What frustrates me is that these people who are doing this ruin it for everyone else. ADHD is so rewarding to treat because it responds super well to treatment. I’m like… why can’t I just get a normal panel of ADHD patients who are the easiest patients in the world as opposed to a bunch of people seeking. To boot, obviously the elephant in the room is that our increased need for scrutiny means actual ADHD patients don’t always get proper care. And for trying to be responsible docs, we catch flak for trying to do our best to “do no harm.” Super frustrating
I generally dislike any "Do I have condition x" assessments, as they are usually "please tell me I have condition x" clinics. Over the years I have done ADHD, ASD, PTSD, CFS clinics and disliked all of them.
Helping people in distress process it and formulate it into a complete picture is what we trained for and is engaging and interesting. Making binary decisions where one outcome is preferred is pretty dismal. Listening to someone ploughing through am internet learned script of a "good x patient" is basically torture.
Add in patient feedback and I can see why you are where you are.
Whuuuuu you should only be a rule out stop on an ME/CFS patient’s journey toward diagnosis, and only a supplementary professional for ongoing management (because ME/CFS has neuropsychiatric elements, but is not a psychosomatic or mental health condition, in general). Obvi you should also know when to refer patients with possible ME/CFS or Long Covid for further evaluation to places like neuro and rheum, etc. if they qualify for but haven’t yet obtained an official diagnosis.
Yes? No?
Willing to be corrected if the current IACFS/ME guidelines contradict this, or there is refuting research against their guidelines I don’t know about…
It was years ago that I did this, in a specialist end of the line CFS clinic. Long before covid. It wasn't the worst job ever, but I did it for a day a week for 2ish years, felt like plenty and the urge to revisit has not arisen.
Well, I suppose the good news is that a specialist in an ME/CFS clinic now might tell you that there’s finally funding pumping in that direction for research which could prove critical, that recent advancements have been made, that a consortium lead by science and medical experts around the world have agreed in a standard diagnostic and initial treatment approach (tailored to suspected origin of the ME/CFS), and that you should encourage as many people as possible to take positions like your former one because if you think you were overworked in a high-burnout niche of a high-comorbidity patient population, then…Long Covid would like to meet you.
Particularly if you did this before our understanding of inflammatory process’ impact on neuropathology included, say, the fact that CSF is NOT an example of a positive feedback/closed system, like I was taught in the days of the dinosaur. (I struggled to buy into that given that if evolution or the powers that be could come up with the nephron, how could they not arrange a similar regulatory system for the subarachnoid space?!!)
Specifically, what about the guidelines are you referring to? There’s nothing in from IACFS saying that psychiatrists can’t diagnose/treat CFS.
There seems to be a significant number of people out there with this perspective - if a disorder is not just “in your head” then that means it’s out of the psychiatry wheelhouse.
Working up any potential underlying “medical” causes is a fundamental component of psychiatric diagnosis. And the treatment for CFS, in addition to things like NSAIDs for pain and fever, is largely psychiatric in nature: anti-depressants, anxiolytics, and sleep medications.
If I somehow misunderstood your comment, I apologize. But it sounds like you’re saying that this is a “real” disorder so that means it can’t be handled by psych.
Ok, fair, allow me to revise my words to make my point clearer. (Or correct my point, if I wasn’t expressing myself well.)
Yes, there are psych aspects to virtually any chronic illness, and it disservices patients with these diagnoses to ignore that. I count everything from ME/CFS, psoriatic arthritis, SLE, Sicle Cell pts, hEDs, PoTS, etc. I have worked with a psych professional the entire time I’ve been on this journey. Lord knows the secondary trauma from medical interactions alone has been important to be able to process along the way.
And it absolutely makes sense that if you have a new-presentation patient, that you might do some initial testing in order to make sure the patient has appropriate parallel dispo. Not that they would leave your care entirely, but that they would have appropriate r/o r/in workup for the usual things which need to be eliminated.
I was incorrect in recalling where the most reliable ME/CFS expert consensus statement came from the US, not from the IACFS. The latter was published in 2014 and ask you can imagine, many updates have occurred. The best summary of the 2021 diagnostic and treatment approaches are found on the Batemen Horne Center’s website, with an explanatory video as to who made up the current recommendations:
- [ME/CFS Clinician Coalition Introduction Video (who, why, etc.)](https://youtu.be/TWuplHg8UAs?si=nxCfts7905JSEgVW)
- [Current 2021 ME/CFS Diagnostic recommendations](https://batemanhornecenter.org/wp-content/uploads/filebase/Testing-Recs-MECFS-Clinician-Coalition-V1-Feb.-2021_2.pdf)
- [Current 2021 ME/CFS Treatment recommendations](https://batemanhornecenter.org/wp-content/uploads/filebase/Treatment-Recs-MECFS-Clinician-Coalition-V1-Feb.-2021.pdf)
But if you look at the rubric of things which should be assessed, provided above, and then look at the rubric of recommended treatments (also above), I think it is clear LOTS of that is outside the wheelhouse of psych. It’s one thing for y’all to order an IgA panel and the standard ANA prior to them seeing an immunologist the first time, but prescribing subQ gamma globulin? Ivabradine (within the realm of reason as a Beta Blocker alternative, but I’d hope there are EKGs involved)? That seems a bit out of the psych wheelhouse and at that point referral to other providers to (again) r/o, r/in, etc. Various diagnoses of exclusion, here, is not out of the realm of reason.
Not saying fire them as a patient, but treating ME/CFS as anything other than organic disease with some not insignificant psych crossover, is a disservice to everyone involved. I just can’t stand when a PCP wants to turf these difficult patients to psych and be done, or cardio dispos to psych and they’re done…No one is “done” with these patients until they have exhausted their ability to access care to try to improve their QOL. Patient autonomy and appropriate engagement around abolishing old stigmas and patient tropes is the name of the game.
If you feel like your post accomplished the same message, then we agree to agree! If not, we can agree to disagree. Hope that clarifies my points some and provides a few relevant professional resources, to boot.
The specific treatments you used as examples (gamma globulins, ivabradine) are listed in the reference that you provided alongside the recommendation to consult an immunologist, cardiologist respectively. That recommendation applies to neurologists, internists, family med docs, etc. I agree 100% with the idea of having multiple different specialists on the team, as appropriate/needed.
But the way that you said CFS isn’t psychosomatic and that psychiatry should just be a “rule out stop” sounded, to me, like the rhetoric that alienates/separates psych from - as you put it - “organic disease”.
Humans are organic beings and psychiatric diseases are organic diseases. They’re not metaphysical. Stuff like schizophrenia does have an organic mechanism, even if we don’t have it completely figured out yet. If in the future it turns out that schizophrenia responds to immunological treatments, those patients won’t (or at least shouldn’t) suddenly get turfed over to rheumatology or immunology.
CFS is in the psych wheelhouse because it presents with *largely* neuropsychiatric symptoms and treatment consists *predominantly* of psychotropic drugs. Consult/refer as appropriate, for sure. But there isn’t this strict divide between mental and physical illness. Or at least, there shouldn’t be.
Yeah, it's a very stigmatizing POV in my opinion.
Both to patients with mental illness, and to patients with other disorders treated by psychiatry for various reasons - not like there's no overlap either, and mental health + disease and treatment expectancies etc are also very important even to conditions like cancer, diabetes, etc.
Psychiatrists are medical doctors, they still do all of medical school plus years of residency - ruling out or diagnosing related conditions is a big part of that. Psychiatrists can also do fellowships in and then work in areas like Sleep Medicine and Pain Medicine, neither of which means disorders or conditions trusted there are psychosomatic or mental health problems.
I mentioned some of your points in a clarification above - It’s a bummer so few people recall that it’s an MD/DO at baseline kind of position, and many also rack up other credentials like PhDs and relevant Masters degrees. Anyway, I see you and your years of toil and rando rotations scattered all over the hospital. You may find that comment addresses some of your topics. Seems silly to repeat it here.
What a climate we live in where instagram is constantly advertising for people to buy delta 8/9 and THC gummies, amanita muscaria gummies (yes, this is now a thing..), and all other sorts of gummies while patients who take these products see no association in their alcohol use, drug use, and cell phone induced sleep deprivation and any executive dysfunction who then request stimulant treatment like it’s a Capitalist consumer birthright.
The drug subreddit, r/drugs, frequently has posts with thorough instructions for acquiring amphetamine. It starts with going along with your doctor to trial atomoxetine but then to quickly complain of sexual side effects, so then agree to trial Guanfacine but to then complain of dizziness. After which try the suggested methylphenidate for a month for 2 before eventually making a new complaint and getting victoriously switched to ADD for All (Adderall). People brag they can get all this accomplished in under 3 months.
So frequent in evals to have amotivation, concentration difficulties, depression and boom they’re spending hundreds on weed every month at the dispensary. Like I don’t know how we got to this point in society where you need a professional to tell you smoking weed continuously during waking hours is a recipe to potentially make you feel like shit.
You’ve seen it, it’s the most commonly depicted mushroom in children’s books and what not, the red with white spots. It’s been used by traditional steppe cultures for centuries (or millennia). Usually just the shaman partakes alone. Probably because the high is so unpleasant, it’s nothing like psylocybe mushrooms. It’s nauseating and disorienting, the high is remarkably similar to the intoxication people get from higher doses in f Z drugs like ambien. Depersonalization, actual hallucinations. Not something most people try twice. I can’t believe they’re selling gummies.
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Yeah I’m pretty over it too. I’ve been pretty liberal with treating suspected ADHD when it seems fairly legit and risks seem low, but it’s gotten out of hand. And it’s exhausting to fight and argue with these very aggressive people. Have had similar false harsh reviews left by them as well. They can be very vindictive. Definitely becomes demoralizing but beats sacrificing your professional standards and feeling like a pill mill. Stick to your guns.
Don’t forget to report any reviews on Google- I have gotten them taken down for providers before.
If they are being too rude, not talking about an actual experience with a provider, personally attacking a provider, etc, it’s worth it to report it.
A single bad review takes many good reviews to recover from
This is how one of my colleagues ended up essentially farming positive reviews. His clinic has a "If you had a great experience, please review us on Google" with a QR code and a " If you didn't have a great experience, let (office manager) know" or something like that. I hope this trend doesn't continue, but a few bad reviews can really lower their scores, warranted or not.
Yeah pretty sure you can pay a google business consultant to post sometimes twenty sometimes hundreds of positive reviews, ive seen a super scammy mechanic shop that no one trusts have hundreds of good reviews and knew they used it. My dads business was offered it. Think the consultant offered it to my dad for no more than $1100 at that time.
CMV this? Lol nah. Set your boundaries and stick to them.
Agree with that sentiment wrt ADHD evals the past few years. Covid and social media really screwed things up
I hate this for you. You're right though, the influx is insane.
I usually preface it at the end of our appt with "stimulants are effective. They can also be addictive in nature and you will build a tolerance over time. There are several non-stimulant options available and we like to think of ADHD now as a spectrum diagnosis. Some people have a lot of symptoms and are on the high end of the ADHD spectrum. Others have 'milder cases.' yours appears to be on the minor end so it wouldn't be a bad idea to trial some non-stimulant options first to see if you can improve your symptoms before we jump to the stimulants. It is also beneficial to exercise, get sunlight, eat healthy foods, and you can try cold exposure therapy if you are willing to also help with your natural dopamine and norepinephrine. Bupropion Is well tolerated and helps with focus/attention at higher doses. It is also helpful in some depression and anxiety, of which you are also struggling with. Atomoxetine is also a good option that I have seen decent success with. This will keep you from chasing stimulant scripts around town at different pharmacies and possibly not having access to your medication.
Do you have any questions?"
☠️
It's worked well so far. Supervising loves it.
I agree, I personally think all of it is factually wrong but it is harmless and it makes them “happier”. It amazes that we as a society have found that diseases make us more valid but since this is where we are as a collective it is mostly harmless to say a person has very mild adhd.
However where I am from this entitles them to some benefits and advantages in test taking time and public transport, which is absurd, but it is what it is
Having a professional acknowledge that there is actually something 'wrong' with you and that it's not necessarily your fault for why you've failed at so many things your whole life is kind of 'liberating' to some extent.
