Impact of Telehealth on the Management of Adult ADHD

Theresa 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 in working with your adult patients with ADHD?

Birgit H. Amann, MD: I’ll begin with saying it was very difficult for all of us at first. I know for me, turning my private practice over into telehealth and getting used to it, getting used to talking to the patient by looking at the bright white light on the device and trying to maintain eye contact, and the patient on the other end was struggling just as much. We’re supposed to assess them, and in a lot of cases is we’d never met them. It was one thing with our patients who we’ve known for years, we could make our way through. We had challenges, at that time, our electronic medical record did not do electronic prescribing of federally controlled medications. So they had to still come into the office to get the prescription. We had issues, and we still do sometimes, with getting vital signs because we always get vital signs when they come for a visit. We had to help them determine 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’ve come a long way. I don’t personally think telehealth is going to go away, it’ll be here in some format. But I think we’ve gotten a lot better with it, both in assessing them and also continuing treatment, making sure we’ve done everything properly. Thankfully now for us, our electronic record will do electronic prescribing because in Michigan, as of January 1st, it’s a mandate. They can no longer take a paper script.

Rakesh Jain, MD, MPH: Theresa, I would add to it by saying that the early part of the pandemic really showed the major fault lines in how we think about adult ADHD. And just like decades before, ADHD one more time was pushed to the back seat, put on the back burner. But you know what happened? It became very apparent that if the adult individual’s ADHD was not identified, not addressed, the suffering is going to be dramatic. I think in the second half of this pandemic, something has shifted. I think the community as a whole is appreciating that we are missing something. And one of the things that we are missing might well be adult ADHD. Just like you, Birgit, many of us have found ways to adapt to this. We are finding ways to not just prescribe, if you will, but to use screeners online, have people fill them out, be more alert to it.

They say paranoia is bad. Well, it’s a wonderful trait for a clinician to have. I might want to remind our colleagues that even though the adult prevalence of ADHD is 4.5%, that’s out actually in the population. That’s not true in your population. If you’re an internist or in primary care or a general psychiatrist, it’s not 4.5% in your population or mine. It’s multiple times that because we don’t see people, we see clinical populations. So, when you put all that together this pandemic, as I said before, showed where the fault lines are in American medicine in regard to adult ADHD. And many of us are wanting to fix that as soon as possible.

David W. Goodman, MD: I will make a comment about telehealth, it’s pro and con. The pro has been the clinicians have transitioned to telehealth because of COVID-19. That has allowed more patients to access health care professionals in order to get a diagnosis. The con side, however, is now the online assessment for ADHD and the seduction of patients and people into getting stimulant prescriptions who may not actually have a diagnosis. And my concern is that online diagnosis, if it’s not done accurately, will give a patient a diagnosis that gives them legitimacy for getting a stimulant prescription. Well, it’s not easy to make a psychiatric diagnosis. It’s even harder to erase an inaccurate diagnosis once it’s made. My concern is that we’re going to see prescriptions of stimulants given to people who are not accurately assessed and in fact don’t have the diagnosis of ADHD. The other part of that is that you don’t confirm a diagnosis of ADHD based on a positive response to stimulant medication because as we know, if we give everybody a stimulant, you’ll say your mood, your energy, and your cognition is better. It doesn’t mean you have ADHD, it just means I rearranged your brain chemistry.

Birgit H. Amann, MD: That’s a very valid point. We still have patients in our office do an objective measure, the QbTest. They have to come in for that, wear a mask, and we do all the COVID-19 disinfecting. But we still expect that objective measure in addition to all of our scales and tools for that very reason.

Rakesh Jain, MD, MPH: I like that. I was just going to comment on that very important point, that objective testing, while very helpful and I’m glad your clinic does that, Birgit, I think we should remind our colleagues that’s not a requirement to make a diagnosis in primary care or other care. It’s a useful thing, but I would recommend that colleagues don’t assume that’s a requirement in order to make a diagnosis. And I think we should talk about that a bit because often I do hear my primary care colleagues say, “Unless it is confirmed through some magical means, I’m too afraid to make a diagnosis of adult ADHD.” I think Birgit would say that’s not necessarily how one should proceed with every patient, right?

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

Greg Mattingly, MD: Let me put it in perspective for our primary care friends. Think about something most of you already are comfortable doing, and that’s diagnosing depression. When you diagnose depression, there are 9 symptoms you look for. You probably use a scale like the PHQ-9 [9-question Patient Health Questionnaire]. Those symptoms have to be there. They have to be there with a certain duration for depression, it’s 2 weeks, and they have to be causing impairment. The same thing is true with ADHD. It’s a set of symptoms, there are 18 of them. You have to have at least 5 in one of the 2 clusters. They have to have gone on for a certain period, with some of them going back to childhood, not all of them; I can remember I had some of these things back when I was a kid. And they have to be causing impairment. That’s the diagnosis. You don’t have to have outside psychologic testing. It’s nice to have psychologic testing, it’s nice to have a QbTest, it’s nice to have all these things, but in the clinic, it’s symptoms, duration, impairment.

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

Transcript Edited for Clarity