Lenard A. Adler, MD, is a Professor of Psychiatry and Child and Adolescent Psychiatry at the NYU Grossman School of Medicine and Director of the Adult ADHD Program at NYU Langone Health.
Topics covered:
Visit our website for more insights on psychiatry.
Podcast producer: Jon Earle
Lenard A. Adler, MD, is a Professor of Psychiatry and Child and Adolescent Psychiatry at the NYU Grossman School of Medicine and Director of the Adult ADHD Program at NYU Langone Health.
Topics covered:
Visit our website for more insights on psychiatry.
Podcast producer: Jon Earle
[00:00:00] DR. THEA GALLAGHER: Welcome to NYU Langone Insights on Psychiatry, a clinician's guide to the latest in psychiatric research. I'm Dr. Thea Gallagher, a clinical psychologist and assistant professor at NYU Langone. Each episode, I interview a leading psychiatric researcher about how their work translates into clinical practice.
Today, I'm speaking with Dr. Lenard Adler. Dr. Adler is director of the Adult ADHD Program, where he treats adults who have ADHD. He also helps manage associated conditions such as major depressive disorder, bipolar disorder, and anxiety disorders. His research examines ways to evaluate and treat people who have ADHD, using new assessment tools, medications, and psychotherapies.
Dr. Adler, why don't you tell us a little bit about what you do, what your line of research is, what your main focus is right now.
[00:00:50] DR. LENARD ADLER: Sure, I run the Adult ADHD Program in the Department of Psychiatry at the NYU Grossman School of Medicine. I've been doing that since 1995. It's my primary area of research. We work with adults with ADHD. It's a clinical and research program. We look at the pathophysiology, meaning the underlying causes and the symptoms and impairments of the condition, and also look at—done a lot of work on new treatments. So we spend our time establishing rating scales, ways to diagnose and assess symptoms and also associated symptoms, things that travel with the symptoms of adult ADHD, which are important because we're understanding that it's not just the core symptoms of ADHD but the other symptoms that travel with it that lead adults to have great difficulty. So that's how we spend our time, and it's been a very gratifying area to work in.
[00:01:48] DR. THEA GALLAGHER: Wonderful. And when you're talking about the core symptoms versus the other symptoms, can you break down exactly what those are?
[00:01:55] DR. LENARD ADLER: Sure, so let's back up the truck just a little bit and talk about how the diagnosis is made. So for a DSM-5 diagnosis, the diagnostic manual requires four things. The first are for an adult, it's current symptoms, so significant symptoms in the last six months of five out of nine inattentive symptoms. Those are the trouble paying attention, easy distraction, forgetfulness, and/or five out of nine hyperactive impulsive symptoms: restlessness, trouble staying seated, impulsive talking, trouble waiting.
But symptoms alone aren't enough to make a diagnosis. If you have either the inattentive and/or the hyperactive impulsive, you also have to have trouble from the symptoms. And the trouble from the symptoms has to occur in two out of three domains in the individual's life, meaning either at school or work, home or in social settings. Because we wouldn't make a diagnosis just based upon having symptoms; you have to have trouble from it.
The disorder has to have its onset in childhood. Older diagnostic criteria require the onset by the age of seven. We now require it by middle school, so it's by the age of 12. You have to have significant symptoms in more than one setting. That's the third criteria. And the last criteria is that you have to be sure that the symptoms and impairments are from ADHD and not another mental health disorder, because ADHD often co-travels with other conditions.
So there are nine inattentive symptoms and nine hyperactive impulsive symptoms. But the research that we and others have done have shown that there are other major symptom sets that co-travel with ADHD and somewhat with other conditions that can be quite impairing and somewhat difficult to treat that lead adults with ADHD to have difficulty. And those symptom sets are symptoms of executive function deficits. Those are higher-level problems with organization planning, task execution, task completion, and working memory, which is keeping things in mind.
Now those symptom sets don't occur just with ADHD, they occur with other mental health disorders. But they occur about as often as the inattentive symptoms occur for adults, and that means they happen at least half the time for adults with ADHD—over half the time, and they're quite troubling. And then there are also symptoms of emotional dysregulation, meaning not a mood symptom where they're persistently present, but a changeable mood, trouble regulating your mood, overreactivity of mood, losing control of your mood very quickly, changeable mood throughout the day.
