I read Dr. David Brody’s article on the Adderall shortage, published on Smerconish.com, and I think it calls for a perspective and context that newsletter readers deserve. I have been treating adults with ADHD as a significant component of my 40+ years of psychiatric practice and am very familiar with the issues he discusses.
Dr. Brody is right that the pandemic has taken a broad toll on Americans’ mental health, complicated by the obstacles it presented with direct access to care. He’s also right that telepsychiatry has made access easier for many. The FDA eased the rules about prescribing stimulants and other controlled substances specifically to support telehealth, especially for the treatment of chronic pain and substance use disorder; the ADHD-stimulant issue piggy-backed on.
Associated with the pandemic came an increased demand for prescribed stimulants which manufacturers haven’t been able to address; therefore, the shortage (Psychiatric News, https://doi.org/10.1176/appi.pn.2023.06.6.13). It doesn’t mean the increased demand is illegitimate; the suppliers were unprepared for it and have struggled to respond. It is at least plausible, though, that some of this demand may stem from less-comprehensive evaluations 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 which do evaluation and treatment of ADHD. One of these, which Dr. Brody should have mentioned, is donefirst.com, of which he is the Medical Director. Further, this company, along with cerebral.com and some others, have recently been under FDA scrutiny or sanctions for possibly prescribing without a sufficient evaluation. Some of those working at his firm were reported to have felt pressure to prescribe stimulants.
To condemn the Daily Mail and not mention that his own firm is criticized in the article is disingenuous and misleading, just as he criticizes them for being.
Diagnosing ADHD can be done pretty quickly in some cases, but others are more painstaking. The temptation to please the patient and provide stimulants is a well-known hazard for psychiatrists. ADHD rarely exists in isolation, and concurrent conditions, such as anxiety, depression, and substance use disorders, are frequent if you look for them. Some situations look like ADHD but are really something else. Checklists won’t find them.
Dr. Brody’s point that the suicide rate among ADHD people is five times that of the general population is also relevant here in that he is lumping together people with ADHD and the disorders I just mentioned, each of which has a higher suicide rate than the general population. That’s enough to explain the higher risk. The suicide risk in people with ADHD and no other psychiatric disorder is not as elevated as Dr. Brody states. A review published in 2017 cited a study finding that the suicide risk in ADHD alone was about 50% higher ( not 500%), but that the risk with co-occurring other conditions raise the risk more in line with his statement. Any condition that increases suicide risk is important, but so is keeping the risk in perspective.
I agree with Dr. Brody that ADHD is under-diagnosed and under-treated. What’s also likely is that ADHD is over-diagnosed and over-treated. This is a tougher matter to prove, partly because there are no agreed-upon objective diagnostic criteria and because treatment can help some who don’t have ADHD. The less well a physician knows a patient, the higher the risk of misdiagnosis. It’s not unusual for a person to come to me and tell me what they believe their diagnosis is; sometimes, they are right. Some are gaming 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-intentioned physicians – to say that if one’s business is the prescribing and managing of ADHD, one can insist that online evaluations don’t run at least some risk of over-diagnosis.
Richard Moldawsky, M.D
I have been practicing general adult psychiatry since I finished my training in 1979. I am board-certified. I had a joint appointment in Psychiatry and Medicine at the University of California, Irvine, Medical School I was 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.