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Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Now we'll talk about being an adult with ADHD. An article in The Atlantic focuses on how treatment protocols are actually more developed for kids and the recent Adderall shortage has helped shine a spotlight on that. Remember how at the end of last year, we spoke about various shortages, number of essential medications, including Amoxicillin, Tamiflu, children's Tylenol, and more, with RSV, COVID-19, and the flu running rampant at the time?

The shortage of those medications were particularly noticeable and understandable, albeit frustrating and scary, but amongst these drugs used to treat colds and flu, a completely different kind of medication also faced shortages. In October of 2022, the FDA confirmed that Adderall, a stimulant medication used to treat those diagnosed with ADHD, or attention deficit and hyperactivity disorder, was in short supply, and now, six months later, while other drugs have recovered from the shortage, for the most part, Adderall remains inaccessible to many who rely on it.

Why is this? Well, in her latest piece in The Atlantic titled Adult ADHD is the Wild West of Psychiatry, staff writer Yasmin Tayag, who's joining us now, points to the gaps in care guidelines for the treatment of adult ADHD as a likely factor. Yasmin, thanks for joining us for this. Welcome back to WNYC.

Yasmin Tayag: Thank you so much for having me.

Brian Lehrer: You want to give us some basics first? Just remind everybody what ADHD is and why Adderall is effective in some people, in treating it?

Yasmin Tayag: Yes, ADHD is a disorder that we commonly associate with children and teenagers, and some of the common symptoms are fidgeting, being impulsive, having an inability to focus. You often see it in kids being disruptive in a classroom, and what we haven't seen for or what we haven't realized for a long time is that this disorder can also affect adults, and so over the years, one of the best treatments for this disorder has been stimulants like Adderall and other related ones, and that's where we're running into some problems right now.

Brian Lehrer: In the headline of your article, which is Adult ADHD is the Wild West of Psychiatry, obviously, you have that Wild West imagery. Why that?

Yasmin Tayag: Well, I use that term to refer to the sort of lawlessness when it comes to diagnosing and treating adult ADHD in particular. Now, for children, it's really well-established how to care for kids with ADHD. The American Academy of Pediatrics has a guidebook that lays out exactly how to treat them, how to diagnose them, but for adults, that doesn't exist. If you're a provider and a patient comes to you looking for help with ADHD symptoms, they're an adult, there is no playbook for what tests to use or what symptoms to look out for, where to look for information about this person, or even what medications to prescribe to them. In that sense, it is a Wild West, because the provider is on their own.

Brian Lehrer: Do you know why that is? One would think that something as common as ADHD would have developed protocols for adults as well as children by now.

Yasmin Tayag: You would think, but here's the thing. It is well understood for children, but the realization that ADHD is a disorder that affects adults is a relatively new one in the field of psychiatry, of adult psychiatry. It was only in the past 20 years that it came to be recognized as something that treated adults, and so the field is really behind in treating it. Part of the reason is that for a really long time, ADHD was thought to be, as I said, a childhood disorder that eventually went away. People would say, oh, they'll grow out of it, but as researchers found more recently, that's really not the case.

If anything, the symptoms in adults can appear a little different. Sometimes they're not, but whereas for children, you might have very visible effects, disruption, as I said at the classroom, for adults, the symptoms of ADHD might be a little more internal, so it might manifest as racing thoughts or inability to focus or call your mom back or pay your bills on time, and these sorts of symptoms tend to go unnoticed, and it wasn't until recently that the field of adult psychiatry realized, "Oh, this is also a thing that we need to start treating." No guidelines yet.

Brian Lehrer: Yes. Now, before we open up the phones to our listeners, I want to get through one other piece of your reporting here that's very relevant, and it's relevant to the shortage of Adderall, because you spoke with David Goodman, an ADHD expert and a psychiatry professor at Johns Hopkins, who worried about whether the demand amongst adults for Adderall is legitimate, and you note that there's been increased demand for Adderall amongst adults, in particular during the pandemic and these years following its peak. What's going on? What's the legitimacy question? It seems like people who have not been diagnosed with ADHD are going for Adderall.

Yasmin Tayag: Yes, the increased demand for Adderall among adults is possibly one factor contributing to the shortage. I want to make that clear that there's many factors, but the fear is that there are adults out there who have been getting prescriptions for stimulants like Adderall inappropriately, like they don't actually need it, and part of the reason is that during the pandemic, there were a lot of telehealth startups that would prescribe ADHD medications, and those did not always provide the scenario for the best sorts of evaluations.