And those symptoms happen about 45 percent of the time for adults with ADHD. Those two symptom sets are quite noticeable and also tend not to respond as well to our standard pharmacologic treatment that we use to treat the classic symptoms of trouble paying attention and hyperactivity impulsivity. We've also been studying one other symptom set that I think we'll talk about a little bit later, which is sluggish cognitive tempo symptoms, which also seem to co-travel. But the important thing is that these symptom sets not only co-occur, but can be quite troubling and impairing for adults with ADHD.
[00:05:21] DR. THEA GALLAGHER: Yeah. And I know that there has been a lot on social media about ADHD specifically. I feel like maybe the most attention has been brought to that in the last year about, have you not been properly diagnosed. And women maybe missing diagnoses as a child, and you talked earlier about how important it is to be diagnosed when you're younger. What are your thoughts about this idea that there is this adult onset, or is it just a misdiagnosis? And also, this concept of maybe women being underdiagnosed.
[00:05:55] DR. LENARD ADLER: So it's not that you have to be diagnosed as a child. It's that you have to have significant symptom onset in childhood. Most adults with ADHD actually are not diagnosed in childhood. Many are, but most aren't, and it requires significant symptoms. And many bright individuals with ADHD get by in childhood. You have to retrospectively go back, look at their report cards, talk to their parents, and find out that the symptoms were there, they were just underperforming or they were very bright and they skated by.
It's when life got much more complicated that the symptoms really came to the forefront. When they got to middle school and they had to change classes and they had a backpack and they had to—homework wasn't handed to them, and they had to manage things on their own. Or it's when they got to college and they picked their own classes and nothing was handed to them. They had to manage their own time. Or later in life when they got married and they had another set of expectations to manage. Or sometimes we see that it's when they got a promotion and they went from managing themselves to having to manage others.
So there can be adult presentation of ADHD, the actual adult onset of ADHD without any childhood symptoms can occur, but the literature is that's uncommon. As for the issue of differential presentation for men and women, that's actually quite real. We know that the diagnostic rates for girls and boys are different. It's about two to one, twice as common in boys as girls, and it's about even in terms of the gender split for adults, men and women. In our program we find we have about as many men and women in the adult program.
And that's in many ways because women tend to present later in life. It's for multifactorial reasons, we think. In part because women tend to carry a higher burden, the studies have shown, of the inattentive symptoms. And therefore, they tend to be missed in childhood a little bit more commonly. It's something we're working on, but if you tend to be more behaviorally disruptive because you have more hyperactivity, you're more likely to be disruptive in the classroom and come to attention. But if you have more of the inattentive symptoms, you're gonna be just seen as underperforming and not diagnosed and that may lead more women to come in as adults.
[00:08:20] DR. THEA GALLAGHER: And what should parents, psychiatrists look for in children to maybe be more aware of these inattentive symptoms, like you said, underperforming—how are they typically measured or how can we be more aware of the symptoms?
[00:08:36] DR. LENARD ADLER: I want to focus on adults with ADHD if we can today.
[00:08:38] DR. THEA GALLAGHER: Sure.
[00:08:39] DR. LENARD ADLER: Rather than children, because I'm an adult psychiatrist. But the key thing is that these symptoms need to be present in more than one setting. So if a child is having difficulty at home in terms of following instructions and following through and also in the classroom, that really needs to start being something to think about and to follow through on.
For adults, a variety of things tend to bring them into attention and bring them into treatment. Sometimes it's that they've had a change in their life events, as I mentioned, sometimes it's that they've gotten a promotion and something's happened where their cognitive load has increased. And that brings their symptoms forward. Sometimes it's that they have a child that's been diagnosed with ADHD and they or their spouse see the same symptoms that they've been experiencing. And that will bring them into attention.
[00:09:27] DR. THEA GALLAGHER: And when we're talking about this concept of neurodivergence that you hear a lot, can you expound on whether we use that clinically as a way to categorize adulthood ADHD?
[00:09:41] DR. LENARD ADLER: So in terms of neurodiversity, that's really speaking of a spectrum of attentional issues. And when we think about ADHD, we really try to think about it as a formal diagnosis where we reach a threshold of impairment, that this is something different from what we observe in the normal population, and that there is significant impairment and therefore this is a disorder and it's a condition. And we know that there's an issue that makes it a true disorder because untreated adult ADHD has significant consequences.
