Clinical Pearls from Real-World Psychiatric Practice: The Chaos of Treating ADHD
It has taken me a while to write this article about ADHD. Even though this diagnosis has exploded in the population, there is a lack of ADHD training in most psychiatric residencies, so taking this on as a staff psychiatrist has been daunting.
When I first entered practice, my instinct was to try to avoid diagnosing and treating ADHD completely. I would refuse ADHD consults and tell patients with concerns about ADHD that it was not a part of my practice. I would not prescribe any stimulant medication. However, it has become such a prominent complaint that I needed to change my approach, particularly when I want to help the most people I can, the best I can. So here is how I started and continue to build an ADHD-inclusive practice that "works" for me:
Start with Patients Already on Stimulants and Have a Diagnosis of ADHD
My exposure to ADHD started with patients who came to me already on stimulants with a previous diagnosis from either a family doctor or other specialist. I sought out feedback on ADHD treatment and their symptoms even when ADHD was not the chief complaint of the patient. I did this so I could start building a template in my mind of what to look for or ask about should I start considering diagnosing and treating ADHD in my practice.
Then there were the clear-cut cases of ADHD that would make it into my office. These are the cases where the patient meets all the criteria for ADHD in childhood through adulthood and has no other psychiatric comorbidities to explain the dysfunction. Some of these patients might show increased distractibility and hyperactivity in our appointments helping further cement the diagnosis. Sometimes there would even be a psychoeducational assessment from childhood and report cards that objectively commented on inattention and hyperactivity as a child available. In these cases, diagnosis is obvious and treatment can be started. Unfortunately these kinds of cases are very, very rare.
Familiarize yourself with a set of trusted ADHD Guidelines
I use the Canadian guidelines, also known as the CADDRA guidelines. They can be found here https://adhdlearn.caddra.ca/wp-content/uploads/2022/08/Canadian-ADHD-Practice-Guidelines-4.1-January-6-2021.pdf
In the real world however, I have found the questionnaires that are intended for family and the patient can lead to very biased answers, if I can get them filled out at all. I suspect this is because a lot of people want a diagnosis of ADHD and they have done their own research in advance of what the symptoms are. In addition, trying to get report cards from early childhood is difficult. When you can get them, they are not always helpful. So guidelines are a great place to start. They tell you the ideal body of information that would be needed to make the diagnosis, but does not necessarily match with what you can gather in reality.
Know Something about Nonpharmacologic Treatments for ADHD
ADHD is not just about taking a pill. Psychoeducation for patients about how to accommodate ADHD in their lives even without medication is important for success. This includes good sleep habits and regular exercise. This also includes keeping an agenda, using their phone for reminders and knowing when in the day patients notice their ability to concentrate and focus are best and knowing how long they can last before taking a break. Patients also need to make sure they have a place to work that is free from distractions. It is about optimizing the conditions for optimal concentration and focus, an uphill battle for many who constantly have their smartphones in hand. There are other therapies geared towards ADHD that are effective, like Cognitive Behavioral Therapy. I always recommend making some of these adjustments and changes first, even before trying a medication. I am amazed, but not surprised at how often patients are not willing to do this legwork first. I am amazed, but not surprised at how patients can feel entitled to a medication first and the pushback I get when I voice caution and a more conservative approach.
Another issue that complicates ADHD diagnosis and treatment is that psychiatrists and the medical field simply do not know enough about the many different reasons someone can present with concentration, academic and behavioral difficulties. More often than not, I am seeing patients who have comorbid anxiety or depression, possible developmental delay and addictions issues, so diagnosing ADHD in this population is very difficult if not impossible. In other cases, another learning disorder can be responsible, but this is outside the scope of the expertise of medical physicians and psychiatrists. The result is that all learning difficulties that present to a physician will end up being labelled as ADHD because that is the only overlap that exists between neuropsychologists/learning disorder specialists and the medical field. It is also the only diagnosis where there is medication treatment requiring a physician's involvement. It would make sense then that physicians would inaccurately diagnose and over-diagnose where there is a lack of information to help guide us further, and patients in distress in our offices asking for help.
