Sample Summary of Successful Treatment of an Adult with ADHD
re: PATIENT MR. X (date of birth 1/1/1992)
Dear sir or madam:
Patient X has been under my medical/psychiatric care since we first met on 10/2/2021. My understanding is that Mr. X will be moving back to the San Bernardino area later this year. In order to maximize a smooth transition to a new treating physician/psychiatrist, below is my summary of my assessment and treatment of Mr. X.
About my professional medical credentials: I am a physician, licensed to practice medicine in the State of Washington. I completed a general adult psychiatry residency program, and then completed a two–year fellowship in child & adolescent psychiatry. I am a diplomate of (– that is, I am “Board Certified” by) the American Board of Psychiatry and Neurology. I have served as volunteer clinical faculty for OHSU Department of Psychiatry; I also served as Clinical Assistant Professor of Family Medicine/ Psychiatry, College of Osteopathic Medicine of the Pacific. I am an internationally published expert and authority on the assessment and treatment of attention–deficit/hyperactivity disorder (ADHD) in children, adolescents and adults (both in and out of prison). Additional information about my professional medical credentials (and my resume) can be found on my website at: mortimermd.com
Now about Mr. X: Mr. X is a 30 year–old computer programmer who presented to me for continued treatment of attention–deficit/hyperactivity disorder (ADHD). We first met on 10/2/2021. Our most recent meeting (with Mr. X and his girlfriend) was on 7/1/2022. Information sources have included: Mr. X’s elementary school report cards from kindergarten onward; his psychiatric records (193 pages) from Dr. Z (in San Francisco, CA); various normed and un–normed symptom/behavioral checklists; computerized continuous performance task (CPT) testing; and clinical interviews with Mr. X and his girlfriend. Based on the information which I have collected, the Problem List as I see it has included:
- Chronic problems with attention, concentration, and motivation since childhood. A review of Mr. X’s elementary school report cards show teacher comments typical of those students with untreated attention–deficit/hyperactivity disorder, e.g., relative weakness on following classroom/school rules (first grade); easily distracted/off task (second grade); assignments not handed in on time (third grade); not working up to academic ability (fourth grade), etc. On review of the attention–deficit/hyperactivity disorder (ADHD) diagnostic criteria as listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM V), Mr. X endorsed/ subscribed to 9 of 9 inattentive ADHD symptoms and 4 of 9 hyperactive/impulsive ADHD symptoms, with the onset of at least some ADHD symptoms occurring before 12 years of age. Scored on 11/1/2021, the Wender Utah Rating Scale (used to help identify adults with ADHD, which has been modified by me) was elevated at 56. [In one published study, WURS scores of 36 or above had 96% sensitivity, and 96% specificity for the diagnosis of ADHD; and scores of 46 or above had a specificity of 99% for the diagnosis of ADHD.] Scored on 11/1/2021, the Brown Attention Activations Disorders Scale (used to help identify adults with the inattentive type of ADHD) was elevated at 88 (self–rated); with girlfriend’s assessment of Mr. X scored at 43. [In one published study, BAADS scores greater than or equal to 50 had a sensitivity of 90% and specificity of 70% for a diagnosis of ADHD.] While Mr. X’s ADHD symptoms were identified as problematic during his childhood, Mr. X’s parents (both of whom were teachers) believed that they could provide Mr. X with sufficient structure throughout his secondary education to adequately manage his ADHD without medications. Mr. X’s ADHD problems became ostensibly impairing by his early 20s. Mr. X’s medical treatment of his ADHD symptoms only started in July 2017 after consulting with Dr. Z in San Francisco. Baseline results with my computerized continuous performance task test (with Mr. X having taken Adderall XR 50 mg that morning) on 10/2/2021 showed 27 errors of omission; 5 errors of commission; 2 random errors; and a slow average reaction time of 547 milliseconds. [In my clinical population, those adults without ADHD or a cognitive disorder should be able to complete this four–minute test with no more than 0–2 total errors, and with an average reaction time of close to 400 milliseconds.] Mr. X’s clinical picture is consistent with attention–deficit/hyperactivity disorder (ADHD), combined type – which, at the time that we first met, I concluded was suboptimally managed.
- General medical history was remarkable only for tonsillectomy
- Family/genetic history is remarkable for: ADHD (both parents; sister); alcohol dependence (uncle); suicide (second cousin); autism (cousin); and impairing shyness (cousin).
Medications/ treatments/ substances at the time of our first meeting were:
Alcohol 2-3 drinks/week. Last alcohol was 5 days prior to our first meeting.
Caffeine (one cup of coffee every morning)
Adderall XR 50 mg in the morning (for the past 5 years)
Adderall IR 10 mg in the afternoon (– which has not been obviously helpful and has been associated with end–of dose rebound)
No cigarettes, cannabis, supplements, herbs, or illicit substances
Medication trials have included:
Focalin XR capsules (from 11/12/2021 to 1/7/2022) up to 40 mg in the morning was helpful for managing ADHD symptoms but this dose was still suboptimal, and its benefit for ADHD symptom management was too short in duration to be practical to continue with it.
Focalin IR tablets (from 12/10/2021 to 1/7/2022) 2.5-5 mg twice daily was not as effective as the amphetamines (listed below)
Mydayis (starting 11/23/2021) was too expensive for Mr. X to have filled.
Mr. X’s current medications are:
Adderall XR (restarted 1/7/2022) 60 mg every morning
Vyvanse (starting 10/22/2021) 70 mg in the morning (along with Adderall XR)
Adderall IR (tablets, restarting 1/7/2022) 30 mg at 3PM (split over an hour to prevent end–of dose rebound)
Today, Mr. X reports that with his current medications and doses as above, he enjoys excellent ADHD symptom control throughout his waking day. He summarized: “This dose combination of Vyvanse plus the Adderall capsules and tablets makes me to be my best me.” Mr. X is also pleased to report today that last month he received a 30% salary raise. Today, Mr. X’s girlfriend added that with the above medication combination, Mr. X was more attentive, and more organized – and he no longer misplaced his car keys! All three medications as above are well–tolerated. Mr. X’s overall health is good. On repeat, computerized continuous performance testing today, Mr. X’s scores were: zero errors of omission, one error of commission, and zero random errors. Mr. X’s average reaction time was also much improved at 427 milliseconds. Overall, Mr. X’s CPT performance was more than 3,400% better today than it was on 10/2/2021 (when Mr. X took Adderall XR at 50 mg that morning).
Mr. X, his girlfriend, and I concur that Mr. X’s ADHD symptoms are under optimal control with the above off–label stimulant combination of Adderall XR, Adderall IR and Vyvanse at the above doses. Today, I wrote for three months’ worth of prescriptions for each of the three stimulants and gave them to Mr. X. The current plan is to meet with me again on 9/30/2022 – assuming that Mr. X hasn’t yet moved back to California.
If Mr. X does move to California before we meet again on 9/30/2022, then Mr. X and I are optimistic that this summary will be sufficient to allow for the continuation of Mr. X’s optimal ADHD symptom management at the stimulant doses above. Once I receive a signed authorization from Mr. X, I will send a copy of Mr. X’s medical/psychiatric records (via CD) to his now–future California physician/psychiatrist. In the meantime, I would continue these medications at the above doses indefinitely. I can make myself available to answer any questions the California physician/psychiatrist might have, and I would be happy to see Mr. X again should something "come up." I am...
Dale Mortimer, M.D.