Menu

Doctor’s Blog

ADDitude Magazine Webinar “ADHD in Older Adults” David W. Goodman, M.D. May 1, 2018

, , , , , , , , , ,

Technology is not always a cooperative servant. My ADDitude Magazine webinar scheduled on Febuary 27, 2018 was interrupted by a technical problem after 10 minutes. No one was more upset about this than I. However, good news. the webinar has been rescheduled for May 1 Tuesday 1pm for 1 hour. This will be a 30+ minute presentation with slides followed by Q and A live. You can register for the webinar and, if not available for the time, watch it at a convenient time for you.

In this webinar, you will learn:

  1. how to identify and understand ADHD symptoms in adults over age 50
  2. the importance of an accurate diagnosis in older adults who are experiencing mental changes
  3. why clinicians don’t consider that ADHD might be the reason for “thinking problems” in older adults
  4. signs that clinicians and older adults should be aware of in the diagnosis process
  5. how stimulants might fit into a treatment regimen for adults who are taking multiple medications
  6. how medication and organizational skills can improve daily functioning and quality of life
  7. how to approach a parent who you suspect has had lifelong inattention and disorganization

Hope you can join us…and tell anyone who might benefit….like your parents who have had symptoms for as long as you can remember. While the webinar is billed for clinicians based of the research basis of the presentation, it will not be beyond the scope of the general public to understand.

David W. Goodman, M.D.

So you can’t get your ADHD medication approved by insurance? Part 2

, , , , , , ,

This is Part 2 to a previous blog:

This brings us to the next objection insurance companies will raise – the issue of safety. In citing safety as a reason for the denial of daily stimulant doses that exceed FDA daily max allowances, they deliberately and knowingly misrepresent the meaning of FDA max daily dose. For most ADHD medications, the FDA daily max dose is established on efficacy (how well it reduces symptoms), not safety. That’s to say the FDA has decided that no higher dose brings about a better reduction in symptoms. This may be because the study didn’t test higher dosing because the pharmaceutical company didn’t want the uncertainty of what would happen at higher doses (like extra side effects).

For many stimulant medications the FDA max daily dose for adults is less than the research clinical trial submitted to the FDA. One clear example, Concerta has a FDA maximum daily dose for adults of 72 mg a day, yet the adult ADHD research trial submitted to the FDA ran the dose up to 108 mg a day. In fact, in that trial, approximately 30% of the adults were at 90 mg daily or higher. This is publically available published research data. I was a prinicipal investigator (PI) on this trial some 20 years ago. The same can be said for Adderall XR with an FDA recommended daily dose for adults at 20mg yet the adult ADHD research trial submitted to the FDA ran the dose to 60 mg a day. Again, published available research on which I was also a PI.

In my previous post on this subject, I alluded to the fact of a “physicians review of medical information”, may not have even been performed by anyone. This speculation has been recently confirmed by a medical director at Aetna. He is now on the record saying that in many cases that were denied he never reviewed most of or any of the patients’ medical records.

So, all this information begs the question “what can I do to get my needed effective medication?”
First, you’ll need to follow the insurance companies procedures. Get a prior authorization, if denied submit an appeal if you are “wedded” to your medication. One secret to the appeal process is patient involvement. While I as a physician will try to submit the most relevant and supportive medical information, insurance companies may respond with more attention if the patient is very invested in the outcome. This may work best by composing a one page letter and attaching it to your doctor’s submission of medical information. Then follow this up with a phone call that will go on the record in their files.

However, if the prior authorization is denied and the subsequent appeal is denied what recourse then? I have recommended to patients to submit a complaint to the state insurance commissioner’s office. If you are comfortable, you submit a copy of the records that were submitted for the appeal process along with a cover letter from you explaining why you are filing a complaint with their office and what action you’d like them to take. The basis of your complaint can be strengthened by your physician/psychiatrist/prescriber’s reasons that justify the medical necessity for you to remain on your medication without change in compound, preparation, or dose.