Have a Consistent Approach to Patients with Comorbid Addictions
It is impossible to escape the overlap between ADHD and addictions or substance misuse. This has been the most difficult population for me. I have reactivated addictions in several of my patients and these experiences have greatly affected me because of how badly our therapeutic relationships have ended when I tell a patient I am no longer comfortable prescribing the stimulant when the patient started misusing it.
My rule of thumb now is that if a patient is using any substance both recreationally AND to self-medicate or function in some way they are not a good candidate for a stimulant trial unless they are engaged in addiction treatment and have had a period of sobriety. The reason for this is that these patients have no awareness of the line between recreational use and therapeutic use. They will start with one intent in mind and cross over into the other without an awareness or ability to stop. Many patients with addiction do not know the difference between the two. This means then, it is almost certain these patients will use the stimulant the same way: both recreationally and/or to self-medicate. This is NOT responsible or safe use of a stimulant. Patients have to know the difference between these two states and how to manage cravings and other maladaptive addictive cues/behaviors before it is safe to try a stimulant. In my city, addictions treatment is accessible through self-referral and is publicly funded, so there are no barriers for the patient in accessing addictions support. I put the responsibility squarely on the patient if they want me to consider a stimulant trial and when possible, I would ask to work with their addictions therapist because the stakes can be very high if someone experiences a relapse in their addictions while on a stimulant.
So, it is only when a patient with a history of addictions is receiving addictions treatment and is no longer abusing a substance that I would consider starting a stimulant. However, even in these cases, I would start with a nonstimulant, like atomoxetine first.
I have spoken to an addictions physician who recommended stimulants never be started in patients who have had a history of cocaine or methamphetamine addiction because the risk of relapse into addiction is too high, no matter how long they have been engaged in addiction treatment and sobriety. I have also had patients who I may feel it is worth the risk of trying a stimulant, because they have been sober from their substance of choice for over 5-10 years. However, it is the patient who refuses because they simply do not want to take the risk of reactivating their addiction knowing the real-world consequences this could have for them. So for some patients, no matter what, the risk for abuse and addiction is never zero and a stimulant trial is just not an option available to them.
My Thoughts about Harm Reduction (ie starting a stimulant in someone abusing substances with the idea that it would bring down their substance use because the ADHD is now treated)?
I have heard the argument that treating ADHD can result in a reduction in harm in patients with active addictions. I can understand this point: If a patient is self-medicating, to merely function with a substance like cocaine he may be getting from the street or an unsafe supply, would it not be better to provide these patients with a government-approved stimulant medication? Even if the patient can then use both the stimulant and cocaine, or even divert their supply of stimulant and sell it on the street?
These are the incredibly tough decisions clinicians have to make on a case-by-case basis. All I can say, is that in my experience, the harm-reduction approach has not worked in the patients I have worked with. I am also a more conservative and cautious clinician, so some risks other doctors may feel are justified in taking, if I do not think or feel something is safe, I will not do it…if I can help it. These last words need to be added because patients with addictions are incredibly persistent. They can wear down even the best of clinicians and I will admit, I have been worn down. It is for this reason I can not see too many of these patients at one time, and I keep my involvement relatively short if I can. I have been on the receiving end of the anger, felt injustice, desperation and charm these patients throw at care-giving professionals. The emotional impact these patients can have on clinicians can not be understated though it is often dismissed.
I have found that the doctors who make the argument for harm-reduction generally do not offer longer term follow-up and so can not report on the outcomes of some of the patients to which they have prescribed stimulants. I have seen far more cases of stimulants being abused and diverted. It is a strong value of mine to not contribute to this black market economy.
As I have alluded to earlier, I used to give these patients the benefit of the doubt, I can not afford to do this anymore. The impact to me personally and professionally is too great. I therefore only prescribe stimulants to patients I trust, patients with whom I have a healthy physician-patient relationship. Even then, I have been burned, which only reminds me of the power of addictions and to take this illness very seriously. The harm from a relapse into a severe addiction far outweighs the benefit these patients hope to gain from a stimulant trial.
