Unmet Needs in ADHD

Theresa R. Cerulli, MD: What are some of the unmet needs? What happens with misdiagnosis? What are the dangers of underdiagnosed and undertreatment of ADHD [attention-deficit/hyperactivity disorder]? Rakesh, do you want to lead off our panel with that discussion?

Rakesh Jain, MD, MPH:There are tragedies, and then there are tragedies in clinical medicine. If you’re in primary care, if you miss someone who has hypertension, that’s a pretty significant tragedy. There are a series of long-term consequences to that missed opportunity. I want to alert our colleagues, no matter what your background might be, as Greg said, we’re all seeing these patients. Are we identifying them correctly? You might be asking, so what? What does it matter if I identify them or not? That’s why this conversation matters, because this misdiagnosis or non-diagnosis comes with consequences.

It’s not that diagnosing ADHD in adult patients is complicated. It actually isn’t. There’s a certain set of symptoms, a duration requirement, an impairment requirement. We have very good operational criteria for the diagnosis of ADHD. That’s not the challenge. The challenge is that we clinicians often don’t think about it as a possibility. If you have a patient who’s reporting certain difficulties in life, maybe the thing to do is to screen, having heard Greg and others describe how common this condition can be underneath that anxiety or depression or other things.

That’s why, Theresa, this issue of routine screening is really important. With high prevalence disorder, routine screening, if it can be done easily, is a wonderful thing. The dangers of not diagnosing are pretty obvious. Not only do we end up with a patient who doesn’t get better, but often there’s a loss of confidence. There’s a loss of belief in the medical system that they can help me, the patient. That leads to a cascade of events that can be quite problematic. Underdiagnosis leads to undertreatment. Undertreatment then leads to suboptimal outcomes. And all of this can be avoided if you think about it, by being suspicious about the possibility of seeing these patients, seeing patients with adult ADHD, applying the basic tools of diagnosis, and then taking it forward.

Birgit H. Amann, MD: I have to echo a couple of things that Rakesh said. We screen everybody, no matter why they come in, for depression, anxiety, and ADHD. We find so often that even if they’re treated, even if these adults have been diagnosed and treated—they’re on the first dose, they’ve never tried anything else, the dose has never been increased—they waited 4 to 6 months to get into the specialist. That’s quite unfortunate. There are such simple tools to utilize. The ASRS [Adult ADHD Self-Report Scale], for example, is quick, easy, and free. It has a 6-question screener. You can eyeball it and see if there’s any concern. If there is, move on to the other 12 on the screener. Those are very easy ways to see if we need to probe further. This is common. This is more common than uncommon. I tell people, “If I’m screening you for everything, it doesn’t mean I wasn’t listening to you.” Negative results are just as important to me as positive. Those go a long way.

Theresa R. Cerulli, MD: Dr Amann, we’re going to cover this in more detail in segment 2. You’ve done a wonderful job at beginning our discussion and diagnosis.

David W. Goodman, MD: Rakesh and Birgit talked about the individual patient. Let me draw the camera back a bit and talk about economics and issues at a policy level. The burden for adult ADHD in the United States is between $100 billion and $200 billion. There’s a study to be published, which I coauthored. You’re about to hear it hot off the press. It’s a large study that looked at matching diagnosis with prescriptions and then prescriptions with economics. What they found was that if you look at those patients who are unmedicated for ADHD, annual direct costs are $18,500. If you look at those who were on a long-acting and an immediate medication, so you had the longest duration of action, the cost was about $5500. That’s a 3-fold decrease in treating adult ADHD for as long over the course of a day as is possible. And that’s the ultimate goal of any treatment for adult ADHD.

Transcript Edited for Clarity