Goodman had told me, you need a long time to proper evaluation for adult ADHD, but if these patients were going on these telehealth platforms and talking to a provider for like 15 to 30 minutes, that's not enough time, and so the likelihood that they're getting prescriptions that they don't actually need is pretty high. The fear is that there were enough of these people getting these inappropriate prescriptions that they're driving up the demand, taking up Adderall that people who actually need it then can't get.

Brian Lehrer: Listeners, now we're going to open up the phones for you at 212-433-WNYC. Are you an adult who's been diagnosed with ADHD in the past few years? What brought you to seek an evaluation and what does your treatment look like? Has any doctor ever said to you, "We know how to treat kids with ADHD, but adults, not so much"? If you have ADHD and you're struggling with the Adderall shortage, what is life like for you at this moment with that? How are you managing work, relationships, et cetera?

Doctors, have you noticed an upsurge either in adult ADHD in the pandemic years or patients specifically looking for Adderall prescriptions who may not be ADHD patients? 212-433-WNYC, 212-433-9692, and for anybody who thinks you're not an ADHD patient per se, but Adderall is helping you some way, you like Adderall, call us up and tell us that story. Let's take a call right now. Ben in Mamaroneck, you're on WNYC. Hi, Ben.

Ben: Hi, Brian. Yes. I'm an adult with ADHD. I actually was diagnosed when I was seven. I was lucky enough to be treated by a psychiatrist who also had ADD, and the issue I'm dealing with right now actually is he died last year and I've been struggling to find a new psychiatrist to prescribe medication and also struggling a lot with- My PCP has been prescribing in the interim, but I've been dealing with the shortage of getting my Ritalin which, like the author of the article said, it's very frustrating.

This actually has happened several times over the last decade. It seems like there is probably a lot of overprescribing. What actually I find really difficult in addition to what she was talking about is to get a prescription because it's a controlled substance. I have to see the specialist provider every month to get the prescription. It's not like my mother has [unintelligible 00:10:26] needs heart medication, they can just prescribe it over the phone call it in. It's like we're being discriminated against because of her disability.

Brian Lehrer: Who do you get it from if you don't have a current specialist?

Ben: Currently, my primary care is prescribing it while I'm searching for a psychiatrist. It's limited because I have to deal with the limits of the insurance networks that I'm in, and then it's still very expensive. I haven't found anyone who's either taking new patients or seems like a good fit yet. Actually, these last few months, there has been a few months, I haven't even been able to get the prescription filled and there was one month that it was filled and the pharmacist he gave half of it to somebody else so I couldn't even get the full prescription. I've been taking half the medication that I normally would take to try to stretch it out in the interim. It's been very difficult.

Brian Lehrer: Would you mind describing--

Ben: I actually literally just spent the morning trying to contact other psychiatrists. Then I was like, "Ah, I'm exhausted." I turn on WNYC. Literally, your segment came up so I called in.

Brian Lehrer: I'm glad you did and I'm sorry we couldn't take you out of your head for these few minutes. Just jumped right into--

Ben: It was good to talk about the frustration with somebody.

Brian Lehrer: Are you willing to say, so our listeners understand it better from an individual's experience, what it's like for you when you don't get the Adderall that you would normally be prescribed because it's not available and how you cope?

Ben: Sure. I'm on Ritalin. I know it's a slightly different thing than Adderall in terms of stimulant but it's [unintelligible 00:12:13] like when I'm not on any medication or just the frustration difficulty of not being able to get it or both.

Brian Lehrer: Ben, thank you very much for your call. We really appreciate it. Hang in there. Here's a physician calling in, a Dr. Cohn in Montclair. Dr. Cohn, thank you for lending your voice. Hi, there.

Dr. Cohn: Hi, Brian. Thanks so much for taking my call. I love that you're talking about this concept or this issue because it affects so many people. Your guest was talking about the difficulty in diagnosis for adults and I'm a family medicine physician in Montclair and I see a lot of adults asking or having questions about ADHD or trying to manage it. One concept that I wanted to bring up that makes it so difficult for a diagnosis is that anxiety and ADHD can be two sides of the same coin. When children have ADHD, and they have hyperactivity, it's very easy, I don't want to say easy to diagnose, because it can other issues, behavioral or psychiatric issues can look like ADHD.