Take Note of OBJECTIVE Signs of Dysfunction from ADHD (and not only the subjective)
For me, and this is clearly based on the population I treat, ADHD must cause clear dysfunction. Always ask, what am I prescribing the stimulant for? What symptoms am I hoping to improve or reduce? I have patients who are working full time, performing well and in stable relationships with no clear dysfunction who tell me they feel they should be able to concentrate better. In these cases, patients are looking to be enhanced, or to reach some potential they believe they are not meeting. In these cases, I am clear that I do not see a role for a stimulant and that being on a stimulant has its own downsides and side effects. Stimulants can worsen anxiety and sleep for example. Some people seek out stimulants knowing that a side effect is appetite suppression and hope to use this to lose weight. To prescribe a stimulant in these cases would be cosmetic psychiatry and is not the kind of psychiatry I aim to practice.
Consider other Learning Disorders
When in doubt, and if the patient can afford it, I would ask for a neuropsychological assessment from a clinician you trust. Unfortunately in the public system where neuropsychological testing is not covered, at times we do not know exactly what we are treating, but we are trying our best. This is where the rating scales and questionnaires from the patient and family are helpful as well as any past scholastic assessments. However, in the absence of these records, I am realistic of what I can do. I am more likely to try a stimulant in patients who have not been able to complete high school or college, or are clearly employed below their intellectual potential. Often these patients have internalized an identity that they are stupid and lazy because of their academic failures. This is very common in patients with both ADHD and learning disorders unfortunately. In addition, learning disorders are highly comorbid with ADHD. There are cases where even without all the information I would want, I would rather err on the side of diagnosing ADHD because the harm of missing this diagnosis outweighs the harm of an ADHD treatment trial.
Have Objective Measures for the Effectiveness of a Stimulant Trial
Rating scales available include the ADHD rating scale - 5 or the Adult ADHD Self-report scale. I admit, I could do better with this myself. I often rely on the Clinical Global Impression Scale, which is less objective and specific to ADHD than I would like.
I will also not prescribe a medication to someone who has no work/school/responsibility or volunteering in their day and who have no ambition to pursue these things. These patients have more to work on that is getting in their way. In other words, even if they did have ADHD, it is not the main cause of their dysfunction and dissatisfaction.
A Few Words on our Attention-fragmenting Culture
I have seen first-hand how symptoms that mimic ADHD in adulthood but with no childhood symptoms have increased and are causing more distress in the population at large than when I first started practicing. I see validity to the argument that our society has ever-increasing demands on our attention and cognition, while also sabotaging our attention and cognition at the same time. More and more, people are having to multi-task, or sustain focus while being bombarded by constant interruption. For example, with more people working from home, my patients are telling me that looking after their children or loved one while needing to work on a report, while being on a team chat about another project, while needing to respond to emails within a 24-hour period, while on the side having another window open on their phone because they have to buy a birthday present for a friend's party this weekend - is a really common and universal experience. On a break time, you are scrolling through TikTok, reacting to other people's messages/stories/photos on social media AND playing a game, all of which reinforces short bursts of reward and compulsive engagement. We enable the loss of our ability to focus and to experience the gratification that comes with sustained focus. And so there are cases where the person likely does not have ADHD, but is having impaired functioning in their lives with their normal and healthy brains. I have only just begun to wrap my head around the implications of this for me in my work and for society at large. It is sobering and baffling. I admit I feel powerless and insignificant in the face of such strong cultural and technological forces.
Some news articles and personal accounts will call these concentration difficulties ADHD unmasked in adulthood. Whether it is because of our attention economy or a specific set of life stressors, it actually does not make a difference in how I practice psychiatry. This is because I treat each person on a case-by-case basis, and there is just so much we do not know and too many confounding variables in most of the patients I see to get a clear diagnosis, be it anxiety, complex trauma or ADHD. So, like much of psychiatric prescribing, I use medications, stimulants included, where it is most clinically relevant, and this can mean using medications off-label.