If you don't treat adult ADHD, and this is why we developed screeners and want to improve recognition, if you don't treat adults with ADHD, they're less likely to obtain the same educational level as adults who don't have ADHD, they're more likely to be divorced and separated; they're more likely to use substances; they're more likely to smoke cigarettes; their quit rate is half; they're more likely to have motor vehicle accidents; they're more likely to contract sexually transmitted diseases. There's a whole risk of consequences and impairments that occur if the ADHD is not diagnosed and treated.
[00:10:51] DR. THEA GALLAGHER: Yeah. And when you were talking earlier about the emotion dysregulation, is that causal? Is that a symptom of the ADHD that because it's so difficult and challenging to manage the symptoms that the emotion regulation comes as a result? Or is that part of the sequelae of symptoms at the base of them?
[00:11:13] DR. LENARD ADLER: No, we actually think it's an associated co-traveling symptom set as it is part of other symptoms that occurs in other conditions. But it seems to be a co-traveling symptom set and not just a sort of— like an anxiety disorder, or something that would be the result of having ADHD and having it untreated. It's actually a part and parcel of a co-traveling symptom set and it's actually the symptom set that tends to be the least medication-responsive of all the symptoms.
The literature shows that although the executive function deficits—these higher level organization planning, procrastination, keeping things in mind—they respond somewhat to our stimulant medicines and our non-stimulant medicines, but not as well as the trouble paying attention and the hyperactivity impulsivity. The emotional dysregulation symptoms are even less responsive and not significantly responsive, and this is where cognitive behavioral therapy, our main therapy, can be most helpful for adults with ADHD.
[00:12:16] DR. THEA GALLAGHER: Yeah. And I want to get into talking more about the treatment. But before we do, can you tell us more about this other symptom you were talking about, the sluggish cognitive tempo?
[00:12:24] DR. LENARD ADLER: Yeah, sure. So in addition to these sort of the core, trouble paying attention and hyperactivity impulsivity and the other associated symptoms, there's another nine symptoms of sluggishness. So there are some adults with ADHD, and it is probably less than half of them, that have a lot of sluggishness, trouble getting started, daydreaming. And they're not just inattentive, they're really slow moving. And there are nine core symptoms here.
It happens in kids and adults. It happens less than half the time, but when it happens, the literature is—and in a study we just finished with the group at Mount Sinai in adults—we find that they have a lot more impairment in adults with ADHD than the group that just had ADHD alone. So having the two together, and some of the work from Russ Barkley also showed this, having the two together leads to more significant impairment. So the group that had these two comorbidities came in with a lot more difficulty.
And we just completed and published in the last year a treatment study with one of the stimulants, looking at adults with ADHD who had both conditions, both ADHD and sluggish cognitive tempo, and treated them with lisdexamfetamine versus placebo in a crossover design, groups got either lisdexamfetamine or placebo and then crossed over to the alternate treatment, and the stimulant was highly effective in treating both the ADHD and the sluggish cognitive tempo. Of note, only 25 percent of the improvement in the sluggish cognitive tempo symptoms was due to improvement in ADHD symptoms.
So we really have a lot of work to do here in parceling out a recognition of sluggish cognitive tempo, what it means and how we treat it, but this was the first stimulant study in adults looking at how we treat it in adults with ADHD.
[00:14:15] DR. THEA GALLAGHER: And if a patient is presenting with sluggish cognitive tempo, what would a clinician look for or try to assess—obviously, and you can tell us which measures people should administer—but is there something, some symptoms that they should be looking for?
[00:14:33] DR. LENARD ADLER: So the first thing when working with adults with ADHD is to get the diagnosis correct and I think you have to—there are no shortcuts. There is a DSM-5 screener that we've developed with Ron Kessler at the Harvard School of Public Health. The screener is available on a website www.adhdinadults.com. You can register and screen all your patients if you want to. But a screener only identifies individuals at risk for the condition. It doesn't give you a diagnosis.
And there's no shortcut in terms of assessing current symptoms, impairments, childhood onset, and ruling out the comorbidities—that the symptoms are and impairments are from ADHD and not something else. And there are scales that can help you do that, and clinicians should be aware there are symptom checklists that are available that help you get an inventory of current symptoms. But first, you've got to get the diagnosis right and see whether adult ADHD is present in and of itself and whether there are any co-traveling conditions because things like mood disorders, bipolar disorder, major depression, anxiety disorders and substance use disorders commonly co-travel with ADHD. And you really need to know what you're treating.
