guests to /r/Psychiatry shown their disdain for a Psychiatrist implying that an unemployed loser who watches tv all day shouldnt be taking stimulants

ive never made a post before sorry ill try my best

In outpatient practice I inherit or get a lot of new patients that were on stimulants for reported ADHD that are either retired or chronically unemployed their adult lives (many on disability for one reason or another, sometimes questionably). Obviously, many are resistant to coming off stimulants. In these scenarios I try my best to assess any ongoing necessity for this - for instance people getting in MVAs because their ADHD is do bad when unmedicated. The people I'm speaking up mostly sit at home watching TV and aren't doing anything cognitively demanding. They'll often complain of poor motivation even with stimulants. I also discuss diet, exercise, sleep schedule, and try to maximally treat psychiatric comorbidities. In my mind, potentially forgetting to finish the laundry or run an errands isn't worth the risks of taking a stimulant in perpetuity. How do you all handle this discussion? I try to give everybody a fair shake, but I'm sure my skepticism shows through in this paragraph.

I could get on my soap box about overdiagnisis and oversaturation of ADHD in the clinic setting, but I'll leave that for another time.

this was the original post, and a lot of "fellow psychiatrists" and patients chime in

for those who admit they arent a professional, i will mark them in bold

I just had 6months off work and I tried to not take my stimulants because of this type of thinking "why bother, you're not working" but turns out ADHD affects more than work !? I was frustrated and unproductive without it, unable to initiate tasks. I eat well, exercise, go to therapy blah blah blah. Your patients might need it to function at baseline.. even that boring life of watching tv, doing chores, not having anger outbursts or sensory meltdowns.

My advice would be ask for a trial of a lower dose but make them keep an activity / mood diary to track tangible difference. Or switch from long acting to short acting so they can use it for targeted activities. But also, just try ease up on the capitalist mindset that work is the only legit reason for meds.

the op replies, earning himself 9 downmarseys:

I understand where you're coming from. I've had patients and close friends that can't function daily without it. So I know it happens. Regarding jobs, I meant more from a highly cognitively demanding standpoint, not really a productivity thing. Thank you for your input!

another person replies, earning themselves 17 downmarseys

"anger outbursts or sensory meltdowns."

Anger and sensory meltdowns are not ADHD symptoms and stimulants are not the solution

to interrupt, you might be wondering why its a problem to just give someone ritalin or something forever

to keep it simple, stimulants, which are usually a form of amphetamine, put a lot more strain on our bodies cardiovascular system

long term use can eventually lead to issues with your heart

to be less medical, high doses, which are increasingly common with internet or phone doctors, can make you feel very irritated, on edge, and wired, possibly making things like anxiety much worse! it is an amphetamine after all

so someone who doesnt do anything with their life that ADHD might interfere with (i.e, being unemployed), you are just damaging their heart and their wallet slowly overtime for something with little therapeutic benefit

anyway

Assuming they stay unemployed (stimulant or not) and the stimulant improves quality of life (employed or not), I don't see the point of making this distinction apart from a moral value judgement. If the stimulant isn't helping that should be addressed but that's a separate issue from whether they're employed or not. Surely the goal is to improve quality of life, with employment hopefully being a consequence of that? Not the other way around.

unsurprisingly, a patient thinks this is a moral judgement and totally unfair

If i give a stimulant to 100 people, ADHD or not, I'd bet good money more than 90 of them would say they feel better and are more productive. It doesn't mean everyone should get adderall if they want it and feel better.

op got downmarseyd again for this

Of course, when I say improving quality of life I mean correcting the reduced quality of life caused by the disorder. Presumably the reason you prescribe stimulants to people with ADHD is because the benefits outweigh the risks for them and not the general population. Either way I don't see how your reply addresses why employment is a factor in this

a patient still doesnt understand why keeping someone on drugs forever might be a bad idea. then again, they are a 19 year old posting on drug subreddits and about adhd quite a bit so, im sure you know the kind of person they are

Your use of productivity in this way seems inconsistent with treatment standards. Is there a reason you're not examining the degree of improvement to life domains? Your proposed metric seems biased towards puritanical ideas.