What’s the likelihood that time spent on this process will yield a positive outcome? In my experience, surprisingly likely. State insurance commissioners office tend to be protective of patients’ medical care. In the state of Maryland, the insurance commissioner’s office will forward a copy of the complaint to the insurance company who is left to respond. In my experience, in about 50% of cases, the insurance company responds with a letter to the Insurance Commissioner saying they’ve reviewed the specifics of the situation, reconsidered the decision, and approve the medication and/or dose. It is worth a try. If nothing else, the commissioner’s office keeps track of compliants.

In closing, if you are on a high dose of ADHD medication and/or on an unusual combination of medications for ADHD, anticipate having to go through this process, especially with policy and pharmacy formulary changes effective Jan 1, 2018.

Understanding and planning the steps to take if your medications come under review will help you quickly get approval and/or consider other options. This planning will decrease the likelihood of a disruption in your prescriptions and treatment. Work with your health care prescriber to navigate through the stormy seas.

In future blogs on this topic, I will cite specific insurance companies and pharmacy benefit management companies who obstruct the established and effective treatment of my patients.

Hope this helps you.

David W. Goodman, M.D., FAPA

So you can’t get your ADHD medication approved by insurance? Part 1

, , , , , , , ,

My patients have been complaining for years about getting there prescribed ADHD medications approved by their insurance companies. With each passing year this becomes increasingly more difficult. Since January 1, 2018, with insurance companies making changes to policies and formularies (tier system that determines copayment amounts for medication), patients have found the medications they have been on for months to years are now being denied. Insurance companies, citing “step therapy”, are requesting patients try medications on tier 1 before they get approval for higher tier ADHD medication.

So how has this evolved? Years ago the focus on cost was not as acute as it has become in the last two years. As a result, designated medications on Tiers have changed with consideration to cost containment by the insurance companies and their designated pharmacy benefit managers (CVS Caremark, UnitedHealthcare, etc.). It used to be that prior authorization for medications was a routine administrative procedure. For cost containment, prior authorizations are now often denied on the basis of doses exceeding FDA approved daily maximum, change in the tier status of a medication, or number of pills contractually covered per month.

Such denials can then be addressed in an appeal process. However, if the initial denial is based on the request for “step therapy” and you are a patient in Maryland, it is important to know that Maryland made step therapy illegal in 2014. So, you send back the initial denial with a letter stating Maryland law on step therapy.  You can also find this information on my previous blog. As far I know, Maryland is the only state with this law and I, for one, have used it effectively to get step therapy denials overturned.

Routinely, the appeal process involves sending additional medical documentation. What do they want to see? Have you been on lower tiered medications, doses, duration, effect and side-effects? Composing this information and letter is very time consuming for your prescriber and will frustrate both of you when the appeal denied. I simply send copies of my medications sheets and let them cull through it for the information they request.

You and your prescriber can escalate the process and request a peer-to-peer review. By phone, the treating physician reviews the medical history with an insurance designated physician, who may or may not be a psychiatrist. After I provide the necessary medical information and historical course of treatment to the reviewing physician, he/she asks additional questions necessary to fill out their form they submit to the insurance company. What is surprising is that the reviewing physician has no authority to make a determination as to the legitimacy of the requested medication or daily dose. The reviewing physician simplies gathers information to submit to the insurance company. More often than not this turned into a pro-forma administrative time-consuming obstacle as the outcome was often a second denial. Here too insurance company misleads us into believing the physician-physician review results in a medical agreement about treatment but no such thing happens since the reviewing physician has no authority to authorize medication- as one physician told me “This is my contracted role in this process.”

An example of the response to such an appeal comes from CVS Caremark on a recent denial for my patient’s high dose Adderall XR: “A doctor has reviewed all the documentation it was submitted and is determined that your request for medication was not medically necessary or experimental and investigational.” But as you see, the doctor who reviewed the medical information with me had no authority to authorize medication, so how could he/she authorize the denial?  This patient had been on high dose Vyvanse then high dose Adderall XR over the past three years. His control of ADHD symptoms was much better, duration of control was approximately 12 hours, and he did not have any significant side effects or changes in blood pressure and pulse. In my opinion, there was no medical justification for the denial and interuption of his effective daily dose of Adderall XR for the past 1 year, which, by the way, had been approved up to this new year.

