I'm going to say that was his last (edit-forgot to write the word "last" when I first posted this) strike....damned if he feels terrible without them. He's going to have to find another doctor to give them out.

here is also evidence that administering inflammatory agents may induce depressive symptoms in individuals.

I totally agree. With the exception of very very good inflammatory agents (e.g. Beef Wellington, filet mignon), I pretty much avoid beef entirely. I've been trying to get several of my patients to engage in an antiinflammatory diet.

 

[pre med 2014]

A bunch of adult psychiatrists debating ADHD is so cute. It's like y'all think you have a clue what you're talking about.

(and shame on you if you get mad for this one!)

A bunch of MDs discussing which severely disabling fake diagnosis to give to a person is scary.

 

[pre med 2014]

To be fair, this guy is unusual.

He actually finished a masters degree in economics a few years ago. His career achievement certainly is not commensurate with his educational level, that is for damn sure.

If you guys keep giving him diagnosis', pretty soon the only career option he is going to have is janitor.

 

[Therapist4Chnge]

A bunch of MDs discussing which severely disabling fake diagnosis to give to a person is scary.

 

[nitemagi]

 

[pre med 2014]

But, from the brief story that you told, perhaps you would consider a personality disorder NOS diagnosis? Is it...gasp...time for long term psychoanalytically oriented psychotherapy?

I am not a troll, it is comments like the one above that incite passionate responses against psychiatry. As a diagnosis of personality disorder could severely handicap a person going into any professional career requiring you to fill out one of those sheets that asks "if you've ever been diagnosed with a mental illness".

As a pilot I know completely normal people's lives severely burdened if not ruined by Psychiatry.

There was a court case in 2006 of a poor fellow who couldn't get his pilot license because he faked symptoms of Schizophrenia to get attention as a teenager, btw, other Psychiatrists undiagnosed this and agreed but that is how strong the label is. These are the kind of cases that really grind my gears about Psychiatry.

I have a suspicion kids who've been diagnosed with ADD don't have the easiest time getting a pilot license as it is a disqualifying condition under the FARs. Which is completely unfair, since everyone from high school I've ever known with 'ADD' was a completely normal person fully capable of flying an airplane. There really isn't that much thinking that goes into it guys. Up, down, left, right.

Perhaps Psychiatrists should change their treatments to cures, so when the issue is no longer a problem for the patient, they don't have to be burdened with the handicap of the diagnosis? This of course is logic and considering how much subjectivity is involved in any diagnosis it would only be reasonable.

 

[nitemagi]

I am not a troll, it is comments like the one above that incite passionate responses against psychiatry. As a diagnosis of personality disorder could severely handicap a person going into any professional career requiring you to fill out one of those sheets that asks "if you've ever been diagnosed with a mental illness".

As a pilot I know completely normal people's lives severely burdened if not ruined by Psychiatry.

There was a court case in 2006 of a poor fellow who couldn't get his pilot license because he faked symptoms of Schizophrenia to get attention as a teenager, btw, other Psychiatrists undiagnosed this and agreed but that is how strong the label is. These are the kind of cases that really grind my gears about Psychiatry.

I have a suspicion kids who've been diagnosed with ADD don't have the easiest time getting a pilot license as it is a disqualifying condition under the FARs. Which is completely unfair, since everyone from high school I've ever known with 'ADD' was a completely normal person fully capable of flying an airplane. There really isn't that much thinking that goes into it guys. Up, down, left, right.

Perhaps Psychiatrists should change their treatments to cures, so when the issue is no longer a problem for the patient, they don't have to be burdened with the handicap of the diagnosis? This of course is logic and considering how much subjectivity is involved in any diagnosis it would only be reasonable.

So your issue with psychiatry is that laymen who are not psychiatrists take our diagnoses too seriously. That should be a beef you take up with the FAA, not psychiatry. WE recognize where the gaps in our knowledge are. You should put your energy into better educating the public into the complexity of mental illness, and that like all of science it's a work in progress, rather than feeding the vitriol of the ignorant, undereducated, and antagonistic.

There are almost no "cures" in any area of medicine. As I've written before, most medical conditions are managed, not cured. Asthma. Cancer. Hypertension. Even an infected appendix is removed, not "cured."

 

[pre med 2014]

So your issue with psychiatry is that laymen who are not psychiatrists take our diagnoses too seriously. That should be a beef you take up with the FAA, not psychiatry. WE recognize where the gaps in our knowledge are. You should put your energy into better educating the public into the complexity of mental illness, and that like all of science it's a work in progress, rather than feeding the vitriol of the ignorant, undereducated, and antagonistic.

There are almost no "cures" in any area of medicine. As I've written before, most medical conditions are managed, not cured. Asthma. Cancer. Hypertension. Even an infected appendix is removed, not "cured."

I agree, a large part of the problem is government regulation.

 

[PETRAN]

A bunch of MDs discussing which severely disabling fake diagnosis to give to a person is scary.

I have a suspicion kids who've been diagnosed with ADD don't have the easiest time getting a pilot license as it is a disqualifying condition under the FARs. Which is completely unfair, since everyone from high school I've ever known with 'ADD' was a completely normal person fully capable of flying an airplane. There really isn't that much thinking that goes into it guys. Up, down, left, right

ADHD is real though. It is a form of (most possibly) congenital frontal lobe dysfunction and i'm not sure if it is surely a good idea for someone to fly a plane if he/she forgets all the time where has his left his/her keys, gets distracted very easilty from whatever, is impulsive and can't concentrate to a single source for more than a few seconds, just saying...



