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We sit down with psychiatrist Morgan Hardy to explore the complex rise in adult ADHD diagnoses. Morgan shares insights on the growing demand for ADHD evaluations, the impact of social and environmental factors, and the fine line between appropriate treatment and overdiagnosis. We delve into the risks and rewards of stimulant medication, the challenges of making accurate ADHD diagnoses, and the potential influence of today’s tech-driven world on attention spans.
Morgan Hardy is a psychiatrist.
He discusses the KevinMD article, “Is the surge in adult ADHD diagnoses helping or harming patients?”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Morgan Hardy. He’s a psychiatrist. Today’s KevinMD article is “Is the Surge in Adult ADHD Diagnoses Helping or Harming Patients?” Morgan, welcome to the show.
Morgan Hardy: Thank you. Thanks for having me on.
Kevin Pho: So let’s start by briefly sharing your story and journey.
Morgan Hardy: Yeah, absolutely. So I am a psychiatrist with the U.S. Air Force. I’m currently based out here in the UK. And I should note that everything I share on here is not the official policy of the U.S. Air Force or the Department of Defense—it’s my own opinion. But I’ve been out here for about three years, and I graduated residency in Texas in 2021 and then came out to the UK after that.
Kevin Pho: All right. So you are working, of course, in the Air Force. So from that standpoint, what are some of the typical things that you’re seeing? What are some of the typical diagnoses and cases that you see regularly?
Morgan Hardy: Absolutely. So, working in the military, I’m working primarily with a young population. Eighteen to thirty is my average demographic. And these are individuals across the broad swath of the American public. And so I see a lot of the same conditions that you would see in young adults—depression, anxiety, and definitely an increase in the number of adult ADHD cases that we see. In addition, we see a fair amount of PTSD, which I think is common in the military patient population.
Kevin Pho: All right, and let’s talk about one of those conditions in your article. Is the Surge of Adult ADHD Diagnoses Helping or Harming Patients? Now, for those who didn’t get a chance to read that article, tell us what it’s about.
Morgan Hardy: Yeah, so, I was very interested in this topic of this recent increase that we’re seeing in adult ADHD diagnoses. There was a recent CDC article that was published that showed that one in sixteen Americans have been diagnosed with ADHD—that’s 15.5 million Americans. And this has been a trend that’s been increasing over the past 10 to 15 years. And I myself was seeing a lot of these patients coming through the clinic, and I became very interested in this trend. Is this something that is good? Is it bad? What does this really mean for us? And so my article discusses this. And what’s really interesting, Kevin, is that when you look at the data, it’s very nuanced. And there is very robust clinical data that suggests that treatment of ADHD is a good thing. It decreases all-cause mortality. It decreases rates of substance misuse among people with ADHD. And so it seems like this is a very good trend that we should be increasing our diagnosis and treatment of ADHD. But there are also some potential harms that we have to recognize. And there’s evidence to suggest that it increases the risk of cardiomyopathy in young people. It increases blood pressure, heart rate, and also increases the risk for psychosis. And so treatment of ADHD is not always benign, and so we have to look at this very nuanced picture—that, yes, there are people being helped, but there are also some potential harms that come along with that.
Kevin Pho: So when you look at the root causes that account for the increase in those numbers, what do you think is the cause? Is it simply improved awareness? Social media? Is it the fact that our society in general is more distractible? Do you have any hypotheses in terms of why those numbers are rising?
Morgan Hardy: Yeah, I think it’s a very mixed picture. I think on one hand, there is increased recognition of ADHD as a diagnosis. We used to think that ADHD was a condition you just saw in children and that it largely went away when you were an adult. And what we’ve now found is that at least 50 to 75 percent of people who have ADHD as a child continue to have it as an adult. And so a lot of my patients that I’m seeing either were treated as kids and then stopped treatment prior to the military, thinking they were fine, and then continued to have problems, or they were never diagnosed as children but clearly had significant issues that were never recognized. So, yes, there definitely is this trend toward increased diagnosis, which I think is very appropriate. On the other side of the coin, as you alluded to, there are a lot more people coming in with concentration and attention issues that I think are largely socially driven. There is good evidence out there that social media and technology definitely increase rates of distractibility. But also, I think the modern work environment contributes to this. We definitely saw this with COVID, where suddenly everyone was working from home a lot more. They were on their computers, and this blending of work and personal life happened more frequently, where people don’t have a clear nine-to-five job. It all blends together, and people could be responding to emails or text messages about work throughout their day. And so I think that also contributes to this increased distractibility that people feel, which may look very much like ADHD. I think another problem that doesn’t get talked about enough is that most of us don’t get enough sleep. When I ask my patients how much sleep they’re getting, they’re routinely telling me five to six hours of sleep, which is definitely not enough. We should be getting seven to eight hours at least. And so I think we’re all more sleep-deprived, more connected to technology, and have fewer boundaries between work and personal life, which really turns into a lot of these attention and concentration symptoms that can be misdiagnosed as ADHD.