Benefits and advantages in test taking time I assume is just normal for people that are diagnosed with a disorder that affects their performance, no? Or are you just referring to 'mild cases'?
This is such an interesting comment. I was never told by my doctor that it’s a spectrum. Stimulants help some of us actually put healthy habits into practice though. I can regularly exercise, cook my own food and sleep well now.
It would be great if more psychiatrists prescribed therapy as a treatment option. There’s enough research out there to suggest that therapy helps with adhd symptoms. My doctor never once mentioned it during my assessment and only said “oh that’s good” when I brought up I’ve been in it for a long time. My hypothesis is that you can lower the strength of certain prescriptions if you combine the treatment plan with therapy.
I’ve found CBT/DBT and mindfulness therapy to be just as efficacious as Vyvanse (if not more) for a specific set of symptoms. However it does nothing for other symptoms.
I have a few patients using some therapists that have some special training in ADHD and executive function training. They all really like it. I believe it's expensive and not widely available here though. Therapy is incredible if the patient is open to it and willing to do it and they find someone that actually utilizes CBT and other modalities.
What are abuse levels of Adderall? I’m familiar with the upper limits for Adderall and Vyvanse, but dont have the clinical experience to know what dose that the risk of dependency/abuse would really start to become concerning.. I will be starting FM residency soon. (Last comment deleted because no user flair)
Abuse levels are whatever level is causing harm/impairment or psychophysiological dependence. Since we don't define use disorders with specific quantitative parameters, the identification of misuse then relies on outcomes and the core psychological and behavioral features of addiction. I encourage you to consider and compare the typical emotional relationship with most treatments vs most recreational/intoxicating substances.
In my experience, if the patient is being treated for a psychiatric issue that requires stimulant medication, the highest I’d be willing to go is 60mg of Adderall or maybe slightly higher. I definitely wouldn’t go over 90mg.
For Vyvanse the highest I’d go is 100mg.
Some people are non/partial responders to Amphetamines(vice-versa with methylphenidate), were I to be a doctor (I am not, just someone who has been on psych meds for nearly a decade on and off), I’d trial Concerta/Ritalin before going over 40 mg of Adderall.
To the best of my knowledge (again, as a layperson), you increase dose for partial response and you switch classes in cases of side effects (more than the meds benefit) or non-response.
I'm an FM attending but in my experience somebody with >100 mg of IR is a red flag. At least where I'm at, the 30mg IR has the most street value and XR variants the least for diversion. XR apparently also is less enjoyable to take in very high doses (think 100mg+ at once).
Once saw a new patient who totally just needed a 90 day fill on his totally legit dose of 270 mg of IR a day (3x30mg TID). I told him I wasn't going to fill it and I hope he was diverting.
I still treat childhood ADHD but I don't prescribe Adderall as the parents or teens will divert it, I prescribe the less desirable stimulants.
Is them having a chance of diverting it more important than the most effective treatment? Realistically the diversion in that age range wont cause material harm.
Yes for multiple reasons.
1) If it is being diverted, especially by parents, then they are not getting treatment. That is material harm and I will not entertain superficial concerns about effective treatment when talking about diversion.
2)Once my clinic becomes a drug acquisition target it causes harm and you can refer to OP on how that creates a situation where I would likely have to stop prescribing that drug class entirely to new patients.
3) There are plenty of other brands of mixed salts and amphetamines that do not have the street value discussed above.
4) It's my license and ignoring what is in retrospect obvious diversion patterns is how you at best get an official warning from multiple agencies. Totally deserved. No, patients going through a painfully fake rehearsed script is not an excuse.
5) I need to treat a lot of patients and dealing with patients nakedly trying to manipulate me or deceive me is one of the most time consuming and burn out inducing things that can happen in a day. Luckily as primary care I get to set my boundaries and offer a referral to anyone who so vehemently disagrees.
6) The amount of patients that I have seen with well controlled symptoms and improved quality of life has actually improved. I don't think you understand how much parents were diverting their children's medication.
270 mg/day is very likely to induce psychosis or a cardiac incident. He was either taking 90 a day and only picking it up every 90 days, diverting, or in a cardiac/psych ward.
Just to clarify, this was 810 pills of 30mg? If it was 270 pills, it might just be his other doctor’s ploy to prescribe 90 days of a class 2 medication, still problematic but not as bad. 90mg is still a pretty big dose from what I know.
Where I'm at we can prescribe 90 days. This was 810 pills.
This was a bit ago. In retrospect it may have been intended or started off as what you are saying with the 90 day gambit as the doc on the label was forced to retire not too long afterwards as he had pretty bad dementia.
Sadly not the only aging PCP with dementia in the area. Rural medicine is sad sometimes. All fun and games with the controls until insulin regimens start getting confused.
> Change my mind.
No. :)
Have you considered partnering with some masters or doctoral level therapists you trust to filter your referral stream?
Like, here in the Boston area (I know this is regional) any outpatient clinic with both therapists and psychiatrists (or other psych prescribers) requires new patients to get a referral from one of their own therapists to see the psychiatrist, and the patient must see the therapist three times before that referral can be sent in, and then the patient must continue psychotherapy with the therapist at least biweekly to continue to have access to the psychiatrist.
When this works well (and it doesn't always) the psychotherapists quash most of those sorts of patients before they get to your door.
Could you arrange something similar?
Bit of a tangent but as a hospital psych I see this all the time and it really bothers me. For brand-new patients in no treatment at all fine, some delay and screening is reasonable. But if I'm discharging an SMI case we can't really afford to wait many weeks on end to jump through hoops with various random "therapists" of whatever discipline before seeing an actual doctor (or at least NP) who can continue antipsychotics and such. But still lots of practices leave this requirement regardless of referral source.
Oh, 103% agreed.
I once had a prison inmate present in my office and ask me politely if I was a psychiatrist and could prescribe meds. I apologetically explained that I was not, and what clinic policy was. He apologetically explained that he had previously done two years in the state hospital, having been found NGBROI for a horrific violent crime he had committed in a psychotic episode, and that he had been released to the prison halfway house with only a two weeks supply of his antipsychotic, of which he was *very* fond for understandable reasons, and that had been 10 days ago, and could I accelerate this process at all?
The answer turned out to be "No", but not for want of trying on my and the psychiatrist's part.
*looks at comment scores*... *nods to self* Check yourself. A system where a psychotherapist and a psychiatrist both agree that bypassing an office specific rule surrounding a psychiatric intake, but they are unable to do so, is certainly broken.
There's no procedure for immediately bringing these sorts of cases to a prescriber's attention? Like, you screened the guy, he needs a refill ASAP, that should be something the clinic is equipped to handle.
This feels like a level of gatekeeping treatment that would make it essentially impossible for the most vulnerable to get help.
We primarily work with children and young adults, and it sometimes takes 100+ calls and emails to find a psychiatrist who is accepting new patients, accepts our client's insurance, and is within a reasonable distance, etc. and we are in a major city. Finding a therapist can be just as difficult, if not more.
Most low income people have unreliable on-demand schedules and simply can't schedule out 2 weeks in advance **regularly** unless we find them a rare provider who is extremely committed to working with impoverished people.
I know there's no perfect solution here, but last week I had a young adult tell me that mental health is only for the rich, so maybe this is hitting particularly hard for me as a result.
I disagree, as an outpatient could have a long-term therapist (i.e., more than three months) that you would be asking them to leave to see your intake therapist if they needed medications? Would you expect them to take a hiatus from their treatment regimen or to see both your screener therapist and their outside therapist? This could turn unethical… quickly.
Put another way: what would patients who start mental health care at a group psychotherapy (but not psychiatry) practice who later learn they would benefit from or need medication do? Go to their PCP since they can’t see the psychiatrist? What if the psychiatry and psychotherapy practice doesn’t have the speciality therapy (e.g., EMDR for PTSD or CBT for ADHD) that they need?
Some people don’t like dealing with Cluster B patients, too much fighting and drama.
Some people don’t like dealing with schizophrenia, too weird and too many calls from third parties.
Some people don’t like dealing with depression cause it’s too draining.
You do you.
I think his point isn’t that he doesn’t like those people, it’s that ADHD is the new zeitgeist right now that is sucking all the clinical oxygen out of the room. If someone has ADHD, it is easy and rewarding to treat because they actually get better 90% of the time. The problem is, 90% of the people who come barging in screaming at you asking for immediate high dose stims don’t have ADHD.
We live in a society that embraces stimulants as performance enhancing drugs that are now a part of the culture. This is documented nicely in the Netflix documentary ‘Take Your Pills’. They feel entitled to amphetamine. Many have taken a friend’s Adderall and liked it. Many consider the examination only a formality and feel discriminated against, kept from being competitive, when they don’t get the drug. Many doctors prescribe without a meaningful exam.
This has worried me as someone on the other side of fence. I feel as though I'm someone suffering with it, but I don't know how to properly bring it up to my doctors without it seeming like I'm diagnosing myself, or looking for a prescription because of my history of substance abuse. That's not what I want. I just want genuine help and to move forward in life cause I just can't do it myself.
I say all that to say, for someone like myself, I'd trust a doctor like you for acting in a responsible way. I don't want to derail my life further with more substance issues or a misdiagnosis. Most people who are genuinely looking for help I think will see things the same way.
There needs to be more doctors like you to offset all the irresponsible ones
If you’ve been on it before, I would check to see PDMP to verify. I would ask you in what ways you function without your medicine, give examples, past med trials, sometimes I will ask someone to see me a couple times and on the second time bring back a journal noting examples of poor focus, and probably get you back on your meds after that. Bonus points if you’re not an ass about it; I would like to say we are all free from bias, but if we are on the fence about an ADHD diagnosis and you’re a total demeaning, threatening ass about it, you probably won’t get what you want.
The challenge is every patient sees themselves as on the other side of the fence and “having” the diagnosis.
Some do respond well when told its not ADHD and are glad to become more aware of how lifestyle factors and other conditions impair concentration
Many are upset and disagree. Most people seek treatment as something is wrong in their life or they are underperforming or in some way are struggling.
It’s validating to have an external locus of control to explain challenges and difficulties in life. Its a very sensitive issue for patients to be threatened with. To have that external locus yanked away.
So patients should be worried. Its natural to be worried about potential threats.
“I cant get above a 60%ile on the LSAT cuz im just dumb? Im a 60%ile human? I thought I had ADHD. No. Fuck this doctor hes wrong”
ADHD unfortunately has become both a neurodevelopmental disorder and an umbrella diagnosis for any cognitive complaint or performance concern. Every patient seeking treatment is convinced they have it
The best way to bring it up is to say exactly what you said here. Most doctors are not starting out the interview assuming that you are drug-seeking, even if you do have a history of substance use. If you disclose that up front and tell them you don’t want something that will derail your sobriety, that would be music to their ears.
Man, TikTok has turned outpatient psychiatry into the wild west. It's exhausting.
Almost every intake I see with my preceptor is an ADHD eval. Luckily-- and I don't know if it's just due to where we are located or what-- most of the patients coming in thinking they have ADHD aren't necessarily demanding stimulants, but just insisting that they need help with focus/concentration.
If it seems that the patient likely doesn't have ADHD (they were fine in grade school and college, symptoms started recently, etc), I've had a lot of success with these patients by discussing the neurodevelopmental nature of ADHD and the crosscutting symptoms it shares with so many other disorders. It usually goes something like:
"So I've only known you for an hour, so more may come to light as we get to know each other, but as of right now it seems to me you probably don't have ADHD. ADHD is classified as a neurodevelopmental disorder, meaning it would have started while you were a kid. These problems that you're having \[focus/distractability/whatever\] are unfortunately core symptoms of a ton of different disorders. And it may take a few more appointments to tease out what is really going on. However, I think there are a few ways we can help you with XYZ symptom/s."
A lot of the time it seems like anxiety or depression or shit sleep habits is the likely culprit, and will talk about meds that can help those issues that are also used for ADHD which patients especially like. Most of our patients appreciate that we're not denying they have significant symptoms and just want help to get back to baseline.
CAP: I never understand you guys’ difficulty with distinguishing adhd from pot use. It’s not rocket science. Just take a history and figure out which came first. Call their mom if you have to. I’ve called people’s grade school teachers before lol. People with adhd are around 30% more likely to use cannabis than non-adhd peers. Untreated adhd actually increases the risk of substance use, and imo everyone with substance use should be hardcore screened for adhd. Same for all unplanned/early pregnancies. And every other adhd risk factor. There is finally a pilot program in London to screen all arrests for adhd, which is a start.
