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- [00:01]
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Today, learn how to recognize adults who have ADHD and screen out those who don't.
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Welcome to the Carlat Psychiatry Podcast Keeping psychiatry honest since 2003.
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I'm Chris Akin, the editor in chief of the Carlat Psychiatry Report.
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And I'm Kelly Newsom, a psychiatric NP and a dedicated reader of every issue. Two weeks ago, the Department of Justice marked an historic first the criminal prosecution of a telehealth practice, Don Health for unlawful drug distribution of stimulants. At the core of the case is an accusation that we all ought to pay attention to prescribing stimulants without a legitimate medical reason. According to the doj, Dunn Health fabricated ADHD symptoms to justify the scripts. That kind of behavior is never okay, but where do we draw the line with off label use? Today we'll look at one of the most common forms of off label stimulant use, adult onset adhd, that is symptoms of ADHD that begin in adulthood. But first, a preview of the CME quiz for this episode. You'll find the link to the CME quiz in the show notes and the answer in the research update at the end of this episode. In a new meta analysis, which medication led to the most weight loss when added to an antipsychotic? A Metformin B Exenatide C Melatonin D Semaglutide. A 43 year old woman presents to you for an ADHD evaluation. She says her brain is overloaded, she can't complete tasks or organize her thoughts. There's so much mental noise that I can't fall asleep at night. She did well in school, but looking back she thinks she could have done better. I compensated well back then, but I haven't been able to compensate since I got promoted to regional manager. She is not impulsive, she is not hyperactive, but she uses a lot of social media and wishes she could cut back. Six years ago she went through surgical menopause after developing ovarian cancer.
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This patient has ADHD symptoms, but does she have adhd? She might have had some attention problems in her early years, but not the full spectrum of ADHD symptoms back then. And she never had impairment until she presents now in middle age.
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Yes, but I'm looking at the DSM criteria and they don't actually require impairment as a child. There just needs to be impairment when they present, which can be as teens or adults.
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You've hit there on one of the biggest controversies in DSM 5's revision of the ADHD criteria. First they move the age of onset from a requirement of 7 years to 12 years. They based this on a single study of 68 children that showed that shifting the onset to 12 wouldn't change the prevalence much. Next, they eliminated the need for impairment in childhood as long as they have impairment when presenting as teens or adults. This change was not based on research, but it was based on an idea that ADHD affects people with all levels of IQ and family supports. We spoke with Xavier Castanalos, vice chair of the DSM Committee on ADHD back in DSM 5, and he explained it this. The change is to allow for cases in which the impairment only becomes problematic when the situational demands exceed the individual's ability. Here's how that looks in practice. Imagine a very intelligent patient who eased through elementary school with good grades, but they didn't really live up to their potential. And the report cards are filled with comments about their inconsistencies, distraction and missing deadlines. This child may not have had impairment until the courses got more difficult, say in high school, college, or maybe even in law school.
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But somehow I don't think this patient is what they had in mind. She didn't have trouble until she got promoted at the age of 43. And that was after surgical menopause and chemotherapy. Maybe the DSM should have kept the age where impairment began like somewhere in their schooling. Otherwise the impairment could just be the result of an abusive boss or a competitive work environment or the PETA principle. The PETA principle.
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That's the idea that every employee tends to rise to their level of incompetence. It was laid out in a 1969 book by Lawrence Peter, and it's a criticism of the competitive hierarchical work structures we have in the US suggesting that given time, most job positions are going to be held by people who aren't competent to do them as they rise to their level of incompetence. Let's look at our patient. She did well in school, did well in high school, even did a two year postgraduate program in management. When she went to work for a large law firm, she successfully managed the HR department, did so well that she was promoted to manage a single office location. She succeeded at that and then was promoted to regional manager. And that's where she reached her maximum level of competence. And that's where things started to fall apart.
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Okay, and let's not forget the corollary, the polar principle. It holds that women often work at levels far below their ability because they are less likely to get promoted than men. We see it play out in movies like hidden figures Working Girl and Erin Brockovich. And we see it in real life.
- [06:16]
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Yes, there's a lot of Paulas covering for the incompetent Peters out there. So with these new job demands, they this is the first time our patient has had impairment from adhd. And besides the new job, there's early menopause, sleep problems and excessive social media use, possibly even inflammation from the cancer. All of these can cause inattention. As she looks back, she's likely to see some problems with her attention in her school days. But who didn't daydream in class sometimes? Who didn't struggle with at least one subject, like. Like foreign language or math? By requiring nothing more than several ADHD symptoms before age 12 and no impairment, the DSM has left us with a lot of Liberties here.
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In 2019, researchers in Australia published a criticism of these changes. In it, they cited new studies suggesting the prevalence does go up when the age criteria is loosened. For example, raising the diagnostic rate by 65%. In a study of college students a few months later, Rathia Ha started Dunn, a company that would raise the prevalence of ADHD even further and threatened to bring down the ADHD field in the process causing shortages of stimulants, scrutiny from the government, and attrition of public trust.
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Dunn spent $40 million on social media advertisements that suggested people can have ADHD without any impairment. Like this young woman who has enough executive functioning to manage her symptoms.
