Executive Dysfunction is a challenge for many people with ADHD, as well as Depression, Bipolar Disorder, Trauma and Anxiety, among other disorders. Executive Dysfunction impairs ability to plan, focus attention, remember instructions, and manage multiple tasks. Because of this, it’s sometimes hard to make it to appointments on time or remember when you need a refill on a medication.
So what do we do about it?
We kind of get stuck between the idea of “what can I do to help myself remember?” and “my mental health professional should understand and work around me.”
I’m here to focus on what we in mental health can do to help you.
While it’s unrealistic for mental health professionals to always be able to accommodate someone who is late or frequently misses appointments or requests a refill at the last minute, there are things we can do to help support you to be able to succeed with treatment.
Technology is a wonderful thing in many ways. Many Electronic Health Records, or EHRs, are able to automatically send out text, email or voice reminders; email and text reminders can often be imported directly into your calendar, to make it easier to set an alarm.
Alarms don’t work for everyone, though. For virtual appointments, I’m often able to do a text or a phone call to remind patients to join, if you haven’t within the first few minutes of the appointment. This doesn’t always work for high-volume practices, but is something that can help for some.
March 2020 brought with it many terrible things, but telehealth, particularly in psychiatry, has been an improvement in many ways. It does allow for a lot more flexibility, like people being able to schedule an appointment for during times that wouldn’t normally work- as well as being able to join at the last minute. This can be a huge help for people with ADHD and executive dysfunction issues!
There are some limitations though.
We can’t do telehealth if you are:
- In another state or country where the provider isn’t licensed
- Actively driving (including sitting in traffic)
- Not in a confidential area
- Don’t have an adequate wi-fi or cellular connection
We also need to be careful about telehealth if you need things like blood pressure checked, which can be an issue with ADHD medications. Some patients also greatly prefer in-person sessions, or are better able to engage or be observed in-person.
There are some providers that offer telephone-only telehealth appointments, but we should all be prepared that at some point insurers may say that is no longer an option. Telephone-only can also be an issue with some of the medications that people with ADHD or anxiety take. I personally require an in-person visit for anyone that isn’t able to use a video service for telehealth, but while it’s available, telephone only can work in a pinch.
3. Scheduling and prioritizing
And of course, there’s the issue with appointments…
I think another area where we can be helpful for our patients with ADHD and Executive Dysfunction issues is to be mindful of how we schedule. Many of us with ADHD know that we tend to have “time blindness” – or difficulty with keeping track of the current time and underestimating how long some with take- like commuting to an office, or firing up the computer.
Sometimes it helps to talk about what those barriers are. For example, if you get out of work at 5PM, and are likely to sit in traffic for 45 minutes, it isn’t rational to schedule an appointment for 5:30PM- even if it’s the last one of the day. You’ll always be in a rush, trying to leave work early, and probably missing part of your appointment. Even though we know it’s not rational, the time blindness can make that difficult to reconcile- and talking about that honestly with your provider can help.
As a private practice owner, I have the luxury of being able to decide how long my appointment times are, and for most of them, 5 or so minutes late isn’t necessarily a barrier to treatment. On the other hand, I’ve worked in clinics where the schedule is set for me, appointment times are very brief, and spots are often overbooked, and I had no control over that. In that case, being a few minutes late may mean that there’s no place else in the schedule to put a late patient, without causing a lot of other appointments to be late.
4.Setting Expectations for Prescriptions
I try to make sure that when I prescribe a controlled substance for ADHD or anxiety, that my patients know that while I will send the prescription to the pharmacy today, the pharmacy can only hold onto it for 30 days. At that point it expires and a new prescription would need to be issued if it hasn’t been picked up. I think it’s also helpful to know that pharmacies cannot transfer a controlled substance prescription to another pharmacy, even within the same chain. These are a couple of things that are specific to the US, and some of the rules can vary by state, but these are things that providers can make sure their patients know.
I also try to make sure that my patients know that I request that prescriptions are requested a few days before they’re needed. Usually I send a prescription when I see someone, but there are patients who perhaps don’t need to be seen monthly, but legal or insurance limitations mean I can’t give a refill or a 90-day supply. I’ll usually get to a refill the next business day if requested after hours or on the weekend, but if someone isn’t able to remember to request until they’re out on a regular basis, I think the best way I can support that is to make sure that we schedule monthly appointments so the prescription is part of the routine.
Separate from knowing the rules/regulations around prescriptions, is how we get them to you or the pharmacy. Another wonderful advance in technology is the ability to send prescriptions- including prescriptions for controlled substances that are used to treat ADHD- electronically. It wasn’t that long ago that if you ran out of your controlled substance for ADHD that you would have to physically come into the office to pick up a prescription, if there was someone in the office who could write it. Now we can write them from anywhere! Sort of.
e-prescribing is a game changer for last-minute prescriptions! But like all things, there are some limitations.
- Not all states require that controlled substances be sent electronically, so not all providers have the software or ability to do this.
- When sending a controlled substance, the provider needs at least 2 devices to send the prescription (one to send it from and another to authenticate the prescription).
- Not all states will allow an out-of-state prescriber to send a controlled substance prescription for a patient who is visiting (or moving to) the other state.
This is a huge step-up from just a few years ago, but not a panacea. It does still require that you request the medication in enough time that the provider can actually send it. I’ve also seen some patients have difficulties because their pharmacy is out of their controlled substance, and they need to contact the provider to send it to another one, rather than just being able to take back a paper prescription and go to another pharmacy.
These are some actionable ways that we can help you keep on track with treatment. Are there ways you can think of that we can help you function in treatment?