When my patients talk about "not getting anything done", that counts as productivity (chores, errands). People are really trying to roast me on this $ and capitalism ideal I made no mention of. Part of my job is to minimize risk, I'm trying to do that job the best I can. That includes difficult discussions with people about controlled substances.

You didn't answer my question.

I stand by my position that you're using a puritanical lens here rather than the standard of treatment (to weigh the benefit to their life domain functioning versus the risks). Whether someone is working or not is irrelevant. Considering you based your question on something that you've failed to explain the relevance of is the basis of the judgment you're receiving, IMO.

I've explained time and time again in this thread that not all people need stimulants when they're not doing something that they need maintained attention and concentration. Examples being work and school. This has nothing to do with morals or whatever you're getting at. The standard of treatment is to balance risk/benefit. When you prescribe stimulants, how do you manage it?

"I've explained time and time again in this thread that not all people need stimulants when they're not doing something that they need maintained attention and concentration."

That is the problem. Life is dimensional, not categorical. Your thinking that someone needs stimulants (or doesn't) based on sufficiently intensive tasks completely ignores the benefits of stimulant treatment to their life domains outside of what you have judged as meeting your identified threshold.

"This has nothing to do with morals or whatever you're getting at."

I find it utterly chilling that you still have been unable to even begin to understand my point, especially considering the complete absence of attempts on your part to clarify your understanding. You don't get it and you've demonstrated no interest in changing that. You seem utterly emblematic of paternalistic medicine.

Learn more about the ADHD experience. You're overly invested in your own viewpoint. I'm signing off of this conversation. Good luck.

by the way this guy prescibes adderall to a guy who smokes weed daily so

op tries one final riposte, but the downmarseys are too strong:

I'm talking about having a discussion with patients about why they may or may not still need their meds after a dramatic change in lifestyle. If you think that doesn't warrant a discussion about medications, you're mistaken. Yes, I use my judgment and my thresholds to prescribe. That's how my job works. If I left my prescribing entirely up to my patients, I'd be really bad at my job. Adderall and Xanax for everyone!

almost the entire thread is against OP here, and seem to think those with ADHD are some sacred cow you dare not deny their meth

You're fixing something that isn't broken.

I used to think when I was a younger psychiatrist that people who are unemployed or don't have a job should not be prescribed medication for ADHD. Don't they just sit around all day? But I started looking at each case with more nuance.

Sometimes, these people with ADHD, although unemployed or retired, have significant problems with irritability, insomnia, and are at higher risk of abuse of substances when they are not receiving treatment. Forgetting all their grandkids, kids, and spouses birthdays and anniversaries and forgetting important medical appointments also can cause them significant problems in their lives.

TLDR: If the patient's social or occupational functioning is impaired, I treat ADHD, whether they have a job or are in school or not.

when you cant eat or brush your teeth because you dont have your meth

this reply annoys me a little specifically, its really common with ADHD discussion online to mention 'irritability' being common with ADHD sufferers (it sort of is), and that stimulants will somehow improve that situation

it can quite often do the opposite! adverse affects are so commonly ignored in discussions and even by those that prescribe it themselves

common sense would tell you this but its controversial at this point to believe it might not be some miracle drug for every problem in someones life when they have some level of executive dysfunction

The idea that you need to be producing value for share-holders in order to earn treatment for your mental health problem is a very dystopian take, IMO.

What an unhinged comment. Productivity does mean making money. It can be chores and errands. Many people can manage fine without stimulants when not working or in school. I'm not talking about their contribution to society. I wanted to know how other mental health professionals approach this. I don't know what's with these capitalism witch hunt comments. We have a duty to assess risk/benefit. That's all

ADHD impacts many areas of life, even in patients who are not working. If you explain the risks and benefits, and they want to continue, why fight them? It seems like you're assuming that this particular patient population has the same values as you do, which is probably not the case. Your job is to treat illness and reduce suffering, not to be a stimulant cop.

stimulant cops

there is a bit more in the thread, and more comments rolling in because its a fairly fresh thread, these discussions often go this way online about ADHD

this is my first post i hope i did it right thanks for reading