Patient Case #1: Co-Managing ADHD


Drs Stephen Faraone, Theresa Cerulli, Craig Chepke, and Andrew J. Cutler discuss how to co-manage a patient with ADHD with other specialties.

Theresa Cerulli, MD: You hit the nail on the head there, not enough psychiatrists. We need each other, between the primary care physicians and psychiatry, it takes a village. We need the PCPs to be aware, for example, the screenings, that's where it should start. Most of the time the patients aren't even willing to come to see a psychiatrist, we're the shrinks, we're the people that are just going to put them on medications. Starting with the PCPs, educating those on the front lines on how to screen for, and at least initiate treatment, both psychopharmacologic and non-psychopharmacologic treatment discussions with the patients is essential to moving the dial, moving the needle on our ability to evaluate and treat these patients.

Andrew J. Cutler, MD: Every currently available medication to treat ADHD requires medical monitoring, certainly, from the point of view of blood pressure and heart rate, cardiovascular issues also rate.

Theresa Cerulli, MD: Right. Sleep issues, Andy, that's the other thing that comes up a lot. A lot of times when a patient has been referred to a cardiologist for any kind of prior condition, they're terrified to start treatment for ADHD. A lot of the time I find myself having to collaborate with the cardiologist to understand if their cardiac condition is stable, and managed, how to proceed, and help that patient feel comfortable proceeding with an ADHD treatment. We need to collaborate, I wish there wasn't such a barrier between primary care and psychiatry.

Andrew J. Cutler, MD: Some mental health providers are comfortable getting blood pressure and heart rate, and some may not be. Certainly, it's hard to get EKGs if we want to get an EKG as a mental health provider, that's where we can share information and help each other out. I find, unfortunately, a lot of our colleagues, and maybe you guys have heard this too, certainly, in the PCP world, there's a tendency toward underdiagnosing because they feel like people are trying to game them to get stimulants. It's probably a real issue, but I think there's a little bit of an over-concern to some degree that colors people, that biases them.

Stephen Faraone, PhD: That's a good point, Andy. It is a real issue, there are websites that you can go to that will tell you how to fake ADHD to get stimulants. Physicians and prescribers have to be wary of that. But let's go around the table, what do you folks do in your practice when you think somebody might be faking ADHD because they're really a drug seeker?

Theresa Cerulli, MD: I'm a fan of getting observer input, I mentioned it's a challenge with adults, I still spend time doing it. I want to hear from people in the household, sometimes it's someone outside of the household, a good friend, a co-worker, a boss that may have referred the patient. I want to hear from someone besides the patient, that's number one. Two, again the gold standard in terms of our evaluations, getting a good history, checking any prior prescription management program to see if the patient has requested prescriptions from multiple providers. You just must do your due diligence. And then collaborate with other providers, are they seeing a therapist? Have you called their PCP? People that can provide additional data will go a long way. Then, in my own evaluations, I do try to add any objective information we can get, so, rating scales, I know that you can game those. There are also some objective tests I have used in the past, things like the T. O.V. A. Currently, Qbtech has a product you can even have the patients do online at home or have them come into the office. They're just that, they're adjunctive tools, they're not stand-alone diagnoses, but it's nice to have some additional information that can help and aid in not over-diagnosing this condition and feeding into the risk with substance abuse. But it's a good time to raise the question because if you notice this patient in our presentation and case discussion, didn't want to be on meds. He's a college student who didn't want to take meds and it's the reason he didn't go seek help. And I hear that often, even though there are the bad apples that spoil the bunch, so to speak, there are so many patients that it's the opposite, they are afraid you're going to medicate them. And you don't want to be missing the opportunity for someone who finally gets up the will and confidence and trust to come to see us, and then to blame them that they might be a lot of times they won't show up for the second visit.

Stephen Faraone, PhD: Right.

Theresa Cerulli, MD: Or they'll come in asking for a specific drug which is always a red flag.

Andrew J. Cutler, MD: Or, "My friend said Adderall is really great." Or watch out for the fraternity brothers who refer each other.

Stephen Faraone, PhD: It is one of the biggest risk factors for misuse of medication, is belonging to fraternity studies show.

Andrew J. Cutler, MD: The other thing is I've been doing this just so long, I've been doing research and treating ADHD for over 25 years that I can usually ask people for very specific examples of what they mean by the symptom and how it impacts them. Give me examples, tell me more. It's very easy to just game the symptoms, but it's very hard to give me very specific examples. That's another one. Would you all agree with that?

Theresa Cerulli, MD: Absolutely.

Craig Chepke, MD, FAPA: Definitely. And one other thing I think is that stimulants for ADHD are, as we talked about, schedule 2, they are high risk in certain regards. We must think about the risk/benefit ratio when we're prescribing. When I'm confident that someone has ADHD, it justifies the risk in my mind, to prescribe them stimulants because it is risky for non-treatment. However, when I'm not confident in that diagnosis of ADHD, that changes my risk/benefit calculus and so non-stimulants rise in my decision tree. And if the patient is accepting of that, and they do show some benefit with that, then if they don't reach their goals, then maybe I can be proved wrong, maybe they do have ADHD, and then I might lean towards it now. And as Andy said, oftentimes when I go that route, then they just never show up, never fill the script, and that tells me everything I need to know. I find that the people that truly have ADHD, they're willing to do anything to get treatment, and it doesn't necessarily have to be one specific product or class, or anything like that and they'll be happy to do whatever we think is going to be in their best interest and that they agree with. That is a very telling decision tree on their end, in my mind.

Andrew J. Cutler, MD: Also, the pharmacokinetics we talked about Craig earlier. When somebody wants an abusable medicine, they want a rapid rise to peak.

Craig Chepke, MD, FAPA: Absolutely.

Andrew J. Cutler, MD: The immediate release. And I just sort of have the feeling that the extended-release stimulants are not what they're looking for when they want to get a high, so I refuse to prescribe the immediate-release stimulants if I can help it.

Craig Chepke, MD, FAPA: Or, as Theresa said, the street value of the extended releases are not nearly as high as the instant, that's another deterrent for people who are just seeking to divert.

Stephen Faraone, PhD: Correct. Well, this has been great. I'm going to add one more comment about the importance of co-managing with a PCP, and that is the relatively new evidence that ADHD shares genetic risks and therefore comorbidity with many somatic disorders, particularly cardiometabolic disorders like diabetes, obesity are probably the 2 main ones, hypertension as well. Hypertension can be caused by the medications for ADHD, but there's also an underlying risk. The genetics that are shared amongst these disorders.

Andrew J. Cutler, MD: Steve, that's an important point because I think the stereotype is we think of kids who are thinner, and the medicine as you said, can cause weight loss. We don't realize that on average, adults with ADHD are heavier, and they have more cardiometabolic, and more diabetes. That's an important point.

Stephen Faraone, PhD: That's right, and the diabetes appears not to be as well managed if they're not treated for their ADHD. It's very important to maintain that conversation, that co-management with their primary care practitioner. Although I do recognize how difficult that can be in the real world.

Transcript edited for clarity

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