Yep, my suspicion as well. Psychiatrists had wisened up to the presence of bipolar disorder, SUD history, +/- cluster B traits, and probably recognized stimulants as inappropriate in that context, so patient sought out someone else. Speculating, but definitely wouldn't be the first time that's happened.
Exactly this. The MDs were on to his bullshit, he was provider shopping and found a pliable provider who would just give him what he wanted.
In my town there's a business called "Northwest ADHD" and as far as I can tell, it's a bunch of NPs writing Adderall prescriptions on the basis of Zoom meetings with clients. I found out about it when one of them overdosed my patient. She was 8 years old, had grown 1 inch since her 7 yr WCC (2.5 inches is typical) and weighed the same as she had when she was 5.
I had to mind my biases on this one because, while not a 100% accurate generalization, psych NPs being too casual with stimulants for vague complaints of "can't focus" is almost a meme among psychiatrists.
But having said that, I think this lawsuit was probably an effort to monetize a tragedy. Some sloppy work, but not so sloppy I would say it caused this patient's suicide, and if a patient (an adult patient, no less) only volunteers a history of ADHD and withholds everything else, I'm not sure how an NP would be expected to even know that there is relevant collateral available, much less how to get it. It's easy for me to say from my couch that I would do a more thorough inspection for ADHD or demand prior records verifying the diagnosis, but saying that not doing so led to this patient killing themselves is a stretch.
As it stands, the expert's opinion here just seems to read as a grab-bag of pedantic criticism, rather than presenting an actual theory for what the NP specifically did that led to the patient's suicide.
I'm honestly surprised that psychiatry is one of the least-sued specialties because if providers can be sued for failing to read their patients' minds, I would think nearly every case of suicide could be converted to at least a settlement extraction if the surviving family can find an attorney with a pulse.
Intermittent care at multiple facilities is very problematic for the physician. I have patients in the hospital reporting several admissions at different hospitals in the last 6 months- sometimes they can’t remember which hospital. I’m not sure how much effort I should exert to tract down all of these records. It sometimes seems excessively onerous to the question at hand. However, a patient hospitalized a few months ago because he put a gun in his mouth - I would think that should’ve come up in even a cursory history. When reading this, I was wondering about the role of the parents. After all he did live at home.
It seems like the relationship with the parents was strained, both between the patient and the father (recent physical fights), as well as between the father and all of the clinicians (2008 hospitalization they refused all meds, 2012 hospitalization the father apparently kept calling to criticize). Another pearl I didn't add, was that the plaintiff in the case was actually his sister, not the parents. Same sister that was going to take him in after he was released from the 2012 hospitalization. And it looks like she's now gone to law school and works for the Department of Justice.
The idea that psychiatrists (or psych NPs, or any clinicians) should obtain all clinical records is absolutely insane. First off, patients lie sometimes, making us unaware that past records exist, as seemingly in this case. Second, how far back are we supposed to go? When I see an 80-year-old, do I need to be trying to obtain records from when they were a kid? Frankly, my history-taking should be adequate/comprehensive enough to make a proper diagnosis in most cases. There will be some where something is off, or I need more info, and that's when I'll seek outside records.
The real problem this NP has is her very poor history. Whenever I do an ADHD evaluation, I go through a comprehensive interview of childhood ADHD symptoms. I also go through a full evaluation of all manic and depressive symptoms. The initial psychiatric evaluation doesn't even mention whether there's a hx of depressive or manic episodes, or what questions were asked.
I do think there is a genuine malpractice case here. Had the NP done a proper assessment in the first visit and found the mood disorder diagnosis which she missed, she could have been able to get the patient appropriate treatment for that and possibly prevent the suicide. I do not think that not obtaining records has anything to do with that.
Also, when the expert says "history of substance use is a contraindication for prescribing Adderall," this is absolutely false -- this is not a labelled contraindication. Studies show untreated ADHD leads to higher rates of substance abuse; treating the ADHD with a stimulant *reduces* the abuse. I would monitor a patient closely, do periodic drug screens, ensure there's no diversion, etc.; but I would not leave their ADHD untreated. That just drives them back to using drugs.