What did we learn today?

  1. Obtaining your ADHD medication may grow more difficult.
  2. Anticipate that medication previously approved may be denied as insurance formulary tier designations change.
  3. Plan alternative medications with your prescriber if necessary.
  4. Do not accept the insurance companies’ explanation as to the legitimacy of their denial.
  5. Coordinate with your prescriber to see if they have some insight. They have to do this with dozens or hundreds of patients.

What’s coming in next blog on this topic? I’ll enumerate additional insurance objections and misleading information, and how to effective challenge their position to get the medication you need. Forewarned is better armed.

Sincerely hope this sheds some light in the dark corners of ADHD treatment access.

David W. Goodman, M.D., FAPA

 

 

US News and World Report interview David W. Goodman, M.D. on Social media use by ADHD people

, , , , ,

U.S. News and World Report interviewed me  in December 2017 about recent research publication (Language of ADHD in Adults on Social Media, Dec 2017) comparing the use of social media between ADHD and non-ADHD people. The authors specifically looked an the vocabulary between each group and discovered, not surprisingly, that ADHD individual tend to use more “colorful” language like profanity. They analyzed approximately 1.3 million tweets written by 1,399 Twitter users with self-reported diagnoses of ADHD, comparing their posts to those used by a control set matched by age, gender and period of activity. They found that users with ADHD are found to be less agreeable, more open, to post more often, and to use more negations, hedging and swear words.
More importantly, using artifical intelligence analysis, the authors could pick out the ADHD individuals with approximately 80% accuracy based on language and syntax. Translation: the use of vocabulary and syntax can reveal much more about you than you would have ever thought possible.

I have taught psychiatric residents at the Johns Hopkins Hospital for over 30 years. I tell each one “When ever someone is speaking, they are telling you something personal about themselves. The question is ‘Do you have the secret decoder ring?’ With the above research, apparently artificial intelligence will be the decoder ring in the near future. Imagine wearing glasses that would give you this insight in real time as you conversed with someone…and someone you are talking with is wearing the glasses. Scary? No, worse. Incomprehensible. Well, never mind. It’s not available…yet.

Thank you for reading my musing.

 

ADDitude Magazine Webinar “ADHD in Older Adults” David W. Goodman, M.D.

, , , , , , , ,

ADDitude Magazine online invited me to present a free webinar on ADHD in Older Adults Tuesday, February 1pm EST. Because I co-authored the first literature review of world-wide scientific research on ADHD in older adults, ADDitude Magazine believes it is an important issue for its millions of readers. Register for the webinar and if you can’t make the time, it will be available for replay and podcast download from iTunes.

While it is well established that ADHD persists into adulthood in 60% of children with ADHD, there is almost no recognition of ADHD in people over age 50. However, there is enough international research to alert people and clinicians that ADHD should be considered and part of the evaluation for cognitive complaints in aging patients.  This is especially true when ADHD has been diagnosed in a first degree relative (mother, father, son, daughter).

So, if an older family member has a history of life-long inattention, poor memory, forgetful, misplacing things, taking too long to complete tasks, shows up late, doesn’t listen in conversations, easily eruptive and impatient, …well, you get the picture, then join me for the webinar where I’ll cover some the scientific research along with insights for diagnosis and treatment. Perhaps more importantly, how to approach an older family member with your observations and concerns.

For my older patients diagnosed and effectively treated, they are grateful to function at a higher level, relieved of the fear of dementia, and now realise “That (ADHD) wasn’t me as a person.” At any age, that insight is liberating.

In this webinar, you will learn:

  1. how to identify and understand ADHD symptoms in adults over age 50
  2. the importance of an accurate diagnosis in older adults who are experiencing mental changes
  3. why clinicians don’t consider that ADHD might be the reason for “thinking problems” in older adults
  4. signs that clinicians and older adults should be aware of in the diagnosis process
  5. how stimulants might fit into a treatment regimen for adults who are taking multiple medications
  6. how medication and organizational skills can improve daily functioning and quality of life
  7. how to approach a parent who you suspect has had lifelong inattention and disorganization

Dr. David W. Goodman Interview by NPR Morning Edition May 29, 2017

, , , , , , , , , , ,

National Public Radio recently posted my interview (click on “Heard on Morning Editon”) from April 2017 about a research publication reviewing a revised adult ADHD screener developed in coordination with the World Health Organization. What the journalist didn’t know at the time that I will share with you is that I was a pre-publication peer reviewer on this study. That means I was very knowledgeable about the details of the study and had offered my critique to the publisher prior to publication. For additional background on this screener, see my previous blog.

