Program avoids stimulant medications when possible

Host Amber Smith: Some people with ADHD are not diagnosed until adulthood, when they struggle with impulsiveness, restlessness or difficulty paying attention. Upstate now offers a program specifically for adults with attention-deficit/hyperactivity disorder, and today I am talking with the person who oversees that program, John Ringhisen. He's a nurse practitioner of psychiatry and behavioral sciences and a member of the Pharmaceutical Subcommittee of the U.S. Guidelines Task Force for Adult ADHD through the American Professional Society of ADHD and Related Disorders.

Welcome back to "The Informed Patient," Mr. Ringhisen.

John Ringhisen, NP: I appreciate the invitation. It's good to see you again, Amber.

Host Amber Smith: Let's start with a description of ADHD. Is this a mental health disorder or a physical disorder?

John Ringhisen, NP: It's a mental health disorder. Attention-deficit/hyperactivity disorder is a cluster of persistent behaviors that make completing tests difficult and generally fall into two broad categories.

You have either trouble remaining focused, or you have trouble remaining still.

Host Amber Smith: So how does it manifest in adults, compared with kids?

John Ringhisen, NP: In adults, it usually starts to manifest where people start really struggling professionally. That's where they usually see it first. They have difficulty at work completing tasks, or they have difficulty in the home, if the home is the profession, with staying on top of appointments or staying on time on a task in the home, to where simple tasks like laundry or cleaning dishes or taking care of children starts to pile up on people and starts to feel very overwhelming to people. The amount of time to get tasks done seems much longer than what it should be.

And that often starts impacting how they see themselves or how they see their performance.

Host Amber Smith: Do most adults who have ADHD, do they develop this as adults, or is this something that they probably had, and it went undiagnosed throughout childhood?

John Ringhisen, NP: There's a lot of research out there that's really trying to come to a succinct answer on that because the answer's probably somewhere in the middle. It's both. There are some individuals that possibly do start to exhibit symptoms later in life. And there are individuals that, because of either lack of resources or lack of being engaged with a mental health provider when they were younger, typically through the school system, they weren't picked up as ADHD when they were going to school, or maybe they left school early and for whatever reasons that they had to, and so they never been engaged with anybody in a capacity to be able to determine whether they have ADHD.

Host Amber Smith: What's the oldest age person that you've seen diagnosed with ADHD?

John Ringhisen, NP: The oldest in our clinic that came in diagnosis-free (undiagnosed) was a gentleman that was 57 years old, and we do have individuals that have been previously diagnosed, either in childhood or even in middle adulthood, that are continuing in our clinic, that are well into their 60s and retirement age.

Host Amber Smith: How likely is it if an adult who feels like they have trouble focusing actually has ADHD? Because it seems like maybe there's some symptoms that could be ADHD, but maybe they're not.

John Ringhisen, NP: Yeah, that's what makes an ADHD diagnosis very tricky. Things like depression, anxiety and other things that we struggle with in daily life. Trauma and some people's personalities can start to look like ADHD. For example, with anxiety, you just have to really dig into why you're so distracted, or what's the root cause of what pulls you away from being able to focus on things.

Because if it's your anxiety getting the better of you because you have intrusive thoughts, possibly from trauma, or you're persistently worried about things that are overwhelming you in your daily life, the distraction is more a step to, or result of, being very anxious. And it presents like ADHD, but it's not truly related to being an ADHD diagnosis, and similar things can happen with depression as well.

Host Amber Smith: So let's talk about how an adult typically gets diagnosed, and the program that you oversee, do people come there already diagnosed, or do they come to you to potentially be diagnosed?

John Ringhisen, NP: Both. And we go through an extensive screening process, where there's a survey item, where it's a self-assessment. So that means that it's a document that we give the patient in the waiting room, and they fill it out, assessing themselves on a lot of the symptoms and some of the behaviors and some other questions that we ask that give us a sense of whether ADHD might be something that we would suspect in the individual.

We also encourage people to consider bringing a support person because a lot of times with adults, being able to assess themselves is difficult. And so having a spouse, a friend, a loved one who knows you well and that you would trust having present at your appointment is helpful in getting some of the collaborative, meaning the people around you's, opinions of kind of how you're presenting.

A real good example of this is one of the questions it asks is, "Do you often interrupt people, or do you often find yourself shifting topics quickly during conversation?"

If you do that as part of your natural conversation style, you might rate yourself very high. Or there's some people that underscore themselves, and then their wife kind of nudges them and says, "You interrupt me all the time."

