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What forces influence your decision to treat ADHD? Case vignettes and a back-to-basics approach may bring clarity to the diagnostic and therapeutic clinical processes that surround the decision.
That clinicians practice in an ever-changing, more complex environment that increasingly exposes them to multiple factors that may influence care is a clichÃ©-and an understatement. A clinician’s behavior can be influenced by many factors that range from indirect approaches to direct financial compensation.
At a very basic level, patients attempt to influence our behavior. For instance, strong patient preferences and the right to refuse treatment are conscious efforts directed at changing a recommendation that may not be liked. Transference, a psychodynamic construct generated by unconscious forces, may also result in patient attempts to change the physician’s behavior. Clinicians are familiar with these doctor-patient forces in the relationship.
External forces also exist. For example, doctors view advertisements, navigate financially sensitive formularies, and try to manage insurance requirements. These tactics do not involve direct monetary arrangements, but they influence physicians’ decisions and may have macroeconomic consequences. Moreover, some clinicians receive direct compensation from the medical industry for participating in activities such as advisory boards, research trials, and promotional talks.
By nature, physicians are strong-willed and make recommendations based on the Hippocratic principle and with their patients’ best interests at heart. Despite this, payments to physicians have been a concern because the doctor’s judgment may be biased toward the source of remuneration.1,2 The field of ADHD has been singled out in the controversy, in particular as it relates to whether the condition is being overdiagnosed and consequently overtreated.3,4 A regulatory response to this issue, applicable to all physicians and conditions, is the Sunshine Act, which mandates that the industry post a list with the names of doctors who receive payments and the amounts paid.5,6
A back-to-basics approach
Physicians wield great power over individual lives as well as the financial outcome of medical products. The following case vignettes illustrate potential challenges that physicians confront in day-to-day practice and offer a rationale to help resolve influencing forces.
Married to a public school teacher, Mrs B, a 46-year-old stay-at-home mom, complained of lifelong distractibility. Her husband was emotionally supportive, calm, and well organized. The couple had 2 boys, aged 8 and 5. Mrs B explained that she had had a very successful career and had done very well financially. This money allowed her to stop working when her first son was born and for the family to enjoy a very comfortable lifestyle. She reported having concentration problems since early childhood and that she had been accident prone until she reached puberty. Her school performance was poor, but with a lot of effort she managed to graduate from high school. She was often referred to as “being in her own world.”
Her father experienced alcohol-induced violent episodes. Both her brothers had been treated for ADHD during childhood and did not do well as adults. Despite her difficult upbringing, Mrs B was very ambitious and completed an associate’s degree. A bubbly personality and a desire to advance helped her land a job with an Internet start-up. Her work required frequent travel. Mrs B’s contributions were instrumental to the success of the start-up, and she made a small fortune by selling her stock after the company went public.
Although she had never received a formal diagnosis of ADHD, several features point to the condition. As a child, she had problems with concentration and was overactive. A career in sales, working in the field rather than in an office setting, and a spouse who could help her set complex schedules are typical examples of compensating strategies for adults with ADHD.7 A strong family history of ADHD further validated that Mrs B met criteria for the condition.
Mrs B was not looking for diagnostic accuracy when she requested a consultation. After all, she had known that there was something wrong with her cognition for a long time and she was aware of her brothers’ diagnoses. She had successfully dealt with her problems on her own up until now, but a change in circumstances motivated her to seek treatment. Because a recent financial crisis had depleted the family’s savings, Mrs B needed to begin earning income again. She wanted to remain very involved with child care, so she decided to start a business locally to avoid traveling. She attempted to write a plan, put together financials, and study the relevant regulations, but she found it impossible. She could not concentrate on the many documents she needed to review and had difficulty in keeping a schedule without her husband’s help. She was getting confused about appointment times, was unable to help her sons with schoolwork, and was leaving pans on the lit stove. She had tried to improve her organization by using scheduling software and getting help from friends, but these methods had only minimal impact.
Her older son had recently received a diagnosis of ADHD and was doing well with medication. Her goal was to receive the same medication to help her get organized so that she could manage both her career goals and her family life. She had no doubt that she wanted to take the same medication that had helped her son.
Although in Mrs B’s mind this was a fairly simple logical request, there were many factors that tilted the risk-benefit ratio toward risk, possibly making medication not advisable. She unquestionably had ADHD, but her adaptive skills had served her very well over the years so that fine-tuning with an experienced coach could improve her performance.8 In addition, while stimulants are generally considered safe in younger patients without a history of cardiac symptoms, their growing use in middle-aged adults has been cause for concern.9 The patient also seemed to lack significant need for medication.
A strong history of substance abuse in the patient’s family cautioned that a high genetic vulnerability might trigger chemical dependence. The controversy over the relationship between use of stimulants and substance abuse in ADHD is still unresolved.10 Finally, given all of the considerations against medication, would a recommendation to use stimulants in this case validate the accusation that doctors succumb to industry’s heavy marketing?
