The Attention Mortgage: The High Cost of Fast ADHD Care

A Note on Context and Purpose: The following article is a systemic and philosophical analysis of decision-making, consumer behaviour, and healthcare standards. It’s intended for educational purposes only and doesn’t constitute specific medical advice for any individual case. The comparisons drawn between material goods and clinical care are metaphorical, designed to illustrate the concepts of value, longevity, and cognitive load. We support patient choice and the variety of service provision within the healthcare sector.

Introduction: The Parable of the Work Boots

There is a famous economic concept, often found in literature, known as the "Boots Theory of Socioeconomic Unfairness."

It describes a cruel reality: a person with little money is forced to buy cheap boots that leak and break, eventually costing them more over a decade than the wealthy person who could afford the "End Game" boots upfront.

In the boots metaphor, the tragedy is that the poor person has no choice. In the current landscape of mental health, we face a similar tragedy. Due to the overwhelming pressure on the NHS, many patients are forced into a private market they didn't ask to be in. They are looking for the "Budget Option" not because they want low quality, but because they are desperate for access.

However, for those patients who do have the privilege of financial choice, there is a vital lesson here. If you treat your neurobiology like a "false economy"—seeking the quickest, cheapest assessment available—you risk falling into the same trap: a cycle of temporary fixes, rejected shared care, and long-term costs that far exceed the initial investment.

The "Attention Mortgage"

We are navigating a marketplace designed to induce decision fatigue. Whether you’re pursuing a medical diagnosis or a pair of boots, the market offers you a spectrum.

(Note: We understand that for many, this is the only option due to systemic failures in public funding. However, for those with the privilege of choice, this option often proves to be a false economy.)

The "High-Volume" Model

Services prioritising speed often utilise condensed assessment formats. While accessible, this can compromise clinical detail. Such reports may not always be accepted by other medical providers or institutions, leaving you with a diagnosis that lacks universal transferability—often forcing patients to seek unregulated advice on online forums.

‍The "Hybrid" Model

More detailed than a checklist, but reliant on rotating staff to handle volume. This creates fragmented care—you may be diagnosed by a consultant and titrated by another clinician. The trade-off is continuity: you become a set of case notes, forcing you to manage the narrative between strangers.

The "Consultant-Led" Model - Diagnosis and Treatment

A higher initial investment of time and capital, but designed for longevity. This approach prioritises rigorous bio-psycho-social mapping over simple tick-box exercises. It offers true stability with continuous medical oversight, looking beyond just medication to support your wider health. Crucially, it provides a permanent clinical partner who understands your history, ready to support you if new challenges or complex conditions emerge in the future.

The Hidden Cost: Calculating the Mortgage

For the neurotypical mind, navigating this spectrum is a chore. For the ADHD mind, it is a trap. The cycle of buying - researching, purchasing, finding the solution inadequate, and replacing—isn't just a financial drain. It creates what I call "The Attention Mortgage."

You aren't just spending money; you are taking out a loan against your future focus. Just like the leaking boots, every failed attempt to "fix" your mental health quickly results in more time lost, more administrative stress, and more cognitive dampening.

The Neurochemistry of "The Hunt"

If the 'Middle' is an uncertain middle-ground, why do we keep choosing it? Why is the ADHD brain so susceptible to the cycle of "Buy, Consume, Replace"? The answer lies in Dopamine.

The Thrill of the Chase

For the ADHD brain, the acquisition of a solution is often more stimulating than the application of it. We call this "The Hunt."

"When you decide you need a solution, your brain enters a state of hyperfocus. You open multiple tabs. You compare specifications obsessively. You daydream about how this service will change your life. "Once I have this, I will finally be productive."

This research phase is intoxicating. It is pure, distilled possibility. In the context of the boots, buying the new budget pair feels like a solution. "Finally," you think, "Dry feet." But because the quality isn't there, the solution is temporary. The "Hunt" must restart in six months.

The Pollution of Focus

Every "semi-broken" thing in your life is a cognitive drain.

• The printer that jams every third page.
• The shoes that let in water.
• The clinical care that leaves you with unanswered questions.

These are "Micro-Frictions." They are tiny interruptions to your flow. For a neurotypical brain, they are annoyances. For an ADHD brain, which struggles with emotional regulation, they can be disastrous interruptions.

The "End Game" Philosophy

The solution to this entropy is a shift in strategy. We must move from Cost Per Purchase to Cost Per Wear.

What is "End Game"?

In gaming culture "End Game" gear is the equipment you acquire at the highest level. It is the best-in-slot.

Once you have it, you never need to look at that equipment slot again.

Applying this to clinical care means: "I am going to acquire the most robust, comprehensive version of this solution, and I am going to rely on it for decades."

To be clear, "End Game" in psychiatry does not mean the condition is cured or the medical journey is over. It means you have finally secured the highest quality tools to manage it for the long run.

The Benefits of "One and Done"

• The Silence: When you have confidence in your care, you stop looking at advertisements. You stop searching for upgrades. You’ve exited the market. This frees up massive amounts of mental bandwidth.
• The Reliability: "End Game" solutions address the "Micro-Frictions."
• The Legacy: True quality is not disposable. It is an investment in your future self.

