ADHD - 28 Discussion Points

 

There was some of the usual controversy in the media today.  Is Attention Deficit~Hyperactivity Disorder over diagnosed or underdiagnosed?  The usual controversy contained the usual stories of how easy it is to get a diagnosis of ADHD in some places.  In some places it seems like just a matter of expense - a thousand dollar test battery. In other places there are people disabled by the condition who cannot get adequate treatment.  In the meantime there are international experts cranking out reams of papers on the importance of diagnosing and treating this condition in childhood. Occasionally an article shows up in the papiers about the cardiovascular safety of these medications. And in the New England Journal of Medicine there was a paper about a higher incidence of psychosis due to these medications.  Where does the reality lie?

I was fortunate enough to have worked at a substance use treatment center for about 12 years just prior to retiring. Only adults were treated at that facility. A significant number of them were diagnosed and treated as children. There were also a significant number of patients newly diagnosed as adults - some as old adults in their 60s and 70s. Whether or not ADHD can occur as a new diagnosis during adulthood is controversial and establishing a history consistent with childhood ADHD is problematic due to recall errors and biases. Secondary causes of ADHD in adults such as substance use problems and brain injuries increases in prevalence.  Although I am speculating, secondary causes seem a more likely cause of attentional symptoms in adults and therefore acquired ADHD without childhood ADHD if it does exist is an entirely different problem.

Prescribing stimulants to patients who may have stimulant use disorders is problematic for a number of reasons. Initially we had an administrative safeguard on the practice. Stimulant prescriptions could only be approved with a second opinion by another psychiatrist after reviewing the record. Eventually we had a core of psychiatrists who practiced the same way and the second opinion was no longer necessary.  Over the course of 12 years I developed these discussion points.  I think they are a good example of the minimum ground you need to cover in an evaluation for ADHD.  I typically had a 60-90 minute time frame to work with and could see people on a weekly basis for 30 minute follow ups. These evaluations were often controversial and resulted in collateral contacts, typically with a family member who was advocating for the stimulant prescription. 

A few basic points about ADHD and establishing the diagnosis. Like many psychiatric disorders there is no gold standard test.  Like some of the media discussions, I have been told that a person underwent days of testing before they were given the diagnosis of ADHD.  These are typical paper and pencil tests, but there have also been tests based on watching a computer screen and even crude EEG recordings. There are a few places that use very sophisticated brain imaging techniques. Unfortunately none of these methods can predict a clear diagnosis or safe and effective use of a medication that can reinforce its own use.  That leaves clinicians with diagnostic criteria and and a cut off based on functional status as a result of those symptoms.  That may not sound like much, but it eliminates a large pool of prospective ADHD patients who have no degree of impairment and those who are obviously interested in possible performance enhancement rather than ADHD treatment.  

Stimulant medications are highly abusable, as evidenced by several epidemics of use dating as far back as 1929. We are in the midst of a current epidemic.  For those reasons it is important not to add to the problem as either the individual or population levels. In my particular case, I was seeing patients who were all carefully screening for substance use and adequate toxicological screening. Since they voluntarily admitted themselves into a treatment center it was also more likely that they recognized the severity of the problem and were more open to treatment.  Even against that background - it is worth covering the above points.  Covering those points often involves repetition because of cognitive problems in detox or disagreement.

These are just a few health and safety considerations. My main concern in this area is that psychiatric treatments somehow have the reputation that they don't require medical attention. They are somehow isolated from the rest of the body. The person prescribing this medication needs to assess the total health status of the individual and determine if the medication prescribed is safe to use. Cardiac and neurological conditions are at the top of that list. I gave a blood pressure example because I have been impressed with how many people tell me that their blood pressure was not checked after a stimulant prescription or a stimulant was started despite diagnoses of uncontrolled hypertension, cardiovascular disease, cardiac arrhythmias or cerebrovascular disease.  These were typically new prescriptions in older adults with no prior history of ADHD.  

Coexisting psychiatric disorders are also problematic. Most have associated cognitive symptoms if they are inadequately treated. That is not a reason to diagnose ADHD or start a stimulant medication.  Typical symptoms that can be caused by stimulants are have to be recognized and the medication must be stopped if adjusting the dose is not helpful.