(maybe neuropsychological testing would be more appropriate to reveal the degree of fucntionality since, IMO, ADH is more like a syndrome or "spectrum" rather than a clear-cut disorder)

 

[pre med 2014]

ADHD is real though. It is a form of (most possibly) congenital frontal lobe dysfunction and i'm not sure if it is surely a good idea for someone to fly a plane if he/she forgets all the time where has his left his/her keys, gets distracted very easilty from whatever, is impulsive and can't concentrate to a single source for more than a few seconds, just saying...



(maybe neuropsychological testing would be more appropriate to reveal the degree of fucntionality since, IMO, ADH is more like a syndrome or "spectrum" rather than a clear-cut disorder)

As a pilot, I ALWAYS stand against Psychiatry.

 

[whopper]

Perhaps Psychiatrists should change their treatments to cures, so when the issue is no longer a problem for the patient, they don't have to be burdened with the handicap of the diagnosis?

Hmm, well trust me, if I knew a cure to schizophrenia, I'd make it known. If you go into medicine, by the time you graduate, you'll have as much mental prowess in finding a cure as I would. You should take your own advice and find a cure.

As a pilot, I ALWAYS stand against Psychiatry.

Well I don't see a connection with being a pilot and having to stand against psychiatry. I will say that I've seen plenty of bad psychiatrists and if my only psychiatric experience ever was with one of those bozos, I'd be against psychiatry too. There are bad doctors in every field, but there too are good ones.

 

[Fastball32]

I agree General Psychiatrists will need to be more comfortable with treating ADHD.
When DSM-5 comes out, the ADHD criteria will change and now specifically account for older adolescents and adults.

A few of the highlighted changes:
- Age requirements for children will be raised from "by age 7", to now "by age 12".
- For people over 17yo, they will only need 4 symptoms instead of the current 6.

With these proposed revisions, there will be a LOT more adults and children who meet criteria for ADHD... This will have a lot of ramifications...
This could be a separate thread in itself.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383

 

[nitemagi]

I agree General Psychiatrists will need to be more comfortable with treating ADHD.
When DSM-5 comes out, the ADHD criteria will change and now specifically account for older adolescents and adults.

A few of the highlighted changes:
- Age requirements for children will be raised from "by age 7", to now "by age 12".
- For people over 17yo, they will only need 4 symptoms instead of the current 6.

With these proposed revisions, there will be a LOT more adults and children who meet criteria for ADHD... This will have a lot of ramifications...
This could be a separate thread in itself.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383

I'm still not going to use stimulants in my PP.

 

[Fastball32]

I'm still not going to use stimulants in my PP.

Although nothing works as well as stimulants for "true" ADHD, I still like your response.
Child Psychiatrists have a different level of comfort with ADHD and stimulants and will continue to use stimulants.
What's concerning is Family Physicians, who initially have less experience with ADHD and with the proposed revisions to ADHD in DSM-5, will be the target for many drug reps.

 

[nitemagi]

Although nothing works as well as stimulants for "true" ADHD, I still like your response.
Child Psychiatrists have a different level of comfort with ADHD and stimulants and will continue to use stimulants.
What's concerning is Family Physicians, who initially have less experience with ADHD and with the proposed revisions to ADHD in DSM-5, will be the target for many drug reps.

It's blazingly clear to me that if you go through all the podcasts available online for psychiatry CME's, one after another (at least 75%) are on ADHD treatment. Coincidence? I think not. Pharma has found the loophole to the drug dinner. Sponsor the "topic" in general to "increase awareness," which is a nice indirect way of marketing their medication for said condition. Same thing is happening with primary insomnia, fibromyalgia, female sexual desire disorder...

I'm not looking to get into it as to whether each of these are legitimate conditions, just saying it's magical how CME's magically seem to pop up based on what's now FDA approved (or pending approval), rather than what's old hat or can be treated with generics.

/Soapbox off.

 

[Bernardo_11]

I agree General Psychiatrists will need to be more comfortable with treating ADHD.
When DSM-5 comes out, the ADHD criteria will change and now specifically account for older adolescents and adults.

A few of the highlighted changes:
- Age requirements for children will be raised from "by age 7", to now "by age 12".- For people over 17yo, they will only need 4 symptoms instead of the current 6.

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=383

The bolded text above is concerning to me. I always thought 7 years of age was a good set point to identify the presence of ADHD symptoms in early childhood. By increasing it to 12, I think there will be many older children misdiagnosed with ADHD, but what they may have instead is an underlying Learning Disability.

For example, a 13 year old comes in with ADHD symptoms for the past couple of years, perhaps meeting all the criteria for ADHD, inattentive type. You find that they were model students throughout Elementary school (no behavioral problems, straight A's, etc.). But come middle school, the academic demands become difficult and the student starts failing specific subjects. Teachers note that they have poor focus, unable to stay on task, problems completing homework.

I've always found the "before age 7" requirement to be useful in helping me demarcate the two. Granted both ADHD and LD can be co-morbid with each other, but I would just hate to see a student with LD not getting their educational needs met, all the while masking some of the symptoms with stimulant medication (which I would wholeheartedly prescribe if there was any indication of ADHD symptoms, especially if they occur during non-academic tasks).

Nardo