But in addition to that, assessing for these co-traveling symptoms is important because the executive function deficits and emotional dyscontrol and some sluggish cognitive tempo can lead to these pockets of impairment that if you don't recognize that they're there, you may improve the core symptoms of inattention and hyperactivity and impulsivity in your patients, but they may be telling you they're not getting better, and it may be because you haven't assessed these executive function problems. And if you don't look for trouble in planning, trouble in task execution, or a changeable mood, or for sluggish cognitive tempo, they may still have sluggishness that isn't getting better. You have to ask about it, or else you won't know.
[00:16:28] DR. THEA GALLAGHER: And when we're talking about even things like decision making, does that play a role in the symptoms as well?
[00:16:35] DR. LENARD ADLER: So difficulty making decisions can be due to a variety of different things. So that can be due to trouble with task initiation. Adults with ADHD, if it is, it can be from ADHD core symptoms or also from some of these executive function problems. Some of our imaging studies show that trouble with task initiation is quite difficult for adults with ADHD if they're not interested in the task. The salience of the task is quite critical for individuals with ADHD.
We all have difficulty doing things that we're not interested in. It's not that easy, but we chore through it and do it. But for an adult with ADHD, it's quite difficult. If they're not interested in the task, they really don't want to do it and will often just put it off and that leads to the procrastination. And that can lead to difficulty in making decisions because they just won't make them if they're not interested in the task. They'll just put it off.
[00:17:34] DR. THEA GALLAGHER: And so shifting a little bit into treatment, I want to start with what do we know about ADHD and medication that maybe we didn't know 10 years ago?
[00:17:44] DR. LENARD ADLER: So we know we've got lots of good treatments available. There is an ADHD professional society, which is APSARD. If people want to learn about it, it's at www.APSARD.org, and we're in the process at APSARD of starting to develop adult ADHD guidelines in the US. And we don't have treatment guidelines yet in the US for adults with ADHD. There are international guidelines at this point. But what we do know is we have a variety of medications that work, and when we look at the treatment of adults compared to the treatment of kids, adults have lived with their symptoms for a majority of their lives. And medications play a more prominent role in treating adults for that reason.
And we have two classes of medicines for adults, the stimulant and the non-stimulant medicines. And the stimulant medicines break out into two classes. The stimulants are the methylphenidates and the amphetamines. The methylphenidates are the Ritalin-type compounds, and then the amphetamines are the Adderall-, Vyvanse-type compounds.
They all come in long-acting forms and in fact, the FDA-approved indicated medicines for adults tend to be the long-acting ones, and those are the ones that we tend to recommend using preferentially for adults because we want to treat adults throughout the day, and adults have long days. And remember, diagnostically as part of the diagnostic criteria, you have to have trouble in two out of three domains of your life. You're not just impaired at work. And if you treat the individual just at work and not at home and they're impaired at home, they're still gonna have trouble.
So we're really looking to treat the individual throughout the day, and some of the short-acting versions of these medicines will only last three to four hours, and it requires administration multiple times a day. Not that you don't use them, but generally we will start with a long-acting version of these stimulant medicines. And there are a variety of different preparations of them—that is new. Some of them are prodrugs, meaning that they don't work until they have a metabolic change in them and then they're absorbed into the brain.
All of the stimulant medicines are controlled substances, meaning that they are scheduled compounds and require ongoing monitoring and a prescription each time and can't be renewed. But their effects are quite robust and do need ongoing monitoring. They all have side effects and have the potential, as I mentioned, mostly in individuals who don't have ADHD, for abuse liability and have to be monitored for that. But also have effects on blood pressure and pulse and do require monitoring for that, but also a variety of other side effects. But again, they have very large beneficial effects on ADHD symptoms. One of the largest in psychiatry that we have.
The non-stimulant medicines have effects throughout the day. And there are two that are approved for adults: atomoxetine (Strattera) has been on the market for over a decade. And then a newer one, viloxazine, (Qelbree) has been on the market for about a year. And they both are effective and they are selective norepinephrine reuptake inhibitors. The stimulants affect two chemicals in the brain, both norepinephrine and dopamine, and the non-stimulants affect just the norepinephrine piece. So we have a variety of medications that we can use—that as new—they come in different ways that they act in terms of how they're delivered, in terms of whether they're stimulants or non-stimulants, whether they're shorter acting or longer acting. The point is to get the right fit for the right patient in terms of individualizing the treatment.
[00:21:26] DR. THEA GALLAGHER: And is there anything with getting the right fit for the right patient that stands out for who would get what kind of medication?
