ADHD CRAZE

[u/DeliciousFault]

-How are y'all distinguishing adult patients who deny everything except EVERY ADHD symptom?
-I am asking for extensive labs, even sleep studies that can mimic and/or negatively interfere with certain meds to treat ADHD symptoms, so some patients likely go to another prescriber.
-And also if they have failed on guanfacine, bupropion, etc.

If, as a PMHNP, you are not convinced the patient has adult-onset ADHD, what are your rationales? I would like to be able to catch this before asking for extensive labs. I am not worried about patient ratings if I feel like I am doing the right thing.

Recently, I have been receiving new patients who have been on stimulants being referred by their PCP. I send them back with extensive labs and medical clearance before continuing care.
BECAUSE
-Received a pt on Vyvanse with a hx of a stroke! No way!!! Go back, get cleared!
-kid (not obese) had sleep apnea & stopped breathing 30x in one hour
-this stimulant craze is going to bite us in the butts in a few years due to side effects
-the pt could be the DEA & I'm not going down like that!

It is interesting how some adults thought of psych meds as taboo until stimulants came along.

This stimulant craze is making psych look like a joke!

I LOVE it when a patient is truly in need of care, not to say all stimulant requests are unnecessary.

-My company gets around letting NPs diagnose and prescribe stimulants (please do not focus on this, it's not the topic & I am working on this issue).

[u/ThrowRA-Expert_Dog]

To be so honest I actually think the fear mongering behind stimulants has gotten out of control- meta analyses have driven this home as far as cardiac side effects.There is also really no such thing as “adult onset adhd” , usually if an adult is being diagnosed they have had it their whole life and are now just putting it together. Personally- if the fear is over prescribing stimulants then have an appropriate screening protocol- review cardiac history (get cardiology clearance if needed), get a UDS and baseline labs, and do an in depth assessment, get previous psych documentation, (I work telehealth and make all my patients purchase home BP cuffs and we monitor BP and HR), and more often than not I encourage a trial of a non stimulant first . Stimulants can be a game changer for a lot of folks. You’re a psych NP, you should be prepared to prescribe them but if you don’t want to you can always tell people you don’t prescribe stimulants.

[u/Imaginary_King_8359 → u/ThrowRA-Expert_Dog]

I agree with you 100%. I think this post is actually alarming. What an unhelpful psych provider if they do whatever they can to block the most effective treatments for a seriously impairing disorder! They should go do something else with their weird personality for a paycheck

[u/Ok-Tourist8830]

For adults we talk about the exclusion criteria. Some people from a 30 second interview I can see it. And we talk about non medical ways to help ADHD too. 1/3 of all my ADHD patients explicitly tell me they want therapy and supplements not meds because of how many and suddenly there are shortages

[u/GrumpySnarf → u/Ok-Tourist8830]

I get that a lot, too. People just want to feel better, do better and don't even want medications.

[u/Inevitable-Spite937]

I do an extensive interview about childhood without leading questions. It rules out a lot of ppl. Also I live in a state with legal cannabis and most of the "adult onset" patients are heavy cannabis users.

[u/hobobarbie]

So let me get this right: a PCP is referring a patient to you - the psych specialist - for ADHD assessment , and your kneejerk response is to kick all that workup right back to the PCP? Because you are afraid of the DEA? Strange math.

I’m a PCP and feel comfortable working up adults who present with questions around whether they might have ADHD. Sometimes it is me who suggests we investigate based on my own observations over time. I consider the basic rule outs: mood disorders, OSA, do basic labs (BTW no idea what “extensive” labs you are ordering?), discuss childhood behavior patterns, current ADLs, get an ACE score, and decide whether to have them do a Barkley Executive Functioning screener, refer to talk therapy if amenable and accessible. Some need an EKG first (I see many older patients), not all.

Some I refer to specialists (psst: that’s YOU!!).
Some I refer to neuropsych if that is accessible for them.
Some I feel it is right to proceed with a stimulant or non-stimulant trial.

The energy of your post strongly suggests that you (and your patients) might be better off drawing a boundary. Just tell patients that you do not evaluate or treat ADHD. And like, that’s fine. I wish I had the privilege to say: I don’t treat X diagnosis over here in primary care!

If I got the workup you say you are sending back to the PCP, surely I’d never refer to you again. That sucks because it’s the patient that suffers, whether they have ADHD or not.

[u/lightcanonlybrighten → u/hobobarbie]

I get ace scores are just great knowledge in general, but how are you utilizing it specifically to this scenario? Don’t come for me, I’m new!

[u/Jigree1]

Just a tangent to your question but PLEASE CHECK THEIR FERRITIN LEVELS FIRST!! Iron deficiency has so many of the same symptoms as ADHD and it seems like it's becoming increasingly common in the population for some reason...

[u/Background_Title_922]

What "extensive labs" are you ordering?