*Definition of Off-label prescribing: the practice of prescribing an FDA-approved (or otherwise government-authorized) medication for a use, dose, patient population, or route of administration that has not been officially approved by the regulatory agency and thus is not listed in the drug's approved labeling or package insert
A Clinical Case for Off-Label Stimulant use and My Justification
In the end, I am trained to treat the patient in front of me. We call this patient-centred care. I have a duty to that person and so societal implications take a back seat. In exceptional cases, I will consider a stimulant with the patient, so long as they are aware that their difficulties may not be ADHD and I am using the medication off-label. Ideally, I would use the medication in these circumstances for a limited time (a couple of months) to see if it can help them get out of the rut they are in.
The Clinical Case:
The patient is a working mom with a relatively absent husband due to frequent business trips that take him abroad. After her second child, who has high needs, she finds herself chronically tired with low energy despite having adequate sleep (for a parent with 2 young children). She is so tired and drained from her demanding client-facing job and then single-parenting her children, she has not been able to exercise to lose the weight from her last pregnancy and she is unable to focus on the work she takes home (because she must leave work early to pick up her children). To further complicate matters, she had a significant head injury 10 years ago and the impact of this on her current functioning is unknown.
After following her for 6 months, I optimized her medications for her depression and anxiety with good success. She cut out drinking and tried to start exercising regularly. Unfortunately, she still had chronic tiredness and was unable to consistently stick to it. Predictably, she would experience set backs in her mood and anxiety when her husband went away again, and what grew more palpable with each session was her demoralization and self-consciousness with her weight. Stimulants can be used with good effect in patients with cognitive impacts of concussion as well as patients diagnosed with chronic fatigue syndrome. She was at low risk for substance misuse and I felt strongly that she deserved all attempts to maintain and improve her functioning, especially when she was working so hard to contribute productively to her community and to her family. I suggested a stimulant trial in this case.
It has been 4 months and so far she has responded well. She notices she is less irritable at home and interestingly she is sleeping less but feeling better rested. She notices she is able to complete all of her work at the office freeing up time in the evenings. She has also had the time to take her weight loss more seriously and was started on a weight loss medication and is running with co-workers twice a week. Life got in the way in that her mother had a fall and she needed to help out in her recovery. During these 2 weeks, she actually stopped her stimulant because she noticed her anxiety was higher and started having panic-like symptoms. As soon as she stopped the stimulant, her anxiety symptoms improved. When she returned home after her mother stabilized, she waited another 2 weeks before restarting her stimulant because she found herself lagging again at work and with her self-care. She has resumed the stimulant now for the past few months, on a lower dose since her mother's fall and she reports feeling the most stable she has in a long time. We will keep her on her current medication regimen for now and re-evaluate in coming appointments to make sure she continues to benefit.
Some other articles worth reading re: ADHD:
https://www.sciencefocus.com/wellbeing/adhd-in-adult
https://www.nytimes.com/2025/06/17/podcasts/the-daily/adhd-diagnosis-prescriptions.html
https://ghaemi.substack.com/p/diagnostic-invalidity-of-adhd
Addendum: I have recently travelled to Taiwan and have started a sabbatical working as a psychiatrist in the public health care system in New Zealand. Both these countries have more restrictions and regulations regarding the use of stimulant medication.
In New Zealand, stimulants are only allowed when there is evidence of a formal diagnostic process for ADHD, involving questionnaires, formal assessment protocols (they use the DIVA questionnaire) and psychological assessment. In absence of these, stimulants can not be used. They can not be used off-label and physicians face consequences when they are audited and do not have enough objective evidence for an ADHD diagnosis beyond patient report.
It seems I am back to my initial approach in treating ADHD here in New Zealand. In Canada, I was using stimulants in more complex cases where a diagnosis could not be determined due to many variables, and in a culture where increasingly nonspecific and vague symptoms were attributed to possible ADHD putting pressure on clinicians to prescribe stimulants even when we might not have felt comfortable or confident in the diagnosis. Here, it is only the clear-cut cases where treatment is allowed. This is a relief because in Canada, a lot of my intellectual and emotional energy were spent on the most complex of cases where I often felt like I was policing stimulants and that my clinical judgement was the sole determinant to a patient accessing or not accessing stimulant medication. Here, I am in a mental health team with psychology available to help in ADHD assessments, and in a system that promotes more judicious use of stimulants. I am hopeful then that I will be freed up to focus on other clinical interests and presentations.