It is important to keep the range of biological heterogeneity in mind. Once you have narrowed down a population of people who most likely have ADHD, they will not all have a uniform response to medication.  They may not all want to take medication.  As adults many stopped taking ADHD medication and adapted to a work and lifestyle that works very well for them. That is a very suitable outcome for an initial assessment.  There is another group who want to try a verbal therapy for ADHD in some cases because they recognize they can no longer take stimulants because they were escalating the dose. That is also a suitable outcome for the assessment. In those people who have ADHD are want to take a medication, I think a non-stimulant medication like atomoxetine is a good place to start. In my experience it works very well.  Disagreement about stimulants, especially in people with a stimulant use disorder typically requires extended conversations with the patient and their family. A quality control initiative can provide very useful data for that conversation. I suggest that any clinic or clinician who prescribes stimulants collect outcome data on those prescriptions.  The key piece of data is a comparison of the relapse rate of those patients taking stimulants compared with patients treated with non-stimulants. Other data could be collected as well - like how long the prescriptions were refilled. There are rules about collecting that data depending on your practice setting.  Check those rules first.  Outcome data will be the best data on whether a correct decision was made about prescribing the stimulant.

I added the following slide based on polypharmacy considerations in the paper cited in reference 1.  This is a common clinical problem that needs to be approached rationally and that includes limit setting on the concept that every side effect or symptom needs to be addressed by a medication rather than a medication discontinuation, reduction, or substitution.  I always include a discussion of rare but serious side effects, synergistic side effects, drug interactions, interactions with comorbid medical problems and associated medications, and very serious interactions that could lead to hospitalization or death, like serotonin syndrome. 

I am going to end on a note about countertransference based on a disagreement I had at a conference about my methods. The speaker advocated for prescribing stimulants as a general operating practice for anyone with ADHD. When I confronted him about the problem of substance use he claimed his motivation was that he considered it his priority to "help" people and he thought that stimulants were the most helpful medication.

Whether or not a medication is helpful for any psychiatric disorder depends on a very careful assessment and clinical expertise that considers several dimensions including the potential risks and benefits for the patient and the incorporation of the patient preferences and values into the clinical decision making process.  In my evaluations, I try to sum all of that up in an informed consent discussion. In the area of ADHD evaluation and treatment, that covers a lot of ground and there is no simple uniform recommendation.

George Dawson, MD, DFAPA

Photo Credit:  Many thanks to my colleague Eduardo A. Colon, MD for allowing me to use his photos. 

The Spine In Psychiatric Practice

I am not talking about the spine as a metaphor, I am talking about the real spine.  I am also not going to discuss some alternate therapies affecting the spine, I am going to refer to it only in the context of actual medical practice.  Maybe it was my interest in chronic pain and neurosurgery that led me to the observations, but many years ago I started to notice the high number of patients who were seeing me and had associated spine problems either associated with their psychiatric disorder or making it worse. As far as I can tell, this problem is really not well addressed in the psychiatric literature.

The spectrum of spinal disorder presentations varied from undiagnosed, to incorrectly diagnosed, to diagnosed and treated many times.  There is also the issue of how normal imaging studies vary greatly with age and eventually produce radiology reports that sound pathological but do not necessarily explain the observed pain or disability.  The usual psychiatric diagnoses included depression, anxiety, insomnia, and chronic pain.  The correct diagnoses were most often only possible by a detailed discussion of the problem.  In many cases the patients I was seeing had never actually seen a physician for back pain.  Let me illustrate with a couple of examples (none of these vignettes represent actual patients).

Patient A is a 35 year old woman being seen for depression.  She is in a stressful work situation because she is expected to be physically vigorous and move many 40 pound boxes of paper per day, but she is limited by neck pain and muscle atrophy in the left arm.  She injured her neck at a different job 5 years earlier lifting a heavy piece of equipment down from a shelf.  She felt immediate neck pain and over the next several weeks had muscle twitching in her left arm.  She did not have health insurance from her employer and was never assessed for the injury.  She has had daily pain since the injury and on days where she has more physical activity, she has more pain and more depression.  She is interested in treating the depression.