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I have adhd, but most people wouldn't know that because I still get good grades. I've developed a bunch of systems over the years to not let it get
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in my way or this testimony. Listen closely. It sounds like he had great attention as a young child.
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It has absolutely improved my life. I have so much control. I feel incredible. My attention to detail is back to what it once was when I was a young student. So this is just absolutely. It's just an incredible feeling. I was scared at first, but now I'm so glad that I did it. I'm so glad that I know the people at Dunn. I have a great open line of communication with them. It feels like family.
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DSM may have blurred the lines in their criteria, but the text of the book still maintains that ADHD is a disorder that begins in early childhood. That is, it is neurodevelopmental. They allow a cutoff at age 12, not because the disorder begins that late, but because of difficulties in establishing precise childhood onset retrospectively.
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The idea behind adult ADHD did not come from people who were stressed out and sleep deprived and suddenly unable to concentrate in middle age, it grew out of an awareness that many children with ADHD continue to have symptoms into adulthood. Here's a brief history.
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1968 the diagnosis first appears in DSM 2 as hyperkinetic reaction of childhood, emphasizing hyperactive symptoms that usually diminishes by adolescence. 1980 DSM III changed the name to Attention Deficit Disorder. The new focus on inattentive symptoms sparks greater recognition of adult cases as the hyperactive, impulsive symptoms tend to fade with time. Girls too, gain greater recognition as they too have fewer hyperactive symptoms.
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Meanwhile, researchers were following hyperactive Gen X boys into their teens and adulthood, and by the mid-1990s the results started coming out. Around 40 to 60% of them continued to struggle with ADHD into their adulthood, which in these studies is age 25. Most of this research came from Paul Wenders at University of Utah and Joe Biederman at Mass General, but not all studies supported it. In Long Island, Salvador Manuza and colleagues found only 4% of hyperactive boys continued to have ADHD by their mid-20s.
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For many adults, the symptoms continued at a milder level that didn't meet the full ADHD criteria, and the hyperactive symptoms quieted down. But one thing was ADHD did not get worse in adulthood the way we'd expect bipolar or schizophrenia to. So if your patient says their cognition was much sharper in their youth, look for a different diagnosis. And this is why DSM 5's decision to drop the requirement for childhood impairment is so controversial. It means that people who were not impaired in childhood but now come in as adults with major cognitive problems can still meet criteria. Sure, they may meet criteria, but how often are we overlooking the effects of sleep deprivation, drug use, concussions, or sleep apnea? Just that one sleep apnea, we find in 30 to 50% of adults with ADHD.
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Adult ADHD is not just about cognitive problems. Paul Winder's criteria required symptoms of emotional swings, hot temper, stress, intolerance, or impulsivity. By the mid-2000s, the controversy over adult ADHD was largely settled. The FDA had approved the first stimulant for adults, Adderall XR, in 2004, and two years later, Steven Ferrone and colleagues pulled together the research in a sweeping meta analysis that showed ADHD dampens down in adulthood but still persists by age 25. 15% of children still meet the full diagnostic criteria, and another 40 to 50% don't meet the full symptom count but still have impairment seven years later. Now to 2013 DSM 5 would lower the number of required symptoms in adults. So today those figures might look a little different. We're going to continue this series next week with more updates on new research questioning whether ADHD can start in adulthood.
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Today's research update looks at what to do about antipsychotic weight gain. A network meta analysis by Nicolette Stojgius and colleagues in JAMA Psychiatry.
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Their team pooled 95 randomized trials of nearly 6,000 patients, testing 39 different drugs against placebo. Most of these trials ran for under
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six months and the results Semaglutide came out on top with almost 11 kg or 24 pounds more weight loss than placebo. Liraglutide came next at around 12 pounds. Topiramate and metformin nearly tied at around 9 pounds, followed by the GLP1 exenatide about 7 pounds.
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Missing from the analysis was tirzepatide. This GLP1 has the most weight loss overall, but it just hasn't been tested much. With antipsychotics, meta analyses often get tripped up on these trivial points, causing them to miss the forest for the trees. In the data at hand, semaglutide and metformin were the only drugs that got a meaningful share of patients down 5% or more in their body weight. A few other drugs, like switching to aripiprazole or adding ramelteon or nizonidine showed some signal too, but the evidence there was less robust. Metformin also improves triglycerides, insulin sensitivity and prolactin on antipsychotics.
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Ramelteon for weight loss? Yes, that's the Melatonin agonist sleep medicine Melatonin causes weight loss by improving insulin sensitivity and shifting the body from fat storage to fat breakdown mode. Another analysis came out this month looking at supplements for antipsychotic weight loss. Here the research is, well, thinner, but too stood out as replicated in multiple placebo controlled trials. Melatonin 3-5mg at night and a probiotic with a prebiotic. The Carlap Medication Factbook is our best selling book. But it's not just a book anymore. The new edition, updated for 2026, comes with a new bundle of AI and digital tools, including our popular Carlat Psychiatry Toolkit app and the new Ask Corlat AI. Clinicians can get the medication facts they need quickly and easily. Dani Karlat calls it their best deal in psychiatry.