Re

Dear Editor:

We would like to thank Dr Paris and colleagues ¹ for bringing much-needed focus to adults suffering with attention-deficit hyperactivity disorder (ADHD), an illness associated with considerable personal and societal burden. We share their goal of ensuring that patients are correctly diagnosed by applying evidence-based screening and diagnostic criteria for ADHD. However, we have concerns with the negative tone of Paris et al.’s article, which may further stigmatize this illness and prevent people with ADHD from receiving the treatment they deserve.

Paris et al. expressed concerns about overdiagnosis of ADHD despite a lack of evidence to support this. The increase in diagnosis of ADHD has followed a similar trajectory as other psychiatric disorders that were once thought to be rare, such as social anxiety, autism spectrum disorder, and bipolar II disorder. It only seems logical that an increase in the recognition of the disorder in children would lead to rising rates of ADHD in adulthood, as central nervous system dysfunction leading to attentional problems would not be expected to disappear after the 18th birthday.

Perhaps Paris et al.’s article suggests a profound misunderstanding of the syndromal presentation of ADHD, which includes attentional difficulties and also deficits in executive function, affective dysregulation, and higher risk of accidents, premature death, marital discord, and educational and vocational underachievement. ^2,3 Effective treatment of ADHD improves symptoms, emotional lability, and patient functioning. ⁴ While Paris et al.’s main concern is overtreatment of ADHD, we believe the risks of missed diagnosis and undertreatment, are far more compelling.

Paris et al.’s article could deter some people from seeking help, and discourage clinicians from assessing and treating ADHD. They suggest nonmedical benefit seeking of people on ADHD treatments. ¹ This contrasts with literature suggesting that stimulants do not enhance cognitive performance outside the treatment of ADHD. ⁵ It is ridiculous to suggest that researchers are inflating prevalence rates to boost their funding for grants or that the pharmaceutical industry is medicalizing ADHD to market new stimulants.

Paris et al.’s criticism of clinicians for overrelying on screening tools, or for treating without establishing a correct diagnosis of ADHD, ignores the facts that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, requires that the clinical interview confirm both childhood onset and impairment to establish a diagnosis of ADHD and the diagnostic criteria appear to be working. Studies suggest up to 40% of adults seeking an evaluation for ADHD do not meet full criteria for the disorder. ⁶ In contrast to Paris et al.’s position, there is no evidence supporting the value of neuropsychological testing for improving the accuracy of diagnosis; indeed, neuropsychological testing may contribute to worsening diagnostic accuracy by missing up to one-third of confirmed ADHD cases. ⁷

As clinicians in the field, we must be mindful of misdiagnosis of any psychiatric condition, and remind the authors that patients deserve the best evidence-based assessments and treatments for ADHD, but they do not benefit from a perspective paper that further exacerbates the stigmatization of the disorder in the field of psychiatry.

Martin A. Katzman, MD, FRCPC START Clinic for Mood and Anxiety Disorders, Lakehead University, University of Toronto, The Northern Ontario School of Medicine, & Adler School of Professional Studies, Toronto, Ontario, Canada [e-mail] Tim Bilkey, MD, FRCPC Ontario Bilkey ADHD Clinics, Barrie, Ontario, Canada Pratap R. Chokka, MD, FRCPC University of Alberta, Edmonton, Alberta, Canada Angelo Fallu, MD, FRCPC Clinique Woodward & Diex Research Inc., Sherbrooke, Québec, Canada Larry J. Klassen, MD, FRCPC Eden Mental Health Centre & University of Manitoba, Manitoba, Canada