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Explore the complexities of adult ADHD with Muhamad Aly Rifai, a practicing internist and psychiatrist. This episode dives into the evolving understanding of ADHD as a lifelong disorder, the stigma surrounding diagnosis and treatment, regulatory challenges limiting access to care, and innovative approaches to managing symptoms. Join us for an insightful conversation on how clinicians, patients, and policymakers can work together to optimize ADHD treatment.
Muhamad Aly Rifai is a practicing internist and psychiatrist in the Greater Lehigh Valley, Pennsylvania.
He discusses the KevinMD article, “Why ADHD in adults is more common than you think.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Muhamad Aly Rifai. He’s an internal medicine physician and psychiatrist. Today’s KevinMD article is “Why ADHD in Adults Is More Common Than You Think.” Muhamad, welcome back to the show.
Muhamad Aly Rifai: Thank you for having me to talk about attention deficit hyperactivity disorder, ADHD.
Kevin Pho: All right, let’s jump straight into this article. Tell us what it’s about for those who didn’t get a chance to read it.
Muhamad Aly Rifai: Sure. So, over the past few years, we have seen a significant focus on the topic of attention deficit hyperactivity disorder. It’s a disease that starts in childhood and progresses through adulthood. Now, a lot of people don’t know, but it is one of the three or four most common psychiatric illnesses, along with depression and anxiety. ADHD is either number three or four, depending on how you look at it, so it’s quite a common illness.
The past few years have really brought in some interesting phenomena. We have seen actually a doubling or even tripling of the rates of diagnosis of new ADHD cases in adults, even in children. Some of that started with the COVID pandemic, and we are starting to explore that phenomenon. But that has created an avalanche of different issues for individuals who have ADHD.
It’s a disease that impacts attention, concentration, and most importantly, executive functioning. So people who have ADHD have problems with executive functioning, have problems with activities of daily living, and that impacts them significantly. It is a disabling condition that, if not treated, can affect a person significantly. So, we are seeing an avalanche of new cases happening, and we have some explanations of why we think that is happening. But that has been coupled with some unfortunate responses from the different health care agencies in the country in terms of availability of medications, in terms of the diagnosis, and in terms of the ability of physicians to treat these patients who have this disabling attention deficit hyperactivity disorder.
Kevin Pho: Now, let’s talk about adult ADHD. How does one go about diagnosing that?
Muhamad Aly Rifai: Sure. So, adult attention deficit disorder is a disease that starts in childhood. There are no cases that just an adult only develops ADHD. ADHD is a neurodevelopmental disorder. The brains of individuals who have ADHD are different than individuals who don’t have ADHD. There are changes in the structure of the prefrontal cortex, there are changes in neurotransmitter levels (dopamine and norepinephrine) in the brain, and the brain connections are different between different parts of the brain, including between the prefrontal cortex, the basal ganglia, and the reticular activating system. So, the brain of individuals with ADHD is different.
Individuals with ADHD, when they’re diagnosed in childhood, there’s a wide range of severity of this condition. Some mild cases, as well as moderate cases, could be managed just with behavioral management and coping skills—psychotherapy, increased exercise, changes in diet—and some severe cases require medications. The medications are either stimulants for ADHD or non-stimulants, and there are very few non-stimulants. There are a lot of stimulants, and stimulants are controlled substances. They’re Schedule II controlled substances under the Controlled Substances Act.
As people get older, there are some individuals—young individuals—who may be able to outgrow their ADHD, but it’s still a disease that is still there. They’re able to develop coping skills. They’re able to, like individuals who have a stroke, retrain themselves, create different neuronal functions, and manage their ADHD OK. There may be individuals who may not be able to do that development, and they will require medication into adulthood.
The diagnosis is a clinical diagnosis, but there is available testing—neuropsychological testing or computerized testing—that may aid the physician in terms of making the diagnosis. But the psychiatrist has to do an extensive inquiry into the symptoms, family history, etc., interview other family members, as well as conduct neuropsychological testing or computerized testing to confirm the diagnosis of attention deficit hyperactivity disorder.