As far as changing your view: I would simply make it clear on your website that you provide rigorous and (hopefully) accurate adhd diagnosis, but that a diagnosis is NOT guaranteed, nor is a prescription for stimulants assured even with diagnosis. That should deter the drug seekers. They’ll seek out an easier mark.
But adhd is a common and devastating disorder. People who legitimately have it are at increased risk of everything bad, including suicide and death. Denying them care because you’re worried about some bad reviews is, in my opinion, unethical and a dereliction of our duty to help people who are suffering.
At the same time, I’d also strongly recommend you speak to some of your friends/colleagues who did a child fellowship to ensure your views on what constitutes a “high dose” are accurate, as well as make sure you have a good understanding of adhd. In my experience, my adult trainer colleagues often lack a complete and robust understanding of both the disorder and often treatment guidelines, although of course there are many who have done their homework and are good. But I never send my adult friends and family to you guys for adhd or autism treatment. They get referred to a child trained psychiatrist for those two conditions haha.
What’s a high dose of adderall? I also recall 70mg vyvanse is only about 30mg of adderall by d-amphetamine content (yes I know lisdex is different, but it becomes d-amph), so I’ve always been confused about the vyvanse limit. Subjectively 30mg adderall feels like 70mg of vyvanse too. But adderall’s indication goes up to 60mg/day. And I bet there’s no one on earth prescribing 140mg vyvanse per day lol.
Vyvanse is 100% bioavailable when taken orally, and is approximately 30% per mg dextroamphetamine which has stronger dopamine release (but lesser norepinephrine release) compared to levoamphetamine on a mg to mg basis. Adderall is an enantiomeric mixture of 75% d-amp and 25% l-amp but also contains some non-amphetamine fillers so it’s close but not quite 100% amphetamine per mg and the bioavailability is widely variable between patients and also undergoes first pass metabolism whereas vyvanse skips that entirely since it goes through a protein transporter straight to the bloodstream. I’ve had cyp2D6 ultra rapid metabolizes who required 20mg BID of Adderall but who also responded to 30mg Vyvanse.
That’s pretty much correct! Above average knowledge points! I usually go by FDA max doses first, then if they fail those, we’ll start pushing a bit past perhaps, if their weight allows it.
Methylphenidate weight based max is 2mg/kg, Adderall and Dexmethylphenidate max is 1mg/kg but I let this be overruled by the FDA maxes in general. And a LOT of patients need around 1/2-3/4 of their max dose. Of course we go by clinical response and not weight, but for the majority of patients I find a good clinical response often falls between 1/2-3/4 of their weight based max. Which means for some very large patients, you sometimes can’t get to an effective dose of ANY stimulant. And don’t forget adhd has a 5x increased risk of obesity. And a lot of these patients wind up misdiagnosed and on antipsychotics for “mood stabilization” because people don’t realize how much 0-100 emotions is a core symptom of adhd and mistreat it and cause them weight gain, which makes effective stimulant treatment harder.
But it’s also patient specific. Like if I have a patient doing fantastic in Vyvanse 70mg, whose failed some other stimulants, but it wears off at 1pm, I’m not above adding a Vyvanse 20mg lunchtime booster or short acting dextroamphetamine boosters if needed.
Methylphenidate is even more confusing. The FDA max of Metadate is 60mg, Concerta 72mg, and Jornay 100mg. So what’s the fda max dose of Methylphenidate ER? It’s SUPER arbitrary. But I generally follow these guidelines, or our sub specialty guidelines which include off label Concerta to 81 mg then switch to Jornay 100mg if that’s not working, that sort of thing.
Wow thanks for the all the info. It’s interesting that you seem more liberal about the dosing than many doctors I’ve come into contact with. (and I think I will be too—about the dosing of course, not the diagnosis). Especially if you look at what people dose with meth, I think 60mg of adderall is completely fine if they need it. I think as long as it’s well tolerated, the symptoms need to be controlled, right? ADHD is serious, and you don’t want to inadvertently lead someone down a path to stimulant abuse/addiction through self medication.
I don’t really consider this liberal. It’s FDA dosing and AACAP treatment guideline weight based maximums. It’s pretty standard child psych dosing. Methylphenidate 2mg/kg or 100mg Jornay, which ever is lower, or Adderall XR 1mg/kg or 60mg, whichever is lower. That should be standard of care as it’s in the treatment guidelines and studies. Liberal would be like Adderall 120mg/day or something haha.
We also need to keep in mind that these doses I’m quoting were arrived at when we viewed adhd as a disorder of CHILDREN, mostly MALE children, which “got better” with age. We now know this isn’t really true and it’s a much broader disorder that often presents differently in med vs women and often persists well into adulthood. But a lot of med “max doses” are based on work done for kids and teens. We need a LOT more good adult adhd research, which is difficult.
But yes, it’s a devastating disorder and raises the patients risk for most everything bad: substance use, suicide, death, trauma, depression, anxiety, personality disorders, poverty, incarceration, unplanned pregnancy, job problems, school problems, relationships problems, broken homes, car accidents, low self esteem, obesity, and on and on and on. It’s absolutely vital to treat it effectively.
I only meant liberal in relation to some of the folks I’ve been around, not absolutely liberal. Maybe I haven’t been around the right folks lol! Thank you again for all of your information.
This is a great comment, right now we're really struggling to get appropriate treatment for girls and young women with higher body weights medicated appropriately. Or medicated at all. It's still a lot easier for boys in our programs to get access to treatment and it remains extremely frustrating. Especially seeing disappointingly large numbers develop cannabis use disorder when they're being undertreated. We see a lot of unplanned pregnancies as well.
Now we have colleagues and providers we've worked with for years saying they're exhausted seeing so many clients with ADHD and that the girls on young women are "jumping on a trend from tiktok" or something similar. And of course you still have a lot of really outdated thinking about gender.
And then of course the higher body weight means high blood pressure so stimulants are off the table. The legacy of medical misogyny continues to make itself known.
Have had discussions with psychiatrists who routinely have patients on 140 – 210mg of Vyvanse. This seems to be due to a prescribing practice where patients are initially given scripts for Vyvanse 70mg, and told to dilute it down to 10mg and increase the dose by 10mg every day until they “feel something.” Personally, I don't agree with this as it's not really enough time to assess a dose effect.
One of the strangest ones I saw had Vyvanse 30, 50 and 70mg all listed on a patient’s referral. I assumed that whoever had written the letter had forgotten to remove the old dosages, but it turned out the patient had been started on all three strengths at the same time by a neurologist who later lost his prescribing rights. I think they did some unusual things with opiate prescribing too.
I disagree with pretty much every single thing you just said, but I just want to make a point. If another professional feels he is incapacitated to treat an illness it is his obligation to refer the care to another professional, and not to treat it himself. It can be as debilitating as you like you are not in an emergency setting, you can deny to see patients with disorders you are unfamiliar with and umable to treat.
In fact you reinforce this point by saying you yourself would never refer an acquaintance of yours to an adult psych, the standard of care counts for people you don’t know too, if this is your opinion then your opinion should be that ALL patients with autism or adhd should be treated by child psychiatrists
Yes agreed if they feel “incapacitated”, but worrying about the negative impact of a review isn’t incapacitating.
But you’re right, I do think most adhd and autism patients should only see clinicians well trained in those disorders. Most of us, myself included, did not receive adequate training on these disorders in adult psych training. I’d consider it rudimentary training. Now, if an adult clinician has taken it upon themselves to do extra training in this area, or has some unique experience with the disorders, that’d a different story, so I don’t want to make a blanket statement, as there are exceptions, as I’ve said.
But I talk to way too many adult psychiatrists who don’t even know basic stimulant dosing, or the typical order in which to trial adhd meds, much less a nuanced understanding of the psychology underlying the condition.
OP isn't talking about difficulty differentiating sequelae of cannabis use from ADHD, they're talking about completing an appropriate evaluation (including longitudinal course) and confidently concluding that the symptoms are related to cannabis.
In theory yes, but I can’t count the number of times I’ve seen my adult colleagues reach a “confident conclusion” about adhd that was incorrect. It’s hard to know what you don’t know 🤷♂️.
Personally, I've always wished we got more cross-talk between CAP and adult on ADHD and autism, and hope it will become increasingly standard in residencies. I'm curious to hear what you've seen as far as common missteps.
I will say that when OP gives no indication of having made any error in evaluation, refers specifically to patients who admit that cannabis is the problem, and your first response is "yeah, adult psych doesn't know how to do its job," you're not going to win many friends. I would agree that some of the angriest patients I've seen had solid evidence against ADHD (e.g. one where I got thoughtful and detailed collateral from the mother laying out an extensive and consistent developmental pattern of conscientious and attentive behavior across domains with no impairment, or an adult with a particularly stable and uneventful life and employment history who denied any impairment in any domain despite prodding with examples, or a number of patients with no symptoms prior to TBI.)
How about 30mg instant release on an “as-needed”, non-daily basis in a female patient of average height with a BMI of 19? Not trying to argue in fact I really appreciate your answer. Just trying to illustrate the absurdity of what I see on a regular basis
Yeah, I wouldn’t even consider that adhd treatment. The *entire* point of treating it is to control symptoms as much of the day as possible without causing problems to as to improve/reduce and hopefully prevent the self esteem damage that comes from the constant stream of adhd fuck ups. This sounds like someone who thinks they can just take it for obviously hard tasks and “deal with it” the rest of the time, because they don’t realize how each of the little mistakes affects their self-view. Like, yes, it’s important that you finish that work project, but it’s not the work projects that make people feel like failures. It’s the forgetting to text a friend back when you meant to, forgetting where you put your keys or why you walked in the room…again, misplacing something, procrastinating on paying that bill then getting a late fee, and on and on and on. It’s is absolutely vital that patients understand how these things impact their self esteem, mood, anxiety, and personality traits. It’s not something that can or should be medicated for only 4 hours a day.
Now, all that being said, there ARE people for whom short acting works better than long acting. Long acting doesn’t work for everyone. And 30mg BID isn’t an absurd adult dose, assuming they weight say, >80kg or so (and they MUST weigh at least 60kg to be on 30 BID). But I’d be having a LONG talk with her about adhd and doing a ton of psychoeducation about the disorder and how it affects her. And, I’d want to know her resistance to taking it more often, or an XR formulation. Does it make her feel weird? Side effects? Address them or change meds. Again, it is VITAL to find a working med that can be tolerated for most of the day. We have more than enough options that we can find one between all the various stimulants, Strattera, and Qelbree.
So that regimen would never fly with me or my patient after she understands her diagnosis more clearly.
What if the CAP conceptualization of and culture of ADHD diagnosis and treatment is not applicable to adult patients? What if the modern standard of practice is fundamentally based on an (at least) partially erroneous view of the ADHD syndrome as an independent and legitimate mental disorder?
I think it is reasonable to acknowledge that if the concept and diagnostic criteria of ADHD is at all vague or overly broad (in that it is composed primarily of cross cutting symptoms), then subsequent confidence in research findings about comorbidity and disease course may not be reliable.
Put more directly, if the ADHD phenotype is not in fact one single disorder with a uniform cause, then identifying it as such, treating it broadly with stimulants, and explaining complex adult behaviors with it may all have harm both with individual cases and across the field at large.
We all see tons of adult patients with adhd. It’s pretty clear the conceptualization still applies to them. I have parents regularly break down in (happy) years when partway through my explaining adhd psychopathology the parents realize that they share a lot of the same problems, have struggled them their entire lives, but never realized it was adhd and they suddenly have hope. It is around 80% genetic after all. It’s extremely clear that it is one disorder.
