Sunday, March 25, 2018

Mental Health Medications: Common Unspoken Issues

Mental health meds. too often get a “bad rap.”  It’s definitely true that they have their problems, are used too hastily by some doctors, don’t solve everything, may cost too much and are promoted by an industry with questionable ethics, but they do offer significant help and relief to millions.  Ask those people to give-up their meds.  Go ahead!  It is also clearly true that these meds. should, most always, be used only in conjunction with other treatments. 
Here are a few points that way too often are not mentioned in discussions about MH meds. 
Most Primary-Care Physicians Have Inadequate MH Knowledge
  • PCP’s are the main prescribers of psych. meds. in the USA!
  • 2013 Study = 92% of PCP’s do not follow guidelines for MH eval. or treatment
Due to any of the following:
  • Too limited/narrow an evaluation.
  • Failure to consider “Differential” diagnosis.
  • Failure to explore co-occurring conditions.
  • Inadequate pt. education, poor pt./dr. relationship, inadequate monitoring
  • Clinician resistance to certain diagnoses, e.g., ADHD or ASD in seniors
Inadequate Monitoring, Due to Clinician Shortages
  • Shortage of clinicians leads to insufficient time spent on monitoring meds.
Inadequate Monitoring, Due to Clinician Ignorance
  • About evidence-based matching of meds. with pt. symptom-profiles
  • About typical pt. experiences with specific meds.
  • Does-Response Method vs. mg/kg dosing for all psych. meds.
  • About nuances of dosing considerations with certain meds.
  • About meds. efficacy and side-effects
  • Resulting in prolonged use of ineffective meds.
Inadequate Patient Education Re Meds.
  • An aspect of all the above.
Failure to give sufficient consideration to additional/alternative treatments
  • Psychotherapy – CBT, Family
  • Pediatric OT – for kids with Sensory issues
  • Case Management for impaired seniors
Negative Propaganda
  • Over-emphasis on side-effects without preventive information
  • Over-focus on pharmaceutical industry profit-motive
  • Vilification of meds. as “drugs”
  • Minimizing symptom severity plus over-emphasizing pt. self-sufficiency
  • Emphasis on “natural” remedies without solid evidence
  • Outright denial of existing scientific evidence about MH conditions


Wednesday, October 04, 2017

Why Are Diagnoses of ADHD, ASD, BD…Increasing So Much? (Revised)

“We Have Seen the Enemy and He is Us” 

This seems like an obvious "truth", yet I haven’t seen anything published that says this.  It seems plainly obvious…

Clearly, diagnoses of ADHD, ASD, Bipolar, etc. have been increasing dramatically.  But so has knowledge about these disorders.  Also, we humans have a well documented inclination to minimize, under-estimate and to project the blame/cause for our personal problems!  One particular pattern within this inclination is for us to develop “Cognitive Biases.”    

Three particular Cognitive Biases are the most-likely-suspects for much of the excessive, over-the-top claims of ADHD, ASD, etc. being "Over-Diagnosed."  
Availability Cascade” - repeat it often enough and long enough and more people will accept it as "true.".

Bandwagon Effect” - "group-think" or "herd behavior."

Confirmation Bias” -  tendency to search for, interpret, focus on and remember information in a way that confirms one's preconceptions.

My Opinions  -  These Diagnoses are Increasing So Much Because:
1)  Prevalence of most MH problems have been grossly underestimated;
2)  Knowledge about identification/diagnosis has increased dramatically;
3)  The public are more aware and, thus are reporting more to physicians;
4)  The seriousness of these problems and the degree to which they interfere with daily-life is often down-played by some clinicians and journalists; 
5)  These problems are serious; engender much personal desperation; thus, spur people to seek help as it becomes increasingly available. 

Most of us clinicians, including me, try very hard to do our “due diligence” with differential-diagnosis and using multiple, different assessment/diagnostic tools to arrive at a “preponderance of evidence” to support any diagnosis.  