Kevin Pho: So tell me, what type of symptoms should I look out for in my exam room, in my primary care office, that may potentially lead me to think of an ADHD diagnosis?
Muhamad Aly Rifai: Sure, sure. So, individuals who have an ADHD diagnosis have mostly problems with attention, focus, and concentration, as well as hyperactivity. Most adults outgrow hyperactivity. Now, we as psychiatrists see a lot of adult patients who continue to have hyperactivity, who are evident as soon as they come into the exam room that they have a hyperactivity component of ADHD. Most adults will have problems with attention, focus, concentration, and executive functioning, and those manifest as usual symptoms: They can’t focus and concentrate on things, they have to write lists, they are forgetful, they lose objects—we talk about losing objects as one of the “soft signs” that people don’t ask about. One of my most severe cases, a patient lost their cell phone 27 times. They had to replace their phone 27 times because they lost it.
So, there are some signs that you can ask about. One of the most important things is interviewing and discussing with the patient’s family—parents, mother and father—was this person, as a child, hyperactive or did they have problems with attention, focus, and concentration, as well as talking with other family members. Then testing is something you can do to ascertain the ADHD diagnosis. But it’s a clinical diagnosis supplemented by testing—neuropsychological testing or computerized testing—to confirm the diagnosis.
Kevin Pho: You mentioned that the diagnosis frequency of ADHD has been increasing, and you talked about there are some reasons for that. So let’s get into that. Why do you think the diagnosis is increasing?
Muhamad Aly Rifai: So, our data about the prevalence of attention deficit hyperactivity disorder dates back to 1990, the Epidemiological Catchment Area study that the National Institute of Health conducted, and the prevalence of ADHD was pretty low. It was between two to three percent; at maximum, it was around three to five percent lifetime prevalence for individuals. But what happened is—and what we think happened—is that, that estimation underestimated the moderate cases or the cases that were not severe, so it only diagnosed severe cases.
What happened is, with the COVID pandemic, with the lockdowns, there was a significant increase in the demands of attention and focus. With the lockdowns, there was the disappearance of a daily routine for individuals. There was the lack of possibility for daily exercise that people were able to do to cope with their ADHD. So, we saw an explosion of new cases of ADHD. Now, a lot of the health care agencies as well as the regulatory agencies—such as the Drug Enforcement Agency—thought that this explosion was just related to individuals who were seeking stimulants for recreational purposes, and not an actual explosion of ADHD cases.
What we know now from literature from Scandinavian countries—for example, in Finland and Sweden—is that they have seen the same phenomenon: two to three times more new ADHD cases. New Zealand: two to three times more ADHD cases. So, that actually goes well with what we’re seeing here in the United States, that there’s an explosion of ADHD cases. Now, we’re seeing the lifetime prevalence may be as high as five to ten percent of ADHD.
Now, that was coupled also with the fact that during the COVID pandemic, there was a disruption in supply chain, and there was a reduction in the ability to manufacture controlled substances for ADHD. So, the Food and Drug Administration declared that they had a shortage of medications, plus the pressure from the Drug Enforcement Agencies on physicians not to diagnose ADHD. Then the Department of Justice rushed and started indicting and charging physicians and companies that treat ADHD, and we just have a recipe for disaster for individuals who have ADHD.
Kevin Pho: So talk more about that. You said that there is a movement in government agencies to suppress the diagnosis of ADHD because of the potential to prescribe stimulant medications.
Muhamad Aly Rifai: Yes. So, basically the thought is that this explosion or increase in the rates of ADHD cases was mostly individuals who were seeking ADHD medications for recreational purposes. The regulatory agencies basically use the analogy of antibiotic stewardship, that physicians were supposed to be very selective in who gets prescribed ADHD medications because of the fear of inducing a wave of stimulant use disorder, similar to what happened when physicians were treating individuals with pain with opiates.
