Treatment Landscape for the Management of ADHD - Episode 20
Theresa Cerulli, MD: It’s so wonderful to see the advances in the field. That said, we certainly have other challenges now, don’t we? We’re in unprecedented times. David, what advice do you have for our community physicians who are managing ADHD [attention deficit hyperactivity disorder] in the wake of the current coronavirus pandemic?
David W. Goodman, MD: COVID-19 [coronavirus disease 2019] has upset our daily functioning—the economics, the social, the work, the education. Everyone has to adjust to a new normal. As it relates to adults and even children with ADHD, the disruption in the routine becomes problematic. There is a fundamental assumption that patients with ADHD take medication for performance issues. That is, you give your medications to the children so they do better in school. You take your medicine when you go to work so you can perform better at work. And now you’re neither at school nor work, and some patients have adopted the attitude, “Well I don’t have as much to do today. I’m not sure I need to take as much medicine.” Or “I’m not sure I need to take it at all.” They disregard the social impact at home with everybody in the house.
The other aspect is with the children, if you have a child who has hyperactive and impulsive behavior and is not on medication, they’re much less likely to maintain social distance and understand what social distance means when they’re playing with other children during these particular times.
We’re highlighting for patients that routine is critical. Going to bed at the same time and waking up at the same time is recommended. We recommend few psychological changes. When you get up, and after you shave, shower, bathe, brush your teeth, and have breakfast, put on your work clothes. Don’t spend the whole day lounging around in sweatpants and a T-shirt, because your mindset won’t adapt to the fact that you need to sit down and do your work.
You may want to do the same thing with the children who might be inclined to say, “It’s a snow day, so I don’t need to get dressed.” If they get dressed as if they were going to school, it sets the mindset to the routine in the morning. And I know these sound like simple suggestions, but they actually have a tremendous impact in setting your mind for the day.
Compliance is really important. For the primary care physician or for the practitioner who is monitoring this, it is important to keep track of them. Have videoconferences, and stay in touch with them to monitor compliance and ensure they’re taking their medicine on a consistent basis.
Practitioners can do that by also checking their state prescription databases to see whether patients are filling prescriptions regularly. I think there are a variety of other issues. Let me toss it over to some of the other panelists and see what their suggestions are.
Timothy E. Wilens, MD: As the chief of a division, I’ve been monitoring telehealth carefully. What we’ve found is that our no-show rates have plummeted. We’ve had almost no no-show rates because we’re practicing telehealth. And No. 2, patient satisfaction and practitioner satisfaction is up.
We’re just slightly below where we were at a year ago when we were making people come into the hospital. So I’m a real advocate that we want this to continue, and we have to figure out a balance. What’s the best way to do it? We’re a little bit in unchartered territory.
People should know that there is a well-known NIH [National Institutes of Health] multisite study that showed telehealth worked as well or better than treatment as usual. Telehealth has been demonstrated under randomized controlled conditions to work for ADHD, and we’re all seeing it in our clinical operations.
David W. Goodman, MD: Well, that’s interesting. I routinely run 25% late on patients, yet I’m having 100% punctuality to my videoconferences, which is great. Those of us in the mental health arena have been able to move to telemedicine fairly fluidly. But we need to remember people in other areas of medicine. Approximately 55% of physicians surveyed have seen a 50% or greater drop in their patient visits. That becomes very difficult.
If you have to touch and examine patients, access to medical care is severely restricted. But I agree with Tim, and this is a wonderful thing. People who would not otherwise get access to mental health might find it much more available. In addition, there is a cost to seeing your doctor. The cost is you have to drive there, so that’s 30 or 40 minutes. You have to park. Maybe you have to pay for parking. You have to sit in the waiting room. You have to see the doctor. Then you have to drive back home. That’s half a day at minimum in expense, and that’s very expensive for people. Now that people realize that, I’m concerned that we may not go back to face-to-face meetings with a lot of patients. They’ll say, “Look, it worked just fine on the computer. Why don’t we just do that?” And we may lose something, because there is a difference between a video chat and an in-person meeting.
Andrew J. Cutler, MD: Maybe we’ll have a hybrid model. There is 1 other wrinkle to this. With stimulants, in particular, we do have to monitor cardiovascular parameters. And so we have to get creative there. I’ve actually had some patients for whom I can monitor from home. I have them check their blood pressure and pulse at home, and I document that. Or I have them go to their primary care doctor and get that information. But that’s another wrinkle to this too. You can’t really do that virtually.
Theresa Cerulli, MD: I’m curious to know more about the statistics you quoted about the improvements we’re seeing with telehealth. Was that specific to psychiatry or in general? Because as Andy is describing, we can’t touch the patients. For us, that’s required only minimally—for checking blood pressures, heart rates, and I wanted to add to that the random toxicology screens that we sometimes need to do with patients, particularly when it comes to controlled substances.
But certainly, in other areas of medicine there is a much bigger challenge regarding not being able to reach out and touch the patient. Could you clarify the statistics you gave us on improvements? Was that specific to psychiatry, regarding improvements using telehealth?
Timothy E. Wilens, MD: Yeah, so regarding the studies that were done with telehealth, the NIH multisite study was on ADHD and telehealth. They looked at both medicines and some cognitive behavioral therapy, and then they compared that with treatment as usual. It was a long-term study, so it was out to I believe a half a year. They showed initial improvements that exceeded treatment as usual.
That study was specific to ADHD. And the data I was talking about, regarding the percentage of patients who are currently being served with telehealth, are from the department of psychiatry. And as David was saying, when we look at our colleagues in other departments, it is less robust. Largely, we think it’s because of the person-to-person contact that is necessary. But being very parochial to psychiatry, I think this is a terrific opportunity, and we need to advocate. We’re going to have to continue to move forward and make things better. We need to develop better systems and determine what’s working and what’s not.
Transcript Edited for Clarity