 

Now, let’s address the audio quotes.

Dr. Lawrence Diller says “I don’t know what ADHD is anymore” referring to changes over the past 3 decades of changes in the Diagnostic and Statistic Manual used to establish diagnostic criteria for psychiatric disorders. I’m surprised by his comment given 20+ years of international research (tens of thousands of scientific publications from around the world) that has better defined the symptoms and impairments of ADHD. It is this research that has contributed to better defining ADHD in children and the progression of ADHD into adulthood  therefore accounting for the evolution of changes in the current DSM 5. The diagnosis of ADHD is not based on a cluster of symptoms at one point in time. The diagnosis is based on the cluster of symptoms as they impair the person over the course of their life. Everyone has some inattention and distractibility at some point but few have the symptoms since childhood that have never gone away and are observed by others as a problem.

How about Alan Schwarz’s comments who disqualifies published peer reviewed science by indicting the experts and researchers who have conducted research with and without pharmaceutical support. To indict the international ADHD research community would be to suggest an international conspicacy of hundreds, if not thousands, of physicians and psychologists across 7 continents. This is a basic journalistic method (shoot the messager) to distract readers from the merits of an issue. I have personal experience with Mr. Schwarz who took to indicting me in his New York Times article when he conveyed to readers that I was advocating teaching primary care physicians how to diagnosis ADHD based on a short video clip. What he deliberately chose not to include in his article was the fact that the video was a visual representation accompanying a 2500 word, 168 scientific references, and peer reviewed article. Focused only on his agenda to act as “educator” to save the “victims” of ADHD medications from the “villians” of doctors, he deliberately misrepresented information for his self-serving purposes.

So, I’ll leave you with my saying, “The credibility of information is dependent on intent of the provider”. A salesperson gives you only information he/she wants you to have to close the sale. An educator gives you information so that your interest is best served first. You need to carefully discern this for yourself.

I will continue to present science in the halls of opinions.

Thank you for your interest….and focused attention.

David W. Goodman, M.D., FAPA

Dr. David W. Goodman interviewed by Vox.com Misdiagnosis of ADHD

, , , , , , , , , , , , ,

Dr. David W. Goodman was video interviewed by Vox.com on misdiagnosis of ADHD as a counterpoint to Dr. Allen Francis, psychiatrist, who believes ADHD is overdiagnosed. The video is excellently edited and very engaging. While it is easy to say ADHD is overdiagnosed because of the extensive media coverage, it is not overdiagnosis. The basis for my opinion lies in the research facts: 4.5% of US adults ages 18-44 are believed to have ADHD, a diagnosis whose basis is the persistence of symptoms since childhood of which 75% were never diagnosed as children. Of the adults with ADHD in the U.S., only 25% have been treated in the last year. With the prevalence rate of ADHD internationally ranges from approximately 2-10%, appallingly few adults outside of the U.S. are identified and treated.

Setting aside those adults who are accurately diagnosed  with a comprehensive evaluation, there are patients who are given the diagnosis of ADHD and don’t have it. Inadequate clinician training, little time spent obtaining the history, and strong patient demand for ADHD can lead to misdiagnosis. These patients who do not have ADHD should not be placed on stimulant medication. More often, primary care clinicians are prescribing short-acting stimulants which can be abused, misused, and sold/given away to friends/customers.

SOME FACTS:

65% of all stimulants prescribed in the U.S. are prescribed primary care clinicians; 55% of all stimulants prescribed are short-acting; four international guidelines for the diagnosis and treatment of ADHD recommend long-acting stimulants as first line medication, not short-acting.

Well, that’s enough science for today. I provide this information so that if you are in a conversation about this topic, you are armed with meaningful data, beyond opinion.

