10/22/24

Risking Psychosis and Mania with ADHD

A recent study, “Risk of Incident Psychosis and Mania with Prescription Amphetamines,” found that individuals taking high doses of amphetamines (i.e., Adderall or Vyvanse) had a fivefold increased risk of developing psychosis or mania compared to those who weren’t taking stimulants. Study participants who experienced psychosis or mania were more likely to have a family history of bipolar disorder or psychosis, to take stimulants that had not been prescribed to them, or to use cannabis daily. The researchers suggested caution should be exercised when prescribing high doses of amphetamines, and clinicians should be carefully monitored and screened for symptoms of psychosis and mania.

The lead author of the study said in The New York Times that when working as an inpatient psychiatrist, she noticed that teenagers and young adults were often being hospitalized for new psychosis or mania symptoms without a history of either. Many of these people with first-episode psychosis or mania were taking high doses of stimulants supposedly for ADHD. It was not clear why some people seemed to have a greater risk of manifesting psychosis or mania. A pediatric neurologist and ADHD expert said he had patients on 60-milligram Adderall tablets daily with no problems. He speculated the amphetamine triggered an underlying predisposition and thought more research was needed to understand the risk factors for developing psychosis or mania on stimulants.

The researchers defined a high dose as more than 40 milligrams of Adderall, 100 milligrams of Vyvanse or 30 milligrams of dextroamphetamine. The medium dosage (20 to 40 milligrams of Adderall, 50 to 100 milligrams of Vyvanse or 16 to 30 milligrams of dextroamphetamine) was associated with a 3.5 times higher risk of psychosis or mania.

Amphetamine Use and Psychiatric Disorders

Past studies have linked amphetamine use and psychiatric disorders. “Amphetamine-Related Psychiatric Disorders” noted that, “Psychosis following amphetamine use is characterized by persecutory delusions, visual hallucinations, and symptoms resembling acute psychosis most commonly observed in schizophrenia.” There was also a pattern of high dosage and daily use being associated with higher risks of substance-induced psychosis. “Amphetamines impair the cognitive thought process and subsequently precede acute psychosis. This suggests that continued impairment due to amphetamine use is a precursor to psychosis.”

Amphetamine-induced psychosis appears to have a more rapid recovery. It also seems to resolve with abstinence from stimulants. The NYT article described a 26-year-old female who fits this observation. She had her first psychotic episode while taking Vyvanse for ADHD. She had stopped taking it while pregnant and didn’t resume it until six months postpartum.

She’d often forget when she had taken her last pill and would take one when she remembered—probably leading to her taking more than her prescribed daily dose. She began felt euphoric and highly energetic. “I felt like my brain was exploding with connections.” She thought she was a “super detective,” uncovering people and organizations engaging in child sex trafficking. She also thought someone was drugging her and her baby.

She was hospitalized, taken off Vyvanse, and prescribed an antipsychotic medication. The delusions stopped, but then resurfaced a few weeks later. “Over the course of months, she began to feel like herself again.” The lead author of “Risk of Incident Psychosis and Mania with Prescription Amphetamines” said it can take time for the delusions to clear. “People have to take off a semester or even a year from college before they can go back. So it is very disruptive.”

The woman’s brother was diagnosed with schizophrenia, so at first, she wondered if she was developing a psychotic disorder. But almost a year later, the psychosis and mania have not returned. “She recently began taking a much lower dose of amphetamine: 10 milligrams of Adderall.”

However, the issue isn’t as straightforward as an association between an underlying predisposition for psychosis or mania and stimulant ADHD medication. Medical News Today reported the lead author of the “Risk of Incident Psychosis” study as saying there was limited evidence that prescription amphetamines were more effective in higher doses. “Physicians should consider other medications our study found to be less risky, especially if a patient is at high risk for psychosis or mania.” Another psychiatrist agreed, saying the study prompts an immediate reconsideration of the risk-benefit analysis of prescribing, especially for patients with a history of mental health issues. He suggested using extended-release formulations to minimize peak plasma levels, and emphasize nonpharmacologic interventions as first-line treatments whenever possible.

Additionally, with stimulant use there is a need for regular mental health evaluations and more frequent follow-ups, especially during the initiation and titration phases of amphetamine therapy. There needs to be particular care taken when considering use of amphetamines in patients with a history of psychosis, bipolar disorder, or other psychiatric vulnerabilities.

Another psychiatrist said researchers should explore whether there is a clear causal relationship between high-dose amphetamine prescriptions and the risk of psychosis and mania. The “Risk of Incident Psychosis” study did not find there was an increased risk of psychosis and mania among those who used methylphenidate drugs like Concerta or Ritalin. An article in Science Alert noted both Adderall and Ritalin raise dopamine levels. However, Adderall increases the release of dopamine, while Ritalin blocks the reabsorption of dopamine.

The Ethics of Challenge Studies for Psychosis

When you read the recent reports of the “Risk of Incident Psychosis” study, it may appear the correlation and possible causation of psychosis or mania from stimulant drugs was new information, but it’s not. And the further investigation of whether high dose amphetamine causes psychosis or mania raises some potential ethical questions.

I’ve talked to an individual working to abstain from misusing cocaine, a stimulant, who described paranoid delusions when using cocaine. When using cocaine, he’d think undercover police were hiding in the bushes across from his 2^nd floor apartment, but he could never see them. So, he called in an anonymous tip for a crime happening in the next block of his street, assuming the unseen officers would have to go and investigate. He never saw anyone respond to his “tip.” When he was abstinent, he could describe and laugh about the delusion he had while under the influence of cocaine.

The association of psychosis and mania from using stimulants has also been investigated in psychiatric research for over fifty years. In 1998, Robert Whitaker and Dolores Kong wrote an article for the Boston Globe, “Testing takes human toll.” The authors described how more than 2,000 individuals had been part of a disturbing series of experiments by psychiatric researchers into the biology of psychosis with so-called challenge studies.

In their published accounts, doctors have told of injecting mentally ill patients with drugs designed to exacerbate their delusions and hallucinations. In prestigious journals, they have described studies in which they withheld effective antipsychotic medication from desperate patients who stumbled into hospital emergency rooms. In precise, clinical terms, they have reported how they deliberately stopped giving medication to stabilized schizophrenic patients to see how quickly they became sick again.

These studies were designed to gain knowledge that might lead to improved treatments for schizophrenia and related illnesses. But the experiments offered no possibility of therapeutic benefit to the subjects and exposed them to some measure of psychic pain and risk of long-term harm.

Moreover, this controversial line of experimentation has been marked by repeated instances in which researchers failed to fully disclose the risks to the mentally ill patients and obscured their true purposes.

Dr. Jeffery Lieberman, a former president of the American Psychiatric Association, was one of the researchers who conducted methylphenidate challenge tests. Remember where methylphenidate was not found to precipitate psychosis or mania in the “Risk of Incident Psychosis” study? Yet it was Lieberman’s preferred stimulant in older challenge studies to do exactly that. Dr. Lieberman acknowledged the induced symptoms could be “scary and very unpleasant.” He admitted that some patients got worse, but thought “the symptoms never exceeded the range of severity that occurred in the course of their illness previously.” See “Psychiatry, Diagnose Thyself! Part 2,” for more information on the Boston Globe article and Jeffery Lieberman.

The future research of whether high dose amphetamine use precipitates psychosis or mania essentially means those experiments will likely be some kind of challenge studies. In “Challenge Experiments,” chapter 26 of The Oxford Textbook of Clinical Research Ethics, Franklin Miller and Donald Rosenstein said challenge experiments were among the most controversial forms of clinical research. “They involve experimental interventions aimed at perturbing the biological or psychological functioning of human beings for the purpose of developing scientific knowledge about diseases and their treatment.” No precise definition of challenge experiments has been developed and there is no possible medical benefit for the enrolled participants.