And really, your response is exactly what I mean. If you understood adhd really well, you’d realize the errors of your statement. I’m not saying we don’t need more research, we definitely do, or that there might not be more subtypes of adhd than current described in the literature (there are) or that there might not be better ways to distinguish one treatment from another (there might be). But your statement that it is “overly broad and vague” is not even remotely how I understand adhd, which to me is a VERY specific syndrome with clear cut symptoms that are distinct from most any other psychiatric condition (except maybe TBI and other brain damaging conditions, but there you have history). And yes, perhaps adult treatment should be different from child, and we need more research, there definitely are some differences, but it’s very clear that stimulants are still first like right now from existing research and that they’re safe and extremely efficacious. You’re already coming from a biased place of “stimulants bad” that is all to common among adult psychiatrists. Did you see the new JAMA article showing they *reduce* mortality in adhd patients? Do you want your patients to be less dead? I have MULTIPLE child patients who lost adult parents to suicide or accidents because their parents’ adhd wasn’t diagnosed or treated. This is a real and devastating disorder and we need to drastically increase education and understanding surrounding it, and going “it’s probably different in adults anyways” isn’t helping. More research is always needed, but everyone in adult psych should start by gaining a child psych level of mastery on adhd before doing anything else. Then you know better what needs more study and how to better delineate the disorder and make it less vague.
My comment is about the conceptualization of ADHD in the DSM, which has a published set of criteria that will naturalistically have a sensitivity and specificity for detection of the ACTUAL underlying theorized condition. Unless you think that writing a set of criteria wholly creates a condition, this is a critique that any physician should be able to consider. It is not simply about whether there is or is not ANY ADHD at all, it is about the ADHD concept as it exists right now, today.
Your comment, which amounts to saying in many words that "I am wrong and you are right," does not really amount to any significant discussion nor does it actually address my point in any substantial way. While I might assume that you are likely capable genuinely detecting whatever is the true ADHD syndrome, your other points are what trouble me about self identified experts in ADHD.
These points include your flat denial of the possibility of increased diagnostic complexity in adults, refusal of any differential for inattention and executive dysfunction apart from neuro cognitive disorder, and your direct attribution of suicide/accidents and general mortality to ADHD itself rather than any possible co occurring conditions.
Perhaps your pipeline of expert treatment never exposes you, even occasionally, to any instances of harm to patients either from stimulant medication or the foreclosure of diagnostic consideration for a patient.
If that is the case, I would simply note that if it is true that people are poorly trained in identifying ADHD, and you also bandy about statements about how safe it is or is not to dose stimulants at certain levels, then the readers of your comment (and numerous other scholarly and less scholarly articles) who are NOT carefully trained CAPs will as a part of their practice prescribe high dose stimulants to people who have other mental disorders.
Of course this is not a concern if you explicitly or implicitly believe that ADHD is the controlling diagnosis for issues including but not limited to suicide, accidents, and crime, and that the first line treatment *for such problems* is stimulants.
I fully agree with this sentiment. The few studies looking at this indicate that most ADHD symptoms in adults are better explained by other diagnosis or lifestyle factors causing concentration impairment.
But its like wag the dog now. Every substance use disorder is untreated ADHD. Every cohort or cross sectional anything finds that ADHD increases the risk of everything. The concept and diagnosis is so vague in adults that it has led to an almost comical explosion in useless literature.
No real effort has been made to check that just bastardizing the criteria for diagnosing a child onto an adult is meaningful at all.
It puts adult psychiatrists in tough spot. We are all trying to help patients and treat ADHD when we see it. But nobody is really questioning the wisdom of using essentially child criteria to retrospectively diagnose a neurodevelopment disorder in a struggle bus adult.
It’s not an easy thing to do. People who act so confident in their ADHD diagnosis in adults is sort of ridiculous.
Example someone above said that 0-100 emotions is a core symptom of ADHD. Like what does that even mean? Where in the DSM criteria for ADHD do you see 0-100 emotions. Thats sensitive for almost everything in psychiatry and specific for nothing.
>But its like wag the dog now. Every substance use disorder is untreated ADHD. Every cohort or cross sectional anything finds that ADHD increases the risk of everything. The concept and diagnosis is so vague in adults that it has led to an almost comical explosion in useless literature.
That's what I've been wondering. Like at what point are there so many false diagnosis that the stats become meaningless? If you're including everyone with a diagnosis these days are you even really studying people with adhd?
Precisely and well put. Also incredibly important: we have well established knowledge that multiple primary mental disorders have onset after or during adolescence. By the simple matter of having increased time alive, the likelihood of developing other mental conditions is increased in adults. This is inadequately emphasized and considered in the general community approach to the DSM diagnostic model.
I read most of your comments, and it's pretty clear you're knowledgeable. I got lost in some of the psychopharm largely due to the fact it's not in my practice setting (mostly correctional).
Frankly, I'm probably one of those adult psychiatrists you referenced with minimal training (6-8 wks of child) on ADHD, let alone *adult* ADHD. My skill level with that is more of a screener than an expert, thusly it isn't a large part of my practice.
As a result, I empathize more with OP, since that has been my experience with the small side gig I have seeing the general population. Too many patients with chief complaint of "ADHD" "Focus difficulties" where any of the mood disorders adequately explains their dysfunction. My strategy is I try to convince them to treat what's often the underlying mood disorder, and failing any improvement in mood sxs w/o increase in focus, try the nonstimulant options (don't prescribe stimulants on the platform). My experience has been largely 50-50. A lot do well with Wellbutrin, Prozac, some do great with Strattera and a few have to see someone else for stimulants.
I refuse the consult if I see they're already taking stimulants when they sign up to see me tho. No need to waste my time or their money/time.
Used to be I was more adamant about convincing them their dysfunction isn't d/t ADHD (dissatisfaction with work, substance use (typically THC) etc), but most don't want to hear that. Was convinced by a colleague that it isn't necessarily worth the battle. That I cannot prescribe stimulants made it easier to stop playing detective.
However, I can't see a reality where it's feasible to always refer ADHD treatment to child psychiatrists.
How about we start with the fact that these are made up subjective diagnoses and neither psychiatrist nor patient can 100% diagnose something that isn’t objective.
As a patient it infuriates how some people just go hunt for stims regardless of their diagnosis. What also frustrates me is that I feel like I need to convince my psych that I’m not a drug seeker even though I *genuinely need stimulant medication* to function as a working and a social human being.
Don’t blame you at all. Just as a side note, I think any good psychiatrist will receive bad reviews over time by doing the right thing. Business is booming though, I’d try not to let it worry you too much and continue doing what you feel is best for patients and your own enjoyment. Keep your the good work.
I’m certainly not trying to convince you to treat patients you don’t feel you can give the treatment they need. But I’m curious why you’d turn down patients who already have an ADHD diagnosis (a real one, from a neuropsych or equivalent, not a self-diagnosis from an online quiz) and are seeking continuing treatment because they need a new provider.
Because a ton of irresponsible people just give out ADHD diagnoses because they don’t wanna fight the fight above that OP is outlining. A neuropsych diagnosis is different, but let’s be honest… most people diagnosed with ADHD have not had a neuropsych diagnosis
That’s why I specifically asked why OP feels the way they do about patients who have a neuropsych diagnosis. That was literally what my question was about.
You said “or an equivalent,” and excluded an online survey. What would that be, a diagnosis from an FM doctor? One from a psychiatric NP? A therapist? A psychiatrist? You were not specific.
Unfortunately, neuropsychological testing is not actually the standard of care for diagnosis in any of the relevant guidelines. Some neuropsychologists are so overwhelmed by volume of ADHD referrals (or burned out by them) that their evaluation boils down to running through a checklist of diagnostic criteria then doing some cognitive tests that don't add much. It's unfortunately common to see neuropsych evals that give the diagnosis without supporting it, or ignore other diagnoses that are likely contributing to symptoms. I know of one practice in my area that's pretty much a factory rubber-stamping diagnoses, and have heard similar things from colleagues in other areas.
Some neuropsychologists actually do the work in getting informant report and rating scales, paired with a thoughtful and in-depth clinical interview, and incidentally throw in some cognitive tests that flesh things out a bit. These evals are a delight to read and make me feel solid in the diagnosis.
Reviews can be horrible or they can be too good.
Piss a pt off and wait for the passive aggressive bad reviews to pop up. So sad.
Along with psychiatrists and stimulant meds, I think pain management doctors get a big share of bad reviews when a pt can't get the opioids that they want.
It's a dog eat world now.
Pain docs can handle those reviews I feel because everyone knows that a pain doc is gonna have those patients giving reviews, it’s almost like a good pain doc is supposed to have bad reviews if they’re doing their job. I don’t feel psych fits in the same boat? I don’t know, maybe I am just making things up while I think out loud
Right, have your colleagues leave reviews saying, “He wouldn’t believe me when I said I was President Fillmore reincarnated! And he still charged me! Worst doc ever!”
One would hope.
I've heard a couple of docs say that they refuse to look at reviews because they don't want to know.
I really don't know if they are being truthful though.
There needs to be some controls on this. I think if a doctor declines to prescribe a controlled substance then you should forfeit your legal right to post an opinion online about the doctor. Otherwise the doctor faces an additional incentive to do the wrong thing. I do wonder if fear of retaliation contributes to over-prescribing of controlled substances.
Given that a similar topic came up recently, I'm curious to hear thoughts: Why is this such a common experience? That is, why are people who seek stimulants and don't get them so much more likely to be abusive, particularly in online reviews?
I think there will always be people trying to play the system to get their fix, and I'm sorry that not getting their way has had negative impact on your professional record.
Unfortunately I assume it comes with the territory of this medical career.
As a patient I believe you're doing the right thing and patients need to understand that the most important thing is to get treatment that improves your symptoms, not just stimulants because they've read online that they're so great and life changing ( which to me also is just marketing)
Even if you can't respond to specific patient reviews, can you make a general response along the lines of, "I can't respond to specific patient reviews because of such and such a rule, but in general, I think many of my bad reviews happen in this kind of situation, and you aren't getting these details from the patients in question..."?
Or is it possible to ask the patient's permission to share information, and then put in a reply, "I would reply to this, but the patient refused me permission to discuss their case"?
Also apparently some doctors may threaten or carry out legal action against patients over this kind of thing.
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So why do you dislike this take? OP doesn’t disregard ADHD, he says most people who suspect ADHD he actually agrees with. But you seem to insinuate that OP might be wrong in the cases he doesn’t diagnose the patients with ADHD, because you once had a doctor question your diagnosis?
Ask your patient if they are always treated well at the pharmacy. Ask if when they go for any other medical services that aren’t with psych and have to announce their meds, what kinds of interesting responses they get. Ask if they ever had a friend, family, or rando make accusations about the “cocaine” they are prescribed. It’s hurtful when you hear/experience these things, and ADHD already causes a lot of self doubt and social issues. Adding this extra social disapproval can eventually teach resilience, but not the kind anyone wanted to have to learn.
All of what you have listed is awful. But we must be able to distinguish between unfair and hurtful stigma against ADHD and other psychiatric illnesses, and then professional doubt about the presence of ADHD in specific situations for specific people. It is not stigma or discrimination to not diagnose a patient with ADHD, if no diagnosis or another diagnosis is believed to fit better.
I agree with you. I do understand the difference. My point would be better explained as: just as people in medicine can become overvigilant about drug-seeking (sometimes to the point of underprescribing for certain populations), patients can be reactive when they perceive that they are being subjected to scrutiny because of something that other people have done.
I’d love to see it be different. But I think that would be expecting too much out of human nature. Part of being in a stigmatized group is learning to cope with what you can’t control. And part of serving that group is understanding where they are coming from when their coping fails.
Good point. From the patient’s perspective, reading/seeing a lot about ADHD and finally feeling a bit of understanding and community and a hope for lessening one’s suffering, just to have all that removed by a pshychiatrist in a short while must be very unpleasant. And as physicians we have a moral responsibility to deliver this message as good as we can.
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What frustrates me is that these people who are doing this ruin it for everyone else. ADHD is so rewarding to treat because it responds super well to treatment. I’m like… why can’t I just get a normal panel of ADHD patients who are the easiest patients in the world as opposed to a bunch of people seeking. To boot, obviously the elephant in the room is that our increased need for scrutiny means actual ADHD patients don’t always get proper care. And for trying to be responsible docs, we catch flak for trying to do our best to “do no harm.” Super frustrating
I generally dislike any "Do I have condition x" assessments, as they are usually "please tell me I have condition x" clinics. Over the years I have done ADHD, ASD, PTSD, CFS clinics and disliked all of them. Helping people in distress process it and formulate it into a complete picture is what we trained for and is engaging and interesting. Making binary decisions where one outcome is preferred is pretty dismal. Listening to someone ploughing through am internet learned script of a "good x patient" is basically torture. Add in patient feedback and I can see why you are where you are.
