Thank you for talking about psychiatric illnesses. Like diabetes, cancer and cardiac illnesses, psychiatric illness also needs the attention it deserves.
SSRIs are notorious for killing libido and causing PSSD - Post-SSRI Sexual Dysfunction. This risk benefit ratio is not thoroughly considered by a lot of patients who are starting therapy.
Not only that, but the doctor would probably be encouraged to give BT the SSRI too, even though he asked for the stimulant, and the stimulant can be more effective at treating the ADHD burnout than the antidepressant will be
I think we have to distinguish between what is optimal care and what we do to accelerate access to treatment and/or remove barriers to care.
In my opinion, we would ideally have all patients for attention deficit disorder AND depression see a therapist and a psychiatrist. Unfortunately, the reality (among other issues) is there's not enough providers and delaying care is a problem, too. We can make it easier to get treatment quick while keeping the goal in mind of still getting the patient to optimal care.
Also, while stimulants are very clearly effective in the short-term, we need to ask if they are the best solution for patients to take for decades?* The first kids who grew up on stimulants are just starting to reach ages when hypertension and heart problems often develop. We'll see how that goes.
Many patients end up taking stimulants to cover every waking hour of every day. Even when medication is necessary, we should aim for as little as is needed. Instead of using therapy just to determine that stimulants are needed, why not continue it? Use it to help patients develop other ways to improve instead of just continually raising the dose. Help patients figure out what times it is truly needed and when they can manage without. People with ADD/ADHD don't need to be forced to fit into a box. We can have them use meds sometimes, while still finding school programs, activities, and jobs where they won't constantly require stimulants.
With all the drug shortages, I've seen the difference between patients on ADD meds versus others. In the pharmacy, we've been constantly fielding calls from patients and their doctors trying to find Adderall. Some patients have paid $600 to buy brand name that their insurance doesn't cover. This isn't happening with the shortages for antibiotics or Ozempic for Diabetes.
Its not an issue of threat to life or health, its not addiction or physical dependence. They've been given only one solution and have no idea how to function without it. I've tried suggesting rationing it some so it can last longer and not end up with none later on, but it's a foreign concept.
*This is a problem with many drugs, although for some the risk vs benefits analysis is easier to judge. Although even then, we shouldn't make assumptions, we need more follow-up. For example, recommendations for aspirin have been overturned after recent studies showed the benefits of low dose aspirin forprimary prevention are not high enough to outweigh the risk of GI bleeds.
The massive spike in px of pills to make us feel better or make us focus easier (the data is not all that great for the former) should make us concerned. Our minds are direct extensions of the society we live in. One gets reminded of the “soma” drug in brave new world.
It was alarming during my undergrad days how many of my classmates were using off label adderral or how easily they could get the drug. It was clear the issue was that their dopamine circuits were rewired completely around tik tok, instagram, Snapchat, YouTube, sat night parties, porn, texting, you name it. The young mind is being onslaught w stimuli that the brain’s reward system will always prefer over a lecture.
"Depression is potentially fatal, while attentional issues are not likely to be...
Doctors are used to treating suffering but uncomfortable using drugs for 'enhancing performance.'"
It has become common to say that Western medicine does not provide "health care", but "disease management". Despite my high regard for the scientific method and it's ability to improve medical care, I have come to regard Western medicine as "death prevention". I am sad to say that Michael sums my perspective fairly well. What is medicine for really if not improving life? It is ludicrous that mainstream, acceptable, insurance-covered Western medicine is relegated to little more than stopping dying and easing the pain of it. Preventive medicine is way more than disease detection and the treatments that follow.
Haha! How awful is it that I kind of wish there was a mini-dose ozempic or mini-mounjaro that non-diabetic, non-obese people like me could take after the holidays to help lose those five pounds? Even though my weight is "normal," my blood labs improve when I shave those extra pounds off, and it's easier on my running joints.
Interesting perspective. As a pediatric pulmonologist now retired, I was willing to prescribe relatively low dose SSRI for perceived depression in patients I was seeing frequently. I only prescribed stimulants when patients begged me that they had been prescribed by another physician and were running out. I would have liked more education and guidelines on responsible prescription of these classes of meds. Many psychiatrists and psychologists seem to feel that depressive symptoms need to be either really serious or non-situational to justify SSRI despite my patients had inertia, ennui, and often insomnia that were reactive to their medical situation. Therapy was usually effective in the intermediate term.
Thank you for writing this, there’s this myth out there that those of us with ADHD are out here thriving because we are on amphetamines...hahahaha I WISH! I literally struggle to do what normal people do with medication and “time management training.”