And so it becomes, a bit of a laughing point and breaks the tension in the initial interview. But what we're trying to get at is what's happening around the individual, how is your environment reacting to your possibly having a true ADHD diagnosis. And how your environment reacts to you is very important in being able to accurately diagnose ADHD.

Host Amber Smith: So it sounds like it is challenging, or could be challenging, to diagnose this. There's not a blood test, there's not some medical test that would tell you whether someone has this or not.

John Ringhisen, NP: Correct. And there is what's called neuropsychological testing that a lot of people put a lot of faith in when it comes to "Can I go someplace and do a one-stop test that will tell me whether I have ADHD or not?"

And it's dubious because what neuropsychological testing really tells us is how severe are your symptoms, and do you have symptoms, and how much are your symptoms impacting your ability to function in your daily life?

It doesn't really get into causality, as to what's making those things happen and why you're struggling so much, and that's why it's very important to have conversation with a mental health professional and sit down and interpret those test results to see if an ADHD diagnosis is appropriate.

Host Amber Smith: This Is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with John Ringhisen, a nurse practitioner of psychiatry and behavioral sciences at Upstate who oversees the new adult ADHD clinic..

What does treatment for adults generally consist of?

John Ringhisen, NP: In our clinic, treatment for adults consists of a multifaceted approach.

We encourage psychotherapy, which is talking to somebody in talk therapy, working through skills and coping strategies that will increase their ability to function. We offer supportive measures at school or work, if accommodations are appropriate, particularly in academic settings. We have a lot of adult learners that come to us where they want extra time on tests, or they want a different testing environment, so we can write supportive letters to provide those kind of accommodations.

We provide medication for ADHD through our clinic. We are a full prescribing and medication management clinic. And then, we're getting into and exploring coaching. You can kind of think of these as, when we talk about substance use, we talk about peer advocates, people that have kind of "been there, done that" and that have struggled with addiction before.

We're finding individuals in the community that are becoming coaches, where they struggle with ADHD themselves. And having somebody who has experienced and overcome the struggles associated with ADHD can sometimes be helpful and supportive to somebody, particularly an adult.

Host Amber Smith: Your program focuses on a nonstimulant-first approach?

John Ringhisen, NP: Correct.

Host Amber Smith: Can you describe what that is and why it's important?

John Ringhisen, NP: What we mean by a nonstimulant-forward approach is the medications that we prescribe for ADHD are kind of broadly broken into two categories. There's the stimulants, which is what everybody's probably more accustomed to associating with ADHD medication. That's Adderall, that's Ritalin, Vyvanse, Concerta. And then there's the nonstimulant medications, clonidine, guanfacine, Qelbree (viloxazine), atomoxetine.

The reason that we focus on the nonstimulant medications is because stimulant medications are controlled substances, meaning that there's a lot of rules and regulations from the Department of Drug Enforcement and federal regulation that govern how much we can give a person at a time.

We can only provide 30 days at a time. And the reason that these medications have extra restrictions around them is because they have been associated with misuse, building up tolerance and dependence. And so they have to be very closely monitored from a health standpoint and from an addiction standpoint.

So the reason that we use a nonstimulant-first approach in my practice is to try to reduce the reliance on stimulants in the population. There's also been, and it made national news, that there was a nationwide shortage of stimulant medication, which has also kind of prompted us to try to use more nonstimulants in our patients.

And there's also good evidence where if you are a significant responder, meaning that your symptoms get better on a nonstimulant medication, you can have as good of an outcome as you will with a stimulant. Now it does take a little bit longer for the medication to take hold; it takes a few weeks, versus days with a stimulant.

But the convenience of not having to worry about constantly finding a provider, the health implications of not being on a long-term stimulant, for your heart, for your overall health, is much better. And so it's what we offer first, and particularly patients who have never been on medication before, specifically for ADHD, we put that forward as the "try this first" option.

And then, of course, if they're not a good candidate for the medication, or if they just prefer to be on a stimulant, of course the patient's decision is going to be what ultimately decides the treatment that we prescribe, but we try to offer the nonstimulant as the first trial of medication for patients who have never been on medication before.

Host Amber Smith: Can you explain how a stimulant would help someone who's already hyperactive?

John Ringhisen, NP: It's actually the nonstimulants that work very well for people that are hyperactive. So if moving around and holding still is where you're really struggling, stimulants oftentimes can make that worse if it's truly a hyperactive presentation of ADHD.

Now, if the reason that you're moving around a lot is because you're easily distracted, you're getting up, and you're moving around because your focus is off, then that symptom will actually improve with the stimulants.

Host Amber Smith: So this, it sounds like, is a very individualized treatment plan for each person.

John Ringhisen, NP: Correct.