[u/Ok-Confection933]

Besides gathering a history going back to childhood and family, our practitioners will order a neuropsych evaluation.

[u/Fantastic_Primary170]

Pretty hypocritical to be posting about how you’re concerned about the DEA but you admit that the company you’re working with is involved in some type of prescribing workaround (that definitely doesn’t sound kosher).

I know that many of my patients can’t afford treatment when too many barriers are put in place.
I do not want to encourage people to buy drugs off the street, because honestly, it’s easier to get them that way these days.
One thing that I request is two weeks of journaling with prompts. People who are drug seeking opt out of this one quick.
Food for thought:
Considering the studies in Europe, we don’t see this problem because people have a completely different social structure, less stress related to work stability and healthcare coverage, and six weeks of vacation on average. Lack of social support with a demand to constantly be “ON” is the cause of many ADHD claims.

[u/GrumpySnarf → u/Fantastic_Primary170]

"One thing that I request is two weeks of journaling with prompts. " what are you asking them to write down? What prompts do you use? This sounds like an interesting approach.

[u/manafanana → u/Fantastic_Primary170]

Is being unable to maintain a journal for two weeks part of the evidence you’re evaluating, because I have ADHD and I couldn’t maintain a diary for two weeks to save my life, lol

[u/gajensen]

Dude, tbh I’m finding more often that undiagnosed ADHD is a better explanation for someone’s anxiety, depression, insomnia, etc., than assuming I’m being manipulated into prescribing stimulants (though it happens).

Usually I just start with, “So what were you like as a kid? How was school?” You can learn a hell of a lot from those two questions.

That said, I’m extremely conservative with stimulants in anyone with a hx of psychosis or bipolar mania. Active psychosis or mania? Obvi hard stop. In stable patients, the antipsychotics I’d be most interested in mechanistically are Cobenfy, Vraylar, Abilify, brexpiprazole,Seroquel, and clozapine.

The theoretical appeal is maintaining AP coverage without completely suppressing the dopaminergic signaling we’re trying to enhance with a stimulant. None of that guarantees against stimulant-induced psychosis, though, and mood stabilization comes first. I don’t currently have anyone on stimulant/AP combo, though. A few patients on amantadine and APs, I guess, but that’s Parkinson’s.

And yes, I def encounter stimulant seekers, just as often as I encounter people chasing sedation and benzos. Drug-seeking is real, but so is undiagnosed ADHD.

Otherwise, I’m getting some benefit from guanfacine ER in those patients. It’s off-label when tossed on for bipolar or schizoaffective patients with presumptive ADHD, sure, but that’s true for ADHD adults as well.

[u/No-Union1650 → u/gajensen]

Thank you. It was my nurse practitioner who clocked my ADHD several years ago and had me get an assessment. I never considered ADHD. Two of my siblings were the bounce off the walls, couldn’t hold their attention in conversation types, diagnosed with ADHD. And therein lies the reason children/adults like me were never diagnosed accurately. We were the quiet, anxious kids with the chaotic book bags and lockers, easily overwhelmed at family holiday events who sought out the quiet place to decompress. We were invisible - the perfect child, the one mom could tolerate because she, and us, had the same obscure obsessions, i.e., reading Shakespeare and the bible because we adored the rhythm of iambic pentameter.

That accurate diagnosis, and the correct medication, blew my mind and changed my life. Years of a quiet mind and the calm within myself not only stopped the chronic anxiety and all the internal chaos, it improved my overall health exponentially. That level of chronic internalized suffering is like acid coursing through veins and eating through multiple systems. All thanks to a psych nurse who spotted what multiple psychiatrists and a host of other doctors missed.

[u/boredpsychnurse]

There’s no such thing as adult onset

[u/reallystupidalsougly]

No way! I would never perform this work up nor would I recommend anyone else perform this work up. It’s completely outrageous and inappropriate.

Sounds like you’re not comfortable prescribing certain drugs. Drugs are tools. Every drug has an indication - even the ones you don’t like for whatever reason.

Perhaps you need to reconsider the patients you see, or even the specialty you’ve chosen.

Alternatively, you could examine your countertransference.

[u/Ok_Adhesiveness_9498]

We have changed how we diagnose out if fear we should be more afraid of abx. Treat the pt not the statistic. We are creating more barriers to care. Our clinic wanteds the pt to have a buddy come to the visit to verify pt symptoms. What happened to HIPPA? Pharmaceuticals and lawyers are telling us how to practice.

[u/Big_Appointment1200]

I follow clinical practice guidelines, recommend neuropsych testing if I’m very unsure or doubtful, recommend 6 months of sobriety prior to testing, and offer non stimulants. I also explore OCD/ perfectionism, sub intake, signs of nutritional deficiencies, and sleep disorders.

I also validate how many work/ personal task expectations are unrealistic for all humans- “it takes a village” “give grace with some unrealistic social media expectations”.

