Human management

Impact of telehealth on the management of ADHD in adults

Therese R. Cerulli, MD: I have a question for all of you. How has telehealth in the COVID-19 pandemic affected both your ability to diagnose ADHD [attention-deficit/hyperactivity disorder] in adults and your treatment goals when working with your adult ADHD patients?

Birgit H. Amann, MD: I will start by saying that it was very difficult for all of us at the beginning. I know for me, turning my private practice into telehealth and getting used to it, getting used to talking to the patient looking at the bright white light on the device and trying to maintain eye contact, and the patient to the other bout was in just as much trouble. We are supposed to assess them, and in many cases we had never met them. It was one thing with our patients that we had known for years, we could get away with it. We had difficulties, at that time, our electronic medical record did not electronically prescribe drugs under federal control. So they still had to come to the office to get the order. We had problems, and still have problems sometimes, with getting vital signs because we always get vital signs when they come to visit. We had to help them find a way to get a blood pressure cuff, use their smart device, their Apple Watch, whatever. There were a lot of challenges. I think we have come a long way. Personally, I don’t think telehealth is going to go away, it will be here in one form or another. But I think we’ve gotten a lot better, both assessing them and continuing with treatment, making sure we’ve done everything right. Luckily now for us, our e-record will do the e-prescribing because in Michigan, starting January 1, it’s a warrant. They can no longer accept paper scripts.

Rakesh Jain, MD, MPH: Theresa, I would add to that by saying the early part of the pandemic really showed the major fault lines in how we think about ADHD in adults. And just like decades before, ADHD has been pushed back into the back seat once again, put on the back burner. But do you know what happened? It became very evident that if the ADHD of the adult individual was not identified, not treated, the suffering was going to be dramatic. I think in the second half of this pandemic, something changed. I think the community as a whole realizes that we are missing something. And one of the things we miss might just be adult ADHD. Much like you, Birgit, many of us have found ways to adapt to this. We’re finding ways not just to prescribe, if you will, but to use online filters, to ask people to fill them in, to be more attentive.

They say paranoia is bad. Well, that’s a wonderful trait for a clinician. I would perhaps like to remind our colleagues that even though the prevalence of ADHD in adults is 4.5%, it is in fact in the population. This is not true in your population. If you’re an internist or primary care or general psychiatrist, it’s not 4.5% in your population or mine. It’s many times that because we don’t see people, we see clinical populations. So when you put it all together, this pandemic, as I’ve said before, has shown where the flaws in American medicine lie when it comes to ADHD in adults. And many of us want to fix this problem as soon as possible.

David W. Goodman, MD: I’m going to comment on telehealth, it’s the pros and cons. The pro has been that clinicians have switched to telehealth because of COVID-19. This allowed more patients to access medical professionals in order to obtain a diagnosis. The downside, however, is now the online ADHD assessment and the enticement of patients and people who get prescriptions for stimulants when they may not have a diagnosis. And my concern is that the online diagnosis, if not done accurately, will give the patient a diagnosis that will give them the legitimacy to get a prescription for stimulants. Well, it’s not easy to make a psychiatric diagnosis. It is even more difficult to erase an inaccurate diagnosis once it is made. What worries me is that we are going to see prescriptions for stimulants given to people who are not accurately assessed and who, in fact, do not have the diagnosis of ADHD. The other part of it is that you don’t confirm an ADHD diagnosis based on a positive response to stimulant drugs because as we know if we give everyone a stimulant you will say that your mood , your energy and cognition are better. It doesn’t mean you have ADHD, it just means I rearranged your brain chemistry.

Birgit H. Amann, MD: This is a very valid argument. We still have patients in our practice who perform an objective measurement, the QbTest. They have to come for that, wear a mask, and we do all the COVID-19 disinfection. But we still expect that objective measurement on top of all of our scales and tools for that very reason.

Rakesh Jain, MD, MPH: I like this. I was just going to comment on this very important point, this objective test, although very useful and I’m glad your clinic is doing this, Birgit, I think we should remind our colleagues that there is no need to ask a diagnosis in primary care or other care. It’s a useful thing, but I would recommend to my colleagues not to assume that it’s a requirement for making a diagnosis. And I think we should talk about that a bit because I often hear my colleagues in primary care say, “Unless it’s confirmed by magical means, I’m too scared to diagnose ADHD in adult. I think Birgit would say that’s not necessarily the way to go with every patient, is it?

Birgit H. Amann, MD: No, that’s correct. It’s a tool we choose to use for baseline and follow-up, but it’s not a mandatory thing to do for the diagnosis to be made.

Greg Mattingly, MD: Let me put this into perspective for our friends in primary care. Think of something most of you are already comfortable doing, and that’s being diagnosed with depression. When you diagnose depression, you are looking for 9 symptoms. You are probably using a scale like the PHQ-9 [9-question Patient Health Questionnaire]. These symptoms must be there. They have to be there for a certain duration for the depression, it’s 2 weeks, and they have to cause impairment. The same is true with ADHD. It’s a set of symptoms, there are 18 of them. You must have at least 5 of them in one of the 2 clusters. They must have lasted some time, some going back to childhood, not all; I remember I had some of these things when I was a kid. And they must cause a deficiency. It’s the diagnosis. You don’t need to take psychological tests outside. It’s good to have psychological tests, it’s good to have a QbTest, it’s good to have all those things, but clinically it’s the symptoms, the duration, the impairment.

Therese R. Cerulli, MD: Well said, Greg.

Transcript edited for clarity