ADHD

Adult ADHD, medicated carefully.

Adult ADHD is real, common, and badly served by two extremes: the ten-minute questionnaire that hands stimulants to anyone who asks, and the reflexive suspicion that treats every adult who asks for help as a drug seeker. Medication management here takes the slower road: a genuine evaluation first, then stimulant and non-stimulant options chosen on evidence, and 30-minute follow-ups that track whether the medication is changing your actual life, at work, at home, and on the ordinary Tuesday.

Evaluation before prescription

An hour of history before a single milligram

ADHD medication works well when the diagnosis is right and poorly, sometimes harmfully, when it is a guess. So the first visit is the full 60 minutes, and it reaches back further than most intakes do.

Measurement and the follow-through problem

The medication is the easy part. Staying on it is the treatment.

The open secret of adult ADHD care is that a large share of patients quietly stop their medication within the first year or two. Not because it stopped working, but because nobody was tracking whether it worked, the dose drifted, the side effects nagged, and life got busy. A prescription without a follow-up system is how that happens. Here, the follow-up is the system: 30 minutes, the ASRS repeated, and a plain conversation about what the medication did to your mornings, your inbox, your temper in traffic, and your ability to finish the thing you started. If the honest answer is "not much," the dose, the timing, or the medication changes. What does not happen is a year of refills nobody evaluated.

Adjustments follow one rule: one change at a time, with a date to judge it. Dose increases, formulation switches, and timing moves are all ordinary tools, used in sequence so each result teaches us something. And deprescribing has its place in ADHD care too. Some patients, after a stable stretch with real systems built around them, want to trial a lower dose or a medication break, on breaks from work or over a slow summer. Done deliberately, with measures running and a restart plan in hand, that is good medicine, not noncompliance. What I will not support is the unplanned version: running out, drifting off, and concluding from a chaotic month that the medication never helped.

The in-person visit, stated up front

One visit a year, in person, planned together

Most ADHD medications are controlled substances, and honesty about the rules belongs on this page, not in fine print after you book. Federal and DEA requirements call for an in-person visit, typically once a year, for patients prescribed controlled substances. This practice is telehealth by design, so those visits happen by arrangement, not on a fixed office schedule: I see patients in person in different states to meet federal and DEA requirements, planned together well in advance. The practice keeps offices in San Francisco, New York, and Austin, and the practice locations page lays out where the practice is based. None of this is a surprise we save for later; it is part of the first conversation, before the first prescription is written.

Safety and the long view

Baselines first, and a plan that outlasts the honeymoon

Before any stimulant is prescribed, the baseline is set: blood pressure and pulse, a cardiac history taken seriously, sleep as it currently runs, appetite and weight, and a substance use history taken without theater. Stimulants raise heart rate and blood pressure modestly in most people, and modestly is a word that should be verified in your body, not assumed. Those numbers are rechecked at follow-ups, because the point of a baseline is the comparison. If your history includes cardiac disease, fainting, or a family history that deserves a second look, that conversation happens before the first capsule, and coordination with your cardiologist or primary care physician is part of the plan when the picture calls for it.

The structure around controlled substances is deliberate and stated up front. One prescriber owns the prescription. Refills live inside the follow-up rhythm: the medication is renewed at visits where its effect, its side effects, and your measures are reviewed, not by message in between and not in five-minute encounters. The annual in-person visit described above is part of the same structure. None of this is suspicion; it is how a controlled medication stays a medical treatment instead of a habit with a label.

And once a year, at minimum, the long question gets asked: is this dose, this medication, still the right size for the life you are actually living now? Jobs change, bodies change, and a dose set for a crisis year can be more than a settled year needs. A careful reduction trial, planned in a stable season with the ASRS and your own report as the judges, is a normal part of good ADHD care, and so is deciding together that the current dose is earning its place and leaving it alone.