[00:21:33] DR. LENARD ADLER: So we're not at this point able to look at the symptoms per se and say who should get which medicine pre hoc based on predicting, based on symptoms. There are some low hanging fruits that will help us pick which medicine. If there's recent substance use, obviously the substance use needs to be brought under the treatment umbrella and you would consider use of a non-stimulant because there's no abuse liability there. So that's one thing to obviously think about.
Tics would be another consideration in that the stimulant medicine runs the risk of tic exacerbation, although the literature is that most of the time they don't exacerbate tics. It's a rule of thirds there with the long-acting versions of these medicines—about a third of the time they improve the tics, a third of the time it's unchanged, and sometimes they do worsen and it has to be monitored. And tics can be treated, but if the tics are really prominent and bad, you're gonna think about a non-stimulant first there.
And then you also look for familial response. If there is a child in the family that’s responded to a particular medicine, or if they've responded to a methylphenidate compound. You might preferentially use that compound for the individual coming in for treatment. And then you start to look at things in terms of the profile of the medication that you're selecting. How long is it acting? What is the delivery system? Those sorts of things can influence the medicine you'll select.
[00:22:59] DR. THEA GALLAGHER: And with the gold-standard treatment, is it recommended that adults with ADHD get both cognitive behavioral therapy and medication? Or can you try medication first and then augment it with a cognitive behavioral therapy approach?
[00:23:14] DR. LENARD ADLER: We don't have any head-to-head studies in adults really comparing the two. The optimal treatment may be combining both cognitive behavioral therapy—and there are some smaller studies that have looked at the combination and have found greater efficacy. And that probably is optimal treatment, but there aren't large scale studies looking at that in adults. So yes, that is the optimal treatment, but many adults will opt for starting with pharmacotherapy first and then seeing if it makes significant improvement in change. And then if they're unable to, then adding in the cognitive behavioral therapy at that point in time.
[00:23:49] DR. THEA GALLAGHER: And let's talk a little bit about this medication shortage. How is that impacting people and what should clinicians know and do about this shortage that we're experiencing?
[00:24:00] DR. LENARD ADLER: So in about the last six months or so, there has been a shortage of stimulant medicines that has been occurring. It's been in mostly the amphetamine-type medicines, specifically mixed amphetamines, so it's—Adderall has been the most prominent. But more recently, it's been occurring more commonly with the methylphenidates and with oral methylphenidate, Concerta. It’s multifactorial, it seems, in origin. It seems to be somewhat due to supply-chain problems, also production problems and also more individuals coming in for diagnosis and treatment, in part due to the pandemic and also online diagnostic providers coming on who are making more diagnoses and prescribing more.
So it's multifactorial, but it's a very real thing. I have patients that have had to go up to 15 pharmacies to try to find their medicines. And it's not a small thing. They run out of their medicine and their symptoms and impairments come back. They can't see if the pharmacy has the medicine till they have a prescription. So you know, we in our program have to send the prescription and then if the pharmacy doesn't have it, then it has to be canceled. So the patients obviously feel bad that they have to call in and keep canceling. It's also quite a burden for them each time we have to send it. They also feel bad that they're asking us to do it, in spite of our reassuring them it's part of what we do and we don't mind doing it at all.
But it really is quite a burden and we've had numerous patients run out of their medicine while they're trying to find it. It's been a problem. It may very well ease in the new year as production—because there is a set amount of each of these medicines that can be produced that sort of is refurbished each year. And it may kick over in the new year and that's the hope.
[00:25:47] DR. THEA GALLAGHER: And is there anything the providers can do to manage it on their end?
[00:25:51] DR. LENARD ADLER: So I think being available, being in contact with your patients or reassuring them that you're gonna stay in touch and that you'll rewrite the prescriptions. And sometimes it's required changing medications, and that can be a little touch and go. But sometimes there have been benefits from it. I've had some patients that have switched preparations and actually found some benefit in trying a new medication that they were hesitant to try previously. They'd been on something for a long time and were hesitant to change and this necessitated a switch and they found some benefits. There was a hidden plus in this. It's not something that we wanted to do, but it just requires ongoing discussion, monitoring and work.
[00:26:32] DR. THEA GALLAGHER: And is there any data to show that there's a difference between generic and brand?
[00:26:37] DR. LENARD ADLER: So that's an area that the FDA—it's up to the FDA. It approves by equivalency of these medications, and in many ways the prescribing is dictated by the pharmacy benefits manager who will approve which medicine is paneled. And that can make a difference in terms of which one will be paid for by the benefits plan.