I take great offense and exception to the notion that the current, officially accepted method of diagnosing these disorders is “overly-subjective.”  This simply is NOT true.  Even some of the so-called “medically objective” diagnostic methods can result in false positive and negative outcomes.  Plus, some individuals are so adept at hiding their symptoms that ONLY a “clinical interview” can ferret them out.

Last but not least, not all of us medical and mental health clinicians are the same.  Some of us are very conscientious and follow accepted guidelines for diagnosis and treatment.  Doing this avoids almost all problems that get so much negative press, e.g., misdiagnosis, under-diagnosis of co-occurring conditions, ineffective treatment and bad reactions to medication.  Just a few years ago the American Pediatric Association did a study which found that over 90% of primary care physicians did NOT follow accepted guidelines for diagnosis and treatment of these disorders.  Now what do you think comes out of that inappropriate practice?

So, let’s stop trying to find the “bogey-man” everywhere else and look inside ourselves?    

Sunday, March 26, 2017

Increases in ADHD? The Most Obvious Reasons…

In all the many “news” stories one sees today about the soaring rates of ADHD diagnosis and dr. visits, no one seems to realize the obvious:

Parenting in today’s world is ever more complicated and difficult.  It never was easy.  There never was an “owner’s manual.”  ADHD kids are decidedly much more perplexing and difficult than their non-ADHD peers.  With the proliferation of “news” about ADHD, is it, therefore, any wonder that more and more parents with troublesome kids are taking them to the family doc?  As a retired ADHD-Specialist, I saw hundreds of such families.  Parents overwhelmed, stressed-to-the-max and scared out-of-their-wits with worry and bewilderment about what to do!  Parents pressured by schools, scolded by relatives and looked-at-askance by other parents. 

Most media stories these days place blame on “Big Pharma”, pushy schools, overwhelmed and “lazy” parents and our “quick-fix” culture.  These all miss the fundamentals.

This brings me back to the other “obvious”, but missed-by-most and glossed-over factor.  Namely, family-physicians are, by far, the one group of professionals that see more troubled kids than any other.  By far!  They have THE MOST influence over how troublesome kids get handled; how they get diagnosed with ADHD; whether they are given meds. or referred for therapy.

The AAP did a study in 2013 showing that over 90% of physicians DID NOT follow accepted guidelines for proper diagnosis of ADHD, and, DID NOT follow accepted guidelines for treatment.  How difficult can it be to surmise the outcomes of that:  misdiagnosis, under-diagnosis, meds. vs. behavior therapy, inadequate meds. monitoring, generally poor follow-up, frequent patient non-compliance and frequent treatment failure.  Why?  Mostly because these docs are not knowledgeable about ADHD, don’t have the required time to spend with patients/families and don’t have expertise with ADHD meds.  Many do not know, for example, that most ADHD patients have co-occurring conditions that must be identified; that behavioral therapy should be tried first or simultaneously with meds.; that monitoring of ADHD meds. is much different than with other meds.; or, that treatment follow-up must be frequent and regular.            

Tuesday, September 13, 2016

"ADHD Nation" Perpetuates ADHD Myths & Half-Truths

The recent book, "ADHD Nation", by Alan.Schwarz, MD and the WSJ story, "The Ritalin Generation", by Sally Satel, MD, perpetuate the existing myths and half-truths about ADHD.

Here's a list of some of those myths/half-truths along with the REALITY as I know it from 40+ years as an ADHD specialist.