What makes challenge studies morally problematic is their potential to exploit research participants for the good of society. As in the case of all clinical research, this form of experimentation stands in need of ethical justification in accordance with standard ethical requirements. To be ethical, challenge experiments must have scientific or social value; employ valid methods of investigation; select participants fairly; minimize risks and justify them by the potential knowledge to be gained from the research; be reviewed and approved by a research ethics committee; enroll participants who have given informed consent or with ethically appropriate surrogate authorization; and they must be conducted in a way that adequately protects the rights and well-being of research participants.

If there is limited evidence that prescribed amphetamines are more effective in higher doses, and other less risky medications are available to patients who are at high risk for psychosis or mania, why do an experiment to confirm what we already know? What is the risk-benefit of prescribing high doses of stimulant medications to patients with a history of mental health issues? Shouldn’t nonpharmacologic interventions be used as first-line ADHD treatments whenever possible?

07/9/24

Coming Up Short with Adderall and Other ADHD Drugs

Since the FDA first announced a national shortage of Adderall in October of 2022, the shortage has now spread to other ADHD medications such as Focalin, Ritalin, Vyvanse, and others. There are an estimated 10 million adults and 6 million children diagnosed in the U.S. with ADHD who are struggling to fill their prescriptions. Medscape said this is especially challenging for people living in rural and underserved areas. The drug shortage is now into its second year, with no apparent end in sight, begging the question how did we get here?

Medscape noted that manufacturers and federal agencies have blamed the rising demand and shortages on each other. Clinicians added that insurers contribute to the shortages by requiring patients to try one, two or three medications before they authorize a more expensive or newer drug like Vyvanse. Congress has also pressured the DEA and the FDA to explain the continuing ADHD medication shortages.

In August of 2023 the DEA and the FDA publicly blamed the manufacturers for the shortages, claiming they were not using up their quotas for the production of controlled substances. Citing CDC data, the agencies claimed when virtual prescribing was widely permitted in 2020-2021 because of the COVID pandemic, prescriptions increased by 10%. Tele-health startups took advantage of an emergency provision during the pandemic that allowed healthcare providers to prescribe controlled substances like ADHD medications via tele-health. They also took advantage of a treatment loophole in diagnosing adult ADHD.

Although there are guidelines for diagnosing and treating children with ADHD, there are no guidelines for adult ADHD in the US. This meant adults can self-diagnose themselves with ADHD after watching some TikTok videos, describe the largely subjective symptoms to their doctor, and get a prescribed stimulant, which they could then use as a study aide or for cognitive enhancement. See “Is Adult ADHD the Latest Fad Diagnosis?”

The failure of manufacturers to increase their production of ADHD medications to meet the increased demand is puzzling. The DEA estimated that drug makers only sold about 70% of their allotted quotas in 2022, “leaving almost 1 billion tablets un-made and un-sold” in the midst of the ADHD shortage. The DEA and FDA agencies said they called on manufacturers to confirm they are working to increase production to meet their allotted quota amount. If they did not want to increase their production, they would be asked to give up their remaining 2023 quota allotment “so it could be redistributed to a drug maker that would increase production.”

According to the American Society of Health-System Pharmacists, some manufacturers have inexplicably discontinued making immediate and/or extended-release ADHD pills, while others gave no reason for their shortage or refused to comment. This has led some impatient adults to turn to online black markets, searching there for “study help” or “study aids.” The Guardian noted where search terms such as “NFL” or “footballs” are also effective, since a 30mg Adderall tablet vaguely resembles a regulation American football.

But legitimacy on the black market is a huge problem. Since the medication shortage began, underground pills sold as Adderall have been found to contain illicit methamphetamine. DrugsData.org found that so-called Adderall pills have been found in circulation from Boston, to San Francisco and LA. In September of 2022 the DEA’s New England office seized 660,000 Adderall pills laced with methamphetamine. The LA Times reported on an elaborate counterfeiting operation in Mexico that “repackages meth as Adderall, Vyvanse and other name-brand ADHD medications.” See “Bad Things Could Happen with ADHD and the Adderall Shortage.”

What may have begun as a little help cramming for a test or temporary help with the demands of a challenging job, can lead to habitual use and a reluctance to forego the perceived “edge” from the medication. Adderall and most other ADHD medications are stimulant drugs with the potential for misuse or addiction. They are listed as Schedule II Controlled Substances, with the same addictive potential as many opioids. A 2018 study by Compton et al in the American Journal of Psychiatry found that among US adults, 6.6% used prescription stimulants; 4.5% without misuse and 1.9% misused them. That is, 28.8% of all those prescribed stimulants misused them. Fortunately, only a fraction of the adult population (.2%) met the criteria for a substance use disorder.

Approximately 16.0 million U.S. adults used prescription stimulants in the preceding year (annual average), 5.0 million misused prescription stimulants, and 0.4 million had use disorders. Cognitive enhancement was the most commonly reported reason for misusing prescription stimulants. Patients who are using their medication for cognitive enhancement or diverting their medication to others present a high risk.

Additionally, a study published in JAMA Psychiatry found a small, but statistically significant association between long-term use of ADHD medication and cardiovascular disease (CVD), particularly hypertension and arterial disease. “In this case-control study of 278,027 individuals in Sweden aged 6 to 64 years who had an incident ADHD diagnosis or ADHD medication dispensation, longer cumulative duration of ADHD medication use was associated with an increased risk of CVD, particularly hypertension and arterial disease, compared with nonuse.” The authors concluded that given that long-term exposure to ADHD medications was associated with an increased risk of CVD, “the potential risks and benefits of long-term ADHD medication use should be carefully weighed.” It was suggested for clinicians to monitor cardiovascular signs and symptoms throughout the course of treatment.

The co-authors of an editorial in the same issue of JAMA Psychiatry said concerns about cardiovascular risk associated with ADHD medications are among the most serious issues to consider when discussing the option of starting medication for ADHD. Medscape reported the increased likelihood of hypertension with long-term use of ADHD medications “cannot be disregarded.” Across the 14-year follow up period, each additional year of ADHD medication use was associated with an average 4% increased risk of CVD, “with a larger 8% increased risk in the first 3 years of cumulative use.” The co-authors said this factor should be carefully weighed against the benefits on a case-by-case basis. Given the observational nature of the study, they could not prove causality.

Hartman et al gave an overview of the comorbidity of ADHD in adults with anxiety disorders (AD), major depressive disorder (MDD), bipolar disorder (BP) and substance use disorders (SUDs) in Neuroscience and Biobehavioral Reviews. Their review found that the prevalence rates of ADs, MDD, BD and SUDs in adults were substantially higher when compared to adults without ADHD. These associations were not modified by sex. The authors proposed monitoring sub-threshold symptoms of these disorders in persons with ADHS to facilitate early detection and preventative measures in order to prevent or postpone the full onset of comorbidity. They suggested further research was needed on whether “adequate ADHD treatment can directly decrease the risk of comorbid disorders.”

These concerns and the supply shortage don’t seem to have affected the income generated by ADHD medication very much. PsychCentral reported that three medications for the treatment of ADHD were among the most profitable for their manufacturers in 2020: Concerta (menthyphenidate, $3.28 billion), Vyvanse (lisdexamfetamine, $3.01 billion), and Adderall, (amphetamine/dextroamphetamine, $2.35 billion). Based on the total number of prescriptions purchased, Adderall was 4^th and Concerta was 10^th. Vyvanse did not make the top 25 prescriptions listed, likely because its patent did not expire until August 24, 2023.