Patient B is a 50 year old man being seen for depression and insomnia.  He has a 5 year history of taking zolpidem for insomnia.  He is referred by his primary care physician because he has had to increase the dose of zolpidem to 20 mg/day because of worsening insomnia.  The patient gives a history of no longer being able to sleep on his right side because he has neck pain with radiation to the shoulder that resolves when he changes his sleeping position.  He has seen the Silenor and Lunesta commercials and is interested in changing his sleep medication.

Patient C is a 60 year old woman with a history of multiple upper and lower back procedures including fusions, discectomies, and foraminotomies.  She has also had surgical complications including infections and a cerebrospinal fluid leak.  She is taking oxycodone 40 mg QID with addition 5-10 mg prn doses of oxycodone.  She is also taking lorazepam 1 mg TID for anxiety and drinks wine on a daily basis.  She is referred for treatment of depression and chronic pain.

These three descriptions of patients highlight a number of problems unique to psychiatric practice.  Psychiatrists often see people with degenerative or traumatic changes to their spine that have never been assessed by a physician.  We also see patients who have had intensive surgical treatment and who have been treated in pain clinics for a long time before anyone thought to refer them to a psychiatrist.  In both cases an antidepressant seems to be a proxy for a psychiatric evaluation or an interview that seeks to determine if the spinal problem is a cause of depression, insomnia, or anxiety.  That type of evaluation is fairly straightforward but it does require time and the ability to do a medical and neurological review of systems and recognize common patterns of spinal syndromes.  The risks are minimal and the potential rewards are great for the patient.  I have had people ask me why I was asking them so many "medical" questions or report that their primary care physician wanted to know the same thing.   But I have also had people tell me that they were glad to know that they really had chronic pain from a fixable spinal problem rather than chronic insomnia and a need to take sleep medication forever.

This issue also highlights the issue of a physical exam in psychiatric practice.  When is it necessary and in what context can it be done?  In my first job I recall asking the clinic administrator whether she would provide a room and basic equipment for a physical exam.  She said that she would but in the three years I worked there it never happened.  If there is no adequate place to examine a patient I don't think an examination should be done.  There is also the question of the emotional relationship with the patient.  Many people seeing psychiatrists consider them to be their primary physician and have had many intense discussions with them over the years.  Psychiatrists should be aware of this emotional context and the meaning of any physical touch that occurs in that context and keep the assessment at the verbal level.  Referral to a physician who you know does a thorough neurological and spine exam is indicated for most cases, but in many cases you are seeing people referred from these physicians and it has already been done.  What about imaging studies?  My rule of thumb is to do them only if the patient has been physically examined.  I have physically examined people only in acute care settings and ordered imaging studies (CT and MRI) in that context.

On the positive side a lot can be done within the constraints outlined above, first and foremost is a detailed evaluation of the problem.  How is it that insomnia from neck pain can be treated for years as primary insomnia without any attention being paid to the cervical spine pain as being the likely source of that insomnia?  The only explanation I can come up with is a cursory evaluation of the pain.  Borrowing a page from Engel any psychiatric evaluation of a person with depression or anxiety, insomnia, and pain needs to be as comprehensive as possible.  The evolution of those problems since childhood and the relationship to physical and psychological trauma as well as other major life events needs to be detailed.  Assessing the patient for any possible addictions is another requirement.  A description of the pain and associated neurological symptoms is critical.  I like to review old records, imaging reports and the images themselves if possible.  There are a few of the highlights of what is necessary to come up with a psychiatric plan of care for people with spinal problems.  In many cases, a psychiatrist is the only person addressing their pain, even though they have a known diagnosis of degenerative disk disease and chronic back pain.  It is very useful to have referral patterns and treatment plans established to be able to offer treatment of the pain or associated spinal problem in addition to addressing the identified psychiatric syndrome.

The ability to help this group of patients also has training implications.  You don't learn about the spine, neurosurgery or neurology doing psychiatry rotations in medical school.  I was fortunate enough to have intensive exposure to these areas and to excellent clinicians.  I was also fortunate to work in a multispecialty clinic for 23 years where I had the benefit of discussing these cases with specialists from all fields.  I was also able to walk down to Radiology and discuss films with an excellent neuroradiologist.  The training suggested by Insel with a clinical neuroscience in psychiatry, neurology, and neurosurgery would enhance the evaluation of these problems. 

It pays to focus on both the central and peripheral nervous system when indicated.

George Dawson, MD, DFAPA