Children express themselves as very obvious. They might have difficulty in school. They might be having conflict. As that child grows up, why we used to think that adults don't get ADHD or they grow out of it is that people gain coping skills, whether they're healthy or not. In that process, they gain psychiatric comorbidities. It might be depression, it might be anxiety or other psychiatric conditions are known to be associated with ADHD. As people become adults, they might have ADHD plus anxiety or depression or a number of other psychiatric conditions which can make it complicated to diagnose and treat.

On the flip side, during a situation like a pandemic, where anxiety is already so high and people are having multiple things to manage like children, work in the home, they're working at home so these really high-stress states, putting a stimulant on board will certainly drive you to get things done, but it's not necessarily the accurate diagnosis. Just like your guest is saying it's really hard to diagnose that appropriately but for some people, it will make things better pretty quickly, to be honest, a stimulant. The question for adults is, of course, having standardized testing protocols that we have more of that for children as she was just saying.

To have more standardized testing protocols, more contact, and deeper evaluations. Then Ritalin or Adderall is not the only option, especially people whose executive function has had a chance to develop more over their childhood. That frontal cortex has developed different than when they were a child. Even if they have the same condition, their coping skills or their ability to cope might be greater. Utilization of coaching and therapies along with medications. Not that medications necessarily shouldn't be used in cases but just like your guest was saying, it takes a lot more effort than sometimes can be given in telehealth visits. Practitioners have to be trained in those methods, and it's still a developing field.

Brian Lehrer: It sounds like you're a good doctor who looks at your patients in all the complexity of their situations. Recalling the last caller, Ben in Mamaroneck, do you find yourself with a lot of people like him, that is people who are on Adderall or Ritalin who because they're controlled substances, I think Ritalin is too, I know Adderall is, have to go to a doctor in person, every month, in order just to keep that prescription active? Is that a burden either for you or in your opinion an unnecessary burden for them?

Dr. Cohn: That's a great question. Controlled substances do require in-person visits to do your due diligence as a practitioner. Most of the prescriptions can be done two three months, every three months, some providers feel more comfortable having that face-to-face encounter every month. It depends on the level of comfort of the practitioner, maybe some policy, whatever policy they have in their office because things can change. Things can adjust. In an insurance-based world, we're incentivized to bring the patient in because that's the way the provider gets paid.

I have a direct primary care practice where I get paid directly by the patient so I have a lot more flexibility, connection, and understanding with my patients. I could give them a call. There's an open line of communication, the way I practice, which I like. There's that freedom there. I may not be as rigid, but some practices need that in-person visit, face-to-face encounter to get paid by the insurance company and that might incentivize them. Of course, it is good care to know your patient and have the connection. Make sure things are on track and evaluate for side effects. Consider whether they're using any other substances at the same time, which might negate some of the effects of their their medication.

Brian Lehrer: Interesting. Let me get one more opinion from you if you don't mind, a second opinion to another caller who's on hold right now. I'm not going to have the time to put both of you on together. This caller says he's a developmental neurobiologist who studies brain development and that there are studies showing that nicotine patches can focus attention in the same way and there's no shortage of nicotine patches. He wonders is nicotine just so demonized that no one wants to look at that as an alternative. I'm just curious if that's something that's ever crossed your attention.

Dr. Cohn: Oh, that happened. I can imagine the neurobiologists probably deeply embedded in details and research on things like that. It's not something that comes to the forefront of things that I read.

Brian Lehrer: Dr. Cohn, thank you so much for calling in. As we have a few more minutes with Yasmin Tayag from the Atlantic who has an article, Adult ADHD Is the Wild West of Psychiatry, which relates to the current Adderall shortage, but also goes deeper into the complexities of diagnosing adults with ADHD. What were you thinking, Yasmin, as you listened to those several callers?

Yasmin Tayag: I really felt for her Ben in New Jersey.

Brian Lehrer: West Chester.

Yasmin Tayag: Oh, West Chester, my bad. My own husband is also experiencing the same issues. He has adult ADHD and has struggled to get the care, get his prescriptions. What really struck me was Ben's difficulty in finding a psychiatrist to replace his former one. A lot of the sources who I spoke to for my story told me that there is a general shortage of psychiatrists who are trained to treat adult ADHD. That again, goes back to this idea that it's such a new concept in the field that people were generally not trained in medical school. A lot of the providers working right now were more than likely not trained to look for the symptoms of adult ADHD or to diagnose it. There's a shortage of expertise and unfortunately, that results in a shortage of providers right now. Just as these concerns are starting to spike.