Yet, not all psychiatrists agree with the DSM-5’s assessment of what constitutes ADHD, let alone its treatment. Sami Timimi said in his article for the International Journal of Qualitative Studies that it required little intellectual effort to conclude the concept and definition of ADHD is full of problems around reliability and validity. “Deciding where to draw the line between what we consider part of the ‘ordinary’ spectrum of behaviours and what we decide is ‘pathological’ is more dependent on cultural than scientific processes.” He said ADHD was not a medical diagnosis, but a cultural construct that spurred the use of stimulant medication, despite the lack of evidence for improved long-term outcomes.

In Saving Normal, Allen Frances, the chairman of the DSM-IV Task Force and part of the leadership for DSM-III and DSM-III-R warned the DSM-5 will mislabel everyday problems as mental illness and turn normal people into “mental patients.” He said, “The easy path to adult ADHD suggested by DSM-5 will mislabel many normal people who are dissatisfied with their ability to concentrate and get their work done, especially when they feel bored and don’t like the work they’re doing.” Symptoms are mostly subjective and based on self-perceptions of poor concentration and task accomplishment. He thought fake adult ADHD would be particularly common in college students, people with demanding jobs, and those who have to struggle to stay awake, like long haul truckers.

Stimulants are among the most effective and safe of medications in psychiatry when given under appropriate supervision for someone who is accurately diagnosed. But they can cause serious side effects in anyone and are especially harmful when taken by someone with another diagnosis that has been misidentified as ADHD (especially substance use or bipolar disorder). The increasing use of stimulants as performance enhancers or for recreation also creates a large and illegal secondary street market.

Frances thought the criteria for a first-time diagnosis of ADHD in adults should be more, not less rigorous. All the many causes of inattention should be first ruled out, and the existing ones be “a continuation of ADHD symptoms that started in early childhood.” He thought any late onset of inattention was caused by something else, not ADHD. “Let’s keep DSM as a manual of mental disorders and not turn it into a vehicle for performance enhancement.”

So, perhaps the shortage with Adderall and other ADHD medications is not such a bad thing. Except, that is, for the people buying what they think is Adderall on the black market. For more information on Adderall, see “Dispatches from the Adderall Epidemic” and its series of articles like: The History of Adderall, My Party Drug of Choice, and Fake Addies.

10/24/23

Is Adult ADHD the Latest Fad Diagnosis? Part 2

Dramatic increases in ADHD diagnoses and prescriptions for ADHD medication noted in Part 1 are not just happening in the U.S. BBC Scotland claimed, “The number of adults receiving an NHS prescription for ADHD had increased seven-fold over the last 10 years.” Data obtained from Public Health Scotland indicated 26,000 patients were prescribed ADHD medications in 2022/23. Almost half were adults. The number of adult prescriptions rose steadily from 1,603 in 2013/14, to 5,920 in 2019/20, and then doubled to 12,182 by 2022/23.

Although ADHD content on social media platforms like TikTok contributes to the current problem of over diagnosis, it didn’t create it. In Saving Normal, Allen Frances, who was the chair for the DSM-IV, said until the mid 1990s ADHD medications had been off patent for decades and could be purchased generically for pennies a pill. There was no advertising to patients or marketing to doctors. Then several newly patented—and expensive—medications ADHD medications came to market. And then drug companies were given the right to advertise to consumers.

The blaring propaganda message was the usual—ADHD is extremely common, often missed, and accounts for why Johnny is a behavioral problem and isn’t learning in school. “Ask your doctor.” Armies of eager sales reps filled the offices of pediatricians, family doctors, and psychiatrists peddling a pill that would magically prevent classroom disruptions and solve home meltdowns. Parents, teachers, and physicians were recruited in an all-out effort to identify and aggressively treat ADHD.

PsychCentral listed the top 25 psychiatric medications in 2020. The top three most expensive medications, making the most money for their manufacturers, were all ADHD medications: methylphenidate (Concerta, $3.28 billion), lisdexamfetamine (Vyvanse, $3.01 billion), and amphetamine/dextroamphetamine (Adderall, $2.35 billion). Adderall had the fourth most prescriptions written with 26.24 million, Concerta was 10^th with 18.55 million prescriptions, and Vyvanse was 20^th with 8.64 million prescriptions.

Dr. Frances Levin of Columbia University, an internationally recognized expert in adult ADHD, said: “It’s difficult to get a clear picture of how many individuals in this country fit a clinical definition for ADHD, when there are no U.S. guidelines for diagnosis and evaluation of ADHD in adults.” Practice guidelines currently exist only for childhood ADHD. She thought both underdiagnosis and overdiagnosis of ADHD are happening. The American Society of ADHD and Related Disorders (APSARD) recently appointed a special committee to write guidelines for adult ADHD in the U.S. Dr. Levin co-chairs the committee. Her understanding of the rise in overdiagnosis is dramatically different than Dr. Frances.

She said in the early 1990s, there was a belief that ADHD diminished with age as well as concern in the scientific community about the validity of diagnosing ADHD in adults. “Then in the 1990s, the increase in diagnoses of childhood ADHD led to greater public awareness.” More adults recognized and reported symptoms in themselves and adult ADHD was added to the DSM-IV in 1994. Older psychiatrists, she said, weren’t schooled in evaluating and treating adults with ADHD; and now younger clinicians don’t get much training or experience with this population. The creation of uniform standards will address a critical need for healthcare providers and patients.

In Saving Normal, Dr. Frances there was no real reason to think that the prevalence of attentional and hyperactivity problems has actually increased. “We now diagnose as mental disorder attentional and behavioral problems that used to be seen as part of life and of normal individual variation.” He suggested six contributing factors to the increase of diagnosing childhood ADHD. There were: wording changes in DSM-IV; heavy drug company marketing to doctors and advertising to the public; extensive media coverage; pressure from parents and teachers to control unruly children; extra time on tests and extra school services if a child had an ADHD diagnosis. “And finally, the widespread misuse of prescription stimulants for general performance enhancement and recreation.”

Unchastened by the false “epidemic” of ADHD already running rampant among kids, DSM-5 has set the stage for creating a new epidemic of ADHD in adults. As usual, the experts worry so much about missed cases, they fail to consider the much greater risk of overdiagnosis. Attentional problems and restlessness are nonspecific and extremely common among normal adults and in those suffering from any of the other mental disorders. The easy path to adult ADHD suggested by DSM-5 will mislabel many normal people who are dissatisfied with their ability to concentrate and get their work done, especially when they feel bored and don’t like the work they’re doing. It will also misdiagnose those whose problem in concentrating is really caused by something else—e.g., substance abuse, bipolar disorder, depression, all the anxiety disorders, psychotic disorders, and many others. No one should ever get diagnosed or treated for adult ADHD until all of these are first ruled out as the primary cause—lest inappropriate stimulant treatment may worsen their already existing psychiatric problems.

He went on to say adult ADHD was already too easily diagnosed. Symptoms are mostly subjective and based on self-perceptions of poor concentration and task performance. “The DSM-5 lowering of requirements will capture many adults who want to be sharper but don’t have specific or serious enough problems to qualify for a mental disorder.” He said fake adult ADHD would be common in college students, in people with demanding jobs, and in those who struggle to stay awake, like long-haul truck drivers. Remember that Allen Frances was the chair for the DSM-IV.

