TCPR: Dr. Parikh, you run a specialty ADHD clinic, so you have a lot of experience in this area. Can you start out with some tips for effective diagnosis of ADHD?
Dr. Parikh: To begin with, you have to specify whether you are thinking in terms of DSM-IV criteria or probable DSM-5 criteria. The major difference is that currently you have to establish that ADHD symptoms began before age seven, whereas DSM-5 is more lenient, requiring that they began by age 12. I tend to use the upcoming DSM-5 standards, and then I try to establish that the symptoms have been a constant in patients’ lives and have affected them in multiple domains.
TCPR: What are the best questions to ask in order to get an accurate history?
Dr. Parikh: Primarily I ask questions about people’s education. What sort of difficulties has the person had with school, because typically we see quite a struggle throughout school for people with ADHD. One thing that I frequently see is that students may be able to make it through junior high and high school fine, but when they reach college it just becomes overwhelming. And so you will see a patient who will go to college for one year and then drop out. Another thing I ask about is a work history. How are you performing at work? Have you had multiple jobs in a short period of time?
TCPR: Anything else?
Dr. Parikh: Look at how the symptoms have functionally impaired a person. Some soft signs are when patients get lost on the way to your clinic, or they are late or even especially early, since a lot of patients with ADHD will compensate for the fact that they know they might get lost by leaving extra early.
TCPR: What are some other “soft” signs of ADHD?
Dr. Parikh: I look at the way patients fill out my required paperwork. Did they miss things that they obviously should have seen? Were things checked incorrectly? Other things I ask are, “How many sets of keys have you lost over the past year?” “How many cell phones have you purchased recently?” and “Are you able to read a book?” I have had patients tell me, “I have never been able to read a book in my life.” They can start it but they just never finish it. I can’t stress enough the importance of having impairment in multiple domains.
TCPR: Do you ask for a family history?
Dr. Parikh: Yes. Frequently you will see patients whose siblings, parents, and children have been diagnosed with ADHD.
TCPR: What do you do about the patients who come into your office and say, “I think I have ADHD,” when maybe they have already been diagnosed with bipolar disorder, an anxiety disorder, or something else. And the implication is that they want to leave with a prescription for a stimulant.
Dr. Parikh: I tell patients that it is going to take more than 15 or 30 minutes to be able to get their complete history and come up with a diagnosis. I keep in mind the high rates of comorbidity with bipolar disorder, depression, substance abuse, and anxiety disorders. So I look for incomplete responses to treatment for these disorders, which can be another soft sign of ADHD. For example, often I find that restlessness can be misinterpreted as anxiety, when, in fact, the patient doesn’t have a true anxiety disorder but is describing a symptom of ADHD.
TCPR: How long is your typical first evaluation, and how often do you see patients after that?
Dr. Parikh: For the first evaluation I reserve an hour, and it may take up to an hour and a half, especially when working with adolescents. I like to see them back in a month. And if they are doing well at the one-month mark, I will see them back in another two months, and if they are doing well then I will see them every three months.
TCPR: With all of the different medications and formulations out there now for treating ADHD, how do you decide on a treatment?
Dr. Parikh: I would recommend getting familiar with one or two formulations (long acting and short acting) in each category—amphetamines and methylphenidate.
TCPR: Which medications have you become familiar with, and what have been your experiences with prescribing them?
Dr. Parikh: I tend to prescribe Adderall (mixed dextroamphetamine and amphetamine) and Ritalin (methylphenidate). Those both come in immediate and extended release formulations and as generics.
TCPR: How do you decide on regular or extended release?
Dr. Parikh: I ask patients, “Do you have difficulty taking this medication two or three times a day?” In my adult patients, I have found that even though you would expect people with ADHD to forget to take the second or third dose of the medication, they don’t. I tend to start with immediate release formulations because they offer more flexibility of dosing and they often cost less.
TCPR: When faced with the decision between Adderall and Ritalin, how do you choose?
Dr. Parikh: I don’t have any data to support this, but my adult patients like Adderall; they seem to do better on it. If they ask for Ritalin or have responded to Ritalin in the past, I’ll try that.
TCPR: How do you dose Adderall?
Dr. Parikh: For most amphetamine products, such as Adderall, my target dose will be 0.5 mg/kilo. So if you have an 80 kilogram (176 pound) male, I would start him with 10 mg in the morning and 10 mg at noon. After about a week, I will increase to 20 mg in the morning and 20 mg at noon. That is usually very well tolerated. The key is to get the medication up to an optimal level, so patients don’t give up on it.
TCPR: And how do you dose Ritalin?
Dr. Parikh: For methylphenidate products I shoot for 1 mg/kilo. This can become a bit troublesome in adults because you may end up prescribing someone 90 mg of Ritalin, which can lead to some preauthorization phone calls from the pharmacist. If possible I will prescribe Focalin (dexmethylphenidate), which I can dose at 0.5 mg/kilo, which seems like a more reasonable dose to people.