When confronted with so many confounding variables, it is helpful to take a back-to-basics approach, such as the one outlined in the following questions:
• Is there diagnostic certainty?
• Does the patient experience significant problems related to the condition?
• Are there nonpharmacological options?
• Is there an evidence-based treatment available?
• Are there any contraindications?
• Is the patient able to give informed consent?
• Is the patient willing to cooperate with the physician?
Following this approach yielded more facts (endorsed by her husband) that illuminated the negative effects of the illness on Mrs B’s daily functioning as well as the difficulties she encountered trying to move forward with her career plans.
Nonpharmacological options attempted by the patient were not helpful, and abundant published data exist on the effectiveness of stimulant medication in adults.11 Besides a need for caution because of her family’s history of substance abuse, there were no absolute contraindications for use of stimulants.
Mrs B understood the risks and benefits of treatment and was willing to undergo follow-up routine cardiac examinations. She also learned about the early warning signs of substance abuse and agreed that dose changes would only be recommended by her physician. It was determined that contrary to initial impression, pharmacotherapy was indeed a reasonable option in Mrs B’s case.
A year later, Mrs B was the proud owner of a lucrative business and was an effective manager of her household. She had achieved her goals with minimal adverse effects, so she continued treatment for several more years.
Sam, a 16-year-old, had recently developed attention problems that were mainly noticeable while playing golf. Sam’s concentration problem interfered with his game performance. To improve his skills, he attended golf camp over the summer. There he made friends with a teenager being treated with stimulants, which had been very helpful with both schoolwork and sports. Sam’s friend offered his medication: after taking the pills for a few days, Sam noticed that his game improved. He was happier and more relaxed than he had been in recent months. Sam’s parents felt the changes were beneficial, and the family talked to Sam’s pediatrician about formally prescribing medication. The pediatrician referred them to a psychiatrist.
As political refugees, the family had endured considerable hardship in their early years in the US. Despite the family’s tradition of high education achievements in their native country, neither parent had had time or money to pursue a college education. Eventually, they started their own business and became successful and wealthy. Their hope was for Sam to go to an Ivy League school, since he excelled academically. Being a top high school athlete was part of the strategy to increase Sam’s chances of entrance to an elite school.
Sam was articulate and engaged easily in conversation. He was popular, respectful, and had no behavior problems. His teachers raved about him. He denied using illicit drugs and was generally healthy. There was no family history of psychiatric illness. Sam described his parents as strict but loving. He was aware of his parents’ hopes for him and felt pressured to do everything he could to fulfill their expectations.
Although he denied major psychiatric symptoms, he reported recent onset of anxiety and poor appetite. He attributed this to the stress incumbent with college applications. While psychological testing is not essential to the usual ADHD diagnostic process, in this case it was obtained to help the decision-making process.12 A comprehensive evaluation concluded that Sam was an adolescent of high average intelligence without psychiatric impairment but who was undergoing situational stress. Therefore, medication was not recommended.
Sam’s parents were conflicted: on the one hand, they were happy that Sam did not suffer from a severe illness, yet they were very upset that medication was denied when they had seen proof of its effectiveness. A back-to-basics approach was used to reassure the parents that medication should not be pursued. It was explained that the comprehensive evaluation showed no signs of ADHD as determined by the history and objective testing.12 A review of the neuropharmacology clarified that healthy individuals can experience gains on attention induced by stimulants, and this is why these agents are frequently abused by otherwise healthy students.13 Sam’s concentration improved not because he had ADHD but because of the inherent properties of the medication. Moreover, stimulants in the absence of convincing therapeutic need could lead to unnecessary adverse effects and, in fact, Sam was already experiencing medication-induced anxiety and anorexia. The additional risk of substance abuse was mentioned as well.
Sam suffered from a mild attention problem and other situational symptoms that were not due to ADHD; he had an adjustment disorder. The symptoms were related to his preoccupation with the family’s tradition of high academic achievements and the possibility that underperforming would disappoint his parents. His distress could best be addressed by giving him more freedom to decide what he wanted to do instead of imposing a predetermined goal. Research supports the use of various psychotherapies for adjustment disorders.14 In this case, family psychotherapy to realign goals and individual psychotherapy to cope with stress were advised. After reviewing all the information yielded by a back-to-basics approach, Sam and his parents were very pleased that Sam was accepted to a non–Ivy League top level school from which he ultimately graduated with high honors.
There is no question that physicians are exposed to multiple forces that attempt to change their behavior. These forces can be clinical and inherent to the physician-patient relationship or external to this relationship. While clinicians have become more aware of the potential conflicts these influences may present, difficult cases, in particular, can make the sorting out of such influences more challenging. In these cases, taking a back-to-basics approach may bring clarity to both diagnostic and therapeutic clinical processes.
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Dr Kaplan is Clinical Associate Professor of Psychiatry at Rutgers New Jersey Medical School in Newark. He is a consultant for Ogilvy CommonHealth.
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