Lastly, it doesn't read to me necessarily that the patient doesn't have ADHD. The childhood behaviors sound similar to Opposition Defiant Disorder, which is highly comorbid with ADHD. I don't doubt the bipolar disorder diagnosis, but I don't see why that precludes ADHD. The high degree of impuslvity also suggests ADHD. Though regardless, if I saw this patient, I would treat/stabilize the bipolar disorder before the ADHD due to the risk of causing a manic episode, and indeed I wonder if that's what happened in the end -- that the increased adderall dose lead to a manic or mixed episode and the suicide.
Basically, the ADHD itself causes executive dysfunction and lack of impulse control, so you get people who especially at early ages try substances impulsively and get addicted. Treatment means they're more able to think through consequences and be less impulsive, so they don't abuse substances as often. And if we're really concerned about giving them a controlled substance because of a hx of substance use, we always have nonstimulant options as well (atomoxetine, viloxazine).
Yeah, two ways to think about it: one is that ADHD generally increases impulsivity, but two is that ADHD can make you less able to pay attention to how much you've already used in a sitting. So what might be a beer or two (for example) turns into a binge and the patient with ADHD may not have even noticed until they're completely hammered.
I will say you will encounter controversy among psychiatrists with what role - if any - stimulants have in the treatment of ADHD with a SUD history. I think many of us would agree with the comment above you that treating ADHD reduces SUD relapse risk, and that an SUD history isn't a formal contraindication to stimulant use. But a lot of us do worry that even well-intentioned and well-monitored stimulant prescriptions are more likely to be habit-forming in patients with that history, and I think a good number of us would probably turn to atomoxetine/viloxazine, clonidine/guanfacine, or possibly even bupropion (especially if comorbid depression) before we dusted off our DEA numbers.
Yes, it's an important part of an ADHD evaluation to rule out bipolar, because stimulants can bring on a manic episode. She should have at least been aware of this, and her bullshit detector was apparently inoperational. It seems that she was a practitioner of "nodding dog" style therapy.
I think this is a good summary and I agree with the vast majority of your points. The sticking point for me is whether the NP's sloppy documentation reflects a genuinely slapdash assessment, or resulted from a patient determined to get a stimulant and therefore minimizing symptoms/history not pertinent to ADHD.
Either way, probably wise to settle this. I think the causation argument would have been strained, but I could see a lay jury buying the Plaintiff's likely story of a "lazy/careless psych NP who couldn't be bothered to coordinate with past providers."
It is tempting for plaintiffs to blame the most recent provider (or most recent med or most recent incident), but these tragedies have a long preceding headwind. The parents, the outpatient psychiatrists, the hospitalizations… they couldn’t prevent it… yet an NP with just a few visits and incomplete information is to blame?
My state doesn't allow nurse practitioners to prescribe C2s like Adderall. I have to wonder, in states where NPs practice under a collaborative agreement with a physician, how much responsibility lies with that supervising physician?
Kind of depends on how close the supervision is. If they're directly supervising, they're getting named for participating in the decisions. If they were distant, they could get sued for not being a better supervisor.
How come they settled here given that it was equivocal whether the adderall was the cause of death? This kid sounds like a classic mentally unstable psych patient, threatening suicide multiple times, can’t imagine any jury would fault the NP for his eventual suicide.
I find that juries get it right the vast majority of the time, but its always a roll of the dice. Settling takes out the possibility of a surprise verdict, usually guarantees that the doc/NP doesn't have to pay anything out of pocket, avoids the stress and lost income of trial. Lots of benefits to settling even if you're in the right.
Makes sense, the settlement still is a significant negative mark on your license/history right? I guess it's not worth it to try to fight and win the case vs settle as a mark on your professional record?
I don't think anyone really pays ton of attention unless there is something massively egregious. You're already going to have to disclose it for licensing and hospital credentialing, regardless of if you win at trial, settle, or it gets dismissed.
Ahh ok. Sorry follow up question, what do you mean anyone really pays a ton of attention? I thought it would be a big barrier to future licensing and credentialing etc?
Can't wait to read the whole thing in more detail but initially the thing that REALLY stands out about not getting any prior records is that it appears the ADHD diagnosis was incorrect and had been documented as such by multiple providers yet the NP just took the patient at their word.