TCPR: For those of us who aren’t up on the formulations, explain what Focalin is.
Dr. Parikh: Standard Ritalin is composed of two different mirror image molecules, or enantiomers, and half these molecules, the dextro-enantiomers, are more pharmacologically active. Focalin is composed of pure dextro-methylphenidate, so this means that you only have to use half as much as you do regular methylphenidate. It’s easier for patients because they have to take fewer pills, and therefore pay for fewer pills. Focalin IR is available as a generic, but Focalin XR is not.
TCPR: What do you see for side effects on these medications?
Dr. Parikh: The common side effects that I hear about from patients are appetite suppression, and some patients report initially having headaches, which usually go away after a couple of weeks. Initially patients may also feel a little jittery, flushed, or sweaty. That is why I ease them into the higher dosing by increasing it after a week. Very few patients are unable to tolerate the medications because of these side effects.
TCPR: What about insomnia?
Dr. Parikh: I have actually seen patients report decreased insomnia once they are started on stimulants dosed in the morning. A lot of my patients say that their insomnia is caused by having “too many thoughts” when trying to go to sleep. Once the ADHD symptoms are treated adequately that gets better. With anxiety disorders, we know that they commonly co-occur with ADHD, so I look at the severity of the anxiety. If a patient talks about panic attacks or other panic symptoms, then I consider starting a benzodiazepine concurrently, or an SSRI, although SSRIs are less well tolerated.
TCPR: Do you have any tricks or tips to help patients get through the side effects?
Dr. Parikh: Sometimes I will switch from an instant release to a longer acting formulation to see if the side effects will attenuate, especially insomnia. If you dose it all in the morning it should wear off well before they go to bed. In some patients, even within the same medication, they can do well on the instant release, but when you switch them to the longacting they report it is not as effective or vice versa.
TCPR: Which of the longer-acting agents do you like?
Dr. Parikh: Going from instant release Adderall to Adderall XR is easy and for most patients the dose stays the same. We can go to Focalin XR from Focalin, but this an expensive choice. I also sometimes use Concerta because it is generic now. There is a dosing problem with Concerta in that it only goes up to 54 mg a day, so you may end up having to use two of the 36 mg pills and a lot of insurance companies may not like that. Assuming you can get beyond that, I sometimes use 72 mg/day of Concerta.
TCPR: And Ritalin LA?
Dr. Parikh: Yes, it is a generic too. Some patients say the effects of that wear off too quickly for them, before they are finished with their work or school, so I add a second dose of Ritalin LA at noon, which is early enough not to interfere with their sleep at night. You can also have patients take a noon dose of a shortacting stimulant, but that gets a little more complicated with having to write two prescriptions for two different drugs that they have to keep track of.
TCPR: What are your impressions of some of the newer agents?
Dr. Parikh: I have had mixed results with Vyvanse (lisdexamfetamine) and I think it’s because we don’t really know how to dose that properly yet. Frequently patients will need more than 70 milligrams a day, and it doesn’t make sense if we follow the 0.5 mg/ kilo of amphetamines rule. I haven’t found Vyvanse to be that long-acting—many of my patients say it wears off by 2 or 3 pm.
TCPR: What about the methylphenidate transdermal patch, Daytrana?
Dr. Parikh: Initially I thought Daytrana would have fewer side effects than oral methylphenidate, but I have found that not to be true. Also it only goes up to a 30 mg patch, so again we run into the dosing problems, with patients having to wear multiple patches at the same time. This is not available as a generic.
TCPR: How about guanfacine (Tenex), which has been recently approved for ADHD?
Dr. Parikh: I am glad that the new long-acting formulation (Intuniv) is available, but I don’t go straight to the brand name. Plain generic guanfacine is dirt cheap, so I like to start with that. I start with 0.5 mg twice daily and go up as high as 2 mg twice a day if necessary. We don’t know about Intuniv dosing yet for adults, since it is new and not well studied.
TCPR: How do you deal with the issue of potential abuse, misuse, and diversion of stimulants with your patients?
Dr. Parikh: First, I see patients every three months for maintenance. And I tell them to be very careful with the prescriptions; that they need to keep them in a locked place and, if they live somewhere like a dorm or an apartment with roommates, they should also keep their pills locked up. I have them read and sign a controlled substance policy, and make it very clear that I will not prescribe extra pills for any reason.
TCPR: And so when you get the pleading phone call from the patient saying, “I am on a trip and I forgot it,” what do you say?
Dr. Parikh: There may be some side effects from stopping a medication cold turkey, but they are not life threatening. This has to do with your therapeutic relationship with the patient, and I will not budge on this rule.
TCPR: Thank you, Dr. Parikh.