The ADHD-Adderall situation: a broader context – SMERCONISH

I have read Dr. David Brodys’ article on Adderall deficiency, posted on Smerconish.com, and think it requires the perspective and context that newsletter readers deserve. I have treated adults with ADHD as a significant component of my 40+ years of psychiatric practice and am very familiar with the issues it discusses.

Dr. Brody is right that the pandemic has taken a toll on the mental health of Americans, complicated by the hurdles it has presented with direct access to care. He’s also right that telepsychiatry has made access easier for many. The FDA relaxed rules on prescribing stimulants and other controlled substances specifically to support telehealth, especially for the treatment of chronic pain and substance use disorder; the ADHD stimulant problem was brought forward.

Associated with the pandemic has come increased demand for prescribed stimulants that manufacturers have been unable to address; hence, the shortage (Psychiatric News, https://doi.org/10.1176/appi.pn.2023.06.6.13). This does not mean that the increase in demand is illegitimate; suppliers were unprepared and struggled to respond. It is at least plausible, however, that Some of this question may arise from less comprehensive assessments by telepsychiatry providers.

Dr. Brody cites a Daily Mail article published in January 2023 as evidence of unscrupulous media devaluing the concept of ADHD as a disorder and the importance of treatment. The article looks askance at some online medical practices that do ADHD assessment and treatment. One of them that Dr. Brody should have mentioned is donefirst.com, of which he is the Chief Medical Officer. Also, this company, along with cerebral.com and some others, recently came under scrutiny or fines from the FDA for prescribing without sufficient evaluation. It was reported that some of those working at his company had felt pressured to prescribe stimulants.

To condemn the Daily Mail and fail to mention that its own company is criticized in the article is false and misleading, just as it criticizes them for being so.

Diagnosing ADHD can be done fairly quickly in some cases, but others are more thorough. The temptation to please the patient and provide stimulants is a well-known risk for psychiatrists. ADHD rarely exists in isolation, and co-occurring conditions, such as anxiety, depression, and substance use disorders, are frequent if you look them up. Some situations look like ADHD but are actually something else. Checklists won’t find them.

Dr. Brodys points out that the suicide rate among people with ADHD is five times that of the general population is also relevant here as it is putting people with ADHD together AND the disorders I just mentioned, each of which has a higher suicide rate than the general population. This is enough to explain the higher risk. The risk of suicide in people with ADHD and no other psychiatric disorders it’s not as elevated as Dr. Brody claims. A review published in 2017 cited a study that found that the risk of suicide in ADHD Alone was about 50% higher (not 500%), but that risk as other conditions occur increases risk more in line with his statement. Any condition that increases your risk of suicide is important, but so is keeping your risk in perspective.

I agree with Dr. Brody that ADHD is underdiagnosed and undertreated. ADHD is also likely to be overdiagnosed and overtreated. This is a harder question to prove, in part because there aren’t any agreed goal diagnostic criteria and why treatment may help some who don’t have ADHD. The less well a doctor knows a patient, the greater the risk of misdiagnoses. It is not unusual for a person to come to me and tell me what he believes his diagnosis is; sometimes they are right. Some play for stimulants who don’t have ADHD and many have learned (from online sites, friends and family) what to say to make the case.

It defies human nature — even that of well-meaning physicians — to claim that if one’s business is prescribing and managing ADHD, one can insist that online assessments don’t at least run a risk of overdiagnosis.

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Richard Moldawsky, MD

I have been practicing general adult psychiatry since I finished my education in 1979. I am board certified. I had a joint tenure in psychiatry and medicine at the University of California, Irvine, medical school. I have been with Kaiser Permanente in Southern California for 40 years, in a variety of clinical, administrative, teaching and research capacities. I am an expert medical reviewer for the Medical Board of California.