An article by Allen Frances on Psychtherapy.net thought the numbers given for the prevalence of current adult ADHD were absurdly high. In the general population, the current rate for adult ADHD is reported to be 4.4% (5.4% for males and 3.2% for females). He thought the best guide was that by Keith Conners, considered to be the father of the ADHD diagnosis. Conners thought the rate of childhood ADHD was around 2-3% and about half that number in adults. Frances then gave the following as reasons for the overdiagnosis of adult ADHD.

Almost all mental disorders and almost all substance addictions can perfectly mimic ADHD since they can cause its two classic symptoms — hyperactivity and trouble focusing attention.

Real or imagined attention problems are a very common complaint among perfectly normal people.
Getting an ADHD diagnosis is a gateway to legal speed — desired for performance enhancement, all-nighters for school tests or work assignments, recreational purposes, or for sale into the extensive secondary ADHD pill market.
Careless diagnosis and prescribing by MDs.
An inevitable consequence of overdiagnosing ADHD in kids is overdiagnosing ADHD in adults.
Promotion via drug companies and social networking.

Frances said the risks of overdiagnosing ADHD in adults were:

Meds used for ADHD are usually quite harmful if the person’s symptoms are due to another psychiatric disorder that has been missed — especially bipolar disorder, depression, schizophrenia, eating disorders, or anxiety disorder.
Overdiagnosis of ADHD results in over-medication with drugs that cause harmful side effects and can lead to or worsen addiction.
There is now a huge secondary market for ADHD meds, especially on college campuses.
There is also a nationwide shortage of ADHD meds for patients who really need them — because the meds are so often prescribed for those who don’t or diverted to the illegal market.

His bottom line was that most of what looks like adult ADHD is not adult ADHD. Most of it is normal behavior, sometimes caused by another psychiatric or medical problem or substance use. ADHD drugs are not safe unless carefully used for accurately diagnosed ADHD. Frances thought it was past the time to stop the adult ADHD fad before it gained more traction.

Easy access to legal “speed” has created a large illegal secondary market of diverted pills. ADHD drugs have become the campus recreational drug of choice at parties and the performance-enhancement drug of choice for all-nighters during finals week. Legal speed can cause many medical and psychiatric adverse effects, and emergency room visits for complications are skyrocketing. The Drug Enforcement Agency and the FDA are now trying to contain the epidemic — but their efforts are too little/too late. The adult ADHD fad will be stopped only if clinicians and patients fight against its seduction and insist on more careful diagnosis and cautious treatment.

Writing for Psychiatric Times, Mark Ruffalo and Nassir Ghaemi noted in “The Making of Adult ADHD” that twenty years ago, the consensus view in American academic psychiatry was that ADHD rarely persisted into adulthood. Now, adult ADHD is the “diagnosis du jour.” The rates of diagnosis and the prescriptions for the psychostimulant drugs that treat them are skyrocketing. They thought adult ADHD was a case of disease mongering, rather than psychopathologists and psychiatric nosologists missing the disorder for more than a century. Along with Allen Frances, they also associated the rise in diagnosis of adult ADHD to marketing by the pharmaceutical industry.

The rise in diagnosis of adult ADHD fully coincides with marketing by the pharmaceutical industry when Eli Lilly and Company got the first US Food and Drug Administration indication for this label with atomoxetine (Strattera) in 1996. Since that date, many academics have been promoting the concept of adult ADHD. The adult ADHD market has become a multibillion-dollar industry, with the rise of digital companies specializing in online diagnosis and treatment—some of which have come under legal scrutiny.

They noted retrospective studies, (that look backwards to determine if cases of childhood ADHD continue into adulthood), commonly find 50% to 60% of childhood ADHD persists into adulthood. “However, these data are disproven by prospective studies, which repeatedly show that about 80% of children with ADHD do not continue to have that diagnosable condition, followed prospectively either into young adulthood or even for 33 years into their fourth decade of life.” Ruffalo and Ghaemi don’t think that adult ADHD is a scientifically valid diagnosis. They don’t mean that the symptoms don’t exist. Adults do have problems with attention, concentration, focus, memory and other related abilities. However:

What we mean is that these symptoms have not been shown to be the result of a scientifically valid disease (adult ADHD) and are better explained by more classic and scientifically validated psychiatric conditions, namely diseases or abnormalities of mood, anxiety, and mood temperament.

They concluded the history of psychiatry shows the field has been vulnerable to a host of diagnostic fads. “Adult ADHD is the latest of such fads, and a careful review of the scientific literature reveals that the range of ADHD-like symptoms in adults is more accurately explained by other empirically validated psychiatric disorders.”

10/17/23

Is Adult ADHD the Latest Fad Diagnosis? Part 1

WebMD has an article on statistics and facts about Adult ADHD, where it estimated adult ADHD affects more than 8 million Americans, with many of them not knowing it. “Several studies suggest less than 20% of adults with ADHD are aware they have it. And only about a fourth of those who do know are getting treatment for it.” Supposedly, every adult with ADHD had symptoms during childhood; and more than 60% of children with ADHD will still have it as adults. This begs the question, why don’t more adults realize they have it?

WebMD said adult ADHD can affect careers, relationships and other aspects of daily life, costing the U.S. economy up to $138 billion a year in lost income and productivity. It tends to occur with other mental health issues, like anxiety, depression or bipolar disorder. “Symptoms of adult ADHD can be mistaken for those conditions.” WebMD seems to presume ADHD is the primary disorder or cause. But what if it is the reverse? Psychiatrist Allen Frances thinks adult ADHD should not be diagnosed until these and other psychiatric problems are first ruled out (see Part 2).

Although researchers don’t know what causes ADHD, it runs in families. Forty percent of children with ADHD have at least one parent with symptoms. “If you have relatives with ADHD, you’re four to six times more likely to have it yourself.” This article ends with a link to the next article, “Do You Have ADHD?”, which then links to, “ADHD Medications and Side Effects.” If you’ve persisted in following the tidbits on adult ADHD, to this point, you’ll read how “Medication is an important part of your ADHD treatment.”

Another source, saying many of the same things, is the CDC, which in “Research on ADHD,” referred to ADHD as a serious public health problem that effects a large number of children and adults. The reader will learn that the criteria used to diagnose ADHD have changed over time. “This has led to different estimates for the number, characteristics, and outcomes of children with the disorder.” Although the exact causes of ADHD are not known, research show that genes play a role, with other factors contributing or making symptoms worse.

This led to the conclusion that there are many unanswered questions about ADHD and how it affects people throughout their life. In “Data and Statistics About ADHD” the CDC used datasets from parent surveys and healthcare claims to understand diagnosis and treatment patterns for ADHD. Concentrating on children, the CDC reported there were 6 million children between 3 and 17 (9.8%) ever diagnosed with ADHD. Many children with ADHD (64%) had at least one other mental, emotional or behavioral disorder. About half had a behavior or conduct problem (52%).

A national parent survey in 2016 reported 62% of children currently with ADHD were taking ADHD medication and 47% received behavior treatment. About 30% were treated with medication alone; 15% received behavior treatment alone. Around 32% received both medication and behavior treatment. And about 23% with ADHD received neither medication treatment nor behavior treatment. Not surprisingly, the American Psychiatric Association reported in November of 2019 that a study, Chung et al, found adult ADHD diagnosis increased 123% between 2007 and 2016.

Chung and colleagues suggest the increase in ADHD among adults may partly reflect an increasing awareness among health care professionals and the public of ADHD in adults. The study authors also address the misuse of ADHD medications particularly among adult-aged students to boost academic performance, noting that “diagnosis seeking to obtain stimulant medication for nonmedical use may be more common among white vs nonwhite patients.” The study found adults who identified as students were at highest risk of ADHD diagnosis.

