How do you approach stimulant prescribing for ADHD in a patient with auditory hallucinations, that can be command in nature (suicide), who will not take an antipsychotic medication?

Without knowing more history, I would never prescribe stimulants for such a patient. I respectfully disagree with Dr. Gill. Stimulants can cause and do exacerbate psychosis. And I’m not sure what Dr. Gill means when he says Wellbutrin is the culprit? A patient with Chronic Schizophrenia with Acute Exacerbation needs to be treated first and only with an antipsychotic medication. Sometimes other agents are required. Once the psychosis has lifted, one should then see what other sorts of signs and symptoms of other conditions are present, and treat such accordingly. One needs to treat the number target symptom(s) with the best agent(s), and which has the fewest side-effects. One also has to have a hierarchy of conditions treated. I was taught t...

The first order of business is diagnostic clarity. Is the disorder causing hallucinations also causing symptoms that are being mistaken for ADHD? Is ADHD pre-existing, and now the patient is presenting with hallucinations? Are the hallucinations secondary to existing ADHD treatment (stimulants can cause hallucinations in some cases, and should be discontinued if this occurs)? Which disorder is primary?

Assuming the ADHD diagnosis is established, treatment with stimulants will depend on the underlying etiology of the hallucinations. If due to untreated schizophrenia, prescribing a stimulant for ADHD is not indicated. If hallucinations are secondary to trauma, treating ADHD symptoms with an alpha agonist may be more beneficial, as it may be h...

It’s important to remember that our psychiatric diagnostic process is not a simple checklist, and a hierarchical approach must not be forgotten. In lieu of psychosis, suicide, and command hallucination, inattention must be considered within that psychopathology system. A diagnosis of ADHD is not warranted, and stimulant use would not be appropriate.

While I generally try to work with patients who refuse the ideal medications (in this case, the antipsychotics), I also would not give them a stimulant (which could exacerbate their condition). I once had a patient who had very high blood pressure tell me I was “Required” to give him Adderall because he had a diagnosis of ADHD. I refused to give it until he had his blood pressure brought under control. He fired me on the spot, which was ok with me. At the end of the day, I had to be the doctor and determine if the treatment would be safe.

With the patient in this scenario, I would refrain from giving a stimulant. If they refused an antipsychotic, I would try to work on other options (lithium to reduce suicidal ideation, etc., psychotherapy)...

I would not prescribe a stimulant medication for a patient with auditory hallucinosis, especially one with command hallucinations of suicidal content. You mentioned that the patient will not take an antipsychotic. At least where I live, if a patient presents a danger to themselves, which I would assume this vignette fits, they clearly are in imminent need of an antipsychotic and would meet criteria for involuntary commitment, in which case medications over objection would be ordered. I hope this is helpful.

I will not prescribe a stimulant to this patient.

More than likely, their ADHD is caused by their psychotic process.

I will wait to treat them with appropriate antipsychotic involuntarily and keep evaluating the MS.

1. Clarify the diagnosis. ADHD will not cause hallucinations. Stimulants may worsen hallucinations, cause hallucinations at high doses, and should NOT be prescribed when active hallucinations are present.

• Is the AH a true hallucination? If so, what is the cause? Considering organic causes are ruled out, the most common psychiatric causes are MDD with psychosis, bipolar disorder, schizophrenia spectrum disorder, and substance abuse.

2. Treat the underlying cause. Treat the patient as a whole and not just a diagnosis. In the presence of AH, this by far trumps the treatment of ADHD. ADHD treatment then becomes secondary until psychosis is treated appropriately.

3. I would get to the bottom of why this patient is refusing the treatment with...