Tuesday, May 22, 2012

Adult ADHD treated by Internists

I caught this eye-opening quote in the AMNews the other day: "ADHD is common enough that the average internist has 20-80 patients with this disorder".  The physician interviewed for the article suggest getting collateral data, making the diagnosis over several visits, getting an adequate family history, using a screening instrument and not prescribing stimulants on the first visit.  The final pearl in this column is:"Any patient who gets mad that you are not prescribing a stimulant after one visit should be a red flag."  With about 150,000 internists and another 130,000 family physicians that represents a lot of adults being treated for ADHD.

The physician suggested approach in this case is fairly comprehensive and includes corroborating symptoms in childhood and adolescence, obtaining collateral information, and using a standardized checklist. There is no mention of screening for addiction, discussing prior exposure to stimulants, or the use of performance based testing as opposed to diagnostic checklists. There is also the frequent scenario of a clinic that is set up to do expensive test batteries referring patients to physicians for the purpose of prescribing stimulants and advising the referred patient that they have in fact made the diagnosis of attention deficit hyperactivity disorder.

These are not insignificant problems given the flood of stimulants available on college campuses these days and at least one cultural viewpoint using stimulants as "cognitive enhancers" rather than medications to treat a specific diagnosis. There is also no accounting for clinician to clinician variability in terms of who is prescribed stimulant medication. The largest dividing point is persons with a history of addiction and the associated politics of believing that a stimulant should not be denied anyone with the appropriate diagnosis as opposed to a person with an addiction being placed at risk by stimulant prescription.

The best approach is a network of interested clinicians who have access to uniform diagnostic and treatment methods and who are dedicated to consistent treatment practices that include not treating at least some people with stimulants and using non-stimulant approaches to the treatment of attention deficit hyperactivity disorder.

George Dawson, MD, DFAPA

Christine S. Moyer.  Orchestrating Drug Management.  American Medical News.  May 21, 2012. 55(10): 12-13.

Sahakian B, Morein-Zamir S. Professor's little helper. Nature. 2007 Dec 20;450(7173):1157-9.

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