As a pathologist who never interviews the patient, I do often make a distinction between a "reported history" of something vs. a "documented history" with the latter meaning I can see the exact lab value/imaging/physician/procedure/etc note *establishing* the diagnosis. Otherwise it's a reported history of a diagnosis.
I wonder when we will see a similar such case involving one of those apps/websites (e.g. hims) where they are advertised less as "get the proper medical care you need" and more "get the prescription drugs you seek." I would bet this case is less an example of "the problems with discontinuity" and rather a deliberate maneuver by the patient to get stimulants when his prior physician cut him off.
I've heard there's an impending onslaught of lawsuits against Cerebral for basically forcing all their telepsych "providers" to give Adderall to anyone who wants it.
That was the company I was trying to think of but couldn't. Hims strikes me less as a controlled substance pusher and more of a bizarre normalization of ED in young men that almost certainly would be better treated with therapy rather than Viagra, but I'm guessing the insurance reimbursement on these virtual viagra visits is much better.
I bet Hims is going to do super well getting men into their system for hair loss in 20-30s, then flipping them over to the erectile dysfunction side when they're older. Not a bad business model at all.
The only wrinkle with that is I recall them being ED stuff first and THEN added their hair loss meds. Also unlike the viagra/cialis commercials with guys/couples who are clearly older, all their ED ads featured young guys/couples.
That could be.... I redact them myself because I prefer to focus on the learning pearls, and also to protect the doctors and patients involved. I technically don't have to, I could publish their names and work locations, etc... I just feel like its a bit unethical and I'd probably have to deal with more people getting mad at me for putting the details of their very sad/intimate situations into the limelight.
Why did he see a NP as opposed to a board-certified psychiatrist? Perhaps to obtain Adderall?
Polysubstance abuse, wanted to obtain prescription stimulants. Is basically what I chalk this case up as. He gamed the system and won (and lost).
Yep, my suspicion as well. Psychiatrists had wisened up to the presence of bipolar disorder, SUD history, +/- cluster B traits, and probably recognized stimulants as inappropriate in that context, so patient sought out someone else. Speculating, but definitely wouldn't be the first time that's happened.
Exactly this. The MDs were on to his bullshit, he was provider shopping and found a pliable provider who would just give him what he wanted.
In my town there's a business called "Northwest ADHD" and as far as I can tell, it's a bunch of NPs writing Adderall prescriptions on the basis of Zoom meetings with clients. I found out about it when one of them overdosed my patient. She was 8 years old, had grown 1 inch since her 7 yr WCC (2.5 inches is typical) and weighed the same as she had when she was 5.
I had to mind my biases on this one because, while not a 100% accurate generalization, psych NPs being too casual with stimulants for vague complaints of "can't focus" is almost a meme among psychiatrists.
But having said that, I think this lawsuit was probably an effort to monetize a tragedy. Some sloppy work, but not so sloppy I would say it caused this patient's suicide, and if a patient (an adult patient, no less) only volunteers a history of ADHD and withholds everything else, I'm not sure how an NP would be expected to even know that there is relevant collateral available, much less how to get it. It's easy for me to say from my couch that I would do a more thorough inspection for ADHD or demand prior records verifying the diagnosis, but saying that not doing so led to this patient killing themselves is a stretch.
As it stands, the expert's opinion here just seems to read as a grab-bag of pedantic criticism, rather than presenting an actual theory for what the NP specifically did that led to the patient's suicide.
I'm honestly surprised that psychiatry is one of the least-sued specialties because if providers can be sued for failing to read their patients' minds, I would think nearly every case of suicide could be converted to at least a settlement extraction if the surviving family can find an attorney with a pulse.
"grab-bag of pedantic criticism" is the perfect description. I may have to steal that line!
I wonder whether the NP fell under the sway of his manipulation, as narcissists are prone to do.
Intermittent care at multiple facilities is very problematic for the physician. I have patients in the hospital reporting several admissions at different hospitals in the last 6 months- sometimes they can’t remember which hospital. I’m not sure how much effort I should exert to tract down all of these records. It sometimes seems excessively onerous to the question at hand. However, a patient hospitalized a few months ago because he put a gun in his mouth - I would think that should’ve come up in even a cursory history. When reading this, I was wondering about the role of the parents. After all he did live at home.