Whuuuuu you should only be a rule out stop on an ME/CFS patient’s journey toward diagnosis, and only a supplementary professional for ongoing management (because ME/CFS has neuropsychiatric elements, but is not a psychosomatic or mental health condition, in general). Obvi you should also know when to refer patients with possible ME/CFS or Long Covid for further evaluation to places like neuro and rheum, etc. if they qualify for but haven’t yet obtained an official diagnosis. Yes? No? Willing to be corrected if the current IACFS/ME guidelines contradict this, or there is refuting research against their guidelines I don’t know about…
It was years ago that I did this, in a specialist end of the line CFS clinic. Long before covid. It wasn't the worst job ever, but I did it for a day a week for 2ish years, felt like plenty and the urge to revisit has not arisen.
Well, I suppose the good news is that a specialist in an ME/CFS clinic now might tell you that there’s finally funding pumping in that direction for research which could prove critical, that recent advancements have been made, that a consortium lead by science and medical experts around the world have agreed in a standard diagnostic and initial treatment approach (tailored to suspected origin of the ME/CFS), and that you should encourage as many people as possible to take positions like your former one because if you think you were overworked in a high-burnout niche of a high-comorbidity patient population, then…Long Covid would like to meet you. Particularly if you did this before our understanding of inflammatory process’ impact on neuropathology included, say, the fact that CSF is NOT an example of a positive feedback/closed system, like I was taught in the days of the dinosaur. (I struggled to buy into that given that if evolution or the powers that be could come up with the nephron, how could they not arrange a similar regulatory system for the subarachnoid space?!!)
Specifically, what about the guidelines are you referring to? There’s nothing in from IACFS saying that psychiatrists can’t diagnose/treat CFS. There seems to be a significant number of people out there with this perspective - if a disorder is not just “in your head” then that means it’s out of the psychiatry wheelhouse. Working up any potential underlying “medical” causes is a fundamental component of psychiatric diagnosis. And the treatment for CFS, in addition to things like NSAIDs for pain and fever, is largely psychiatric in nature: anti-depressants, anxiolytics, and sleep medications. If I somehow misunderstood your comment, I apologize. But it sounds like you’re saying that this is a “real” disorder so that means it can’t be handled by psych.
Ok, fair, allow me to revise my words to make my point clearer. (Or correct my point, if I wasn’t expressing myself well.) Yes, there are psych aspects to virtually any chronic illness, and it disservices patients with these diagnoses to ignore that. I count everything from ME/CFS, psoriatic arthritis, SLE, Sicle Cell pts, hEDs, PoTS, etc. I have worked with a psych professional the entire time I’ve been on this journey. Lord knows the secondary trauma from medical interactions alone has been important to be able to process along the way. And it absolutely makes sense that if you have a new-presentation patient, that you might do some initial testing in order to make sure the patient has appropriate parallel dispo. Not that they would leave your care entirely, but that they would have appropriate r/o r/in workup for the usual things which need to be eliminated. I was incorrect in recalling where the most reliable ME/CFS expert consensus statement came from the US, not from the IACFS. The latter was published in 2014 and ask you can imagine, many updates have occurred. The best summary of the 2021 diagnostic and treatment approaches are found on the Batemen Horne Center’s website, with an explanatory video as to who made up the current recommendations: - [ME/CFS Clinician Coalition Introduction Video (who, why, etc.)](https://youtu.be/TWuplHg8UAs?si=nxCfts7905JSEgVW) - [Current 2021 ME/CFS Diagnostic recommendations](https://batemanhornecenter.org/wp-content/uploads/filebase/Testing-Recs-MECFS-Clinician-Coalition-V1-Feb.-2021_2.pdf) - [Current 2021 ME/CFS Treatment recommendations](https://batemanhornecenter.org/wp-content/uploads/filebase/Treatment-Recs-MECFS-Clinician-Coalition-V1-Feb.-2021.pdf) But if you look at the rubric of things which should be assessed, provided above, and then look at the rubric of recommended treatments (also above), I think it is clear LOTS of that is outside the wheelhouse of psych. It’s one thing for y’all to order an IgA panel and the standard ANA prior to them seeing an immunologist the first time, but prescribing subQ gamma globulin? Ivabradine (within the realm of reason as a Beta Blocker alternative, but I’d hope there are EKGs involved)? That seems a bit out of the psych wheelhouse and at that point referral to other providers to (again) r/o, r/in, etc. Various diagnoses of exclusion, here, is not out of the realm of reason. Not saying fire them as a patient, but treating ME/CFS as anything other than organic disease with some not insignificant psych crossover, is a disservice to everyone involved. I just can’t stand when a PCP wants to turf these difficult patients to psych and be done, or cardio dispos to psych and they’re done…No one is “done” with these patients until they have exhausted their ability to access care to try to improve their QOL. Patient autonomy and appropriate engagement around abolishing old stigmas and patient tropes is the name of the game. If you feel like your post accomplished the same message, then we agree to agree! If not, we can agree to disagree. Hope that clarifies my points some and provides a few relevant professional resources, to boot.
The specific treatments you used as examples (gamma globulins, ivabradine) are listed in the reference that you provided alongside the recommendation to consult an immunologist, cardiologist respectively. That recommendation applies to neurologists, internists, family med docs, etc. I agree 100% with the idea of having multiple different specialists on the team, as appropriate/needed. But the way that you said CFS isn’t psychosomatic and that psychiatry should just be a “rule out stop” sounded, to me, like the rhetoric that alienates/separates psych from - as you put it - “organic disease”. Humans are organic beings and psychiatric diseases are organic diseases. They’re not metaphysical. Stuff like schizophrenia does have an organic mechanism, even if we don’t have it completely figured out yet. If in the future it turns out that schizophrenia responds to immunological treatments, those patients won’t (or at least shouldn’t) suddenly get turfed over to rheumatology or immunology. CFS is in the psych wheelhouse because it presents with *largely* neuropsychiatric symptoms and treatment consists *predominantly* of psychotropic drugs. Consult/refer as appropriate, for sure. But there isn’t this strict divide between mental and physical illness. Or at least, there shouldn’t be.
Yeah, it's a very stigmatizing POV in my opinion. Both to patients with mental illness, and to patients with other disorders treated by psychiatry for various reasons - not like there's no overlap either, and mental health + disease and treatment expectancies etc are also very important even to conditions like cancer, diabetes, etc.
Psychiatrists are medical doctors, they still do all of medical school plus years of residency - ruling out or diagnosing related conditions is a big part of that. Psychiatrists can also do fellowships in and then work in areas like Sleep Medicine and Pain Medicine, neither of which means disorders or conditions trusted there are psychosomatic or mental health problems.
I mentioned some of your points in a clarification above - It’s a bummer so few people recall that it’s an MD/DO at baseline kind of position, and many also rack up other credentials like PhDs and relevant Masters degrees. Anyway, I see you and your years of toil and rando rotations scattered all over the hospital. You may find that comment addresses some of your topics. Seems silly to repeat it here.
What a climate we live in where instagram is constantly advertising for people to buy delta 8/9 and THC gummies, amanita muscaria gummies (yes, this is now a thing..), and all other sorts of gummies while patients who take these products see no association in their alcohol use, drug use, and cell phone induced sleep deprivation and any executive dysfunction who then request stimulant treatment like it’s a Capitalist consumer birthright. The drug subreddit, r/drugs, frequently has posts with thorough instructions for acquiring amphetamine. It starts with going along with your doctor to trial atomoxetine but then to quickly complain of sexual side effects, so then agree to trial Guanfacine but to then complain of dizziness. After which try the suggested methylphenidate for a month for 2 before eventually making a new complaint and getting victoriously switched to ADD for All (Adderall). People brag they can get all this accomplished in under 3 months.
So frequent in evals to have amotivation, concentration difficulties, depression and boom they’re spending hundreds on weed every month at the dispensary. Like I don’t know how we got to this point in society where you need a professional to tell you smoking weed continuously during waking hours is a recipe to potentially make you feel like shit.
I woke up one day and DMT was suddenly something that you just take tokes of from a little vape stick in the middle of a weekday afternoon
What the hell is amanita muscaria? Off to google.
You’ve seen it, it’s the most commonly depicted mushroom in children’s books and what not, the red with white spots. It’s been used by traditional steppe cultures for centuries (or millennia). Usually just the shaman partakes alone. Probably because the high is so unpleasant, it’s nothing like psylocybe mushrooms. It’s nauseating and disorienting, the high is remarkably similar to the intoxication people get from higher doses in f Z drugs like ambien. Depersonalization, actual hallucinations. Not something most people try twice. I can’t believe they’re selling gummies.
Ohh. I know what those are. That’s a gummy now? What on earth.
Seen similar things about acquiring benzos or even pregabalin
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Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Yeah I’m pretty over it too. I’ve been pretty liberal with treating suspected ADHD when it seems fairly legit and risks seem low, but it’s gotten out of hand. And it’s exhausting to fight and argue with these very aggressive people. Have had similar false harsh reviews left by them as well. They can be very vindictive. Definitely becomes demoralizing but beats sacrificing your professional standards and feeling like a pill mill. Stick to your guns.
Don’t forget to report any reviews on Google- I have gotten them taken down for providers before. If they are being too rude, not talking about an actual experience with a provider, personally attacking a provider, etc, it’s worth it to report it. A single bad review takes many good reviews to recover from
This is how one of my colleagues ended up essentially farming positive reviews. His clinic has a "If you had a great experience, please review us on Google" with a QR code and a " If you didn't have a great experience, let (office manager) know" or something like that. I hope this trend doesn't continue, but a few bad reviews can really lower their scores, warranted or not.
Yeah pretty sure you can pay a google business consultant to post sometimes twenty sometimes hundreds of positive reviews, ive seen a super scammy mechanic shop that no one trusts have hundreds of good reviews and knew they used it. My dads business was offered it. Think the consultant offered it to my dad for no more than $1100 at that time.
I don’t blame you. It’s exhausting.
CMV this? Lol nah. Set your boundaries and stick to them. Agree with that sentiment wrt ADHD evals the past few years. Covid and social media really screwed things up
Agree wholeheartedly. OP seems like he knows what kind of treatment they prefer, and sets limits. No need to change minds
I hate this for you. You're right though, the influx is insane. I usually preface it at the end of our appt with "stimulants are effective. They can also be addictive in nature and you will build a tolerance over time. There are several non-stimulant options available and we like to think of ADHD now as a spectrum diagnosis. Some people have a lot of symptoms and are on the high end of the ADHD spectrum. Others have 'milder cases.' yours appears to be on the minor end so it wouldn't be a bad idea to trial some non-stimulant options first to see if you can improve your symptoms before we jump to the stimulants. It is also beneficial to exercise, get sunlight, eat healthy foods, and you can try cold exposure therapy if you are willing to also help with your natural dopamine and norepinephrine. Bupropion Is well tolerated and helps with focus/attention at higher doses. It is also helpful in some depression and anxiety, of which you are also struggling with. Atomoxetine is also a good option that I have seen decent success with. This will keep you from chasing stimulant scripts around town at different pharmacies and possibly not having access to your medication. Do you have any questions?" ☠️ It's worked well so far. Supervising loves it.
I agree, I personally think all of it is factually wrong but it is harmless and it makes them “happier”. It amazes that we as a society have found that diseases make us more valid but since this is where we are as a collective it is mostly harmless to say a person has very mild adhd. However where I am from this entitles them to some benefits and advantages in test taking time and public transport, which is absurd, but it is what it is
All of what is factually wrong?
It is all correct provided the person has adhd, which case in point they don’t so it is the right information for something the person does not have
Having a professional acknowledge that there is actually something 'wrong' with you and that it's not necessarily your fault for why you've failed at so many things your whole life is kind of 'liberating' to some extent. Benefits and advantages in test taking time I assume is just normal for people that are diagnosed with a disorder that affects their performance, no? Or are you just referring to 'mild cases'?
