“Stimulants will help anyone focus better. And a lot of young people like or value that feeling, especially those who are driven and have ambitions. We have to realize that these are potential addicts — drug addicts don’t look like they used to.”
By ALAN SCHWARZ | The New York Times
VIRGINIA BEACH — Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.
It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have A.D.H.D., not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard’s doctor to stop prescribing him Adderall, warning, “You’re going to kill him.”
It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.
The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for A.D.H.D., doctors and other experts said.
Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.
Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.
Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”
Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.
“Any step along the way, someone could have helped him — they were just handing out drugs,” said Richard’s father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Mr. Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it.”
“…when he was in elementary school he fidgeted, daydreamed and got A’s. he has been an A-B student until mid college when he became scattered and he wandered while reading He never had to study. Presently without medication, his mind thinks most of the time, he procrastinated, he multitasks not finishing in a timely manner.”
Dr. Waldo M. Ellison
Richard Fee initial evaluation
Feb. 5, 2010
Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for A.D.H.D.
Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any A.D.H.D. symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Mr. Fee also expressed concerns about the safety of his son’s taking daily amphetamines for a condition he might not have.
“The doctor wouldn’t give me anything that’s bad for me,” Mr. Fee recalled his son saying that day. “I’m not buying it on the street corner.”
Richard’s first experience with A.D.H.D. pills, like so many others’, had come in college. Friends said he was a typical undergraduate user — when he needed to finish a paper or cram for exams, one Adderall capsule would jolt him with focus and purpose for six to eight hours, repeat as necessary.
So many fellow students had prescriptions or stashes to share, friends of Richard recalled in interviews, that guessing where he got his was futile. He was popular enough on campus — he was sophomore class president and played first base on the baseball team — that they doubted he even had to pay the typical $5 or $10 per pill.
“He would just procrastinate, wait till the last minute and then take a pill to study for tests,” said Ryan Sykes, a friend. “It got to the point where he’d say he couldn’t get anything done if he didn’t have the Adderall.”
Various studies have estimated that 8 percent to 35 percent of college students take stimulant pills to enhance school performance. Few students realize that giving or accepting even one Adderall pill from a friend with a prescription is a federal crime. Adderall and its stimulant siblings are classified by the Drug Enforcement Administration as Schedule II drugs, in the same category as cocaine, because of their highly addictive properties.
“It’s incredibly nonchalant,” Chris Hewitt, a friend of Richard, said of students’ attitudes to the drug. “It’s: ‘Anyone have any Adderall? I want to study tonight,’ ” said Mr. Hewitt, now an elementary school teacher in Greensboro.
After graduating with honors in 2008 with a degree in biology, Richard planned to apply to medical schools and stayed in Greensboro to study for the entrance exams. He remembered how Adderall had helped him concentrate so well as an undergraduate, friends said, and he made an appointment at the nearby Triad Psychiatric and Counseling Center.
According to records obtained by Richard’s parents after his death, a nurse practitioner at Triad detailed his unremarkable medical and psychiatric history before recording his complaints about “organization, memory, attention to detail.” She characterized his speech as “clear,” his thought process “goal directed” and his concentration “attentive.”
Richard filled out an 18-question survey on which he rated various symptoms on a 0-to-3 scale. His total score of 29 led the nurse practitioner to make a diagnosis of “A.D.H.D., inattentive-type” — a type of A.D.H.D. without hyperactivity. She recommended Vyvanse, 30 milligrams a day, for three weeks.
Phone and fax requests to Triad officials for comment were not returned.
Some doctors worry that A.D.H.D. questionnaires, designed to assist and standardize the gathering of a patient’s symptoms, are being used as a shortcut to diagnosis. C. Keith Conners, a longtime child psychologist who developed a popular scale similar to the one used with Richard, said in an interview that scales like his “have reinforced this tendency for quick and dirty practice.”
Dr. Conners, an emeritus professor of psychiatry and behavioral sciences at Duke University Medical Center, emphasized that a detailed life history must be taken and other sources of information — such as a parent, teacher or friend — must be pursued to learn the nuances of a patient’s difficulties and to rule out other maladies before making a proper diagnosis of A.D.H.D. Other doctors interviewed said they would not prescribe medications on a patient’s first visit, specifically to deter the faking of symptoms.