It seems like the relationship with the parents was strained, both between the patient and the father (recent physical fights), as well as between the father and all of the clinicians (2008 hospitalization they refused all meds, 2012 hospitalization the father apparently kept calling to criticize). Another pearl I didn't add, was that the plaintiff in the case was actually his sister, not the parents. Same sister that was going to take him in after he was released from the 2012 hospitalization. And it looks like she's now gone to law school and works for the Department of Justice.
The idea that psychiatrists (or psych NPs, or any clinicians) should obtain all clinical records is absolutely insane. First off, patients lie sometimes, making us unaware that past records exist, as seemingly in this case. Second, how far back are we supposed to go? When I see an 80-year-old, do I need to be trying to obtain records from when they were a kid? Frankly, my history-taking should be adequate/comprehensive enough to make a proper diagnosis in most cases. There will be some where something is off, or I need more info, and that's when I'll seek outside records.
The real problem this NP has is her very poor history. Whenever I do an ADHD evaluation, I go through a comprehensive interview of childhood ADHD symptoms. I also go through a full evaluation of all manic and depressive symptoms. The initial psychiatric evaluation doesn't even mention whether there's a hx of depressive or manic episodes, or what questions were asked.
I do think there is a genuine malpractice case here. Had the NP done a proper assessment in the first visit and found the mood disorder diagnosis which she missed, she could have been able to get the patient appropriate treatment for that and possibly prevent the suicide. I do not think that not obtaining records has anything to do with that.
Also, when the expert says "history of substance use is a contraindication for prescribing Adderall," this is absolutely false -- this is not a labelled contraindication. Studies show untreated ADHD leads to higher rates of substance abuse; treating the ADHD with a stimulant *reduces* the abuse. I would monitor a patient closely, do periodic drug screens, ensure there's no diversion, etc.; but I would not leave their ADHD untreated. That just drives them back to using drugs.
Lastly, it doesn't read to me necessarily that the patient doesn't have ADHD. The childhood behaviors sound similar to Opposition Defiant Disorder, which is highly comorbid with ADHD. I don't doubt the bipolar disorder diagnosis, but I don't see why that precludes ADHD. The high degree of impuslvity also suggests ADHD. Though regardless, if I saw this patient, I would treat/stabilize the bipolar disorder before the ADHD due to the risk of causing a manic episode, and indeed I wonder if that's what happened in the end -- that the increased adderall dose lead to a manic or mixed episode and the suicide.
Thanks for the very insightful comment! I didn't realize that treating ADHD leads to reduced substance abuse, its almost a bit paradoxical.
Of course! Here's a longitudinal study on it, if you're interested: https://psychiatryonline.org/doi/10.1176/appi.ajp.2017.17070733
Basically, the ADHD itself causes executive dysfunction and lack of impulse control, so you get people who especially at early ages try substances impulsively and get addicted. Treatment means they're more able to think through consequences and be less impulsive, so they don't abuse substances as often. And if we're really concerned about giving them a controlled substance because of a hx of substance use, we always have nonstimulant options as well (atomoxetine, viloxazine).
Yeah, two ways to think about it: one is that ADHD generally increases impulsivity, but two is that ADHD can make you less able to pay attention to how much you've already used in a sitting. So what might be a beer or two (for example) turns into a binge and the patient with ADHD may not have even noticed until they're completely hammered.
I will say you will encounter controversy among psychiatrists with what role - if any - stimulants have in the treatment of ADHD with a SUD history. I think many of us would agree with the comment above you that treating ADHD reduces SUD relapse risk, and that an SUD history isn't a formal contraindication to stimulant use. But a lot of us do worry that even well-intentioned and well-monitored stimulant prescriptions are more likely to be habit-forming in patients with that history, and I think a good number of us would probably turn to atomoxetine/viloxazine, clonidine/guanfacine, or possibly even bupropion (especially if comorbid depression) before we dusted off our DEA numbers.