Chung et al speculated that this increased risk of diagnosis in students could be due to some individuals seeking diagnosis and treatment for the purposes of “cognitive enhancement” with ADHD medications. They said pharmacological cognitive enhancement with prescription and illegal stimulants among individuals not diagnosed with ADHD has been increasing. There has been to be an concern about cognitive enhancement with ADHD medications among college students for some time. See, “Academic Steroids.”

In a related, but nonacademic article, the Guardian described how some tele-health startups have received criticism for their aggressive and misleading advertising campaigns. “These companies offer evaluations in as little as 30 min with no wait lists and prescribe medication, sometimes including controlled stimulant medications like Adderall and Ritalin.” The startups took advantage of an emergency provision established during the pandemic that permitted healthcare providers to prescribe controlled substances (like ADHD medications) via tele-health. While there are guidelines for diagnosing and treating ADHD in children, “There are no guidelines in the US about how to diagnose adult ADHD.”

The CDC reported that while the prevalence of adult ADHD did increase in recent decades and continued during the COVID-19 pandemic, there was a notable upturn during 2020-2021. Improved access to ADHD care through tele-health during the pandemic “introduced the potential for inadequate ADHD evaluations and inappropriate stimulant prescribing.” The significant increase in adults receiving prescription stimulants during the COVID-19 pandemic “draws attention to the need for clinical practice guidelines for ADHD in adults.”

The Guardian noted that the US medical system can’t serve all the people seeking diagnosis and treatment for ADHD, “and social media is filling in those gaps.” This increased demand contributed to an Adderall shortage that began in October of 2022. See, “Bad Things Could Happen with ADHD and the Adderall Shortage.”

A psychologist in Seattle who conducts adult ADHD evaluations said she thought TikTok accounted for at least 50% of her current requests for intakes. Supporting her estimation, a study in the Canadian Journal of Psychiatry, “TikTok and Attention-Deficit/Hyperactivity Disorder,” found that 52% of the most popular TikTok videos about ADHD were misleading if used to determine if you have ADHD.

TikTok videos with titles like “5 signs you have ADHD” and “5 things ADHDers hate,” are driving a lot of interest around adult ADHD. They list symptoms like daydreaming, swaying to avoid things while walking or picking skin for hours. Some videos have disclaimers, informing viewers that they should not replace medical advice, some are from users who list medical credentials, or are from people who have been diagnosed – but it’s not clear how credible each video is.

According to a psychiatrist who specializes in diagnosing and treating ADHD, the average, normal adult has two or three of these so-called “symptoms.” The DSM-5 diagnosis for ADHD requires at least five ADHD diagnostic criteria or symptoms, and those must cause “significant impairment” in at least two settings, like work and home.

TikTok videos facilitating people getting diagnosed for adult HDHD is an alarming trend. The psychologist in Seattle said she was frustrated when patients come to her because they’ve seen some TikTok videos and are hoping to “understand themselves better.” Some of these patients complain she is “invalidating” their experience when they don’t get the ADHD diagnosis they expect. She’s fearful these “patients” are putting pressure on an already overloaded medical system. The trend raises the question if these TikTok videos have led to more people believing they have adult ADHD, how valid of a diagnosis can it be? More on this in Part 2.

09/12/23

Bad Things Could Happen with ADHD and the Adderall Shortage

In case you didn’t know, the U.S. has been in the midst of an Adderall shortage since October of 2022 when the FDA announced a shortage of the immediate release formulation. At the time, the FDA said some manufacturers having intermittent manufacturing delays, while others reported they could not meet the increased demand. The agency said it has posted information on the shortage and a list of current manufacturers that are still available, and will continue monitor supply and assist manufacturers “with anything needed to resolve the shortage.” But the shortage problem was still with us.

Kate Underwood reported in Green Matters that as of June 2023, the FDA’s Drug Shortages still listed Adderall as a current shortage. While manufacturing disruptions are the typical issues leading to drug shortages, other concerns such as increased demand for the drug, and shortages of the active ingredient or supplies can also occur. Additionally, drug manufacturers don’t usually make a single drug. So, increasing the production of a drug in short supply could negatively impact the availability of other drugs made in the same facility.

Writing for Vox, Dylan Scott added another factor to the Adderall shortage—it is a stimulant drug with the potential for misuse or addiction. The DEA lists Adderall and other stimulant-based ADHD medications as Schedule II drugs, meaning they are considered to have the same addictive potential as many opioids. “The fear is that Adderall would follow the same path as opioid painkillers: careless overprescribing would lead to an epidemic of drug addiction — this time, to stimulants.”

One of the active ingredients in Adderall is amphetamine, and therefore the drug is regulated as a controlled substance under federal law. Its potential for abuse has long been recognized, with the cliche example being college students taking the drug to help them study. A 2018 study by federal researchers found that about 5 million Americans misused a prescribed stimulant, of which Adderall is the most common, at least once in the past year; about 400,000 misused stimulant drugs frequently enough to be characterized as having a disorder. (About 2.7 million people in the US report they have an opioid use disorder.)

Medical News Today described the medical uses, side effects and misuse of amphetamines. The opening sentence on the page says, “Amphetamine is a powerful stimulator of the central nervous system. It is used to treat some medical conditions, but is also highly addictive, with a history of abuse.” Amphetamines are used today to treat ADHD. In the past it has been used to treat narcolepsy, but concerns with side effects have led to it being increasingly replaced by modafinil.

Physical side effects can include low or high blood pressure, erectile dysfunction, rapid heart rate, blurred vision, dry mouth, tics, nosebleed, and others. Psychological effects may include apprehension, anxiety, irritability and restlessness, mood swings, insomnia, obsessive behaviors and grandiosity, or an exaggerated sense of one’s own importance. “In rare cases, psychosis may occur.”

When used as a recreational drug it can speed up reaction times, increase muscle strength and reduce fatigue. A methamphetamine called Pervitin was used by Hitler’s forces for these benefits during WW II; see “Repeating Past Mistakes.”

The DEA Drug Fact Sheet said the following about amphetamines:

The effects of amphetamines are similar to cocaine, but their onset is slower and their duration is longer. In contrast to cocaine, which is quickly removed from the brain and is almost completely metabolized, methamphetamine remains in the central nervous system longer, and a larger percentage of the drug remains unchanged in the body, producing prolonged stimulant effects.

Chronic abuse produces a psychosis that resembles schizophrenia and is characterized by paranoia, picking at the skin, preoccupation with one’s own thoughts, and auditory and visual hallucinations. Violent and erratic behavior is frequently seen among chronic users of amphetamines.

In order to mitigate the potential for abuse, the DEA sets production limits for the manufacturers of Adderall and its generic competitors. In 2019 the DEA announced it was permitting more production of Adderall, but we still don’t know exactly how much production has been authorized or what limits have been set for individual companies. “We don’t know which company gets how much.” Some companies say they are short, but the DEA replies they haven’t used all their supply, so there’s back-and-forth finger-pointing going on. Listen to the On Point program, “What’s behind the ADHD drug shortage” to hear more discussion of this issue.

However, there also seems to a problem that stems from the opioid crisis. In 2021 there was a settlement with the three largest drug distributors that “flag and sometimes block” pharmacies’ orders of controlled substances like Adderall when they exceed a certain threshold. Bloomberg reported that pharmacists said it restricts their ability to fill many different types of controlled substances in addition to opioids. The rules force some independent pharmacists to use creative workarounds. “Sometimes, they must send patients on frustrating journeys to find pharmacies that haven’t yet exceeded their caps in order to buy prescribed medicines.”