According to his parents, Richard had no psychiatric history, or even suspicion of problems, through college. None of his dozen high school and college acquaintances interviewed for this article said he had ever shown or mentioned behaviors related to A.D.H.D. — certainly not the “losing things” and “difficulty awaiting turn” he reported on the Triad questionnaire — suggesting that he probably faked or at least exaggerated his symptoms to get his diagnosis.
That is neither uncommon nor difficult, said David Berry, a professor and researcher at the University of Kentucky. He is a co-author of a 2010 study that compared two groups of college students — those with diagnoses of A.D.H.D. and others who were asked to fake symptoms — to see whether standard symptom questionnaires could tell them apart. They were indistinguishable.
“With college students,” Dr. Berry said in an interview, “it’s clear that it doesn’t take much information for someone who wants to feign A.D.H.D. to do so.”
Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: “reading books — read 10!” her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, “Okay rewrite.”
Richard filled that prescription later that afternoon. It was his third month’s worth of medication in 43 days.
“The patient is a 23-year-old Caucasian male who presents for refill of vyvanse — recently started on this while in NC b/c of lack of motivation/ loss of drive. Has moved here and wants refill”
Dr. Robert M. Woodard
Notes on Richard Fee
Nov. 11, 2009
Richard scored too low on the MCAT in 2009 to qualify for a top medical school. Although he had started taking Vyvanse for its jolts of focus and purpose, their side effects began to take hold. His sleep patterns increasingly scrambled and his mood darkening, he moved back in with his parents in Virginia Beach and sought a local physician to renew his prescriptions.
A friend recommended a family physician, Dr. Robert M. Woodard. Dr. Woodard heard Richard describe how well Vyvanse was working for his A.D.H.D., made a diagnosis of “other malaise and fatigue” and renewed his prescription for one month. He suggested that Richard thereafter see a trained psychiatrist at Dominion Psychiatric Associates — only a five-minute walk from the Fees’ house.
With eight psychiatrists and almost 20 therapists on staff, Dominion Psychiatric is one of the better-known practices in Virginia Beach, residents said. One of its better-known doctors is Dr. Waldo M. Ellison, a practicing psychiatrist since 1974.
In interviews, some patients and parents of patients of Dr. Ellison’s described him as very quick to identify A.D.H.D. and prescribe medication for it. Sandy Paxson of nearby Norfolk said she took her 15-year-old son to see Dr. Ellison for anxiety in 2008; within a few minutes, Mrs. Paxson recalled, Dr. Ellison said her son had A.D.H.D. and prescribed him Adderall.
“My son said: ‘I love the way this makes me feel. It helps me focus for school, but it’s not getting rid of my anxiety, and that’s what I need,’ ” Mrs. Paxson recalled. “So we went back to Dr. Ellison and told him that it wasn’t working properly, what else could he give us, and he basically told me that I was wrong. He basically told me that I was incorrect.”
Dr. Ellison met with Richard in his office for the first time on Feb. 5, 2010. He took a medical history, heard Richard’s complaints regarding concentration, noted how he was drumming his fingers and made a diagnosis of A.D.H.D. with “moderate symptoms or difficulty functioning.” Dominion Psychiatric records of that visit do not mention the use of any A.D.H.D. symptom questionnaire to identify particular areas of difficulty or strategies for treatment.
As the 47-minute session ended, Dr. Ellison prescribed a common starting dose of Adderall: 30 milligrams daily for 21 days. Eight days later, while Richard still had 13 pills remaining, his prescription was renewed for 30 more days at 50 milligrams.
Through the remainder of 2010, in appointments with Dr. Ellison that usually lasted under five minutes, Richard returned for refills of Adderall. Records indicate that he received only what was consistently coded as “pharmacologic management” — the official term for quick appraisals of medication effects — and none of the more conventional talk-based therapy that experts generally consider an important component of A.D.H.D. treatment.
His Adderall prescriptions were always for the fast-acting variety, rather than the extended-release formula that is less prone to abuse.
“PATIENT DOING WELL WITH THE MEDICATION, IS CALM, FOCUSED AND ON TASK, AND WILL RETURN TO OFFICE IN 3 MONTHS”
Dr. Waldo M. Ellison
Notes on Richard Fee
Dec. 11, 2010
Regardless of what he might have told his doctor, Richard Fee was anything but well or calm during his first year back home, his father said.