Yes, it's an important part of an ADHD evaluation to rule out bipolar, because stimulants can bring on a manic episode. She should have at least been aware of this, and her bullshit detector was apparently inoperational. It seems that she was a practitioner of "nodding dog" style therapy.
I think this is a good summary and I agree with the vast majority of your points. The sticking point for me is whether the NP's sloppy documentation reflects a genuinely slapdash assessment, or resulted from a patient determined to get a stimulant and therefore minimizing symptoms/history not pertinent to ADHD.
Either way, probably wise to settle this. I think the causation argument would have been strained, but I could see a lay jury buying the Plaintiff's likely story of a "lazy/careless psych NP who couldn't be bothered to coordinate with past providers."
It is tempting for plaintiffs to blame the most recent provider (or most recent med or most recent incident), but these tragedies have a long preceding headwind. The parents, the outpatient psychiatrists, the hospitalizations… they couldn’t prevent it… yet an NP with just a few visits and incomplete information is to blame?
My state doesn't allow nurse practitioners to prescribe C2s like Adderall. I have to wonder, in states where NPs practice under a collaborative agreement with a physician, how much responsibility lies with that supervising physician?
Kind of depends on how close the supervision is. If they're directly supervising, they're getting named for participating in the decisions. If they were distant, they could get sued for not being a better supervisor.
How come they settled here given that it was equivocal whether the adderall was the cause of death? This kid sounds like a classic mentally unstable psych patient, threatening suicide multiple times, can’t imagine any jury would fault the NP for his eventual suicide.
I find that juries get it right the vast majority of the time, but its always a roll of the dice. Settling takes out the possibility of a surprise verdict, usually guarantees that the doc/NP doesn't have to pay anything out of pocket, avoids the stress and lost income of trial. Lots of benefits to settling even if you're in the right.
Makes sense, the settlement still is a significant negative mark on your license/history right? I guess it's not worth it to try to fight and win the case vs settle as a mark on your professional record?
I don't think anyone really pays ton of attention unless there is something massively egregious. You're already going to have to disclose it for licensing and hospital credentialing, regardless of if you win at trial, settle, or it gets dismissed.
Ahh ok. Sorry follow up question, what do you mean anyone really pays a ton of attention? I thought it would be a big barrier to future licensing and credentialing etc?
Can't wait to read the whole thing in more detail but initially the thing that REALLY stands out about not getting any prior records is that it appears the ADHD diagnosis was incorrect and had been documented as such by multiple providers yet the NP just took the patient at their word.
As a pathologist who never interviews the patient, I do often make a distinction between a "reported history" of something vs. a "documented history" with the latter meaning I can see the exact lab value/imaging/physician/procedure/etc note *establishing* the diagnosis. Otherwise it's a reported history of a diagnosis.
I wonder when we will see a similar such case involving one of those apps/websites (e.g. hims) where they are advertised less as "get the proper medical care you need" and more "get the prescription drugs you seek." I would bet this case is less an example of "the problems with discontinuity" and rather a deliberate maneuver by the patient to get stimulants when his prior physician cut him off.
I've heard there's an impending onslaught of lawsuits against Cerebral for basically forcing all their telepsych "providers" to give Adderall to anyone who wants it.
That was the company I was trying to think of but couldn't. Hims strikes me less as a controlled substance pusher and more of a bizarre normalization of ED in young men that almost certainly would be better treated with therapy rather than Viagra, but I'm guessing the insurance reimbursement on these virtual viagra visits is much better.
I bet Hims is going to do super well getting men into their system for hair loss in 20-30s, then flipping them over to the erectile dysfunction side when they're older. Not a bad business model at all.
The only wrinkle with that is I recall them being ED stuff first and THEN added their hair loss meds. Also unlike the viagra/cialis commercials with guys/couples who are clearly older, all their ED ads featured young guys/couples.
Who redacts these articles? Only reason I ask is that I believe "a_______ a___ parts" is actually a typo for the suicide victim's place of work.
That could be.... I redact them myself because I prefer to focus on the learning pearls, and also to protect the doctors and patients involved. I technically don't have to, I could publish their names and work locations, etc... I just feel like its a bit unethical and I'd probably have to deal with more people getting mad at me for putting the details of their very sad/intimate situations into the limelight.