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17 May 2023

There are concerns around ADHD overdiagnosis. But what about misdiagnosis?

A BBC Panorama documentary raises urgent questions, such as how many people are being told they have ADHD when they need other mental health support.

By Sophie McBain

What’s behind the precipitous rise in the number of adults diagnosed with ADHD? A BBC Panorama investigation broadcast on Monday (15 May) has highlighted a troubling number of private clinics, some of which now also see NHS patients, that diagnose people with the condition and offer prescriptions for stimulant medication on the basis of, in at least one occasion, a 45-minute Zoom consultation centred on a series of generic, meaningless questions such as: “Do you have problems concentrating at school?”

The Panorama reporter Rory Carson was diagnosed with ADHD and offered medication by three private clinics. He paid between £685 and £1,095 per appointment and was quoted prescription costs of more than £50 a month, indefinitely. When he visited an NHS consultant, who met him for an in-person interview that lasted over three hours and delved deeper into his mental health and personal history, the psychiatrist concluded that he didn’t have ADHD. Carson’s research suggested that the overwhelming majority of people who attend these private ADHD clinics receive an ADHD diagnosis. (All three clinics denied that they overdiagnose people.)

The documentary has not gone down well with patient advocacy groups, such as the ADHD Foundation, which argued in its response to the programme that the bigger problem is that the condition remains under-diagnosed and that most people with ADHD are offered little or no support. (The group also observed, quite fairly, that the NHS psychiatrist was the only one given advance notice that his consultation was being filmed as part of an investigation and that few NHS patients receive a three-hour interview.)

ADHD is a neurodevelopmental condition characterised by problems of inattentiveness, hyperactivity and impulsiveness that can be severely impairing: studies have suggested that people with unaddressed ADHD are more likely to be socially isolated, to struggle in school, to be involved in car accidents or suffer other accidental injuries, to have substance abuse problems and to be involved in the criminal justice system. Last year, I reported on the dramatic increase in adults receiving an ADHD diagnosis in the UK.

Yet many of the symptoms of ADHD are widespread – who doesn’t have problems concentrating these days? – and determining who meets the threshold for a diagnosis is not a straightforward decision. Set the clinical bar too high and you potentially exclude vulnerable people from receiving specialist support, life-changing medication and a useful way of understanding how their brain works. Set it too low, and the diagnosis essentially becomes meaningless: ordinary human behaviour is unhelpfully pathologised, people who don’t need it are encouraged to take long-term medication with potentially harmful side effects, and the idea takes root, in certain uncharitable circles, that ADHD is simply an excuse, and not a real “thing”.

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[See also: The NHS can’t help the mentally ill – can influencers?]

Much of the public conversation around ADHD has focused on this problem: are we diagnosing too many people, or not enough? But the urgent question raised by the Panorama documentary is better thought of as: how many people are being misdiagnosed with ADHD, when a different mental health diagnosis, and different support, would be more useful?

A substantial proportion of the people willing to spend hundreds of pounds to see a private psychiatrist, while NHS waiting lists are years-long, will be desperate and emotionally vulnerable. It is not surprising that many of them suspect they have ADHD, given how common the symptoms are and how much the condition has come to dominate online discussions about mental health, but what is surprising – and statistically unlikely – is that around 90 per cent of the time the underlying problem is indeed ADHD, rather than say depression or bipolar disorder or substance misuse or insomnia or simply unhappiness.

This was a concern that Allen Frances, a leading psychiatrist and emeritus professor at Duke University in North Carolina, flagged when I interviewed him last year. Frances, who chaired the publication of the fourth edition of the so-called psychiatrist’s bible, the DSM-IV, and subsequently argued that mental health disorders are being massively overdiagnosed, noted that mental health diagnoses are subject to fads: underlying symptoms rarely change, but how we tend to understand and interpret them does. “Human nature is very stable, but how people understand distress is labile,” he told me. One risk of psychiatrists diagnosing ADHD hastily, sloppily and inaccurately, is that they make people sicker – particularly if they offer these patients the stimulant drugs used to treat ADHD. “You don’t want someone who has bipolar disorder, which is classically characterised by inattention and hyperactivity, to be getting a stimulant because stimulants can make bipolar disorder even worse,” Frances warned. “That’s true for a number of other conditions that get mistaken for adult ADHD.”

When the psychologist employed by a clinic named Harley Psychiatrists told Carson over Zoom that she thought he met the criteria for ADHD, she concluded the call with the words “there’s no expiration date, you’re diagnosed for life”. How might these words be received by someone desperately unhappy, alone and scared? The only follow-up was a seven-minute video call with a psychiatrist who prescribed stimulant medication without even asking Carson if he suffered from any other mental health conditions. Even though the clinic accepted that Carson “should not have been able to obtain a prescription” and claimed to have updated its processes, we have no way of knowing how many desperate people have been misdiagnosed, or even how many have found themselves processed by what one former Harley Psychiatrists patient featured on Panorama, Casey, described as a “diagnostics factory”. “These people were supposed to help me, and they took advantage of me,” Casey tells the BBC, wiping away her tears. Simply seeing this as a problem of “overdiagnosis” understates the size of this medical – and national – scandal.

[See also: Are you mentally ill, or very unhappy? Psychiatrists can’t agree]

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