Recently, one of my pharmaceutical reps asked me a question she’d been asking other doctors.  "If you only had 5 medications to work with, which ones would you choose?"  For me it was easy.

1. Adderall XR

Has the best batting average.  Batting average = how often patients say, "This med is great.  It changed my life and has no significant side effects."  And they’re still saying it after a year.

2. Alprazolam (Xanax or Niravam)

Helps people take back control of their lives.  Was the most prescribed med for stress last year.

3. Ambien CR

Safe sleep medication which gives you normal sleep.  Normal sleep = foundation for health.

4. Effexor XR

Has the most flexibility (SSRI at low doses, dual agent at higher doses), works the fastest, and has no significant drug/drug interactions.

5. Abilify

Best mood stabilizer.  Was the 1st of the new generation of atypicals.

I no longer take insurance.  To be successful I have to use the meds that work the best.  My goal for each patient is to find "the right medication at the right dose."  All of these "Top 5" have alternatives that I often use.  The bottom line is that with these meds I have seen the best long term results.

ADHD and to a lesser extent anxiety disorders are frequently unrecognized and untreated.  As a result millions of adults in the U.S. have a reduced quality of life and chronic stress symptoms that gradually take their toll on physical health.

Adults who have mood and anxiety disorders can also be ADHD.  The National Comorbidity Study (NCS) found ADHD occurs in

• 32% of  patients with a depressive disorder
• 21.2% of patients with bipolar disorder
• 9.5% of patients with an anxiety disorder

However, a large managed care data base reported the following treatment rates for co-occurring ADHD in adults with mood and anxiety disorders:

•  2.5%   in patients with bipolar disorder
•  1.7%   in patients with a depressive or anxiety disorder

New diagnoses for mood and anxiety disorders =

• 12,036,905 new depressive disorders
• 6,573,576 new anxiety disorders
• 1,148,175 new bipolar disorders

New diagnoses for ADHD = 900,897

This means that of 12 million patients diagnosed with a new depressive disorder almost 4 million also were ADHD but only 200,000 were being treated (4%) of the total here.  Approximately 100,000 of 600,000 patients with an anxiety disorder were being treated for ADHD (16%).  Only 250,000 bipolar patients (11%) were being treated for ADHD. 

www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

The National Comorbidity Study (NCS) directed by Dr. Ronald Kessler is accepted as the most reliable study of the U.S. population.  Two hour assessments of all adults in selected households were randomly chosen from all over the country to establish prevalence. 

The NCS also found that anxiety disorders were the most prevalent mental health problem.  Social anxiety disorder was the single most common (8%) of the population followed by post traumatic stress disorder, generalized anxiety disorder, panic disorder and OCD.

Since anxiety disorders are 50% more prevalent than depressive disorders the managed care data base reflects that 2/3’s of anxiety disorders were not being treated.  The most likely explanation is that they usually weren’t diagnosed. 

If anxiety disorders are more common, how do you explain the fact that almost twice as many patients in the managed care data base were treated for depressive disorders (12 million) than anxiety disorders (6.5 million)? 

Other studies have found that doctors, including psychiatrists are much less likely to recognize and treat anxiety disorders.  This is partly because patients don’t have insight into the nature of their symptoms, or, especially in social anxiety and OCD, they are too embarrassed to bring it up.  Many doctors are not proactive in asking about each group of symptoms.  In managed care, reimbursement is a set rate.  It’s more economically effective to keep it simple and focus primarily on the presenting complaint. 

The saddest reality is that the success rate of treatment is appallingly low.  The NCS found that in any given year 30% of Americans will suffer from a mental health disorder, and those with a disorder will have on average 2 co-occurring disorders.  Successful treatment requires identification of all the existing problems and understanding of how each relates to the others.

It’s ironic that ADHD is the most frequently missed diagnosis since it is the most easily and effectively treated.   Anxiety disorders are probably the second most missed.  Although harder to treat than ADHD, they are not as complicated as depressive disorders, especially bipolar type.

The managed care data base didn’t include alcoholism and drug abuse.  Addictive disorders have the highest rate of co-occurring ADHD, but doctors are  reluctant to give the most effective treatment (stimulants) to this group of patients – even though studies show that usually they are safe and effective.

Change begins with awareness.  Our medical system is broken.  The impetus is going to have to come from the people suffering the consequences of the system.