This was illustrated in an article for STAT, written by a “biopharma supply chain specialist” who can’t find the Adderall she’s prescribed. She said she’s been using Adderall for ten years to help her function. Then in February of 2023, she was unable to fill her prescription at the pharmacy down the street. She finally was able to fill it at the 20^th pharmacy she called, although it meant a 50-minute drive. She recommended several steps to increase the transparency in the supply chain of Adderall. “This will foster efficiency, reliability, and the ability to identify potential risks before they spiral out of control, as has happened now with not just Adderall but other ADHD medications.”

Money making considerations are also involved in the Adderall shortage. Vox reported that after Adderall was approved in 1996, it quickly became the most commonly prescribed treatment for ADHD, although Ritalin and other drugs are still used. PsychCentral listed Adderall as the fourth most prescribed psychiatric medications, with 26.24 million prescriptions in 2020. Other medications prescribed to treat ADHD within the top 25 most prescribed drugs included: Concerta (10^th), Vyvanse (20^th), and Focalin (24^th). Three of the most expensive medications, making the most money for their manufacturers were Concerta ($3.28 billion), Vyvanse ($3.01 billion), and Adderall ($2.35 billion). ADHD prescriptions accounted for over a third of the prescriptions in 2020.

Axios reported some different statistics for both generic and branded Adderall prescriptions, according to IQVIA, a health research firm. Since 2017, IQVIA reported Adderall prescriptions rose from 32.2 million to 41.4 million. This was up more than 10% from 2020. See the following graph taken from the Axios article.

Axios said prescriptions skyrocketed as it became significantly easier to get a diagnosis of ADHD and a prescription for Adderall during the pandemic. A wave of telemedicine startups emerged on TikTok and Instagram, suggesting people should look into ADHD medication if they felt distracted. The Wall Street Journal reported some startups diagnosed people with ADHD and prescribed stimulants after 30-minute video calls — “entirely remotely, and much faster than a typical diagnosis from an in-person psychiatrist.” The trouble with rapid diagnoses is it can be difficult to tell whether the problem is actually ADHD. “Anxiety can present as ADHD, and depression can present as ADHD.”

This spike in diagnoses raises questions about whether ADHD is being over-diagnosed, but that’s really a question that predates the pandemic. See (“The Tip of the ADHD Iceberg” and “National ADHD Epidemic”) for more information. If supply can’t keep up with demand, experts are warning we could have a public health crisis. Even worse, we could face another movement of people from the pharmaceutical market to the illicit drug market, as what happened with opioids. Leo Beletsky, an epidemiologist at Northwestern University said, “Lots of bad things can happen. … Conditions are very much ripe for that to happen here.”

Overdiagnosis of ADHD

In “Twenty-Year Trend in Diagnosed Attention-Deficit/Hyperactivity Disorder”, Xu et al estimated the prevalence of diagnosed ADHD among US children and adolescents from 1997 to 2016. They estimated the prevalence of diagnosed ADHD among US children and adolescents was 10.2% in 2016. There was a consistent upward trend across subgroups by age, sex, race/ethnicity, family income, and geographic regions. “These findings indicate a continuous increase in the prevalence of diagnosed ADHD among US children and adolescents.” They said the common perception that ADHD overdiagnosed in the US was not supported by the scientific evidence. But that is not the end of the matter.

A 2021 study by Kazda et al, “Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents” said that questioning the appropriateness of ADHD diagnosis has grown along with the diagnosis rates. They acknowledged that disagreement continues about how much of the increased diagnoses can be attributed to true increases in frequency, improved detection or diagnostic inflation because of misdiagnosis and/or overdiagnosis. They systematically reviewed the research literature to identify and appraise any evidence of overdiagnosis of ADHD in children and adolescents. They found evidence of overdiagnosis and overtreatment of ADHD.

Of the 12,267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

They recommended that practitioners, parents and teachers carefully weigh the potential benefits and harms that can go along with ADHD diagnosis and treatment, particularly when individuals with milder symptoms are identified. “For this group, the benefits of diagnosis and treatment may be considerably reduced or outweighed by harms.”

In his review of the study for Mad in America, Peter Simons said “Each [of the 334 included studies] provided data on at least one of the five conditions. They found that all five conditions were supported by the research.” There was also significant evidence of harm after diagnosis, including how a biomedical view of difficulties was associated with disempowerment. He said the researchers warned that diagnosis “can also deflect from other underlying individual, social, or systemic problems.”

Because there is no biological test for ADHD, and the diagnosis is applied subjectively across age, gender, race, and socioeconomic status, there is room for the diagnosis to expand. Additionally, as the diagnostic criteria are loosened, rates of ADHD have increased. The researchers confirmed that a large proportion of the new cases are on the “mild” end of the spectrum. Rates of stimulant treatment for ADHD have also increased, including those with “mild” or “subclinical” ADHD.

In his book, Saving Normal, Allen Frances, a psychiatrist and the former chair for the DSM-IV, said in retrospect, he wishes there had been cautions in the DSM-IV about overdiagnosis and tips to avoid it. He thought they missed the boat. “No one dreamed that drug company advertising would explode three years after the publication of the DSM-IV or that there would be the huge epidemics of ADHD, autism, and bipolar disorder—and therefore no one felt any urgency to prevent them.” For more on the DSM and overdiagnosis, see “Guild Interests Behind DSM Diagnosis.”

The Demedicalization of ADHD

Not only does it seem ADHD is overdiagnosed, there are some researchers who question whether the diagnosis of ADHD meets the criteria for a disorder set out in the manual used by the medical and psychiatric fields. Freedman and Honkasilta argued that the definition of ADHD relies on subjective cultural values to define “abnormal” behavior. Reviewing their study for Mad in America, Peter Simons said, “The diagnosis thus fails to meet the criteria, as stated in the DSM, that disorders must not be reducible to behavior that violates social norms.” The researchers argued that ADHD should be demedicalized and removed from the DSM, like homosexuality was in 1980.

The British Child and Adolescent Psychiatrist Sami Timimi said in his 2017 article, “Non-diagnostic based approaches to helping children who could be labeled ADHD and their families” that it required little intellectual effort to conclude that the concept and definition of ADHD “is replete with problems around reliability and validity.” The diagnostic guidelines note how ADHD behaviors may be minimal or absent in several settings. These include when the person in under close supervision, engaged in an activity that is particularly interesting to them or in a new, novel setting. Even if a genetic basis for ADHD were found, we’d still have to ask why such behaviors should be treated as disorder rather than differences. “Deciding where to draw the line between what we consider part of the “ordinary” spectrum of behaviours and what we decide is “pathological” is more dependent on cultural than scientific processes.”

He said if he asked the question, “what is ADHD?”, it is not possible for him to reply by referring to a particular known pathological abnormality. Instead, he would have to provide a description ADHD as the presence behaviors like of hyperactivity, impulsivity and poor attention. This was contrasted with answering the question, “what is diabetes?” “Diagnosis in that context sits in a “technical” explanatory framework. In psychiatry what we are calling diagnosis (such as ADHD) will only describe but is unable to explain.”

Timimi concluded that ADHD is then not a medical diagnosis, but rather a descriptive classification. And since it is not a medical diagnosis, “it is not surprising that there has been a failure to find any specific and/or characteristic biological abnormality such as characteristic neuroanatomical, genetic or neurotransmitter abnormalities.” He thought the idea of ADHD as a medical diagnosis was past its use-by date and should be discarded.

ADHD is a cultural construct. It is often argued that the use of categorical constructs like ADHD enables the study of aetiology, treatment and prognosis. Evidence outlined above demonstrates that far from enabling any advancement of knowledge or clinical practice, it has created an illusion of progress and resulted in exposure of possibly millions of children and young people to unnecessary and potentially harmful medications. It has spurred on liberal use of stimulant medication, despite the lack of evidence for improved long term outcomes resulting from this.