Kevin Pho: Now in a military setting, how do patients typically present to you that may be suggestive of ADHD?
Morgan Hardy: I think when patients are coming in with a history of struggling in their job—maybe they’re assigned to a specific position and are getting written up a lot by their supervisors, or they’re having a really hard time adapting to the fast-paced military environment—that’s when I see them. Sometimes they come in at a point where they’re on the verge of being kicked out of the military unless they get some help. When we really dive into what’s been going on, it becomes clear they have significant distractibility, and then I diagnose them with ADHD. We start treating it, and they can often do quite well. So, I’m always really looking at the dysfunction they’re experiencing, and that’s often more important than just the symptoms they describe.
Kevin Pho: Tell me about your decision-making process if someone presents with these symptoms of distractibility and may be suggestive of ADHD. What questions do you ask the patient? What questions do you ask yourself to determine what is the right treatment path for them?
Morgan Hardy: Yeah, so it’s always a question of, as I said, how much dysfunction they’re experiencing and whether it’s appropriate to move forward with pharmacotherapy. I think it’s important that we don’t only look at pharmacotherapy as the solution for people with ADHD. Yes, stimulant medication can be enormously helpful, as I’ve mentioned, but there are many lifestyle changes that need to be made. So, I always address sleep with my patients. I ask them about their sleep habits and really try to help them improve their sleep. We look at their use of technology and whether that’s interfering with their attention and concentration. We also examine how they’re structuring their work and whether there are changes they can make in their work patterns or habits. That can be enormously helpful as well. And then, after all those things, if they’re still struggling, yes, we can talk about appropriate medication to help them.
Kevin Pho: Can you give us a couple of case studies where a patient improved with pharmacotherapy, but also you mentioned some of the risks of pharmacotherapy. So tell us about a case where pharmacotherapy for ADHD-like symptoms was detrimental to the patient. Share with us both a success story and a story of failure with pharmacotherapy.
Morgan Hardy: Yeah. One case that comes to mind is a young man who was referred by his leadership because he was struggling. He wasn’t showing up to work on time, was making mistakes, and was getting written up and facing disciplinary action. It wasn’t really on his radar that he might have ADHD—he just thought that’s the way he was. I started interviewing him and gave him some questionnaires to complete, and it became clear he had a lifelong problem with executive function, attention, concentration, and impulsivity. We started treatment, and things turned around for him. He did a lot better and was much more successful in his job. I’ve had several of these types of cases that are real success stories, where treatment makes a significant difference in people’s lives. On the other hand, I had a patient who was diagnosed with ADHD by a primary care doctor and started on Adderall. He had a severe history of trauma and PTSD, which I think was the primary cause of his perceived attention problems. He started abusing Adderall—saving it up during the week and taking large amounts on the weekend for a euphoric effect. This escalated until he presented to the emergency room with full-blown psychosis. He was paranoid, agitated, and it became clear that this was caused by the Adderall. We had to take him off the medication and enroll him in a substance use treatment program to help him recover. This illustrates how important it is to make the correct diagnosis and educate patients about the risks associated with these medications.
Kevin Pho: Knowing that some of these pharmacotherapy options for ADHD can be habit-forming, do you see any parallels with the increased frequency of prescribing in general with the opioid epidemic going forward?
Morgan Hardy: I’m glad you asked that question because I think that’s something we need to consider as we look at these trends. There are some important differences between this and the opioid epidemic, which I’ll point out, but yes, I think the opioid epidemic is an interesting parallel. When long-acting opioids were being rolled out and marketed to physicians, there was an idea that these were very safe and could be life-changing for patients with chronic pain. That was seen as a positive trend at the time, but it obviously went downhill from there, resulting in widespread issues. I’m not sure if the same thing will happen with the surge in stimulant prescribing. Are we going to see increased abuse of stimulants? There are already increased rates of methamphetamine abuse and overdoses, but it’s too early to say if this correlates directly. However, unlike opioids, there is evidence that long-term stimulant use can have positive impacts for certain patients, whereas long-term opioid use has shown negative effects. So while there are some important differences, we need to be cautious about this trend.
Kevin Pho: We’re talking to Morgan Hardy. He’s a psychiatrist. Today’s KevinMD article is “Is the Surge of Adult ADHD Diagnoses Helping or Harming Patients?” Morgan, as always, we’ll end with some take-home messages that you want to leave with the KevinMD audience.
Morgan Hardy: I think the most important take-home message for all clinicians is to not be afraid to diagnose and treat ADHD in adults. It’s an important message. However, we need to be much more discerning and cautious about our diagnoses and treatments, and we must be aware of both the benefits and risks of appropriate treatment.
Kevin Pho: Morgan, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Morgan Hardy: Thank you.