1. There's an epidemic of over-diagnosis and the blame lies with:
Overzealous Physicians  -  FALSE.
     REALITY:  The vast majority of ADHD diagnoses are done by primary MD's who are poorly trained and poorly informed about ADHD.  Furthermore, most of them tend NOT to follow AMA guidelines for diagnosing or treating ADHD.  A study by AAP in 2014 confirmed this at a level of 92%!  By a very wide margin, MD's have more influence than any other single entity over how and whether ADHD is diagnosed and how treatment is done.
Nervous Parents  -  SLIGHTLY TRUE.
     REALITY:  The vast majority of parents tend to follow the family physicians' advice.  Thus, most parents are as badly misinformed as the their physicians.
Schools Looking to Rein in Troublemakers  -  SLIGHTLY TRUE.
     REALITY:  Most school staff (public or private) tend to be as misinformed about ADHD as most physicians.  The Federal Gov't. sets the rules by which ADHD students are assessed and taught. Many of those rules are inconsistent with evidence-based research about ADHD. Also, a substantial portion of ADHD students are not "troublemakers."  However, they are either struggling or failing academically and often go unidentified.
Pushy Drug Companies  -  PARTLY TRUE.
     REALITY:  Many pharmaceutical firms that market ADHD medications are clear examples of "bad capitalism", i.e., their profit motive has overtaken their ethical obligations to patients with ADHD.  However, again, physicians have much more influence over who is diagnosed with ADHD, how, and what treatment approaches are used.
     REALITY:  The REAL epidemic is one of mis-diagnosis and mis-treatment by primary MD's with insufficient knowledge about ADHD diagnosis and treatment; and failure to make appropriate referrals to ADHD specialists.
2. Many experts agree that the prevalence of ADHD is about 5%  -  SOMEWHAT TRUE.
     REALITY:  Most experts agree that we have no idea of the actual prevalence of ADHD.  Many "experts" believe that the prevalence is significantly higher than 5%.  ADHD is a "spectrum" disorder just as Autism and most other mental disorders.  This means that there are some people who definitely meet the full clinical criteria and that there are others who's symptoms are somewhat below full-clinical-criteria, but who none-the-less have significant difficulty functioning in life.  It is important to note that in recent years epidemiologists have conceded that the prevalence of OCD and Bipolar Disorders have been vastly under-estimated for decades.
3. Diagnosis of ADHD is commonly determined by a checklist  -  PARTLY TRUE.
     REALITY:  A large percentage of primary physicians reportedly do use checklists as their main or only means of diagnosis.  Overwhelmingly, those clinicians who specialize in ADHD adhere to AAP or AACAP guidelines for ADHD diagnosis.  Those guidelines are rigorous and exhaustive.  Few primary MD's refer potential ADHD patients to ADHD specialists.
4. Medication is the default treatment option  -  PARTLY TRUE.
     REALITY:  More primary MD's are recognizing the importance of behavioral/family therapy as a FIRST treatment choice.  However, many do continue to "default" to medication.  There have been several recent studies confirming the value and effectiveness of therapy first.
5. It's easy to fake ADHD symptoms in order to get medication.  -  FALSE.
     REALITY:  For the "trained observer" (i.e., ADHD Specialist) this is generally untrue.  For the common primary MD, with minimal knowledge about ADHD and a very busy schedule this a distinct possibility  - but it needn't be!
6. Horrible reactions and side-effects to ADHD meds. are common.  FALSE.
Case examples given in the above publications are of the "horror story" type, e.g., patient is diagnosed with ADHD, put on medication and later develops addictions to various licit and/or illicit substances
     REALITY:  Those cases are in the minority and largely develop as a direct result of improper physician diagnosis and/or treatment, e.g., primary MD's rarely have the time or inclination to perform the necessary follow-up needed with ADHD patients.  Without proper F/U bad things are bound to happen.
7.  C. Keith Conners, "Father of ADHD", has decried the "over-diagnosis" of ADHD in "epidemic" proportions.  -  FALSE.
     REALITY:  Dr, Conners' persona as the "Father of ADHD" and his recent comments are being misused to dramatize certain statistics about ADHD diagnosis and medication prescription  -  data whose meaning and true causes are still under debate.  This is being done by those who want to force the beliefs of "over-diagnosis" and "Bad Big Pharma" onto the public.  Dr. Conners actually expressed more concern about mis-diagnosis and consequent mistreatment.  The misuse of Dr. Conners in this manner only serves to side-track clinicians from a focus on patient-centered-care and evidence-based practice.  