So, the regulatory agencies were worried that this would be a similar situation, that you’re going to have a wave of stimulant abuse disorder in individuals who may not have ADHD and sought treatment for ADHD just to obtain stimulants, while in reality, many of those individuals have legitimate ADHD that was mild or moderate and only surfaced during the COVID pandemic because they lost their coping skills. As well as what we think now is that COVID, as a virus that may cross the blood-brain barrier, may have caused brain damage and severed some of the neuronal functions that people were able to develop to cope with their ADHD.
Kevin Pho: Now, how are they trying to suppress these diagnoses?
Muhamad Aly Rifai: In terms of scaring physicians not to deal with individuals who have ADHD. So, prosecuting physicians, prosecuting… there are several companies that are under the interest and attention of the Department of Justice for treating ADHD, which scares the regular physician who is in their office seeing individuals with ADHD. They either refer them to a psychiatrist or tell them that they’re not going to deal with what their patient is complaining of. So, by default, that is suppressing the diagnosis of ADHD and not allowing these individuals to seek help.
Kevin Pho: And in general, how effective are stimulant medications when it comes to ADHD treatment?
Muhamad Aly Rifai: So, stimulant medications are life-sustaining medications. They’re life-saving medications for individuals with severe ADHD. ADHD is associated with significant morbidity and mortality. Individuals who have ADHD, for example, are more prone to be involved in motor vehicle accidents, more involved in slip-and-fall accidents, more involved in other accidents. Individuals with ADHD also, if untreated, have a higher prevalence of depression and anxiety, and a higher prevalence of suicide attempts. So, we’re not talking about a disease that’s mild and has no issues. It has significant associated morbidity and mortality, and not recognizing this disease— not letting it be treated, I think, is pretty problematic.
Stimulant medications, which include controlled substances such as methylphenidate (brand name Ritalin) or salts for stimulants like Adderall, are controlled substances. They’re pretty effective in terms of reducing the intensity of ADHD symptoms. We don’t have a lot of long-term studies on what happens to individuals who are on long-term ADHD medications. Most of the studies that we have are about two or three years. We don’t know what happens in individuals who have chronic ADHD and are maintained on medications. There’s also another class of medications which are non-controlled stimulant medications. We also don’t have a lot of data in terms of studies.
So, there is a big demand for studies from research agencies such as the National Institute of Mental Health. Interestingly, I mentioned that in the article: the regulatory agencies and the National Institute of Health delegated comments about ADHD to the National Institute on Drug Abuse rather than the National Institute of Mental Health, which is quite unfortunate and kind of indicates that there’s grave concern about stimulant use disorder more than the grave concern about the severity of ADHD and its associated comorbidity and mortality.
Kevin Pho: In your article, you talk about some non-medicine treatments for ADHD. Talk about those.
Muhamad Aly Rifai: So, therapy is very important. There are several types of psychotherapy that could be helpful in individuals with ADHD. For children and adolescents, there are now several video games that are FDA-cleared, FDA-approved for the treatment of ADHD. There are several software programs that are artificial intelligence–guided that are in development for the treatment and reduction of ADHD symptoms in adults, which are in the pipeline and will probably be approved in the next few years. There are multiple other medications, newer medications that are in clinical trials—phase III clinical trials—that are probably going to be approved for ADHD that are non-controlled substances.
Kevin Pho: We’re talking to Muhamad Aly Rifai. He’s an internal medicine physician and psychiatrist. Today’s KevinMD article is “Why ADHD in Adults Is More Common Than You Think.” Muhamad, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Muhamad Aly Rifai: We have seen a significant increase in the prevalence of ADHD, so primary care doctors and psychiatrists are going to see more cases of ADHD. This is a true phenomenon related to the COVID pandemic and the change in work-life for the American population. People need to recognize ADHD, send patients for treatment, investigate it, and provide these patients with adequate treatment. These are not individuals who are seeking stimulant medications for recreational use; they have legitimate ADHD, and they need to be treated.
Kevin Pho: Thank you so much again for sharing your perspective and insight, and thanks again for coming back on the show.