As I have said before in my blogs, let science be the designated driver on the highway of opinions.

Dr. David W. Goodman interviewed by NPR April 4, 2017

, , , , , , , , , , , , , , ,

National Public Radio  interviewed me this week to comment on a research publication about a revised adult ADHD screener developed in coordination with the World Health Organization. What the journalist didn’t know at the time, that I will share with you, is that I was a pre-publication peer reviewer on this study. That means I was very knowledgeable about the details of the study and had offered my critique prior to publication.

As background, my colleagues just published a research paper revising the adult ADHD screener developed in coordination with the World Health Organization. Because of the diagnostic changes from DSM-IV to DSM-5, the previous adult ADHD screener needed to be revised accordingly.  While the six question screener looks rather basic, the article details the rigorous methodology and statistical factors that contributed to the selection of each of the six ADHD questions.

It should be enphatically stated that the screener simply allows clinicians to identify adults who may have ADHD, but it in no way makes a diagnosis. Because primary care clinicians are increasingly requested to provide mental health diagnoses and treatment. Because their time spent with patients is limited, the screener simply highlights someone who has some symptoms.  This encourages a further evaluation by someone with adult ADHD expertise.

Given that ADHD is a world wide disorder, the World Health Organization has been very interested in developing a preliminary screener to be performed in the offices of clinicians around the world. The previous screener has been translated into many languages to be used internationally.

To those who follow my blog, I apologize for the delinquency in posting any recent material.  My time has been consumed taking care of patients, developing slide decks to educate clinicians, serving on the national boards of directors for APSARD ( American Professional Society for ADHD and Related Disorders Association) and CHADD (Children and Adults with ADHD Association),  and working with journalists in order to present the latest science of ADHD.

Thank you to those who continue to read my blogs.

Emotional reactivity and ADHD in adults

, , , , , , ,

Emotional reactivity, what mental health professionals call emotional dysregulation, is often seen in ADHD children and adults. The reactivity is characterized by sudden, intense reactions, usually impatience, annoyance, or irritability. While not a symptom formally recognized by DSM 5 diagnostic criteria, research demonstrates its presence in many ADHD patients. Many patients treated with ADHD medications report that their emotion fuse is longer-less overwhelmed, frustrated, or annoyed.

What confuses mental health professional is the diagnostic dilemma when observing emotional reactivity. Should it be considered a symptom of a mood disorder (depression or bipolar disorder) or ADHD? That decision has implication in the choices of medication options.

To discuss this further, I wrote a blog for the American Professional Society for ADHD and Related Disorders (APSARD), a national ADHD organization, with the mission to educate medical and mental health professional about ADHD. I anticipate that the issue of emotional dysregulation will become a debated issue between the mood disorder experts and the ADHD professional. I know this because I will present on the topic of Bipolar Disorder and ADHD at the 14th Annual Psychopharmacology CME symposium in Cinncinatti on October 29, 2016 and have been invited to participate in a symposium at the Annual American Psychiatric Association in May 2017.  We’ll see how it all unfolds.

Psychiatric Times interviews Dr. David W. Goodman about ADHD in older adults

, , , , , , , , , , ,

Psychiatric Times interviewed Dr. Goodman about the unrecognized prevalence of ADHD in adults over age 50. The Psychiatric Times, , a profession psychiatric print newspaper, is  distributed to 30, 000 U.S. psychiatrists. You can listen to the concise 6 minute interview and learn more about ADHD that persists throughout one ‘s life. While the challenges of life change at different developmental phases (school, college, first job, marriage, children, job changes/promotions), ADHD symptoms persist to an impairing degree for 60% of children with ADHD.

The impact of untreated ADHD later in life can have significant negative impact on your ability to effective handle daily tasks and responsibilities. In fact, no adults over age 60 diagnosed with ADHD were diagnosed as children. Makes sense since ADHD was rarely considered in the 1950s and 1960s.

Treatment seems to be effective later in life and people with chronic symptoms of ADHD should seek an evaluation with an experienced doctor or clinician. My older patients have been grateful to discover “It was ADHD, not me as a person.”

Load More