Thought provoking article for sure. Count me in the hesitant to prescribe Ritalin group. Why? I guess it's because if someone takes zoloft who is not depressed, there is no clinical benefit, hence no incentive to obtain the drug. But I would suspect that Ritalin improves cognitive performance for most people even if they haven't been diagnosed with ADHD. It IS performance enhancing drugs for cognition, IMO. There are real incentives to score high on this questionnaire even for those without the diagnosis.
Mar 22, 2023·edited Mar 22, 2023Liked by Adam Cifu, MD
I'd love to hear more about the DEA's "War on Stimulants." The difference in how we treat stimulants vs. other drugs (ex: you can't put stimulants on automatic refill, you have to call in to refill them each time) drives me bonkers, and was one of the first logical inconsistencies that had me diving into the politicization of medicine.
Mar 22, 2023·edited Mar 22, 2023Liked by Adam Cifu, MD
I notice that a lot of people on "the left" (a side of the spectrum I am typically aligned with) over the past 10-15 years increasingly define themselves by diagnoses, disturbingly similar to how people say things related to astrology, "well I'm a Capricorn so XYZ." Literally the same exact logic, just take out astrology and plug in DSM code.
And this isn't just self-diagnosis -- the doctors I'm thinking of for the folks I know who fall into this category enable it completely.
This will not stop until people have more meaningful models for self-definition.
However, this medicalization of every aspect of life seems to be a product of secularism, which is generally thought to be a "good" thing because it gets rid of the superstition of religion. It seems that what really happens though is that the basic pattern is still there, just replaced by secular ideologies that are enabled by modern medicine. So what do we have? A new kind of superstition. And the pharmaceutical companies make a killing off of it.
I think doctors need to take responsibility for this. I see this article's effort as an implicit step forward in that direction, but you guys have A LOT of work to do to make this problem more transparent to non-specialists.
Thanks for the article. Taking care of ADHD can be extremely gratifying whether the patient is adult or a a child. I had a patient a few weeks ago tell me happily he's managed to keep a job for over two years, something he previously had been unable to do. These medications should not just be considered performance enhancing, they can bring people back to what most of us would consider normal function.
What I'm seeing is a stigma around almost all controlled medications since the opioid crisis. Not only is it more work for the physician to have to jump through all the hoops (even with meds such as Lyrica or Lomotil) but the presumption has become for the doctor-patient relationship to start out as adversarial. Doctors are expected to approach patients with a sense of skepticism instead of trust. Many doctors don't want to go down that road, and I can't really blame them.
Thank you for this article, which I could not agree more about how we see different medications, and it’s perceptions. Growing up in India, where there is still a huge stigma associated with mental health, which, naturally shaped my own beliefs, about how ignorant I was about it. However, I had my own crisis in intern year of residency, where I got diagnosed with ADHD, and associated anxiety and insomnia. It opened up my eyes, and led to a significant self education of my condition and how it can impact people’s lives. I was misunderstood at my program, as I was fearful of asking for accommodations or stigma related to my condition, which impacted how I performed. I consider myself a high functioning ADHD, and clearly this condition, has so much misconceptions about them. Now as an internist, I treat a lot of my own ADHD patients, which I have seen a tremendous improvement in their overall functioning and health outcomes, including them quitting smoking, alcohol, losing weight with better control over maladaptive eating behaviors.
I practice in a rural Midwest place, and there is a dearth of mental health resources, and I think we have this huge disconnect in terms of separating the mind and the body. It’s all connected, and when I address their mental health, there is a huge overall benefit to them. We need to invest more in making psychiatry as part of a routine internal medicine electives, and having better awareness of the understanding of medications and treatments, rather than being fearful of the perception of them being used as a substance abuse, which I think is completely wrong. Not addressing mental health or ignoring it as a sign of weakness or lack of motivation, I believe is a sign of incompetent care, and our ignorance in understanding complex disease processes.
Agree that side affects of any drug should be discussed prior to prescribing, whether by psychiatrist or primary, though in many years of working with mentally ill clients in the criminal court system, it was obvious that those discussions rarely occurred. There are people whose symptoms intensify after starting SSRIs--are there any docs who are going to check in with patients at two days, two weeks, four weeks, four months? Even if not in formal therapy, it is important that patients suffering from depression/anxiety are followed and interact with professionals regarding status/progress. As I'm sure the author knows, relationship often has more to do with progress than any med, and in the position I had, I was able to sometimes see clients into the early evening when needed. If therapists weren't constrained by 8-4 schedules and insurance demands, and had open appointment times for people whose needs were immediate, maybe potential patients would have more positive perceptions about therapy. When people know the professional is genuinely concerned about them and will make time for them if necessary, progress happens. It is a shame that some have to be involved in the criminal system before they get what they need. Search criminal mental health courts (but not the national organization) if interested.
