Adult ADD

There are a variety of reasons doctors are sometimes reluctant to see patients with ADD:

• Primary care physicians and the majority of psychiatrists and neurologists have relatively little experience evaluating and treating ADD. Although the majority of cases are straightforward, some are more complicated, and this understandably concerns the less experienced doctor.
• The most common treatment of ADD are the stimulants such as Adderall, Vyanse, Ritalin, and others. Stimulants can be abused or given or sold to others.  Some patients sell or give them to friends, some use them recreationally, some take higher doses than are prescribed. The magnitude of these problems are greatly exaggerated by the media but they do exist.  Because they can be abused, the Federal Narcotics Bureau keeps an eye on stimulant prescriptions. Some doctors worry that they may get into trouble with the bureau even if they carefully obey the law.  This concern is greatly unrealistic.  Careful record keeping that documents the diagnosis and the need for stimulant treatment (the most effective treatment for ADD) is what the regulators are looking for.
• People with ADD not infrequently forget their appointments. Even with reminders, they are more likely than other patients to cancel or not appear for their appointments because of traffic, jury duty, baby sitter problems, car problems, or other last minute emergencies.  If the physician is not reimbursed for the time set aside, it makes treating ADD patients less remunerative.  If the patient agrees to pay for missed appointments out of his own pocket and does so, this may mitigate this problem.  But most doctors are unwilling to put a procedure code on a bill when the patient did not get the service being billed.
• Patients with ADD need to take their medication every working day or they will fall back into the distractible and inefficient condition that they were in before starting treatment. (They are not addicted in that they do not have serious withdrawal symptoms, but they do depend on their medication to help them, and the medication wears off quickly.) Refills for stimulants cannot be called in to a pharmacy. They must be written on a prescription and brought to the pharmacy. Not infrequently patients do not make appointments for refills in advance but plan to call for a refill appointment when they run low on medication. Because procrastination is often a problem with ADD, they often wait until the last moment before calling then urgently request a refill or an appointment. This can be disruptive to the doctor’s practice.  The doctor has to be very vigilant to make sure that patients who say their schedule temporarily prevents them from making a follow up appointment do make one before it becomes an emergency.
• A small percent of people with ADD procrastinate about paying their medical bills.
• Doctors who want to do psychotherapy with all their patients will be disappointed that there is no psychological basis for most patients’ ADD. A large portion of the psychological problems are caused by the effects of their ADD symptoms on their lives and self esteem. Most who benefit from medication treatment experience a significant decrease in secondary psychological symptoms.

There are a number of exaggerated or false statements that have been made about prescribing stimulants that may dissuade clinicians from using them:

• “Patients will tell you they have ADD symptoms but then will sell the stimulants you prescribe.” This is a risk, but the clinician’s job is to help people who need help not to be a policeman.   If clinicians carry out and document a careful assessment, there is very little professional risk if some patients occasionally mislead them about their use of stimulants.
• “Patients will take more medication than is prescribed for them.” This may occur when patients feel they need a higher dose that is being prescribed to deal with a temporary stress.  In these circumstances, it may make sense to review the dosing.  It is rare for patients to take a high dose to do so to feel good.  The stimulants rarely have that effect.  Some take higher doses to be able to study or work longer or more effectively.  Research has shown that this often has the opposite effect and this information can be shared with patients.
• “People without ADD will pretend to have ADD in order to get stimulants for recreational purposes or to abuse or sell.” They may happen.  To an extent, its frequency may depend on the nature of the clinician’s practice.  It will happen much less often in a patient population is over 25 years of age and financially secure.  In any case, the only defense is to keep good records and to refer the patient elsewhere if you become uncomfortable prescribing for him/her.
• “Stimulants are dangerous medications that can kill people or destroy the brain.” Except for certain limited circumstances (pre-existing heart conditions, glaucoma, seizure history, psychosis, recent MAOI treatment, and a few others), stimulants are one of the most extensively studied and safest medications on the market.
• “People shouldn’t take stimulants if they have high blood pressure.” Stimulants increase blood pressure in about 8% of patient who take them. If the patient already has hypertension, it should be brought under control before starting stimulants.  If the patient has controlled hypertension, and it is desirable for him to start stimulant treatment, once stimulants are started, the blood pressure should be monitored closely and, if it increases, the dose of anti-hypertensive increased appropriately