Blowing through a month’s worth of Adderall in a few weeks, Richard stayed up all night reading and scribbling in notebooks, occasionally climbing out of his bedroom window and on to the roof to converse with the moon and stars. When the pills ran out, he would sleep for 48 hours straight and not leave his room for 72. He got so hot during the day that he walked around the house with ice packs around his neck — and in frigid weather, he would cool off by jumping into the 52-degree backyard pool.
As Richard lost a series of jobs and tensions in the house ran higher — particularly when talk turned to his Adderall — Rick and Kathy Fee continued to research the side effects of A.D.H.D. medication. They learned that stimulants are exceptionally successful at mollifying the impulsivity and distractibility that characterize classic A.D.H.D., but that they can cause insomnia, increased blood pressure and elevated body temperature. Food and Drug Administration warnings on packaging also note “high potential for abuse,” as well as psychiatric side effects such as aggression, hallucinations and paranoia.
A 2006 study in the journal Drug and Alcohol Dependence claimed that about 10 percent of adolescents and young adults who misused A.D.H.D. stimulants became addicted to them. Even proper, doctor-supervised use of the medications can trigger psychotic behavior or suicidal thoughts in about 1 in 400 patients, according to a 2006 study in The American Journal of Psychiatry. So while a vast majority of stimulant users will not experience psychosis — and a doctor may never encounter it in decades of careful practice — the sheer volume of prescriptions leads to thousands of cases every year, experts acknowledged.
When Mrs. Fee noticed Richard putting tape over his computer’s camera, he told her that people were spying on him. (He put tape on his fingers, too, to avoid leaving fingerprints.) He cut himself out of family pictures, talked to the television and became increasingly violent when agitated.
In late December, Mr. Fee drove to Dominion Psychiatric and asked to see Dr. Ellison, who explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father. Mr. Fee said he had tried unsuccessfully to detail Richard’s bizarre behavior, assuming that Richard had not shared such details with his doctor.
“I can’t talk to you,” Mr. Fee recalled Dr. Ellison telling him. “I did this one time with another family, sat down and talked with them, and I ended up getting sued. I can’t talk with you unless your son comes with you.”
Mr. Fee said he had turned to leave but distinctly recalls warning Dr. Ellison, “You keep giving Adderall to my son, you’re going to kill him.”
Dr. Ellison declined repeated requests for comment on Richard Fee’s case. His office records, like those of other doctors involved, were obtained by Mr. Fee under Virginia and federal law, which allow the legal representative of a deceased patient to obtain medical records as if he were the patient himself.
As 2011 began, the Fees persuaded Richard to see a psychologist, Scott W. Sautter, whose records note Richard’s delusions, paranoia and “severe and pervasive mental disorder.” Dr. Sautter recommended that Adderall either be stopped or be paired with a sleep aid “if not medically contraindicated.”
Mr. Fee did not trust his son to share this report with Dr. Ellison, so he drove back to Dominion Psychiatric and, he recalled, was told by a receptionist that he could leave the information with her. Mr. Fee said he had demanded to put it in Dr. Ellison’s hands himself and threatened to break down his door in order to do so.
Mr. Fee said that Dr. Ellison had then come out, read the report and, appreciating the gravity of the situation, spoken with him about Richard for 45 minutes. They scheduled an appointment for the entire family.
“meeting with parents — concern with ‘metaphoric’ speaking that appears to be outside the realm of appropriated one to one conversation. Richard says he does it on purpose — to me some of it sounds like pre-psychotic thinking.”
Dr. Waldo M. Ellison
Notes on Richard Fee
Feb. 23, 2011
Dr. Ellison stopped Richard Fee’s prescription — he wrote “no Adderall for now” on his chart and the next day refused Richard’s phone request for more. Instead he prescribed Abilify and Seroquel, antipsychotics for schizophrenia that do not provide the bursts of focus and purpose that stimulants do. Richard became enraged, his parents recalled. He tried to back up over his father in the Dominion Psychiatric parking lot and threatened to burn the house down. At home, he took a baseball bat from the garage, smashed flower pots and screamed, “You’re taking my medicine!”
Richard disappeared for a few weeks. He returned to the house when he learned of his grandmother’s death, the Fees said.
The morning after the funeral, Richard walked down Potters Road to what became a nine-minute visit with Dr. Ellison. He left with two prescriptions: one for Abilify, and another for 50 milligrams a day of Adderall.