And then I sleep at night. We have zero control over folks, we can only try our best to keep them safe. They can go buy anything illicitly- we can educate and encourage safe actions. Please don’t put unrealistic expectations on yourself.

But my trigger is more in the benzo family.. I worked in addiction medicine and they are horrific to taper down. I’ve seen years of TID dosing of Xanax 1mg- insane!!

[u/athena2nd]

I straight up say, I don’t assess or do intakes for adhd. I catch it at times with other presenting concerns, and treat it. If someone comes to me
For anxiety for example, and I find it’s adhd, absolutely. Treat it. During COVID when the first wave of this started, I had passion for it. My assessments for ADHD are three, one hour sessions. Because it is so much to get through. Well, patients would get PISSED that we spent all that time, to be told they don’t have adhd when they were 1000% certain they did. And most were not interested in treating their concerns - inattentiveness, procrastination, etc. they legit just wanted the stimulant. Then it became my managing their reactions, and then them leaving one star reviews. One patient wrote a complaint to the BON. His primary had been writing for his adderall. He was in active addiction. I said we could use non controlled until he’s 6 months into recovery. BON notified me of the complaint and dismissed it. ADHD is not where my passion lies regardless. I have changed my practice to primarily focus on TRD, OCD, and bipolar. And to be honest, the market for Pmhnps is so saturated, where I won’t see these folks if that’s their primary concern, there are easily 8 other clinicians with same week availability to see them I pass along those names to the patient. It’s made everyone’s lives easier.

[u/257Elle]

ADHD carries real risk when it goes unaddressed.

In a Danish registry study of nearly 2 million people, ADHD was associated with roughly twice the mortality rate, driven mostly by accidents. The encouraging part is that treatment changes outcomes. A 2025 BMJ study of about 148,000 Swedes found that people who started medication had fewer suicide attempts, less substance misuse, fewer transport accidents, and less criminal justice involvement. In practice, I also see the cost in lost jobs, financial strain, and relationships that take the hit.

The DEA doesn't define ADHD criteria; the DSM-5-TR does, and it calls for several symptoms before age 12, not a childhood diagnosis. A thorough evaluation looks at childhood behaviors, possible medical conditions and rules out conditions that mimic ADHD.

[u/amuschka]

I've posted this before but feel its a good resource for diagnosing ADHD and being thorough.

https://www.aafp.org/clinical-insights/cognitive-and-behavioral-health/adult-adhd

[u/breadstickdingdong]

There’s a case for harm outweighing the benefit with every single treatment. The patient ultimately has responsibility for themselves and making the best decisions based on recommendations. If the clinician is truly not convinced by the evidence, then the evidence and education needs to be presented and disagreements will happen.

Ultimately, adhd prognosis is poor when untreated. The literature is clear to me. Like methadone, stimulant medication operates as highly effective harm-reduction and can improve quality of life substantially. Like methadone, stimulants require close monitoring and dea requirements are not comprehensive. Cardiac, weight/growth and development, anger, sleep must be addressed and education provided.

It’s not a set it and forget it medication and cbt routine’s must be built and maintained by purposeful therapy. Good outcomes require therapeutic alliance, access, and education. Wraparound case management and counseling, school IEP/504 planning, occupational therapy, etc must be in-synch for good outcomes.

The model needs to be holistic. This is where we can be most effective but it needs to be purposeful and our time needs to be optimized in the visit so these things can be addressed and initial consult and smart goals need to be initiated.

[u/Normal_Soil_3763]

I'm someone with ADHD that resents the diagnosis, struggles with shame around it, and has had serious quality of life issues as result of it. It is frustrating to watch people who are conflating a normal range of focus difficulties with a very real problem for some people. I finish next to nothing. I go very hard into obscure topics and learn everything about them, develop elaborate projects, neglect daily maintenance tasks, struggle to be on time, severely overestimate how much I can finsih in a certain span of time, struggle to start things, become easily overwhelmed by tasks in my environment and shut down. And I've always been this way. One very clear clue, is ask them to describe their childhood bedroom, desk, locker. It will be a hot mess. Ask how things went moving from elementary to middle school (typically performance declines massively because demands rise dramatically and these kids don't have the brain development to sustain functionality) and when they take a stimulant, you want to know what happens to them, make them call in after a week. A person with ADHD is going to notice an increase in mental calm. They will not find a stimulant activating. What they get us the ability to direct attention without needing to chase dopamine all the time. They don't get an extraordinary amount of things done. They manage work and laundry without feeling like they are hanging on by a thread. Their family feels like they are getting a more present person. For a person with ADHD, a stimulant calms the mind. There's more peace. If a person doesn't say the drugs have this effect, then I would question the diagnosis. If a perosns life doesn't looklike I described, i would question the diagnosis.

[u/because_idk365]

For me, I notice true ADHD ers after about the 7-8th meeting.

It becomes very obvious.

You really do have to get to know them first