The "Dopamine Review" Trap

One of the most common questions raised regarding "Fast/Rapid" services is the social proof: "But this fast service has 5,000 five-star reviews online. Surely they must be excellent?" To understand why this happens, we have to understand the unique sociology of mental health.

The Mechanism of Validation

A patient seeking an ADHD diagnosis is often looking for much-needed answers. Years of struggle. Sleepless nights. The feeling of being out of place. When they enter a service, receive a diagnosis, and are validated, their brain is flooded with relief.

• Relief: "I am not broken."
• Validation: "It has a name."
• Hope: "There is a way forward."

The Review Harvest

It is in this exact moment—often literally minutes after the diagnosis is delivered—that automated feedback requests often arrive. Asking a patient to review their care in the precise moment of diagnosis is like asking a thirsty traveller to review a glass of water. Naturally, the relief is immediate. They aren't necessarily reviewing the complexity of clinical safety or long-term stability; they are reviewing the immense relief of finally being heard.

The Silence of Success (The Privacy Paradox)

Conversely, why do many rigorous medical practices have fewer reviews than high-volume consumer services? The answer lies in the nature of the condition. In the world of consumer goods, if you buy a great car, you tell everyone. In the world of mental health, success is often silent.

When a high-functioning executive or lawyer recovers—when they save their job, marriage, child's education, secure the promotion, and stabilise their mind—they do not always run to a review platform. They want to close the chapter. They want privacy. They do not want their professional identity linked to a public struggle. Therefore, some of the most successful outcomes in psychiatry are the ones you never hear about.

The Friction of Safety (Why Good Medicine Can Feel Restrictive)

Furthermore, mental health is not linear. It can be a journey of recovery and relapse. In a "Customer Service" model, the customer is always right. In a Medical Model, the patient must sometimes be protected.

A responsible Consultant must sometimes say "No."

• "No, we cannot titrate higher because of your cardiovascular metrics."
• "No, the diagnosis is not ADHD, it is complex trauma."

This friction often results in short-term unhappiness. A patient denied the answer they wanted may feel that the session "didn't work out." But that "No" was an act of medical integrity. A clinical record with absolutely zero friction or negative feedback is a statistical anomaly in medicine—it may imply a reluctance to make difficult clinical decisions.

The Real Review (The 1-Year Lag)

The true test of a clinic is not how you feel 10 minutes after the appointment. It is how you feel one year later.

• When the medication titration becomes complex.
• When side effects emerge.
• When the administrative team is needed for urgent support.
• Crucially: When your NHS GP reviews the Shared Care agreement.

If we could see reviews from patients one year post-diagnosis, particularly regarding Shared Care acceptance, the star ratings might look very different. Immediate ratings are often a metric of Validation Efficiency rather than Clinical Excellence.

It is important to note that while a robust, Consultant-led report significantly increases the likelihood of NHS Shared Care acceptance, it cannot guarantee it. Some regions (ICBs) currently enforce blanket bans on private agreements regardless of clinical quality. However, a comprehensive report remains your strongest asset in advocating for your care or transferring to another specialist, whereas a standard ‘checklist’ diagnosis is unfortunately far less likely to be accepted.

The "Cortisol Tax" (Why Treatment Requires a Safety Margin)

In high-performance engineering, you never run a system at 100% capacity without a safety margin. The same applies to clinical treatment.

Whether you are funding your care from savings, insurance or considering financing options, it is vital to understand that Financial Pressure can be a Clinical Factor.

The Asset of Patience (If You Have the Means)

If you are in the position to fund "End Game" care comfortably, you possess a distinct medical advantage: The Luxury of Patience.

ADHD treatment is rarely a straight line. It is a biological negotiation. One patient may stabilise in four weeks; another may require nine months of complex titration. Because you have a financial "buffer," you are not watching the clock. You do not need to "rush" the result to stop the billing. This allows us to optimise your treatment based purely on physiology, not budget.

The Danger of the "Stretch" (The Debt Trap)

We are acutely aware that advising against "stretching" finances highlights the deep inequality in our healthcare system. It is a harsh reality that high-quality private care is not accessible to everyone, and in an ideal world, the NHS would be sufficiently funded to provide this level of unhurried care to all.

However, until that systemic reality changes, we have a clinical duty to warn against the "Debt Trap."

There is a natural temptation for patients to use loans or credit to access high-level care. While we understand the desperation that drives this, we generally advise caution. Debt creates anxiety. Biologically, this floods the system with Cortisol, which actively dampens the prefrontal cortex—the exact part of the brain we are trying to treat. If you enter treatment with the added weight of accruing interest, you create a biological conflict of interest in your own body.

‍

The Clinical Pivot (Your Mind is Not a Commodity)

Now, we must apply this logic to the most important asset you own: Your Mental Health.

If you buy a budget pair of boots, you get wet feet. If you buy a "rapid" mental health assessment and it "breaks" (i.e., is not accurate or limited in scope), you can lose years of your life.