We are not at the cultural crossroads with ADHD today that we were with homosexuality in 1980. ADHD will likely continue to be a diagnosable disorder. Yet serious consideration of the above discussion of its overdiagnosis, its future demedicalization and removal from the DSM as a disorder and the lack of improvement in long-term outcomes of individuals taking ADHD prescribed stimulants should be done. In retrospect, the Adderall shortage may not truly be the serious public health crisis that is getting all the press coverage. But if it leads people from the pharmaceutical market to the illicit drug market in search of their amphetamines to help them function, like the person in the STAT article, “Lots of bad things can happen.”

03/9/21

Weighing the Risks with ADHD Medication

Did you know that millions of children in the US have been diagnosed with ADHD? The CDC said in “Data and Statistics About ADHD,” that the number of US children diagnosed with ADHD increased from 4.4 million in 2003 to 6.4 million in 2011. It decreased to 6.1 million in 2016. Sixty-two percent of the children diagnosed with ADHD are taking medication. And yet, the prominent Harvard psychologist Jerome Kagan believes ADHD is an invention.

Kagan made this claim in a 2012 interview with Spiegel, when he was asked if he was saying ADHD was just an invention, he said: “That’s correct; it is an invention.” Every child who does not do well in school is sent to a pediatrician who then says: “It’s ADHD; here’s Ritalin.” The neurologist Steven Novella said in “The ADHD Controversy,” that such a characterization was irresponsible. He acknowledged the fact that ADHD is a fuzzy clinical entity, but said progress has been made in understanding what is happening in the brains of most people with ADHD.

The current consensus is that ADHD is a deficit of executive functions. The frontal lobes carry out many critical functions, some considered executive functions: they include being able to focus your attention, maintain focus, switch among tasks, filter out distractions, and impulse control. Executive function includes the ability to weigh the probable outcomes of your behavior and then make high-level decisions about how you will behave.

He went on to say that convergent data from neuroimaging, neuropsychology, genetics and neurochemical studies point to the involvement of a part of the brain known as the frontostriatal network contributing to the pathophysiology of ADHD. “At this point there is no reasonable disagreement about the fact that ADHD is a disorder of brain function.” He referred to an article by David Tuller, whose concerns were more nuanced than Kagan’s. Tuller interviewed Richard Scheffler, co- author of The ADHD Explosion with Stephen Hinshaw. He said the issue was a spike in ADHD diagnoses, not that ADHD was an invented disease.

ADHD is real—it’s not made up. But it exists on a continuum. There’s no marker or white line that says you’re in the “definite” or “highly likely” group. There’s almost unanimous agreement that five or six percent clearly have enough of these symptoms for an ADHD diagnosis. Then there’s the next group, where the diagnosis is more of a judgment call, and for these kids, behavioral therapy might work. And then there’s a third group, on the borderline. These are the ones we’re worried about being pushed into an inaccurate diagnosis.

Scheffler said the research done for their book found that in general, there was a relationship between the rates of ADHD diagnoses and changes in the 1990s with how many states budgeted schools. Money was provided based upon the number of students making positive movement towards performance measures like graduation rates and test scores. Then in the early 2000s, President Bush tied federal dollars to the same kind of budgeting for performance. “We were able to show that these moves were highly correlated with spikes in various states in the diagnosis of ADHD.”

In an opinion article for The New York Times, Hinshaw and Scheffler said that unless we were careful, we faced an epidemic of 4- and 5-year-olds being wrongfully told they have ADHD. Their research showed skyrocketing ADHD diagnoses, especially among the nation’s poorest children. Their research data seems to reflect that reported above in the first paragraph by the CDC in “Data and Statistics About ADHD.”

For example, we found that in public schools, A.D.H.D. diagnoses of kids within 200 percent of the federal poverty level jumped 59 percent after accountability legislation passed, compared with under 10 percent for middle- and high-income children. There was no such trend in private schools, which are not subject to legislation like this.

By the age of 17, nearly one in five American boys and one in ten girls will be told they have ADHD. This is a 40 percent increase over the last ten years and double the rate of 25 years ago. They see this leading to more prescriptions despite the guidance from organizations like the American Academy of Pediatrics that behavioral therapy, not medication, should be the first-line treatment for children under 6. Accurate diagnosis requires reports of impairment from home and school, and a thorough child and family history to rule out abuse or unrelated disorders. “Too many kids are identified and treated after an initial pediatric visit of 20 minutes or even less.”

The CDC data indicated 77% of the children diagnosed with ADHD between the ages of 2 and 17 were receiving treatment. Thirty percent were treated with medication alone; 15% received behavioral treatment alone; and 32% received both. Around 23% were receiving neither medication nor behavioral treatment. approximately 5 in 10 children with ADHD also had a behavior or conduct problem; 3 in 10 with ADHD had anxiety. Seventeen percent were said to be depressed and 14% had autism spectrum disorder.

So there seems to be a problem with accurate diagnosis and overdiagnosis of ADHD leading to medication treatment. What are the implications of these diagnostic problems? And what are the long-term consequences for the children who are medicated?

A Norwegian article, “Drug Treatment of ADHD—tenuous scientific basis,” said that recent systematic reviews indicated there was a weak evidence base for the use of methylphenidate (Ritalin, Concerta) when treating children and adolescents with an ADHD diagnosis. The authors began with an examination of the MTA study (Multimodal Treatment Study of ADHD), stating it was crucial to understanding the current state of knowledge on ADHD treatment. The MTA study showed a reduction in ADHD symptoms in the medication groups at 14 months. But that significance disappeared over the next two years.

After six years, participants in the MTA study who received behavioral therapy but no medication had lower rates of anxiety and depression. The latest results were published in 2017, 16 years after the start of the study. After evaluating the data, the conclusion of the researchers was that the long-term use of central nervous system stimulants was associated with a suppression of adult height, on the average of 1-2 cm. But there was no reduction in ADHD symptoms.

There is no doubt that children with ADHD have genuine and serious problems. However, we cannot ignore the fact that research has yielded only weak evidence to support the extensive use of medication that occurs today. This state of affairs should trigger renewed public and expert discussion on the pharmacological treatment of ADHD in children and adolescents.

There was a further investigation of participants in the MTA study, this time of adolescents and young adults without childhood ADHD: “Late-Onset ADHD Reconsidered.” The purpose of the study was to investigate an influx of adolescents and young adults who present at clinics with complaints of inattention and/or hyperactivity/impulsivity complaints and inquire about stimulant medication. “It remains unclear whether this trend is driven by typically developing individuals seeking stimulant medication for cognitive enhancement or by individuals with late-onset ADHD that warrants medical treatment.” The results indicated that when assessing adolescents and young adults for first-time ADHD diagnoses, clinicians should obtain a thorough psychiatric history and assessment of current functioning.

After using a diagnostic procedure that considered multi-informant data, longitudinal symptoms patterns from childhood to adulthood, Co-occurring mental disorders and substance use, 95% of the individuals who originally screened positive for late-onset ADHD were excluded from diagnosis. When assessing adolescents and young adults for first-time ADHD, 53% of adolescents and 83% of adults who met all the late-onset criteria for ADHD were excluded because their symptoms “were better explained by heavy substance use or another mental disorder.”

SAMHSA, the Substance Abuse and Mental Health Services Administration, noted in “Adults with Attention Deficit Hyperactivity Disorder and Substance Use Disorders” studies that have found adults with ADHD are more likely than their peers without ADHD to develop a substance use disorder (SUD) sometime in their lives. One large epidemiological study found that 15.2% of adults with ADHD also met the criteria for an SUD, compared to 5.6% of adults without ADHD. Research has also indicated that as the severity of ADHD increases, so may the SUD risk. “In a recent analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions, each additional ADHD symptom before age 18 was associated with a greater lifetime chance of developing substance dependence.”

