Recent Increase in Adult Stimulant Prescriptions for ADHD May Be Warranted but More Research and Education is Needed, Experts Say

A new report from the Center for Disease Control and Prevention (CDC) documents years of rising US adult stimulant prescription, with a substantial spike from 2020 to 2021 particularly for women.

Although seemingly rapid increases in ADHD treatment-seeking may cause alarm, they may be medically appropriate for adult women, says a team of ADHD clinical and research experts in a guest editorial in the Journal of Attention Disorders.

Craig Surman, MD, Director of the Adult ADHD Research Program at Massachusetts General Hospital, and an Associate Professor of Psychiatry at Harvard Medical School, is the senior author of the editorial.

The rise in prescriptions may be due in part to efforts to educate patients and providers about adult ADHD, expanding access to care, reductions in healthcare disparities and an increase in information online about neurodiversity and ADHD, the team writes.

The authors also concede they cannot be certain that all patients who were prescribed stimulants have ADHD or that all prescriptions represent appropriate or effective treatment.

More research is needed evaluate the experiences of populations with recent prescriptions to understand who sought treatment, what drove them to seek care, if the pandemic exacerbated ADHD rates and why women sought treatment at higher rates than men, the team writes. Research will also be needed to determine if stimulants represented the best course of treatment for these new patients.

It will also be important to earmark new funding for research on adult ADHD, the team writes. “As of Jan. 2023, our reading of the NIH reporter lists just under $5.5M in funding on adult ADHD vs. $42M in funding for pediatric ADHD.”

Greater attention will need to be paid to the online spread of misinformation about ADHD, and primary care providers will need more education and support on adult ADHD practice guidelines, which are currently under development.

“Regardless of cause, the CDC report highlights that ADHD has arrived as an adult psychiatric condition permeating everyday clinical practice,” the team writes. “ADHD needs to now take its rightful and more central place in adult mental healthcare.”

See below for a Q&A with the Editorial Team:

Tell us about the main conclusions in your op-ed. Was there anything surprising in what you found?

As in previous years, stimulant medication prescriptions continue to rise from 2016-2021; however, there was a specific and unusual spike in medication use between 2020-2021. The group who contributed most to this spike were adult women.

These data substantiate that there was greater demand for stimulant medications during the period leading up to the stimulant medication shortage last year–so it was not just a supply chain issue.

There are a lot of possible reasons that we believe this could have happened, some represent inappropriate prescribing and some represent appropriate prescribing:

Appropriate:

• People may have experienced an increase in ADHD symptom severity during the pandemic due to more stress and demands placed upon them. Women may be disproportionately affected.
• Women and men may also have both felt an equal impact of the pandemic, but women may be more likely to seek help for their ADHD.
• Women may represent a larger portion of consumers of increased social media content on ADHD on platforms like TikTok, Instagram, and Facebook. This content is relatable and may lead some to newly realize they have ADHD.
• Greater access to care for individuals in rural areas or without health insurance during the pandemic due to new telehealth models.

Inappropriate:

• Some individuals who self-diagnosed with ADHD due to something they saw on social media may not have had ADHD. A doctor who doesn’t have proper training may have taken their word for it without conducting a proper diagnostic work up
• Online start-up companies that provide prescriptions for ADHD over telehealth may have marketed heavily to women and may not have used proper diagnostic techniques, leading to over-prescribing
• It may have become easier for people to obtain ADHD medication for reasons other than ADHD (i.e., fatigue, weight control) under the start-up online telehealth models
• Further considerations, not directly related to ADHD
• It's also possible some doctors are expanding their off-label use of stimulants such as treating cognitive symptoms of long COVID with stimulants.

What does this mean for those who suffer from undiagnosed or untreated ADHD?

It could mean that recognition of ADHD in adult women has finally improved and now women are facing fewer barriers to obtaining appropriate care. Many adult psychiatrists and primary care practitioners have received no formal training on ADHD; these data may convince providers to learn more about ADHD in adults and women so that they can help shoulder the growing need for adult ADHD care.

In some ways, women were criticized for seeking ADHD help due to Adderall shortages. How should we feel about the prevalence of more women seeking treatment?

On one hand, it may indicate better recognition of ADHD in women, who are historically under-identified and under-treated for their ADHD.

However, the suddenness of this increase requires us to take a deeper look at just who was seeking new care and why.

• Were some of the women self-diagnosing due to something relatable they saw on social media?
• Is it possible that some women are being prescribed stimulants for a condition other than ADHD such as depression, fatigue, weight loss, or hormonal issues like the cognitive effects of menopause?

Has the current stimulant shortage problem been solved?

I don’t think we know the answer to this yet.

The FDA estimates that the shortage will be resolve between April and June depending on the product. However, if demand continues to increase, and once again exceeds supply, another shortage is possible in the future.

This is one of the reasons it's so important to understand what is driving the trends surveilled by the CDC.

Talk about the disparities between ADHD treatment and that of depression. Why does one get more attention than the other?

The proximity of depression to suicidal behavior makes it an urgent topic, but that shouldn’t take away from the urgency of studying ADHD, which is also an underlying risk factor for a host of serious physical and mental health issues as well as premature death, including from suicide, accidents, and heavy substance use.

There is a great need to increase funding for adult ADHD research. The NIMH’s current funding portfolio for adult ADHD is only a few million dollars, which is about eight times lower than its funding on childhood ADHD. NIMH depression funding is in the hundreds of millions of dollars.

The scarcity of adult ADHD research funding means that we still do not know the answer to very basic questions about this disorder:

• Do women, on average, have a later-onset disease state?
• Is ADHD more likely to wax and wane in women versus men?
• Does trauma and adversity lead to an environmental form of ADHD in some?
• What treatments work best for ADHD in women?

What additional questions do we need to ask?

We need to hear from the women who newly sought stimulant prescriptions during the pandemic.

• Were they primarily receiving care from online start-ups that have been criticized for liberal diagnosis and prescribing?
• Did they self-diagnose due to something they saw online?

Well-trained doctors and mental health providers are typically gatekeepers to accurate ADHD diagnosis because its symptoms can be subjective and confuse even the affected individual.

However, with a shortage of well-trained providers, those with less training may be stepping up, which is helpful in some ways, but could increase inappropriate prescribing.

There are new adult ADHD guidelines in progress from the American Professional Society for ADHD and Related Disorders (APSARD) that will hopefully provide better standards for the diagnosis and treatment of ADHD in adults.