Showing posts with label ADHD overdiagnosis. Show all posts
Showing posts with label ADHD overdiagnosis. Show all posts

Wednesday, November 26, 2014

How Do So Many People End Up on Stimulants?




There is no question that thousands if not millions of people end up taking stimulants unnecessarily these days.  Addiction psychiatrists,  have a unique perspective on this that I thinks goes beyond a typical approach to the problem.  I like to consider it to be grounded in behavioral pharmacology and neuroscience.   For the sake of this essay I will limit my remarks to all adults who are college aged or older and should not be taking stimulants.  Neuroscientific discoveries in the area of brain maturation suggest that a significant portion of the college-aged individuals might not make the same decisions they make a decade later, but the practical consideration is that there are millions of people in college making decisions about stimulants every day.  There are several ways to look at the problem.  The best approach I can think of is to look at the various ways that patients present for treatment.  The request for stimulant treatment can be subtle or overt.  Unlike some the papers in the current literature, I don't think that the diagnostic questions here are subtle.  During an initial clinical assessment - diagnosis and treatment commonly overlap and in some cases that I will illustrate treatment considerations become primary in the initial minutes of the interview.

The general psychiatric interview has always been a screen of sorts.  My recollection is that it was typically more problem focused in the past.  Over time, that interview started to incorporate more disorders as a focus of inquiry.  On the outpatient side the disorders added been primarily Post Traumatic Stress Disorder and Attention Deficit-Hyperactivity Disorder in non-geriatric populations.  Any time a screening is being done whether it uses a symptoms checklist or a lengthy interview there is always the chance of missing the true diagnosis or adding a diagnosis that is probably not there.  Here are a few examples.

1.  "I have been depressed for the past ten years...."  An inquiry about mood disorders at some point will focus on concentration.   Impaired concentration and attention span occurs in a number of psychiatric disorders.  Combined with some developmental history and a history of chronicity it is easy to see the problem as a missed diagnosis of ADHD and initiate treatment for that disorder in addition to the primary mood disorder.  There are problems with that approach especially when the history of the mood disorder is clear and it has never been adequately treated.

2.  "I have a diagnosis of bipolar disorder - manic and these medications aren't working...."  ADHD in adults rarely presents as hyperactivity so severe that it could be mistaken for mania.  Manic episodes are also phasic disturbances making it very unlikely that there would be many patients in any single practice who were both manic and had ADHD.  In the cases where it does happen stimulant treatment complicates the treatment of bipolar disorder and can lead to worsening mania, delusional thinking and hallucinations.

3.  "My son/daughter has ADHD....."  There are two variations in this interaction.  In the first, the parent is told about the high heritability of ADHD and advised that they also probably have it and can be assessed for it or mention to their primary care physician that they may need treatment for it.  In the second, the parent of a child with an ADHD diagnosis reads the diagnostic materials and comes into an appointment and says: "You know, I have read the symptoms and think that I have them.  Should I be treated for ADHD?"

4.  "I have always had a problem reading and I was  never any good in school..."  A common approach is to view this as ADHD, do the screening and proceed with treatment.  Physicians in general have had very little training in the assessment or treatment of learning disorder and although there is comorbid ADHD and learning disorders there is also a significant population of people with pure learning disorders who do not have ADHD.

5.  "I took my friend's Adderall and felt like I could concentrate and study for the first time in my life.  I did a lot better on that test...."  The population-wide bias is that stimulants are a specific treatment for ADHD rather than a drug that will temporarily improve anyone's energy level and attention span.  There is also the cultural phenomenon of cognitive enhancement or using stimulants as performance enhancing drugs that may be driving this request.  It is known that the availability of stimulants on campuses and in professional schools is widespread.  This is associated with students selling their prescriptions for profit and availability of stimulants illegally obtained for the purpose of cognitive enhancement.  The issue is further confused by position statements in scientific journals that support this practice.  I have not seen it studied, but it would be interesting to see questions and responses about cognitive enhancement asked at student health centers and practices that see a lot of college and professional students.

6.  "I have ADHD and need a prescription refill...."  It may be true that the patient has a clear-cut documented diagnosis prior to the age of 12 (DSM-5 criteria).  But what has happened since that initial diagnosis in childhood and now is critical history.  Has there been continuous treatment since then or has the treatment been disrupted.  Common causes of disruption include stimulant side effects, symptom resolution with age,  and co-occuring substance use problems.  A detailed history of the course of treatment since childhood is needed to make the decision to continue or reinitiate treatment.