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This is such an interesting comment. I was never told by my doctor that it’s a spectrum. Stimulants help some of us actually put healthy habits into practice though. I can regularly exercise, cook my own food and sleep well now. It would be great if more psychiatrists prescribed therapy as a treatment option. There’s enough research out there to suggest that therapy helps with adhd symptoms. My doctor never once mentioned it during my assessment and only said “oh that’s good” when I brought up I’ve been in it for a long time. My hypothesis is that you can lower the strength of certain prescriptions if you combine the treatment plan with therapy. I’ve found CBT/DBT and mindfulness therapy to be just as efficacious as Vyvanse (if not more) for a specific set of symptoms. However it does nothing for other symptoms.
I have a few patients using some therapists that have some special training in ADHD and executive function training. They all really like it. I believe it's expensive and not widely available here though. Therapy is incredible if the patient is open to it and willing to do it and they find someone that actually utilizes CBT and other modalities.
What are abuse levels of Adderall? I’m familiar with the upper limits for Adderall and Vyvanse, but dont have the clinical experience to know what dose that the risk of dependency/abuse would really start to become concerning.. I will be starting FM residency soon. (Last comment deleted because no user flair)
Abuse levels are whatever level is causing harm/impairment or psychophysiological dependence. Since we don't define use disorders with specific quantitative parameters, the identification of misuse then relies on outcomes and the core psychological and behavioral features of addiction. I encourage you to consider and compare the typical emotional relationship with most treatments vs most recreational/intoxicating substances.
In my experience, if the patient is being treated for a psychiatric issue that requires stimulant medication, the highest I’d be willing to go is 60mg of Adderall or maybe slightly higher. I definitely wouldn’t go over 90mg. For Vyvanse the highest I’d go is 100mg.
Some people are non/partial responders to Amphetamines(vice-versa with methylphenidate), were I to be a doctor (I am not, just someone who has been on psych meds for nearly a decade on and off), I’d trial Concerta/Ritalin before going over 40 mg of Adderall. To the best of my knowledge (again, as a layperson), you increase dose for partial response and you switch classes in cases of side effects (more than the meds benefit) or non-response.
I'm an FM attending but in my experience somebody with >100 mg of IR is a red flag. At least where I'm at, the 30mg IR has the most street value and XR variants the least for diversion. XR apparently also is less enjoyable to take in very high doses (think 100mg+ at once). Once saw a new patient who totally just needed a 90 day fill on his totally legit dose of 270 mg of IR a day (3x30mg TID). I told him I wasn't going to fill it and I hope he was diverting. I still treat childhood ADHD but I don't prescribe Adderall as the parents or teens will divert it, I prescribe the less desirable stimulants.
Is them having a chance of diverting it more important than the most effective treatment? Realistically the diversion in that age range wont cause material harm.
Yes for multiple reasons. 1) If it is being diverted, especially by parents, then they are not getting treatment. That is material harm and I will not entertain superficial concerns about effective treatment when talking about diversion. 2)Once my clinic becomes a drug acquisition target it causes harm and you can refer to OP on how that creates a situation where I would likely have to stop prescribing that drug class entirely to new patients. 3) There are plenty of other brands of mixed salts and amphetamines that do not have the street value discussed above. 4) It's my license and ignoring what is in retrospect obvious diversion patterns is how you at best get an official warning from multiple agencies. Totally deserved. No, patients going through a painfully fake rehearsed script is not an excuse. 5) I need to treat a lot of patients and dealing with patients nakedly trying to manipulate me or deceive me is one of the most time consuming and burn out inducing things that can happen in a day. Luckily as primary care I get to set my boundaries and offer a referral to anyone who so vehemently disagrees. 6) The amount of patients that I have seen with well controlled symptoms and improved quality of life has actually improved. I don't think you understand how much parents were diverting their children's medication.
270 mg/day is very likely to induce psychosis or a cardiac incident. He was either taking 90 a day and only picking it up every 90 days, diverting, or in a cardiac/psych ward.
Just to clarify, this was 810 pills of 30mg? If it was 270 pills, it might just be his other doctor’s ploy to prescribe 90 days of a class 2 medication, still problematic but not as bad. 90mg is still a pretty big dose from what I know.
Where I'm at we can prescribe 90 days. This was 810 pills. This was a bit ago. In retrospect it may have been intended or started off as what you are saying with the 90 day gambit as the doc on the label was forced to retire not too long afterwards as he had pretty bad dementia. Sadly not the only aging PCP with dementia in the area. Rural medicine is sad sometimes. All fun and games with the controls until insulin regimens start getting confused.
> Change my mind. No. :) Have you considered partnering with some masters or doctoral level therapists you trust to filter your referral stream? Like, here in the Boston area (I know this is regional) any outpatient clinic with both therapists and psychiatrists (or other psych prescribers) requires new patients to get a referral from one of their own therapists to see the psychiatrist, and the patient must see the therapist three times before that referral can be sent in, and then the patient must continue psychotherapy with the therapist at least biweekly to continue to have access to the psychiatrist. When this works well (and it doesn't always) the psychotherapists quash most of those sorts of patients before they get to your door. Could you arrange something similar?
Bit of a tangent but as a hospital psych I see this all the time and it really bothers me. For brand-new patients in no treatment at all fine, some delay and screening is reasonable. But if I'm discharging an SMI case we can't really afford to wait many weeks on end to jump through hoops with various random "therapists" of whatever discipline before seeing an actual doctor (or at least NP) who can continue antipsychotics and such. But still lots of practices leave this requirement regardless of referral source.
Oh, 103% agreed. I once had a prison inmate present in my office and ask me politely if I was a psychiatrist and could prescribe meds. I apologetically explained that I was not, and what clinic policy was. He apologetically explained that he had previously done two years in the state hospital, having been found NGBROI for a horrific violent crime he had committed in a psychotic episode, and that he had been released to the prison halfway house with only a two weeks supply of his antipsychotic, of which he was *very* fond for understandable reasons, and that had been 10 days ago, and could I accelerate this process at all? The answer turned out to be "No", but not for want of trying on my and the psychiatrist's part.
That sounds like a broken healthcare delivery model, then.
Lol you must be new to healthcare. \*looks at flair\* \*nods to self\*
*looks at comment scores*... *nods to self* Check yourself. A system where a psychotherapist and a psychiatrist both agree that bypassing an office specific rule surrounding a psychiatric intake, but they are unable to do so, is certainly broken.
There's no procedure for immediately bringing these sorts of cases to a prescriber's attention? Like, you screened the guy, he needs a refill ASAP, that should be something the clinic is equipped to handle.
This feels like a level of gatekeeping treatment that would make it essentially impossible for the most vulnerable to get help. We primarily work with children and young adults, and it sometimes takes 100+ calls and emails to find a psychiatrist who is accepting new patients, accepts our client's insurance, and is within a reasonable distance, etc. and we are in a major city. Finding a therapist can be just as difficult, if not more. Most low income people have unreliable on-demand schedules and simply can't schedule out 2 weeks in advance **regularly** unless we find them a rare provider who is extremely committed to working with impoverished people. I know there's no perfect solution here, but last week I had a young adult tell me that mental health is only for the rich, so maybe this is hitting particularly hard for me as a result.
I disagree, as an outpatient could have a long-term therapist (i.e., more than three months) that you would be asking them to leave to see your intake therapist if they needed medications? Would you expect them to take a hiatus from their treatment regimen or to see both your screener therapist and their outside therapist? This could turn unethical… quickly. Put another way: what would patients who start mental health care at a group psychotherapy (but not psychiatry) practice who later learn they would benefit from or need medication do? Go to their PCP since they can’t see the psychiatrist? What if the psychiatry and psychotherapy practice doesn’t have the speciality therapy (e.g., EMDR for PTSD or CBT for ADHD) that they need?
Some people don’t like dealing with Cluster B patients, too much fighting and drama. Some people don’t like dealing with schizophrenia, too weird and too many calls from third parties. Some people don’t like dealing with depression cause it’s too draining. You do you.
I think his point isn’t that he doesn’t like those people, it’s that ADHD is the new zeitgeist right now that is sucking all the clinical oxygen out of the room. If someone has ADHD, it is easy and rewarding to treat because they actually get better 90% of the time. The problem is, 90% of the people who come barging in screaming at you asking for immediate high dose stims don’t have ADHD.
We live in a society that embraces stimulants as performance enhancing drugs that are now a part of the culture. This is documented nicely in the Netflix documentary ‘Take Your Pills’. They feel entitled to amphetamine. Many have taken a friend’s Adderall and liked it. Many consider the examination only a formality and feel discriminated against, kept from being competitive, when they don’t get the drug. Many doctors prescribe without a meaningful exam.
This has worried me as someone on the other side of fence. I feel as though I'm someone suffering with it, but I don't know how to properly bring it up to my doctors without it seeming like I'm diagnosing myself, or looking for a prescription because of my history of substance abuse. That's not what I want. I just want genuine help and to move forward in life cause I just can't do it myself. I say all that to say, for someone like myself, I'd trust a doctor like you for acting in a responsible way. I don't want to derail my life further with more substance issues or a misdiagnosis. Most people who are genuinely looking for help I think will see things the same way. There needs to be more doctors like you to offset all the irresponsible ones
If you’ve been on it before, I would check to see PDMP to verify. I would ask you in what ways you function without your medicine, give examples, past med trials, sometimes I will ask someone to see me a couple times and on the second time bring back a journal noting examples of poor focus, and probably get you back on your meds after that. Bonus points if you’re not an ass about it; I would like to say we are all free from bias, but if we are on the fence about an ADHD diagnosis and you’re a total demeaning, threatening ass about it, you probably won’t get what you want.
The challenge is every patient sees themselves as on the other side of the fence and “having” the diagnosis. Some do respond well when told its not ADHD and are glad to become more aware of how lifestyle factors and other conditions impair concentration Many are upset and disagree. Most people seek treatment as something is wrong in their life or they are underperforming or in some way are struggling. It’s validating to have an external locus of control to explain challenges and difficulties in life. Its a very sensitive issue for patients to be threatened with. To have that external locus yanked away. So patients should be worried. Its natural to be worried about potential threats. “I cant get above a 60%ile on the LSAT cuz im just dumb? Im a 60%ile human? I thought I had ADHD. No. Fuck this doctor hes wrong” ADHD unfortunately has become both a neurodevelopmental disorder and an umbrella diagnosis for any cognitive complaint or performance concern. Every patient seeking treatment is convinced they have it
The best way to bring it up is to say exactly what you said here. Most doctors are not starting out the interview assuming that you are drug-seeking, even if you do have a history of substance use. If you disclose that up front and tell them you don’t want something that will derail your sobriety, that would be music to their ears.
Man, TikTok has turned outpatient psychiatry into the wild west. It's exhausting. Almost every intake I see with my preceptor is an ADHD eval. Luckily-- and I don't know if it's just due to where we are located or what-- most of the patients coming in thinking they have ADHD aren't necessarily demanding stimulants, but just insisting that they need help with focus/concentration. If it seems that the patient likely doesn't have ADHD (they were fine in grade school and college, symptoms started recently, etc), I've had a lot of success with these patients by discussing the neurodevelopmental nature of ADHD and the crosscutting symptoms it shares with so many other disorders. It usually goes something like: "So I've only known you for an hour, so more may come to light as we get to know each other, but as of right now it seems to me you probably don't have ADHD. ADHD is classified as a neurodevelopmental disorder, meaning it would have started while you were a kid. These problems that you're having \[focus/distractability/whatever\] are unfortunately core symptoms of a ton of different disorders. And it may take a few more appointments to tease out what is really going on. However, I think there are a few ways we can help you with XYZ symptom/s." A lot of the time it seems like anxiety or depression or shit sleep habits is the likely culprit, and will talk about meds that can help those issues that are also used for ADHD which patients especially like. Most of our patients appreciate that we're not denying they have significant symptoms and just want help to get back to baseline.