We take into consideration, as nurse practitioners, a holistic approach to care. And so we take into consideration what's their work schedule, what's their outside of work schedule, what's their personal schedule, when do they need to be performing at their peak performance, or their optimum levels, so that, that way we can time when the medication is at its best. Some people need to be early risers, very effective in the morning. Other people need it later at night. We try to time that and try to individualize and customize care as best we can.

Host Amber Smith: Are there coexisting conditions that you see typically in people with ADHD?

And how would you handle other conditions that this person might have?

John Ringhisen, NP: The other conditions that a lot of people have when they present with true ADHD is there's usually depression and anxiety alongside. You have to think that these are people that have constantly been measured by how they are not performing how we expect them to in society.

And there's a lot of judgment that enters into that, so you can see where somebody can very quickly become depressed and feel like they're not adequate or doing well, or what they should be doing, or as well as they should be doing, because they're struggling with ADHD. This can also cause people to suddenly feel very overwhelmed or anxious about doing what they need to do to care for the people around them or care for themselves.

And a lot of times we see people that have unfortunately tried to self-medicate using street stimulants, methamphetamine, cocaine, and so substance-use disorder is also very common with people with ADHD, but we don't see that as often anymore.

Host Amber Smith: If the ADHD symptoms improve, do you see the depression and anxiety improve, as well?

John Ringhisen, NP: Typically, it's more linked to how well their performance improves and whether the environment around them has a positive response to their ADHD symptoms getting better. So we do work comprehensively with the patient. We work with them on their mood. We prescribe antidepressants. We prescribe medication for anxiety alongside their ADHD medication if necessary. And we need to provide that support.

Host Amber Smith: I'd like to ask you about the risk factors for ADHD. Is there anything that people can do to reduce their risk of developing ADHD?

John Ringhisen, NP: It comes down to some of the theories of why do people get ADHD. We are finding that there is an increased incidence of ADHD, and we think it is coming from how we train our brains on a daily basis and how we interact with a lot of the technology out there.

Flipping through the average length of a YouTube video when YouTube first came out was something like 15, 20 minutes. You're lucky to see a three- to five-minute YouTube video nowadays. That's kind of the average length of time. So training your brain to constantly flip through shorts, TikToks, Reels on Instagram, or the way that you digest your news if you never dive into and read through an article and really spend time focusing on a topic, you can start to train your brain to kind of behave like it has ADHD, even though you may not truly have ADHD.

Host Amber Smith: That's pretty frightening. But that's research that hasn't been proven yet?

John Ringhisen, NP: It's ongoing. We've got some preliminary studies that show particularly children and adolescents. We're trying to repeat a lot of these studies with adults to see if they behave in similar fashion, and the early results say that adults are similar to kids. If you train your brain to have a short attention span by constantly scrolling through things, you're going to start looking like you have ADHD because you've trained your brain to pay less and less time, and less and less depth of focus, on an individual task or an individual item.

Host Amber Smith: Well, before we wrap up, can you tell us about your role on the Pharmaceutical Subcommittee of the U.S. Guidelines Task Force for Adult ADHD?

John Ringhisen, NP: My role there is, we are putting together guidelines to try to help practitioners have kind of a playbook of how to diagnose, how to treat and how to prescribe and, and my specific role is on the prescribing subcommittee. So, medication and what things to look for and talk about and consider before, during and even after the symptoms of ADHD are present and diagnosis is what we're trying to provide.

People like me and other mental health and, especially, primary care providers, because a lot of the primary care providers out there are the ones that see this first, and then it, lands in my schedule. So we're trying to give them some ideas, some thoughts and a little bit of a playbook on guiding their decisions in how they approach ADHD

Host Amber Smith: What is the best way, if someone's listening to this interview and they think, "I need to visit the adult ADHD clinic." Is there a way to do that, or do they need a referral through a primary care provider?

No, it doesn't require any kind of referral. All you need to do is you need to call the office at 315-464-2689, or if that line is occupied, you can call 315-464-3265. Just specifically request an intake appointment with the ADHD clinic for adults, and we'll be happy to get you in our schedule. Well, Mr. Ringhisen, thank you so much for making time for this interview. It's been very informative.

John Ringhisen, NP: I appreciate you taking the time to speak with me.

Host Amber Smith: My guest has been John Ringhisen, a nurse practitioner of psychiatry and behavioral sciences at Upstate who oversees the adult ADHD clinic, and who's also a member of the Pharmaceutical Subcommittee of the U.S. Guidelines Task Force for Adult ADHD.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

If you enjoyed this episode, please tell a friend to listen, too, and you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube or wherever you tune in.

This is your host, Amber Smith, thanking you for listening.