Mental Health is Not a Simple Utility

We have been conditioned to treat healthcare like a utility. We look for the "Best Value." But mental health isn't a broken bone. A fracture is binary; it is broken, or it is not. Mental health is a complex system woven from biological, psychological, lifestyle and systemic factors. You cannot audit this system in a rushed meeting with someone you’ve never met who is forced by a high-volume schedule to work at speed.

The "Fast-Access" Model

We often see a proliferation of 'Rapid Access' services. 'Get diagnosed in minutes.'

It feels accessible. You get the label. But as the sector evolves into a multimillion-pound industry for private equity, we must look at the history of clinical standards. Historically, a robust ADHD assessment was a significant undertaking. Even today, looking at modern gold-standard frameworks (such as the DIVA-V), it is recommended that this single part of the assessment takes up to 1.5 hours to complete.

If an entire assessment process is completed in less time than it takes to properly administer a single diagnostic interview, we must ask: what is being left out?

The Risks of the "Rapid" Assessment:

1. The NHS Rejection: You take your report to your GP. They often reject it if it does not meet strict NICE guidelines or the local Integrated Care Board (ICB) criteria.
2. The Subscription Trap: Some models require ongoing monthly fees. If you stop paying, you lose your care. You are effectively "renting" your stability.
3. The Missed Complexity: What if your symptoms were actually a thyroid issue, early-stage burnout or complex trauma? A rapid session carries a higher inherent risk of overlooking differential diagnoses.
4. The Result: Years later, you are still struggling and eventually have to seek a second opinion with a Specialist. Total Cost: Multiples of the original investment, plus years of lost progress.

The "End Game" Assessment (Ownership vs. Renting)

What does an "End Game" assessment look like? It is the Gold Standard ADHD Assessment (UK) model: Comprehensive and Consultant-Led. It usually takes a minimum of two hours, involving deep history taking, collateral information from family, and a rigorous exclusion of other causes. But consider the Return on Investment (ROI).

The Clinical "Right to Repair" (Understanding the Mechanics)

Just as a high-quality machine comes with a schematic, a high-quality assessment gives you the blueprint of your own mind.

It explains the mechanics. "Here is how your dopamine receptors interact with your circadian sleep pattern." This empowers you to engage in self-repair. You gain agency.

Just as a high-quality machine comes with a schematic, a high-quality assessment gives you the understanding of your own mind.

Continuity of Care (The Ageing Mind)

ADHD is not static; it evolves as you age. The challenges you face at 18 are distinct from those at 40 or 50. Seeing the same Consultant for years allows for fine-tuning through these seasons. We track the subtle changes in your functioning over decades. This is not a transaction; it is a clinical relationship.

Ownership of the Data

A comprehensive report is a permanent medical document that must stand up to scrutiny. It is yours. You own it. You can take it to a GP, a private insurer, or a university. You are securing a medical reality, not "renting" a diagnosis.

Conclusion: Reducing the Noise

We live in a noisy world. While "fast-track" options promise speed, they often add to that noise, leaving patients with medical uncertainty rather than clarity. The "End Game" option—whether it is a pair of boots or a psychiatric evaluation—is about Silence. It is about doing it once, doing it right, and having absolute confidence in the foundation you have built.

Think about Cost Per Wear. A diagnosis is not a one-off event; it is something you "wear" every single minute of every single day for the rest of your life. If there is one thing that deserves "End Game" quality, surely it is the lens through which you view your reality?

Exploring Comprehensive Care

If this philosophy of thorough, long-term care resonates with you, and you are based in London or the UK, we invite you to explore our practice.

Whether you require a robust initial diagnosis or a specialist second opinion, our Consultant-led service is dedicated to the time, detail, and clinical rigour your health deserves.

‍

References

Sam Vimes ‘Boots’ Theory of Socio-Economic Unfairness | Terry Pratchett

The Relationship Between Financial Worries and Psychological Distress Among U.S. Adults - PMC

How ADHD became a multimillion-pound industry for private equity

Private Adult ADHD Assessment London & UK | Dr Stefan Ivantu

ADHD Diagnosis: More Than Just a Label

ADHD: How to get an accurate diagnosis in UK?

The Luxury of Focus: ADHD in a Trillion-Dollar Economy

How Psychiatrists can Help You Diagnose and Treat ADHD

ADHD: Could It Be an Evolutionary Advantage?

Are Video Games the Future in Mental Health?

The Professional's Guide to ADHD Shared Care Agreements UK

The ADHD-Sleep-Burnout Triangle: Understanding the Cycle

ADHD and Career Burnout: Causes, Signs & Recovery Tips

‍

Disclaimer: This blog is for educational and general information purposes only and does not constitute medical advice, diagnosis, or treatment. The content is not intended nor implied to be a substitute for professional consultation with your own doctor or qualified healthcare professional. Diagnosis and treatment should always be conducted under the supervision of a qualified medical professional. Information about mental health topics and treatments can change rapidly, and we cannot guarantee the content's currentness. For more information, you can check the Royal College of Psychiatrists (rcpsych.ac.uk).

Image Credits: Pexels.com and Shutterstock.com.