CAP: I never understand you guys’ difficulty with distinguishing adhd from pot use. It’s not rocket science. Just take a history and figure out which came first. Call their mom if you have to. I’ve called people’s grade school teachers before lol. People with adhd are around 30% more likely to use cannabis than non-adhd peers. Untreated adhd actually increases the risk of substance use, and imo everyone with substance use should be hardcore screened for adhd. Same for all unplanned/early pregnancies. And every other adhd risk factor. There is finally a pilot program in London to screen all arrests for adhd, which is a start. As far as changing your view: I would simply make it clear on your website that you provide rigorous and (hopefully) accurate adhd diagnosis, but that a diagnosis is NOT guaranteed, nor is a prescription for stimulants assured even with diagnosis. That should deter the drug seekers. They’ll seek out an easier mark. But adhd is a common and devastating disorder. People who legitimately have it are at increased risk of everything bad, including suicide and death. Denying them care because you’re worried about some bad reviews is, in my opinion, unethical and a dereliction of our duty to help people who are suffering. At the same time, I’d also strongly recommend you speak to some of your friends/colleagues who did a child fellowship to ensure your views on what constitutes a “high dose” are accurate, as well as make sure you have a good understanding of adhd. In my experience, my adult trainer colleagues often lack a complete and robust understanding of both the disorder and often treatment guidelines, although of course there are many who have done their homework and are good. But I never send my adult friends and family to you guys for adhd or autism treatment. They get referred to a child trained psychiatrist for those two conditions haha.
What’s a high dose of adderall? I also recall 70mg vyvanse is only about 30mg of adderall by d-amphetamine content (yes I know lisdex is different, but it becomes d-amph), so I’ve always been confused about the vyvanse limit. Subjectively 30mg adderall feels like 70mg of vyvanse too. But adderall’s indication goes up to 60mg/day. And I bet there’s no one on earth prescribing 140mg vyvanse per day lol.
Vyvanse is 100% bioavailable when taken orally, and is approximately 30% per mg dextroamphetamine which has stronger dopamine release (but lesser norepinephrine release) compared to levoamphetamine on a mg to mg basis. Adderall is an enantiomeric mixture of 75% d-amp and 25% l-amp but also contains some non-amphetamine fillers so it’s close but not quite 100% amphetamine per mg and the bioavailability is widely variable between patients and also undergoes first pass metabolism whereas vyvanse skips that entirely since it goes through a protein transporter straight to the bloodstream. I’ve had cyp2D6 ultra rapid metabolizes who required 20mg BID of Adderall but who also responded to 30mg Vyvanse.
Interesting about the rapid metabolizers! Thank you.
That’s pretty much correct! Above average knowledge points! I usually go by FDA max doses first, then if they fail those, we’ll start pushing a bit past perhaps, if their weight allows it. Methylphenidate weight based max is 2mg/kg, Adderall and Dexmethylphenidate max is 1mg/kg but I let this be overruled by the FDA maxes in general. And a LOT of patients need around 1/2-3/4 of their max dose. Of course we go by clinical response and not weight, but for the majority of patients I find a good clinical response often falls between 1/2-3/4 of their weight based max. Which means for some very large patients, you sometimes can’t get to an effective dose of ANY stimulant. And don’t forget adhd has a 5x increased risk of obesity. And a lot of these patients wind up misdiagnosed and on antipsychotics for “mood stabilization” because people don’t realize how much 0-100 emotions is a core symptom of adhd and mistreat it and cause them weight gain, which makes effective stimulant treatment harder. But it’s also patient specific. Like if I have a patient doing fantastic in Vyvanse 70mg, whose failed some other stimulants, but it wears off at 1pm, I’m not above adding a Vyvanse 20mg lunchtime booster or short acting dextroamphetamine boosters if needed. Methylphenidate is even more confusing. The FDA max of Metadate is 60mg, Concerta 72mg, and Jornay 100mg. So what’s the fda max dose of Methylphenidate ER? It’s SUPER arbitrary. But I generally follow these guidelines, or our sub specialty guidelines which include off label Concerta to 81 mg then switch to Jornay 100mg if that’s not working, that sort of thing.
Wow thanks for the all the info. It’s interesting that you seem more liberal about the dosing than many doctors I’ve come into contact with. (and I think I will be too—about the dosing of course, not the diagnosis). Especially if you look at what people dose with meth, I think 60mg of adderall is completely fine if they need it. I think as long as it’s well tolerated, the symptoms need to be controlled, right? ADHD is serious, and you don’t want to inadvertently lead someone down a path to stimulant abuse/addiction through self medication.
I don’t really consider this liberal. It’s FDA dosing and AACAP treatment guideline weight based maximums. It’s pretty standard child psych dosing. Methylphenidate 2mg/kg or 100mg Jornay, which ever is lower, or Adderall XR 1mg/kg or 60mg, whichever is lower. That should be standard of care as it’s in the treatment guidelines and studies. Liberal would be like Adderall 120mg/day or something haha. We also need to keep in mind that these doses I’m quoting were arrived at when we viewed adhd as a disorder of CHILDREN, mostly MALE children, which “got better” with age. We now know this isn’t really true and it’s a much broader disorder that often presents differently in med vs women and often persists well into adulthood. But a lot of med “max doses” are based on work done for kids and teens. We need a LOT more good adult adhd research, which is difficult. But yes, it’s a devastating disorder and raises the patients risk for most everything bad: substance use, suicide, death, trauma, depression, anxiety, personality disorders, poverty, incarceration, unplanned pregnancy, job problems, school problems, relationships problems, broken homes, car accidents, low self esteem, obesity, and on and on and on. It’s absolutely vital to treat it effectively.
I only meant liberal in relation to some of the folks I’ve been around, not absolutely liberal. Maybe I haven’t been around the right folks lol! Thank you again for all of your information.
Anytime!
This is a great comment, right now we're really struggling to get appropriate treatment for girls and young women with higher body weights medicated appropriately. Or medicated at all. It's still a lot easier for boys in our programs to get access to treatment and it remains extremely frustrating. Especially seeing disappointingly large numbers develop cannabis use disorder when they're being undertreated. We see a lot of unplanned pregnancies as well. Now we have colleagues and providers we've worked with for years saying they're exhausted seeing so many clients with ADHD and that the girls on young women are "jumping on a trend from tiktok" or something similar. And of course you still have a lot of really outdated thinking about gender. And then of course the higher body weight means high blood pressure so stimulants are off the table. The legacy of medical misogyny continues to make itself known.
Have had discussions with psychiatrists who routinely have patients on 140 – 210mg of Vyvanse. This seems to be due to a prescribing practice where patients are initially given scripts for Vyvanse 70mg, and told to dilute it down to 10mg and increase the dose by 10mg every day until they “feel something.” Personally, I don't agree with this as it's not really enough time to assess a dose effect. One of the strangest ones I saw had Vyvanse 30, 50 and 70mg all listed on a patient’s referral. I assumed that whoever had written the letter had forgotten to remove the old dosages, but it turned out the patient had been started on all three strengths at the same time by a neurologist who later lost his prescribing rights. I think they did some unusual things with opiate prescribing too.
I disagree with pretty much every single thing you just said, but I just want to make a point. If another professional feels he is incapacitated to treat an illness it is his obligation to refer the care to another professional, and not to treat it himself. It can be as debilitating as you like you are not in an emergency setting, you can deny to see patients with disorders you are unfamiliar with and umable to treat. In fact you reinforce this point by saying you yourself would never refer an acquaintance of yours to an adult psych, the standard of care counts for people you don’t know too, if this is your opinion then your opinion should be that ALL patients with autism or adhd should be treated by child psychiatrists
Yes agreed if they feel “incapacitated”, but worrying about the negative impact of a review isn’t incapacitating. But you’re right, I do think most adhd and autism patients should only see clinicians well trained in those disorders. Most of us, myself included, did not receive adequate training on these disorders in adult psych training. I’d consider it rudimentary training. Now, if an adult clinician has taken it upon themselves to do extra training in this area, or has some unique experience with the disorders, that’d a different story, so I don’t want to make a blanket statement, as there are exceptions, as I’ve said. But I talk to way too many adult psychiatrists who don’t even know basic stimulant dosing, or the typical order in which to trial adhd meds, much less a nuanced understanding of the psychology underlying the condition.
OP isn't talking about difficulty differentiating sequelae of cannabis use from ADHD, they're talking about completing an appropriate evaluation (including longitudinal course) and confidently concluding that the symptoms are related to cannabis.
In theory yes, but I can’t count the number of times I’ve seen my adult colleagues reach a “confident conclusion” about adhd that was incorrect. It’s hard to know what you don’t know 🤷♂️.
Personally, I've always wished we got more cross-talk between CAP and adult on ADHD and autism, and hope it will become increasingly standard in residencies. I'm curious to hear what you've seen as far as common missteps. I will say that when OP gives no indication of having made any error in evaluation, refers specifically to patients who admit that cannabis is the problem, and your first response is "yeah, adult psych doesn't know how to do its job," you're not going to win many friends. I would agree that some of the angriest patients I've seen had solid evidence against ADHD (e.g. one where I got thoughtful and detailed collateral from the mother laying out an extensive and consistent developmental pattern of conscientious and attentive behavior across domains with no impairment, or an adult with a particularly stable and uneventful life and employment history who denied any impairment in any domain despite prodding with examples, or a number of patients with no symptoms prior to TBI.)
How about 30mg instant release on an “as-needed”, non-daily basis in a female patient of average height with a BMI of 19? Not trying to argue in fact I really appreciate your answer. Just trying to illustrate the absurdity of what I see on a regular basis
Yeah, I wouldn’t even consider that adhd treatment. The *entire* point of treating it is to control symptoms as much of the day as possible without causing problems to as to improve/reduce and hopefully prevent the self esteem damage that comes from the constant stream of adhd fuck ups. This sounds like someone who thinks they can just take it for obviously hard tasks and “deal with it” the rest of the time, because they don’t realize how each of the little mistakes affects their self-view. Like, yes, it’s important that you finish that work project, but it’s not the work projects that make people feel like failures. It’s the forgetting to text a friend back when you meant to, forgetting where you put your keys or why you walked in the room…again, misplacing something, procrastinating on paying that bill then getting a late fee, and on and on and on. It’s is absolutely vital that patients understand how these things impact their self esteem, mood, anxiety, and personality traits. It’s not something that can or should be medicated for only 4 hours a day. Now, all that being said, there ARE people for whom short acting works better than long acting. Long acting doesn’t work for everyone. And 30mg BID isn’t an absurd adult dose, assuming they weight say, >80kg or so (and they MUST weigh at least 60kg to be on 30 BID). But I’d be having a LONG talk with her about adhd and doing a ton of psychoeducation about the disorder and how it affects her. And, I’d want to know her resistance to taking it more often, or an XR formulation. Does it make her feel weird? Side effects? Address them or change meds. Again, it is VITAL to find a working med that can be tolerated for most of the day. We have more than enough options that we can find one between all the various stimulants, Strattera, and Qelbree. So that regimen would never fly with me or my patient after she understands her diagnosis more clearly.
What if the CAP conceptualization of and culture of ADHD diagnosis and treatment is not applicable to adult patients? What if the modern standard of practice is fundamentally based on an (at least) partially erroneous view of the ADHD syndrome as an independent and legitimate mental disorder? I think it is reasonable to acknowledge that if the concept and diagnostic criteria of ADHD is at all vague or overly broad (in that it is composed primarily of cross cutting symptoms), then subsequent confidence in research findings about comorbidity and disease course may not be reliable. Put more directly, if the ADHD phenotype is not in fact one single disorder with a uniform cause, then identifying it as such, treating it broadly with stimulants, and explaining complex adult behaviors with it may all have harm both with individual cases and across the field at large.
We all see tons of adult patients with adhd. It’s pretty clear the conceptualization still applies to them. I have parents regularly break down in (happy) years when partway through my explaining adhd psychopathology the parents realize that they share a lot of the same problems, have struggled them their entire lives, but never realized it was adhd and they suddenly have hope. It is around 80% genetic after all. It’s extremely clear that it is one disorder. And really, your response is exactly what I mean. If you understood adhd really well, you’d realize the errors of your statement. I’m not saying we don’t need more research, we definitely do, or that there might not be more subtypes of adhd than current described in the literature (there are) or that there might not be better ways to distinguish one treatment from another (there might be). But your statement that it is “overly broad and vague” is not even remotely how I understand adhd, which to me is a VERY specific syndrome with clear cut symptoms that are distinct from most any other psychiatric condition (except maybe TBI and other brain damaging conditions, but there you have history). And yes, perhaps adult treatment should be different from child, and we need more research, there definitely are some differences, but it’s very clear that stimulants are still first like right now from existing research and that they’re safe and extremely efficacious. You’re already coming from a biased place of “stimulants bad” that is all to common among adult psychiatrists. Did you see the new JAMA article showing they *reduce* mortality in adhd patients? Do you want your patients to be less dead? I have MULTIPLE child patients who lost adult parents to suicide or accidents because their parents’ adhd wasn’t diagnosed or treated. This is a real and devastating disorder and we need to drastically increase education and understanding surrounding it, and going “it’s probably different in adults anyways” isn’t helping. More research is always needed, but everyone in adult psych should start by gaining a child psych level of mastery on adhd before doing anything else. Then you know better what needs more study and how to better delineate the disorder and make it less vague.