7.  "I heard you had a test for ADHD...."  This question often initiates screening at a higher level.  There are any number of places with extended neuropsychological batteries, brain  imaging tests, or EEG tests that they claim will definitively diagnose ADHD.  In fact, there are no tests with that capability.  I have heard one of the top experts in the world on ADHD make that same statement and he was also a neuropsychologist.  I have had several years of experience with quantitative EEG machines and know their limitations.   At this point several hours of extended testing adds nothing to a detailed interview, review of collateral information, and symptom checklists to basically assure that all of the questions have been asked.

8.  "My meds need to be adjusted....."  This could be a question from a person in treatment for another problem or a person already being treated for ADHD.  The unstated issue here is the underlying belief that by adjusting a medication one's mental processes will be closer to perfection.  A child psychiatrist that I work with said it best:   "The goal in treating ADHD is to get them more functional, not to perfect their functioning."  I think the unrealistic goal of perfection drives a lot of prescriptions that exceed the recommended FDA limits.  It also explains a lot of "rescue medications" superimposed on sustained release preparations like Adderall.  Anyone familiar with the pharmacokinetics of sustained release drugs should realize why rescue medications (like immediate release Adderall on top of sustained release Adderall XR) are unnecessary.

9.  "I can't stay sober if I can't get treated for ADHD....."  This can be a complicated and confusing situation.  The child psychiatry literature had suggested initially that children with treated ADHD were less likely to have substance use disorders as adults than children with untreated ADHD.  As the evidence accumulates that is less clear.  Many adult psychiatrists and some addiction psychiatrists have extrapolated those equivocal findings to mean that treating a known or new diagnosis of ADHD in an adult will improve treatment outcomes for ADHD.  There is no evidence that is true.  Some addiction psychiatrists believe that the opposite is true, that there is a cross addiction phenomenon and that treating a person with an addiction makes it more difficult to stay sober from their drug of choice.  If the person is addicted to stimulant medication and has a clear history of accelerating the dose of stimulants or using them in unorthodox ways (intravenously, smoking, snorting, etc) it is very unlikely that person will be able to take a stimulant prescription in a controlled manner.  It is also very possible that the person making this request has a long history of experiencing prescription or street drugs as being necessary to regulate mental functioning.  That can be highly reinforcing even if the effects are sustained for hours or less.

10.  "I have been sober for one month and can't focus or remember anything......" Subjective cognitive problems are frequent during initial sobriety.  The substance used and total amount used over time probably determine the extent that the cognitive changes persist, but it is a difficult problem to study for those same reasons.  Clinicians know that there are cognitive effects but there is no standard approach to the problem.  From my experience, I think that two months sober is the absolute minimum time to consider evaluating subjective cognitive problems.  Even at that time getting collateral history about the person's cognitive and functional capacity and problem solving with them on work arounds would probably be the biggest part of the treatment.

The above scenarios are not exhaustive and I probably could come up with another 5 or 10 but they are illustrative of pathways to questionable stimulant use.  The common thread here is that anyone in these scenarios can endorse all of the symptoms of ADHD.  Figuring out what those symptoms are is fairly obvious on many checklists.  One of these checklists shows the symptoms and checkboxes necessary to make the diagnosis in grayed out panels.  It is easy to fake the symptoms in an interview or on a diagnostic checklist.  It takes a lot of hard work on the part of the physician to figure out not only who might be faking but also who has the symptoms but not the diagnosis.  One of the features of the DSM that was attacked by several critics during the pre-release hysteria was the "generic diagnostic criterion requiring distress or disability" to establish disorder thresholds (DSM-5 p 21).  In the case of ADHD that is Criterion D "There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning."  (DSM-5 p 60).

The diagnosis of ADHD is generally not the diagnosis of a severe functional disorder.  As a psychiatrist who practiced in a hospital setting most of the people I assessed clearly met the functional criteria by the time I saw them and diagnosed severe mood disorders, psychotic disorders, substance use disorders or dementias.   Many of them were by definition unable to function outside of a hospital setting.  It is an entirely different assessment when faced with a successful professional who has worked at a high degree of competence for 20 years who presents with any one of the above problems because they think they have ADHD.  It takes more than a review of the diagnostic criteria.   It takes an exploration of the patient's motivations for treatment.  What do they hope to accomplish by treatment?

It also takes a conservative prescribing bias on the part of the prescriber.  Stimulants are potent medications that can alter a person's state of consciousness.  They are potentially addicting medications and that can result in craving or wanting to take the medication irrespective of any therapeutic effect.  The wide availability of stimulants led to the first amphetamine epidemic in the United States.   When I first started out in psychiatry, I was still seeing people who became addicted to stimulants when they were widely prescribed for weight loss.   It is well known that the medications were ineffective for weight loss but people continued to take them at high doses in spite of the fact that they had not lost any weight.  In talking with people about what drives this many people feel like they are only competent when taking stimulants.   They believe that their cognitive and functional capacities are improved despite the fact that there is minimal evidence that this is occurring from their descriptions of what they are doing at work or in their family.

