Cross-posted from Technorati with permission.
At a dinner meeting a couple of weeks ago I met two psychiatrists who work at Kaiser Permanente, the large HMO system that boasts a 24% health insurance market share in California. (This has nothing to do with my story really. I just think it’s amazing that a quarter of all insured Californians are Kaiser patients.) As we described our practices, I mentioned that I recently helped a patient stop his Adderall, the amphetamine combination drug given for Attention Deficit Hyperactivity Disorder or ADHD. The patient had come to me on a very high dose and was complaining of many side-effects: anxiety, muscle twitching, severe insomnia, weight loss. I gradually tapered and eventually discontinued the stimulant over several weeks, with resolution of most of these symptoms. He thanked me and said he felt much better. I related this story with some pride, and mentioned to my dinner companions that I’ve had more success stopping high-dose medication, especially for ADHD, than I’ve had starting ADHD medication. Moreover, I opined that ADHD is too readily diagnosed in adults, resulting in a lot of unnecessary amphetamine being prescribed.
I had not anticipated how odd these statements sounded coming from a psychiatrist. One of the Kaiser docs, a child psychiatrist, quickly noted how many kids she’d helped by identifying and treating their ADHD. It’s an under-recognized problem, she assured me. The other psychiatrist only saw adults, yet he too underscored how Adderall, Ritalin, and other stimulants helped his patients. Someone mercifully changed the subject, and we let the matter drop.
It got me thinking though. First, could we all be correct? I have no reason to doubt the experience of child psychiatrists who see their young patients perform better, achieve more, and get along better with others when treated for ADHD. I don’t see children myself, and am basically a bystander in the debates over medicating children for ADHD and behavioral problems. Moreover, even in adult psychiatry I believe that prescribed stimulants can sometimes help, not only for ADHD but also for depression in the severely medically ill, and in some other situations.
But my own experience has led me to be cautious. “Adult ADHD” is a fad. Its rate of diagnosis and treatment have skyrocketed in recent years, for no good scientific reason. I get calls all the time from people who have diagnosed themselves using a simple online checklist and are seeking an MD to rubber-stamp an amphetamine prescription. Since amphetamines are performance-enhancing even in normals and have street value as drugs of abuse, these potential patients put me in the uncomfortable position of second-guessing their request. I’m not saying adult ADHD doesn’t exist — in fact, I’m sure it does — but this isn’t the kind of relationship I want with patients. So I tell callers I don’t do ADHD evaluations, leaving me with lingering regrets about thwarting the subset — I don’t know how big it is — who have a legitimate need for this treatment.
And frankly, I’ve seen these medications over- or mis-prescribed by my fellow psychiatrists on a number of occasions. In addition to the patient mentioned above, for nearly a decade I’ve seen a distinguished senior academic for medication treatment of anxiety and depression. He’s never had an ADHD diagnosis. Nonetheless, he asked his psychiatrist back in 1993 to add Ritalin because a relative with ADHD benefited by it. He’s been on it ever since, 16 years. I tapered the dose down by more than half, but my patient resists using less, even though it likely worsens his anxiety and he needs medication for sleep. At this point I expect he’s on it for life. Another patient of mine, a young woman without an ADHD diagnosis but with a history of anorexia, had been prescribed 40 mg of Ritalin daily by her prior psychiatrist. It helped her concentrate, but also suppressed her appetite, which was a major psychological issue for her. We tapered down the Ritalin and discontinued it over about a year and a half, at which point she was doing well and reconciling with her mother — who, my patient said, had abused Ritalin herself for a long time.
Well, you get the idea. I’m not opposed to psychostimulants, honest. And I do believe ADHD is a serious problem and that it responds well to medication, along with other treatment. However, I also believe that, in adults anyway, inattention and hyperactivity can mean lots of things. I believe stimulant medications that cause anxiety, insomnia, loss of appetite, teeth grinding, high blood pressure, and other side-effects ought to be used judiciously. (And I also believe that a patient needs to have had symptoms by age 7 to fulfill DSM-IV diagnostic criteria for ADHD.)
Some of the most contentious, polarized arguments in psychiatry revolve around ADHD and its treatment. Are we poisoning our children with stimulants? Or leaving thousands to suffer unnecessarily? So far, these arguments still generate more heat than light. The main thing I learned at the dinner meeting I attended is that, like politics and religion, ADHD and its treatment remains a touchy topic in polite conversation.