Thank you for talking about psychiatric illnesses. Like diabetes, cancer and cardiac illnesses, psychiatric illness also needs the attention it deserves.
SSRIs are notorious for killing libido and causing PSSD - Post-SSRI Sexual Dysfunction. This risk benefit ratio is not thoroughly considered by a lot of patients who are starting therapy.
Not only that, but the doctor would probably be encouraged to give BT the SSRI too, even though he asked for the stimulant, and the stimulant can be more effective at treating the ADHD burnout than the antidepressant will be
I think we have to distinguish between what is optimal care and what we do to accelerate access to treatment and/or remove barriers to care.
In my opinion, we would ideally have all patients for attention deficit disorder AND depression see a therapist and a psychiatrist. Unfortunately, the reality (among other issues) is there's not enough providers and delaying care is a problem, too. We can make it easier to get treatment quick while keeping the goal in mind of still getting the patient to optimal care.
Also, while stimulants are very clearly effective in the short-term, we need to ask if they are the best solution for patients to take for decades?* The first kids who grew up on stimulants are just starting to reach ages when hypertension and heart problems often develop. We'll see how that goes.
Many patients end up taking stimulants to cover every waking hour of every day. Even when medication is necessary, we should aim for as little as is needed. Instead of using therapy just to determine that stimulants are needed, why not continue it? Use it to help patients develop other ways to improve instead of just continually raising the dose. Help patients figure out what times it is truly needed and when they can manage without. People with ADD/ADHD don't need to be forced to fit into a box. We can have them use meds sometimes, while still finding school programs, activities, and jobs where they won't constantly require stimulants.
With all the drug shortages, I've seen the difference between patients on ADD meds versus others. In the pharmacy, we've been constantly fielding calls from patients and their doctors trying to find Adderall. Some patients have paid $600 to buy brand name that their insurance doesn't cover. This isn't happening with the shortages for antibiotics or Ozempic for Diabetes.
Its not an issue of threat to life or health, its not addiction or physical dependence. They've been given only one solution and have no idea how to function without it. I've tried suggesting rationing it some so it can last longer and not end up with none later on, but it's a foreign concept.
*This is a problem with many drugs, although for some the risk vs benefits analysis is easier to judge. Although even then, we shouldn't make assumptions, we need more follow-up. For example, recommendations for aspirin have been overturned after recent studies showed the benefits of low dose aspirin forprimary prevention are not high enough to outweigh the risk of GI bleeds.
The massive spike in px of pills to make us feel better or make us focus easier (the data is not all that great for the former) should make us concerned. Our minds are direct extensions of the society we live in. One gets reminded of the “soma” drug in brave new world.
It was alarming during my undergrad days how many of my classmates were using off label adderral or how easily they could get the drug. It was clear the issue was that their dopamine circuits were rewired completely around tik tok, instagram, Snapchat, YouTube, sat night parties, porn, texting, you name it. The young mind is being onslaught w stimuli that the brain’s reward system will always prefer over a lecture.
Michael says:
"Depression is potentially fatal, while attentional issues are not likely to be...
Doctors are used to treating suffering but uncomfortable using drugs for 'enhancing performance.'"
It has become common to say that Western medicine does not provide "health care", but "disease management". Despite my high regard for the scientific method and it's ability to improve medical care, I have come to regard Western medicine as "death prevention". I am sad to say that Michael sums my perspective fairly well. What is medicine for really if not improving life? It is ludicrous that mainstream, acceptable, insurance-covered Western medicine is relegated to little more than stopping dying and easing the pain of it. Preventive medicine is way more than disease detection and the treatments that follow.
Haha! How awful is it that I kind of wish there was a mini-dose ozempic or mini-mounjaro that non-diabetic, non-obese people like me could take after the holidays to help lose those five pounds? Even though my weight is "normal," my blood labs improve when I shave those extra pounds off, and it's easier on my running joints.
Interesting perspective. As a pediatric pulmonologist now retired, I was willing to prescribe relatively low dose SSRI for perceived depression in patients I was seeing frequently. I only prescribed stimulants when patients begged me that they had been prescribed by another physician and were running out. I would have liked more education and guidelines on responsible prescription of these classes of meds. Many psychiatrists and psychologists seem to feel that depressive symptoms need to be either really serious or non-situational to justify SSRI despite my patients had inertia, ennui, and often insomnia that were reactive to their medical situation. Therapy was usually effective in the intermediate term.
I (an RN) am so grateful that some docs out there are even asking these questions...!
Thank you for writing this, there’s this myth out there that those of us with ADHD are out here thriving because we are on amphetamines...hahahaha I WISH! I literally struggle to do what normal people do with medication and “time management training.”