Brian Lehrer: Let's get a couple of more callers on here. Our board is full and people have different aspects of this story to tell. Let me try. Jennifer in Mercer County. She is in New Jersey. Hi, Jennifer. You're on WNYC.

Jennifer: Hi Brian. Can you hear me?

Brian Lehrer: Yes.

Jennifer: Hi. Wonderful. Oh, I love your show. I listen to it every day for years and years. This is my first time calling. Thank you.

Brian Lehrer: Glad you're on.

Jennifer: [chuckles] I have ADD ADHD. I am 44 years old. I was just diagnosed with this maybe in my 30s. It's complicated because I have a number of other things going on. I'm also bipolar 1 and I have anxiety and panic attacks. Lots of stuff going on from a very, very early age. This was missed in me and it caused me to have a lot of trouble in school. I think during the 80s when this would've been presenting itself it wasn't a widely given diagnosis to begin with if I'm correct, and especially not caught in girls.

This caused me problems throughout my entire life. Even in college, when I sought help from the school success coach, and this was when I went to school when I was an older adult as well, they were giving me the same strategies that they would give to any other student, and that it just wasn't effective for me.

I did eventually try Adderall. I tried a number of other drugs. First, Ritalin, some other ones, and the Adderall really, really helped me. I went off it for a few years and I just started taking it again and when I heard your topic today, I said my psychiatrist let me know that there's a shortage and I may have a problem getting it. Fortunately, I have not had a problem. I actually have a script waiting at the pharmacy for me to pick up [laughs] which was just prescribed a couple of days ago.

Brian Lehrer: Good. [crosstalk] Everyone was going to want to know which pharmacy. [laughs] I'm kidding. [laughter]You don't have to say. It sounds like, and Jennifer, I'm going to leave it there because we're almost out of time in the segment, but thank you so much. I thank your call is very instructive. Yasmin, I think Jennifer's kind of a case study of a person who was not diagnosed as an adult with ADHD until later than she could have been and that's one of the main points of your story. So much of this is going undiagnosed in adults, right?

Yasmin Tayag: Absolutely. The number of adults being diagnosed is expected to increase.

Brian Lehrer: One more on one other angle. Clementine in Philadelphia, you're on WNYC. Hello, Clementine.

Clementine: Hi.

Brian Lehrer: Hi there. Your point--

Clementine: [croostalk] me?

Brian Lehrer: Yes. Again, because we're running out of time, I'm going to rush you to the point a little bit, but you want to talk about another alternative to Adderall, right?

Clementine: Yes. I wanted to mention my challenge is I was prescribed with Adderall throughout my 20s and struggled with the addictive qualities of Adderall. Adderall definitely has a mild euphoria that goes along with it that can be pretty addictive and pretty challenging to come off of. I'm currently taking Vyvanse which is an expensive alternative that a lot of insurance companies don't cover, but it does reduce the addictive quality which I think is a benefit that folks don't really talk about because even people that have ADHD, and Adderall helped me a lot, but it also created a lot of challenges that I think folks like other addictive medications it's hard to admit and to come off of.

Brian Lehrer: Clementine. Thank you for being open about that. A last word, Yasmin. What do you think the upshot will be of your article? You hear the response it's getting just on this show. I imagine you've been getting a deluge of mail since your article was published in the Atlantic. How do you think it can help people?

Yasmin Tayag: I'm really encouraged to see so many people talking about this. I think destigmatization of ADHD and other mental disorders as mental disorders is really helping people get the care that they need. It's giving them the confidence to go to their doctors and seek help. The hope is that these guidelines will get established and there is an effort to publish them and to get them out into the medical field. Hopefully, that means that this will become a standard part of not only medical practice, but also medical training so that the next generation of psychiatrists and doctors will be able to provide standardized care for the adults who are seeking help for this.

Brian Lehrer: Yasmin Tayag is a staff writer at The Atlantic. Her article is titled Adult ADHD is the Wild West of Psychiatry. Thank you so much for sharing it with us.

Yasmin Tayag: Thank you for having me.

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