There are a number of strategies in clinical practice to avoid some of the problems with excessive stimulant prescriptions that I will address in a separate post.  My main point with this post was to look at some ways that people with mild subjective cognitive concerns, addictions, people seeking cognitive enhancement, people who have been functioning well but believe that they can function better come in to treatment for ADHD and get stimulant prescriptions.


George Dawson, MD, DFAPA

Supplementary 1:  Literature was used to construct these hypothetical scenarios.


Sunday, April 7, 2013

The “Spike” in ADHD diagnoses


There was the usual furor in the press earlier this week about a CDC Study that suggested that ADHD diagnoses have spiked up to 11%.  A previous post on this blog suggests that the real prevalence of ADHD is closer to 6-8%.  The  press predictably implicates overdiagnosis, overprescribing, a Big Pharma based culture that suggests there is a pill for everything, and of course the DSM5 – even though it has not yet been released.  What is really going on?

Before getting into my theories let me express my profound disappointment in the Centers for Disease Control (CDC).  As far as I can tell they have no actual research document on this issue, at least they did not sent me that document or link when I requested it.  The closest I can come is the web page that suggests that it may contain the data.  You can find for example – the full text of the survey that was used for this data.  If you are interested in that actual data that lists several data files that require specialty software.  So we apparently have a “scoop” by the New York Times based on getting and analyzing the data files and other interested people (like me) do not have access to the original data.  That is really not acceptable for a government funded agency.  If I am wrong here – please send me the link or the raw data, but I am very clear that the CDC did not respond to my direct request for clarification and they always have in the past.

Rather than debate the limitations of the study which is not possible because there apparently is no published version of the study, the easiest thing to do is accept that the increase is diagnoses as estimated by surveys is in fact true and go from there.  When I think about drugs that are truly overprescribed by comparison, the first class that comes to mind is antibiotics.  This trend is so well known that the CDC has run a campaign about it since 1995.  There is some consensus that progress has been made but a recent commentary describes the overall effort as a failure with antibiotic overuse as high as 50-100% in some areas and suggests a comprehensive strategy.  The table below highlights a few problems especially with regard to treating infections caused by viruses with antibiotics in the past two years.

Problem
Findings
Reference
Acute sinusitis
3 million outpatient visits/yr in US
Antibiotics prescribed in 83% of visits
50% of patient diagnosed received a macrolide or quinolone and only 20% received amoxicillin – the recommended drug
Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis.Arch Intern Med. 2012;172(19):1513-1514.
Acute Strep Pharyngitis
56% received an antibiotic and only 19.5% had a confirmed diagnosis
Nakhoul GN, Hickner J. Management of Adults with Acute Streptococcal
Pharyngitis: Minimal Value for Backup Strep Testing and Overuse of Antibiotics. J Gen Intern Med. 2012 Oct 6.

Febrile Respiratory Illness (AFI)
The context (number of cases recently seen and pandemic status) affected whether or not physicians prescribe antibiotics for AFI.
Courtney Hebert, Jennifer Beaumont, Gene Schwartz, Ari Robicsek; The Influence of Context on Antimicrobial Prescribing for Febrile Respiratory IllnessA Cohort Study. Annals of Internal Medicine. 2012 Aug;157(3):160-169.
Unnecessary fluroquinolone use in hospitalized patients
39% of fluroquinolone use was unnecessary as defined as excessive duration of therapy or use for non bacterial infection.
Werner NL, Hecker MT, Sethi AK, Donskey CJ. Unnecessary use of fluoroquinolone
antibiotics in hospitalized patients. BMC Infect Dis. 2011 Jul 5;11:187. doi:
10.1186/1471-2334-11-187.


A direct comparison of antibiotic over prescription and the possible over prescription of stimulants is instructive from several perspectives.  It may not be obvious but a clinician faced with whether or not a patient has a bacterial infection or whether they have ADHD has similar problems.  In both cases, the therapy may precede the diagnosis.  By that I mean it is often impossible on purely clinical grounds to determine whether an infection is caused by bacteria or the patient's behavioral or cognitive complaints are cause by ADHD.  If at the end of an assessment the physician comes to the conclusion of bacterial infection or ADHD a medication is prescribed.  Nobody makes a probability statement and there is often the element of an “empirical trial” – if the patient improves the treatment and the diagnosis were correct.   Since any misdiagnosed viral infections will usually improve and most people given stimulants will experience cognitive enhancement whether they have ADHD or not – the empirical trial is a highly flawed approach but one of many biases in an area of diagnostic uncertainty.