Thursday, February 04, 2016

ADHD Meds.: Complaints & Solutions

ADHD Medications:  Typical Complaints & Solutions

Not eating - Allow healthy snacks; during summer break they often make-up for lost growth; eat by the  clock vs. hungry; if still OK on growth chart, don't worry.
Mid-late morning behavior problems - Adjust dose timing - at-home + mid-morn. doses; change to longer lasting medication.
After school behavior problems - Was noon dose given?; Change to long-lasting form.
Very irritable mid-late afternoon - Same as just above.

After 4-6 weeks meds. not working as well – Called “acclimation phenomenon”; increase dose

Trouble falling asleep - Make dosage time earlier, or, amount smaller.

Still can’t get up, wake-up mornings - Give pre-awakening dose; re-review sleep problems for possible solutions.

More withdrawn, crying, angry - Lower dose or change medication.

Too zoned-out; very tired - Same as just above.
Headaches; stomach pain - Try Tylenol and/or Pepto-Bismol, wait 1 week; maybe just initial reaction (not uncommon).

Refuses to take it - Do more education; discuss their resistance: Stigma?; How it makes them feel?; Trouble swallowing pills?; Feel it's "controlling" them?
Nothing happened after 1 month! - Should have increased dose after 1-2 weeks!

Uncertain what to expect? - Get education from doctor, Internet.
Helped some problems, not others - Depends on which symptoms it helped and which it didn't; Discuss with doctor; Consider different medication or second medication.  Re-check diagnosis.

Medication effects don't last long enough - Dose maybe too low; Consider longer lasting form; most meds. last from 6 to 12 hrs.; individual metabolism varies & effects med. duration.
Feel too "revved-up", or shaky - Dose too high; Wrong med.?

Skin itches a lot - Dose too high; Wrong med.; try lotion or Vit. E capsules; stimulants can cause skin dryness.
Everything is much worse - Wrong med.; re-check diagnosis; most ADHD people have at least one co-occurring condition.

Can't swallow pills! - Try new liquid form or patch; if capsule, try sprinkling over food.
Pharmacist says ADHD meds. are all the same, or, all forms of Ritalin (methylphenidate) are the same - Absolutely FALSE!  Different ADHD people tend to respond best to different meds., and, to different formulations of the same med., e.g., Concerta vs. Ritalin LA.

Don’t have insurance; can’t afford meds. – Look on drug manufacturer web site for “Patient Assistance Program” (PAP), or, call their 800#.  PAP’s provide meds. at low cost depending on income.
I’m afraid about what others say about side-effects – All substances, whether prescribed meds. or “supplements” have side-effects.  The vast majority of truly problem side-effects from ADHD meds. occur due to incomplete or mis-diagnosis, and lack of prescriber knowledge about ADHD and how ADHD meds. work.  If your prescriber is a specialist in ADHD or very knowledgeable about ADHD and how ADHD meds. work, you should be able to avoid most if not all side-effects.

I’m concerned about long-term effects of ADHD Meds. – Ritalin has been on the market since 1954.  Amphetamines have been used to treat ADHD about as long or longer.  Although more well-done studies on long-term effects are needed, no significant problems have been documented to date.  The very negative life-costs of not taking ADHD meds. has been well documented, e.g., higher rates of divorce, unemployment, injury, lower income.

1.       Going to see an “ADHD Specialist.”  Not just any old “doctor” or mental health professional will do.

2.       Thorough diagnosis; including co-occurring conditions.

3.       Monitoring responses.

4.       Patience.

5.       Sticking with a “Specialist.”

6.       Always consider diagnosis review/update.