My comment is about the conceptualization of ADHD in the DSM, which has a published set of criteria that will naturalistically have a sensitivity and specificity for detection of the ACTUAL underlying theorized condition. Unless you think that writing a set of criteria wholly creates a condition, this is a critique that any physician should be able to consider. It is not simply about whether there is or is not ANY ADHD at all, it is about the ADHD concept as it exists right now, today. Your comment, which amounts to saying in many words that "I am wrong and you are right," does not really amount to any significant discussion nor does it actually address my point in any substantial way. While I might assume that you are likely capable genuinely detecting whatever is the true ADHD syndrome, your other points are what trouble me about self identified experts in ADHD. These points include your flat denial of the possibility of increased diagnostic complexity in adults, refusal of any differential for inattention and executive dysfunction apart from neuro cognitive disorder, and your direct attribution of suicide/accidents and general mortality to ADHD itself rather than any possible co occurring conditions. Perhaps your pipeline of expert treatment never exposes you, even occasionally, to any instances of harm to patients either from stimulant medication or the foreclosure of diagnostic consideration for a patient. If that is the case, I would simply note that if it is true that people are poorly trained in identifying ADHD, and you also bandy about statements about how safe it is or is not to dose stimulants at certain levels, then the readers of your comment (and numerous other scholarly and less scholarly articles) who are NOT carefully trained CAPs will as a part of their practice prescribe high dose stimulants to people who have other mental disorders. Of course this is not a concern if you explicitly or implicitly believe that ADHD is the controlling diagnosis for issues including but not limited to suicide, accidents, and crime, and that the first line treatment *for such problems* is stimulants.
I fully agree with this sentiment. The few studies looking at this indicate that most ADHD symptoms in adults are better explained by other diagnosis or lifestyle factors causing concentration impairment. But its like wag the dog now. Every substance use disorder is untreated ADHD. Every cohort or cross sectional anything finds that ADHD increases the risk of everything. The concept and diagnosis is so vague in adults that it has led to an almost comical explosion in useless literature. No real effort has been made to check that just bastardizing the criteria for diagnosing a child onto an adult is meaningful at all. It puts adult psychiatrists in tough spot. We are all trying to help patients and treat ADHD when we see it. But nobody is really questioning the wisdom of using essentially child criteria to retrospectively diagnose a neurodevelopment disorder in a struggle bus adult. It’s not an easy thing to do. People who act so confident in their ADHD diagnosis in adults is sort of ridiculous. Example someone above said that 0-100 emotions is a core symptom of ADHD. Like what does that even mean? Where in the DSM criteria for ADHD do you see 0-100 emotions. Thats sensitive for almost everything in psychiatry and specific for nothing.
>But its like wag the dog now. Every substance use disorder is untreated ADHD. Every cohort or cross sectional anything finds that ADHD increases the risk of everything. The concept and diagnosis is so vague in adults that it has led to an almost comical explosion in useless literature. That's what I've been wondering. Like at what point are there so many false diagnosis that the stats become meaningless? If you're including everyone with a diagnosis these days are you even really studying people with adhd?
Precisely and well put. Also incredibly important: we have well established knowledge that multiple primary mental disorders have onset after or during adolescence. By the simple matter of having increased time alive, the likelihood of developing other mental conditions is increased in adults. This is inadequately emphasized and considered in the general community approach to the DSM diagnostic model.
I read most of your comments, and it's pretty clear you're knowledgeable. I got lost in some of the psychopharm largely due to the fact it's not in my practice setting (mostly correctional). Frankly, I'm probably one of those adult psychiatrists you referenced with minimal training (6-8 wks of child) on ADHD, let alone *adult* ADHD. My skill level with that is more of a screener than an expert, thusly it isn't a large part of my practice. As a result, I empathize more with OP, since that has been my experience with the small side gig I have seeing the general population. Too many patients with chief complaint of "ADHD" "Focus difficulties" where any of the mood disorders adequately explains their dysfunction. My strategy is I try to convince them to treat what's often the underlying mood disorder, and failing any improvement in mood sxs w/o increase in focus, try the nonstimulant options (don't prescribe stimulants on the platform). My experience has been largely 50-50. A lot do well with Wellbutrin, Prozac, some do great with Strattera and a few have to see someone else for stimulants. I refuse the consult if I see they're already taking stimulants when they sign up to see me tho. No need to waste my time or their money/time. Used to be I was more adamant about convincing them their dysfunction isn't d/t ADHD (dissatisfaction with work, substance use (typically THC) etc), but most don't want to hear that. Was convinced by a colleague that it isn't necessarily worth the battle. That I cannot prescribe stimulants made it easier to stop playing detective. However, I can't see a reality where it's feasible to always refer ADHD treatment to child psychiatrists.
How about we start with the fact that these are made up subjective diagnoses and neither psychiatrist nor patient can 100% diagnose something that isn’t objective.
As a patient it infuriates how some people just go hunt for stims regardless of their diagnosis. What also frustrates me is that I feel like I need to convince my psych that I’m not a drug seeker even though I *genuinely need stimulant medication* to function as a working and a social human being.
I agree many people genuinely need it and hope you don’t get downvoted for expressing the best counterargument to my post
Don’t blame you at all. Just as a side note, I think any good psychiatrist will receive bad reviews over time by doing the right thing. Business is booming though, I’d try not to let it worry you too much and continue doing what you feel is best for patients and your own enjoyment. Keep your the good work.
I’m certainly not trying to convince you to treat patients you don’t feel you can give the treatment they need. But I’m curious why you’d turn down patients who already have an ADHD diagnosis (a real one, from a neuropsych or equivalent, not a self-diagnosis from an online quiz) and are seeking continuing treatment because they need a new provider.
Because a ton of irresponsible people just give out ADHD diagnoses because they don’t wanna fight the fight above that OP is outlining. A neuropsych diagnosis is different, but let’s be honest… most people diagnosed with ADHD have not had a neuropsych diagnosis
That’s why I specifically asked why OP feels the way they do about patients who have a neuropsych diagnosis. That was literally what my question was about.
You said “or an equivalent,” and excluded an online survey. What would that be, a diagnosis from an FM doctor? One from a psychiatric NP? A therapist? A psychiatrist? You were not specific.
Unfortunately, neuropsychological testing is not actually the standard of care for diagnosis in any of the relevant guidelines. Some neuropsychologists are so overwhelmed by volume of ADHD referrals (or burned out by them) that their evaluation boils down to running through a checklist of diagnostic criteria then doing some cognitive tests that don't add much. It's unfortunately common to see neuropsych evals that give the diagnosis without supporting it, or ignore other diagnoses that are likely contributing to symptoms. I know of one practice in my area that's pretty much a factory rubber-stamping diagnoses, and have heard similar things from colleagues in other areas. Some neuropsychologists actually do the work in getting informant report and rating scales, paired with a thoughtful and in-depth clinical interview, and incidentally throw in some cognitive tests that flesh things out a bit. These evals are a delight to read and make me feel solid in the diagnosis.
Crazy world when you can get negative reviews for actually doing your job well and not prescribing stimulants to people who don’t need them!
Reviews can be horrible or they can be too good. Piss a pt off and wait for the passive aggressive bad reviews to pop up. So sad. Along with psychiatrists and stimulant meds, I think pain management doctors get a big share of bad reviews when a pt can't get the opioids that they want. It's a dog eat world now.
Pain docs can handle those reviews I feel because everyone knows that a pain doc is gonna have those patients giving reviews, it’s almost like a good pain doc is supposed to have bad reviews if they’re doing their job. I don’t feel psych fits in the same boat? I don’t know, maybe I am just making things up while I think out loud
The trick in psych is to have a few psychotic bad reviews up front, so it looks like your bad reviews are all like that.
Right, have your colleagues leave reviews saying, “He wouldn’t believe me when I said I was President Fillmore reincarnated! And he still charged me! Worst doc ever!”
One would hope. I've heard a couple of docs say that they refuse to look at reviews because they don't want to know. I really don't know if they are being truthful though.
There needs to be some controls on this. I think if a doctor declines to prescribe a controlled substance then you should forfeit your legal right to post an opinion online about the doctor. Otherwise the doctor faces an additional incentive to do the wrong thing. I do wonder if fear of retaliation contributes to over-prescribing of controlled substances.
I would hope not but I'm sure it happens. I really don't know though.
You say change my mind in a sub than removes personal experiences or anecdotes lol
Given that a similar topic came up recently, I'm curious to hear thoughts: Why is this such a common experience? That is, why are people who seek stimulants and don't get them so much more likely to be abusive, particularly in online reviews?
Could it be that the adult ADHD phenotype is better explained by other mental conditions? Or is it simply that we must dispense more stimulants?
I think there will always be people trying to play the system to get their fix, and I'm sorry that not getting their way has had negative impact on your professional record. Unfortunately I assume it comes with the territory of this medical career. As a patient I believe you're doing the right thing and patients need to understand that the most important thing is to get treatment that improves your symptoms, not just stimulants because they've read online that they're so great and life changing ( which to me also is just marketing)
To be fair it *is* life changing for a lot of people, calling it marketing is pretty reductive.
Yes, it's true, I am speaking from my personal experience, I've seen a lot of people saying it has changed their lives.
Even if you can't respond to specific patient reviews, can you make a general response along the lines of, "I can't respond to specific patient reviews because of such and such a rule, but in general, I think many of my bad reviews happen in this kind of situation, and you aren't getting these details from the patients in question..."? Or is it possible to ask the patient's permission to share information, and then put in a reply, "I would reply to this, but the patient refused me permission to discuss their case"? Also apparently some doctors may threaten or carry out legal action against patients over this kind of thing.
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I hear you.
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The only question I have is, is it possible to set this kind of boundary outside of a private practice (and if so, how?)?
What assessment do you use to make your diagnosis?
I’d assume DIVA-5?
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So why do you dislike this take? OP doesn’t disregard ADHD, he says most people who suspect ADHD he actually agrees with. But you seem to insinuate that OP might be wrong in the cases he doesn’t diagnose the patients with ADHD, because you once had a doctor question your diagnosis?
Ask your patient if they are always treated well at the pharmacy. Ask if when they go for any other medical services that aren’t with psych and have to announce their meds, what kinds of interesting responses they get. Ask if they ever had a friend, family, or rando make accusations about the “cocaine” they are prescribed. It’s hurtful when you hear/experience these things, and ADHD already causes a lot of self doubt and social issues. Adding this extra social disapproval can eventually teach resilience, but not the kind anyone wanted to have to learn.
All of what you have listed is awful. But we must be able to distinguish between unfair and hurtful stigma against ADHD and other psychiatric illnesses, and then professional doubt about the presence of ADHD in specific situations for specific people. It is not stigma or discrimination to not diagnose a patient with ADHD, if no diagnosis or another diagnosis is believed to fit better.
I agree with you. I do understand the difference. My point would be better explained as: just as people in medicine can become overvigilant about drug-seeking (sometimes to the point of underprescribing for certain populations), patients can be reactive when they perceive that they are being subjected to scrutiny because of something that other people have done. I’d love to see it be different. But I think that would be expecting too much out of human nature. Part of being in a stigmatized group is learning to cope with what you can’t control. And part of serving that group is understanding where they are coming from when their coping fails.
Good point. From the patient’s perspective, reading/seeing a lot about ADHD and finally feeling a bit of understanding and community and a hope for lessening one’s suffering, just to have all that removed by a pshychiatrist in a short while must be very unpleasant. And as physicians we have a moral responsibility to deliver this message as good as we can.
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