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Ron Sterling MD's avatar

Hi Dr. Aftab: Thank you for posting this. I am hesitant to go too far back in a writer's archives, since commenting on older posts seems to invite very few, if any, responses or further discussion. I am reposting similar comments I made earlier with edits appropriate for here.

I am assuming, maybe incorrectly, that the P.S. part of the post is speaking directly to my wanting to be clear about certain aspects of one of your recent posts. I think you made it clear in the PS section for sure.

I think this post hits all the right notes. I went back and read your earlier post on Treatment Related Suicidality. I will comment on it there, and copy to notes so that it may be noticed, since it was a much older post. From my first scan of it, it looks like it significantly speaks to the right concerns, mostly because you are clearly able to formulate the right questions, among other things. In addition, it would unforgivable of me not to say "Your analysis and writing is easily in the top five of any writing by a psychiatrist that I have ever read."

My conclusions as noted below come from over 15 years of an intense dive into diagnosing and treating ADHD in adults who were trying to figure out what the heck was going on with them. A large majority of them were unevaluated for, or even apprised of, ADHD when put on SSRIs for panic, anxiety, agoraphobia, OCD, and depression, among other things.

My early observations led me to doing 3 hour evaluations of new clients, utilizing my own diagnostic evaluation checklists and insisting that new clients bring along someone who would be willing to corroborate or clarify the self reporting of the person being evaluated (a child, sibling, parent, good friend or several members of a family). I have an observational and recorded database that includes more than 300 clients. I also used a standardized method for testing working memory at baseline and during treatment, which consisted of what the literature says is the most useful, cost-effective way to assess working memory capacity -- a reverse digit span protocol.

From all of my observations, research and reading, it seems that working memory at baseline (meaning non-threat scenario) is a valid proxy for understanding what I would call the main vulnerability indicator for possible manifestation of ADHD characteristics. I use the term "free roaming dopamine" to stand for "tonic dopamine," as opposed to synaptic or phasic dopamine. Although phasic may contribute a bit to working memory capabilities, the literature is more than clear about the connection between "tonic" and working memory operations.

Threat scenarios increase tonic dopamine, and, thus, you could say "threats treat poor working memory," and thus, treats the major variable in the manifestation of ADHD characteristics. A large part of my 2013 book discusses my findings related to the "upside" of the ADHD brainset – threat response capabilities. Non-ADHDers (good working memory) aren't so good at threat response due to tonic dopamine quickly accelerating to above optimal, which degrades working memory (the upside-down U shaped curve), among other non-helpful actions.

My data showed that 90% of about 35 TRD diagnosed patients fit or did fit the criteria for the diagnosis of ADHD, but had not been evaluated or diagnosed for ADHD. Twelve of those had received a course of treatment that included a series of increasing dosages of an SSRI, then an "augmentation" medication (usually olanzepine, but also aripiprazole) and then ECT. They clearly fit the criteria for ADHD, but had never been evaluated, or even apprised of the possibility.

A similar set of percentages of undiagnosed ADHD was also found to be true with respect to patients who had been diagnosed with panic and anxiety disorders. Much larger percentages existed for undiagnosed ADHD in OCD, hoarding, AUD, SUD, binge drinking or eating, bulemia, tobacco use disorder, fibromyalgia, etc. In my book, I set out a table showing 25 different disorder types which have been studied for the co-existence of, or the missed diagnosis, of ADHD.

My experience and ongoing studies of the best ways to assess and treat adult ADHD clearly shows TRD and other "sickening" effects of missed diagnosis and mistreatment of such undiagnosed ADHD with SSRIs happens all of the time.

There are few published studies about the prevalence of undiagnosed and untreated ADHD among diagnosed anxiety disorders (including panic disorders and PTSD in a couple of studies) is around 38%. Interestingly, that is close to the same percentage of undiagnosed ADHD found in a more recent TRD study.

Biases are so programmed that docs learn to find ways around even attempting an evaluation which could lead to first line treatment with a so-called "stimulant." Clearly, the influence of what constitutes first line treatment for ADHD, a "stimulant," is a huge obstacle to considering the diagnosis. I call it "comfort-zone prescribing." Being diagnosed with ADHD carries almost no stigma these days. It has been normalized to the extent that it is now "okay." However, the first line treatments have been demonized and carry more stigma than the diagnosis, by far.

You have covered that issue in this post.

The language needs to change before docs will ever get scientific about ADHD and its treatment, rather than engage in emotional responses based on repeated misinformation based on even more biased statements from past, outdated, science. Such a nomenclature using "stimulant" (a side effect) is tantamount to categorizing ibuprofen as a "kidney damage pill."

Until the terminology changes to, let's say, "dopamine enhancers" or "norepinephrine enhancers" or "combined DA/NE enhancers," the clearly almost unalterable highly-programmed response to the term "stimulant" will rule. Not to mention how calling a category of medications "stimulant" is great advertising for encouraging diversion. I mean, come on….

Enough data exists, but clearly more studies are needed on the downside of SSRIs that decrease dopamine dependent working memory functionality. The studies exist. The observations are huge. And, why is it not being studied more intensely?

Suboptimal working memory at baseline (non-threat scenarios) is the common denominator to 90% of the downside characteristics of what we currently call ADHD.

Decreasing working memory below an already low baseline dopamine dependent working memory with an SSRI will create the perfect storm for an ongoing depression with ever more cognitive downsides as the SSRIs and antipsychotics continue the downward spiral, until? Until the patient with the undiagnosed ADHD finally receives a dopamine enhancer (TMS, ECT, ketamine).

This same perfect storm can increase suicidality in those undiagnosed for ADHD presenting as anxiety or depressive disorders. By depressing working memory and other cognitive corollaries with SSRIs, what do you get? Less able to think twice, more forgetful, distracted, more impulsive, impatient, frustrated, fuzzy, less fearful (more risk capable), in addition to likely feeling weird and sickly, not to mention the resulting loss of hope.

I am hoping that you will read my book to get most of the full story. It is still ahead of its time. I will bet good money that you will find it more than a little interesting.

Thank you again for your excellent work and best wishes. Hope we can continue to discuss.

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Sofia Jeppsson's avatar

This is another problem with medically assisted suicide.

I used to be all for it. I even thought it was obvious that we should have it. But it's because I used to buy into the lie that the value of human life is SOOOOO deeply entrenched in modern society that we naturally have a VERY strong resistance towards deliberate killing (at least in the kind of calm, cool-head atmosphere in which medical decisions are allegedly made).

But look at how much medically assisted suicide tends to expand once it's introduced. Look at all the testimonies coming from Canada, of people who's faced pressure from clinicians and care workers to "choose" death. Of people who's received the message, in no uncertain terms, that their lives aren't worth living, they should just die already.

I still think there's a strong case to be made that people should be allowed to choose, e.g., death by meds instead of death by suffocation if they have something like ALS. And I understand the argument that death by meds is better for depressed people than suicide BUT.

BUT.

Even though it's logically possible to do all we can to treat people, while also allowing them medically assisted suicide, this is not how real life works. Once a condition has been placed in the box of "if you have this, it's only rational to want to die", once clinicians regard this condition as something for which we DO have ONE treatment, namely death, that's gonna make a big difference to whether people still think it's worth the time and effort and money to find an actual treatment.

(I'm not sure what I think of Alexandre Bareil's radical ideas, but they're very different from looking at a bunch of specific conditions and go "when you've got one of THESE - and in particular if you're also poor and marginalized - it's only rational to die, would be kinda weird for you to stay alive".)

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