[00:26:59] DR. THEA GALLAGHER: So when patients like and I don't know if you want to answer this, but I know that I've had patients who really swear that they don't experience the benefit unless it's the brand. And that's why the shortage has been so difficult. Any thoughts on that?
[00:27:13] DR. LENARD ADLER: I'm not experiencing having patients finding shortages particularly in brand versus generic. I think that's not been a major contributing factor here.
[00:27:23] DR. THEA GALLAGHER: Okay. What should providers know or do if they are finding the patients—it's treatment refractory?
[00:27:32] DR. LENARD ADLER: So the first thing if a patient is refractory and not getting better is to start back and look at the diagnosis. Be sure that you've gotten the diagnosis correct. That's always the first step, to go back, rethink things, look at these associated symptoms we've talked about earlier today. Also, get a second opinion. It's always good to have another set of eyes look at what's been going on. And another consultation is always a good thing.
Is there a comorbidity that you've missed? As I mentioned, other conditions often travel with ADHD. And it’s not that ADHD wasn't present, but there's a subtle comorbidity that's been present, be it a mood disorder or an anxiety disorder, that's hampering the improvement of the patient, and the patient isn't getting better until that's treated. Is there something else going on in the patient's life that's hampering the improvement? Are there issues with the patient taking the medication? There are major issues sometimes in that ADHD individuals just sometimes don't take their medicine.
You want to be sure that they're taking it. And sometimes it's also these associated symptoms. Go over those with individuals and see if it's executive function problems. You can help attention. Someone can pay attention to a task, they're more able to stay on task, but if they choose not to use their planner, not to write down their appointments, and not to start things even if they're more able to, they may not be functioning better, and that's where cognitive behavioral therapy can really be quite helpful.
[00:29:02] DR. THEA GALLAGHER: Yeah, absolutely. And you were talking earlier that sometimes there's a greater risk for certain risky behaviors or relationship failures or relationship challenges. Or even you said, more likely to have an STI. And are these factors sometimes what draw people to treatment and then, like we're saying, what do you start to treat first? You always try to treat the ADHD first and then hope that the other problems remit or follow suit?
[00:29:35] DR. LENARD ADLER: I think it depends on the nature of the risky behavior. I mean, if it's a gambling addiction—the idea is to bring whatever the risky behavior is under the treatment umbrella. You can't treat through the ADHD or the risky behavior or if they're all not brought under the treatment umbrella. It would be hard to treat the gambling addiction if you didn't recognize the ADHD, let's say. So the point is to throw a large tent here and to bring everything under treatment.
[00:30:06] DR. THEA GALLAGHER: Great. Any final thoughts or something I missed that you want to make sure to highlight for providers out there?
[00:30:13] DR. LENARD ADLER: So for providers, if you have patients with mood disorders or anxiety disorders or substance use disorders that aren't getting better, it's not just for ADHD that I want you to think of, I'm suggesting thinking about those other conditions. There's also reverse comorbidity, that ADHD commonly occurs in those conditions. If you have refractory patients with those disorders, think about ADHD, assess them. If you are a primary care provider and you're listening to this podcast, we have a good screener for you to, just like you screen for depression, you can screen for ADHD.
We know from some of the surveys we've done that ADHD patients tend to come into your practice, and they come in with vague medical complaints and may be clogging up your office. There's real benefits to them and for you in making this diagnosis, and there's real consequences to not having these diagnoses made. So there are no shortcuts in making the diagnosis once you screen for it, but the benefits are really real. And this is a condition that gets better. We have really good treatments. The patients can get better. It's really gratifying to treat, and it's a condition where you can make a real difference. So it's one where we have good treatments and you can make a real difference in individuals’ lives.
[00:31:36] DR. THEA GALLAGHER: That's wonderful and that's a great note to end on. Thank you so much for being with us today, Dr. Adler, and we'll see you next time.
[00:31:43] DR. LENARD ADLER: Great. It's been a pleasure talking with you.
[00:31:46] DR. THEA GALLAGHER: Thanks so much again to Dr. Adler for that conversation. If you enjoyed this episode, be sure to rate and subscribe to NYU Langone Insights on Psychiatry on your podcast app. On the next episode of NYU Langone Insights on Psychiatry, I'll be talking about addiction and health equity with NYU's Dr. Ayana Jordan. I hope you'll join us for that. For the Department of Psychiatry at NYU Langone, I'm Dr. Thea Gallagher. See you then.