Another issue is the expectations of the patient.  Pediatricians often face irate parents if they don’t prescribe antibiotics for certain infections that are likely to be viral.  Internists and family physicians face the same problem explaining why acute bronchitis generally does not require antibiotic therapy.  Patients often have stories about multiple antibiotic failures to treat their bronchitis when it is likely that the process was viral and happened to resolve on its own after the most recent antibiotic trial.  Many patients taking stimulants for no clear reason have similar reactions when their use of stimulants is questioned.

There is the issue of complications of both therapies.  I do think that the potential harm of antibiotic overprescribing far exceeds the harm of stimulant overprescribing and that is the basis for the CDC having an initiative in this area for nearly 20 years.  On the basis of acute complications and medical side effects stimulant medications are some of the safest around.  On the other hand, I have also treated stimulant abusers who were routinely taking several times the recommended dose for years or who went on to use cocaine or other stimulants regularly and had the expected complications from addiction.

An important area of divergence between these classes of prescription drugs is the potential for addiction with stimulant medications and the new cultural movement that has been described as “cognitive enhancement”.  Both of these factors add the dimension that patients can misrepresent themselves to physicians with the intent of getting a stimulant prescription.  That does not happen with antibiotics, but the scope of the problem in terms of which drug is overprescribed more seems decidedly in favor of antibiotics at this time.  That does not bode well for the potential for even higher rates of stimulant overutilization in the future and in fact it seems obvious to me that there is no reason why it would not rise to at least the same level of antibiotics.

The reaction to these parallel problems in the press is instructive.  Rather than seeing the possible over prescription of medications as a problem inherent in the practice of medicine (like antibitotics) – a common reaction in the press is that this is a problem with over diagnosis and leaps to suggesting that the unreleased DSM5 will lead to even more diagnoses.  They quote several experts who respond strictly on the issue of whether the numbers are “real” or not.  The Director of the CDC – Thomas R. Frieden, MD makes an accurate comparison of the problem to both antibiotics and pain medications but concludes:  “The right medications for A.D.H.D., given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate.”  Clear diagnostic criteria for bacterial infections has not been the solution nearly 20 years of antibiotic over prescribing.  From what we know about trends in overprescribing, I would expect stimulant prescriptions to continue to increase irrespective of the release of the DSM5.  It will prove to be an easy scapegoat for a poorly understood problem.

The unfortunate focus of the New York Times article is the familiar: “Are drugs good or bad?”  The appropriate focus for physicians is focusing on the process and how individual and group practices can be modified to reduce overprescribing.  In most cases that would involve four additional steps – a discussion of cognitive enhancement and why it is not a good idea, screening for an addiction diagnosis, making sure that there is a clear level of functional impairment, and urine toxicology.  The effects of an assembly line approach to managing physicians and inadequate time for complex diagnostic thinking cannot be minimized.  A central collaborative model used by the University of Wisconsin for the diagnosis and treatment of dementia could be adapted to a network of clinics to treat ADHD.  This could provide the best solution to practice drift and provide clear markers for uniform prescribing.

George Dawson, MD, DFAPA


Allen Schwartz, Sarah Cohen.  ADHD Seen in 11% of US Children as Diagnoses Rise.  NYTimes March 31, 2013.

Merikangas KR, He J, Rapoport J, Vitiello B, Olfson M. Medication Use in US Youth With Mental Disorders. JAMA Pediatr.2013;167(2):141-148. doi:10.1001/jamapediatrics.2013.431.

Rubin D. Conflicting Data on Psychotropic Use by Children: Two Pieces to the Same Puzzle. JAMA Pediatr. 2013;167(2):189-190. doi:10.1001/jamapediatrics.2013.433.

Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis.  Arch Intern Med. 2012;172(19):1513-1514. doi:10.1001/archinternmed.2012.4089

Gonzales R, Ackerman S, Handley M. Can Implementation Science Help to Overcome Challenges in Translating Judicious Antibiotic Use Into Practice?: Comment on “National Trends in Visit Rates and Antibiotic Prescribing for Adults With Acute Sinusitis” and “Geographic Variation in Outpatient Antibiotic Prescribing Among Older Adults”. Arch Intern Med.2012;172(19):1471-1473. doi:10.1001/2013.jamainternmed.532

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50. doi: 10.1186/1748-5908-4-50. PubMed PMID: 19664226; PubMed Central PMCID: PMC2736161.

Hebert C, Beaumont J, Schwartz G, Robicsek A. The influence of context on antimicrobial prescribing for febrile respiratory illness: a cohort study. Ann Intern Med. 2012 Aug 7;157(3):160-9. doi: 10.7326/0003-4819-157-3-201208070-00005. PubMed PMID: 22868833.