Thought provoking article for sure. Count me in the hesitant to prescribe Ritalin group. Why? I guess it's because if someone takes zoloft who is not depressed, there is no clinical benefit, hence no incentive to obtain the drug. But I would suspect that Ritalin improves cognitive performance for most people even if they haven't been diagnosed with ADHD. It IS performance enhancing drugs for cognition, IMO. There are real incentives to score high on this questionnaire even for those without the diagnosis.
I'd love to hear more about the DEA's "War on Stimulants." The difference in how we treat stimulants vs. other drugs (ex: you can't put stimulants on automatic refill, you have to call in to refill them each time) drives me bonkers, and was one of the first logical inconsistencies that had me diving into the politicization of medicine.
I notice that a lot of people on "the left" (a side of the spectrum I am typically aligned with) over the past 10-15 years increasingly define themselves by diagnoses, disturbingly similar to how people say things related to astrology, "well I'm a Capricorn so XYZ." Literally the same exact logic, just take out astrology and plug in DSM code.
And this isn't just self-diagnosis -- the doctors I'm thinking of for the folks I know who fall into this category enable it completely.
This will not stop until people have more meaningful models for self-definition.
However, this medicalization of every aspect of life seems to be a product of secularism, which is generally thought to be a "good" thing because it gets rid of the superstition of religion. It seems that what really happens though is that the basic pattern is still there, just replaced by secular ideologies that are enabled by modern medicine. So what do we have? A new kind of superstition. And the pharmaceutical companies make a killing off of it.
I think doctors need to take responsibility for this. I see this article's effort as an implicit step forward in that direction, but you guys have A LOT of work to do to make this problem more transparent to non-specialists.
Thanks for the article. Taking care of ADHD can be extremely gratifying whether the patient is adult or a a child. I had a patient a few weeks ago tell me happily he's managed to keep a job for over two years, something he previously had been unable to do. These medications should not just be considered performance enhancing, they can bring people back to what most of us would consider normal function.
What I'm seeing is a stigma around almost all controlled medications since the opioid crisis. Not only is it more work for the physician to have to jump through all the hoops (even with meds such as Lyrica or Lomotil) but the presumption has become for the doctor-patient relationship to start out as adversarial. Doctors are expected to approach patients with a sense of skepticism instead of trust. Many doctors don't want to go down that road, and I can't really blame them.
Thank you for this article, which I could not agree more about how we see different medications, and it’s perceptions. Growing up in India, where there is still a huge stigma associated with mental health, which, naturally shaped my own beliefs, about how ignorant I was about it. However, I had my own crisis in intern year of residency, where I got diagnosed with ADHD, and associated anxiety and insomnia. It opened up my eyes, and led to a significant self education of my condition and how it can impact people’s lives. I was misunderstood at my program, as I was fearful of asking for accommodations or stigma related to my condition, which impacted how I performed. I consider myself a high functioning ADHD, and clearly this condition, has so much misconceptions about them. Now as an internist, I treat a lot of my own ADHD patients, which I have seen a tremendous improvement in their overall functioning and health outcomes, including them quitting smoking, alcohol, losing weight with better control over maladaptive eating behaviors.
I practice in a rural Midwest place, and there is a dearth of mental health resources, and I think we have this huge disconnect in terms of separating the mind and the body. It’s all connected, and when I address their mental health, there is a huge overall benefit to them. We need to invest more in making psychiatry as part of a routine internal medicine electives, and having better awareness of the understanding of medications and treatments, rather than being fearful of the perception of them being used as a substance abuse, which I think is completely wrong. Not addressing mental health or ignoring it as a sign of weakness or lack of motivation, I believe is a sign of incompetent care, and our ignorance in understanding complex disease processes.
Agree that side affects of any drug should be discussed prior to prescribing, whether by psychiatrist or primary, though in many years of working with mentally ill clients in the criminal court system, it was obvious that those discussions rarely occurred. There are people whose symptoms intensify after starting SSRIs--are there any docs who are going to check in with patients at two days, two weeks, four weeks, four months? Even if not in formal therapy, it is important that patients suffering from depression/anxiety are followed and interact with professionals regarding status/progress. As I'm sure the author knows, relationship often has more to do with progress than any med, and in the position I had, I was able to sometimes see clients into the early evening when needed. If therapists weren't constrained by 8-4 schedules and insurance demands, and had open appointment times for people whose needs were immediate, maybe potential patients would have more positive perceptions about therapy. When people know the professional is genuinely concerned about them and will make time for them if necessary, progress happens. It is a shame that some have to be involved in the criminal system before they get what they need. Search criminal mental health courts (but not the national organization) if interested.