This trend alarms experts, who worry adults might be seeking prescriptions in cases where pills could cause more harm than good. Dr. Mark Stein a professor of psychiatry and pediatrics at University of Washington, said medication is not always necessary.
“Everybody has symptoms of ADHD, but that doesn't mean you have ADHD,” Stein said. “ADHD is a disorder characterized by having symptoms causing you difficulties in life. You can have a short attention span, you can fidget, and you can talk a lot, but unless it’s causing you difficulty, that’s not a disorder requiring medication.”
While Adderall/generic equivalent medication can be used off label to treat a variety of psychiatric and neurological disorders, many providers say ADHD patients could benefit from more coordination with primary care providers.
Stein said with digital mental health, patients with milder or sub-threshold ADHD are more likely to be treated. The downstream effect, he said, is that people with a more severe case of ADHD are less likely to be treated with medication because doctors are hesitant of abuse.
Experts say that the quality of digitally enabled ADHD assessments should be called into question because of discrepancies between diagnosis and those who have Adderall prescriptions.
“Looking at the numbers it’s just hard to believe that the observed rate of increase doesn’t involve some amount of misdiagnosis or over-treatment,” said Alli Oakes, a health services researcher at Trilliant.
Aaron Dodini, a therapist and ADHD specialist in Arlington, Virginia, said that while digital health services have increased accessibility, some companies are using subpar ADHD assessments to fast-track patients into medications.
“We need a standard of care that uses robust, objective measures,” Dodini said. “There’s a lot more accessibility and that’s a great thing, but we also need to have responsible ways of evaluating ADHD and do more wraparound services. It can’t be a self-reported ADHD test that you can do online for 10 minutes and then get a script.”
Dodini said the companies that act more like tech companies than healthcare companies are more likely to be the culprits of this trend.
While Dodini didn’t mention Cerebral by name, the company is being scrutinized and investigated by the federal government for its ADHD medication prescribing tactics. In response, the company said it was going to stop prescribing controlled substances for ADHD, including Adderall.
Prior to that announcement, Cerebral and another company, Done Health, were criticized for their quick evaluations of patients seeking ADHD medication. One report said the companies spent 30 minutes evaluating patients before prescribing medication.
“When there aren’t safeguards to protect patients, it’s easy to get in trouble,” Dodini said. He added that ADHD medications are “safe and viable” when a patient has established a relationship with the treatment team.
What can be done
The proliferation and ease of access ushered in by digital health innovation can be blamed, in part, on the increase. However, it’s not the only factor at play. Stein said diagnosing patients with ADHD becomes more difficult as they age.
“The farther you get from a young child, the more complicated it gets,” Stein said. “The diagnosis is not as simple as it sounds.”
Regardless, experts say solutions should be in place to prevent a gaming of the system through digital platforms.
“Increased access is absolutely a good thing and something we should be working toward,” Oakes said. “But we want to make sure that patients are getting evidence based and high-value care via those different and new channels.”
Stein said creating models that reward value-based care and increase integration between primary care and specialists is a good head start. Too often, he said, practices and providers do not have the skills to accurately diagnose patients.
Dodini said that all third-party payers should cover ADHD assessments. He said that the cost of these tests can be up to $4,000, which means patients are often left with no other alternative than to find easier ways to gain access to medications if they are underinsured.
While effective treatments have been around for a long time, Stein said systems of care aren’t working for patients.
“I think it’s a minority of patients that are winning, but many are losing,” Stein said, “ADHD is a disorder that we know a lot about. It’s been around a long time; we have effective treatments. So, this should be low hanging fruit, to be developing an effective system that helps patients and providers. It’s just frustrating that we haven’t moved a little bit faster.”