Much of the research into the misuse of prescribed stimulants has been with college students. College students were found to misuse Dexedrine and Adderall more than other prescribed stimulants. According to the 2012 National Survey on Drug Use and Health, the nonmedical use of Dexedrine and Adderall has risen among college-aged adults and adults 26 and older. Between 4 and 20 percent of college students have used a prescription stimulant without having a legitimate prescription in the past year, typically obtaining the medication from friends who either sell or give their medications away. “Roughly a third of college students with ADHD report that they have sold or given away their medication at least once.” See the following chart.

So, what are the risks with ADHD medications? There are problems with diagnosis and concerns of overdiagnosis, particularly with poor children (See “Demolishing ADHD Diagnosis”). After 2 or 3 years the positive effects of ADHD medications seem to disappear. Long-term use seems related to a suppression of adult height. There appears to be an association between ADHD and an increased risk of SUD. At least one study concluded there is weak evidence for the use of Ritalin and Concerta when treating children and adolescents with an ADHD diagnosis. ADHD was said to be a “fuzzy clinical entity” by a neurologist who believes ADHD is a disorder of brain function.

Web MD said the side effects and risks from long-term use of ADHD medication include: heart disease, high blood pressure, seizure, irregular heartbeat, abuse and addiction, and skin discolorations. Although it’s rare, ADHD medications may be tied to mental health issues like aggression and hostility; and some say they developed symptoms of bipolar disorder. “The FDA has also warned that there’s a slight risk that stimulant ADHD drugs could lead to mood swings or symptoms of psychosis—like hearing things and paranoia.”

05/28/19

The ADHD Fairy

In case you didn’t know, there is a risk of psychosis when using ADHD stimulant medications, such as amphetamine (Adderall, Vyvanse) and methylphenidate (Ritalin, Concerta). A study published recently in The New England Medical Journal indicated the risk was low, with about 1 in 660 patients who used prescription stimulants diagnosed with new-onset psychosis. The lead author of the study, Dr. Lauren Moran, said the risk was low enough that she could not recommend not prescribing Adderall. “But from a public health perspective, there’s so many millions of people being prescribed these medications that it actually leads to thousands of people at increased risk of psychosis.” Using data from the CDC on ADHD, that meant in 2016 about 5,730 children between the ages of 2 and 17 who were taking ADHD stimulants would be diagnosed with new-onset psychosis.

Medscape reported Dr. Moran said the takeaway point was “that it’s really important to screen for potential risk factors.” These risk factors could include a history of bipolar or other psychiatric disorder, a family history of psychiatric illness, or use of cannabis (See: “Gambling with Cannabis and Psychosis”). “If patients have those risk factors, I would shy away from using the amphetamines. You don’t want to have two things that could potentially further increase the risk for psychosis.”

Moran noted that there are many college students in the area around McLean Hospital and that in her anecdotal experience as a psychiatrist working in a unit that treats patients with psychotic disorders, she’s “been seeing cases of young individuals coming in with psychosis” after stimulant use.

Moran said at the beginning of their study, a patient had a 50-50 chance of getting Adderall or Ritalin. But there has been a dramatic increase in Adderall prescriptions, to almost four times as many prescriptions for Adderall. In her experience, ADHD patients hospitalized for psychosis recovered in two weeks; some took as long as two months. But Moran is not suggesting ADHD medications are too dangerous to prescribe. Rather, she’s trying to raise awareness. “Physicians need to be aware of this when prescribing and people who are getting these medications from friends in college need to know this is a risk.”

Speaking to STAT News, Dr. Anthony Rostain said he did not think the results of the Moran et al. study was shocking. The package insert already warns of a small risk of psychosis with ADHD stimulant medication. “It will just simply be important to mention to people that the amphetamine-based compounds have a slightly higher risk… I think the take-home here should be that everyone should be informed when they are starting a medicine about risks like psychosis.” One of the risk factors he gave for psychosis was abusing the drugs—crushing and snorting them. So the implication is that the individuals at risk are those who abuse this medication, which is admittedly an issue on college campuses.

But is that the real problem, namely that the people at risk are those who are abusing ADHD stimulants? First let’s consider the industry ties of the two doctors cited here. Rostain has been a consultant to Arbor Pharmaceuticals, an amphetamine maker, and to Shire, which sells Vyvanse and developed Adderall; Dr. Moran reported only receiving a grant from the NIMH to investigate the risk of psychosis with prescription stimulants. Is Rostain contributing to some misdirection of the issue because of his industry ties?

Did you know that so-called “challenge studies,” where amphetamine and methylphenidate were used to instigate symptoms of psychosis, were done in the name of science? Robert Whitaker co-wrote a series of articles that described how beginning in 1972, psychiatric researchers used amphetamine, methylphenidate and ketamine “to deliberately provoke psychotic symptoms in more than 1,200 schizophrenic patients.” In some cases, the level of psychosis experienced by these patients was called “severe.” Some of these experiments were conducted by prominent researchers at the National Institute of Mental Health. David Janowsky’s work established the idea that psychosis-inducing drugs “could be used as ‘challenge agents’ to turn patients into models for studying psychotic illnesses.”

Symptom-exacerbation experiments were pioneered by Dr. David Janowsky of Vanderbilt University. In 1974, he reported success in developing a new tool for studying schizophrenia. He found that giving schizophrenic patients methylphenidate (Ritalin) caused ”a dramatic intensification of preexisting symptoms, such as hallucinations and delusions,” and that amphetamine also exacerbated their psychosis. Both drugs are known to release dopamine, a messenger chemical in the brain, and Janowsky’s experiments provided indirect evidence that the biological mechanism of psychosis involved an overactive dopamine system.

Dr. Jeffrey Lieberman, currently the department chair of psychiatry at Columbia, did several challenge studies with methylphenidate. In a 1987 study, 34 stable outpatients receiving antipsychotics were given methylphenidate and then withdrawn from their antipsychotics. Three weeks later, they were given another infusion of methylphenidate. They were then followed up for 52 weeks or until they relapsed—in other words until their symptoms returned.

In a 1990 study, 38 patients who met the criteria for schizophrenia or schizoaffective disorder were given methylphenidate. These were patients experiencing their first acute psychosis. The methylphenidate produced an increased psychopathology seen in the worsening of their symptoms. And in a 1987 article, Lieberman and his coauthors commented that methylphenidate appeared to have a greater “psychotogenic potency” than amphetamine. They hypothesized there was a subgroup of schizophrenic patients who exhibited psychotic activation with psychostimulants. “This biologic phenomenon may be clinically exploitable and should be investigated further.” Also see “Psychiatry, Diagnose Thyself! Part 2” for more information on challenge studies.

MacKenzie et al. found an association between the use of stimulant medication and psychotic symptoms in children and adolescents at risk of mental illness. Psychotic symptoms were found in 62.5% of the participants who had taken stimulants versus 27.4% of participants who had not taken stimulants. All participants who had used stimulants and experienced psychotic symptoms were sons or daughters of a parent with either a major depressive disorder or bipolar disorder. “The association of current use of stimulants with current psychotic symptoms and the close temporal relationship between stimulant use and psychotic symptoms in youth who started and stopped stimulants indicated a potential causal relationship.” See “Tip of the ADHD Iceberg” for more information.

ADHD stimulants are addictive. Ritalin and Adderall are Schedule II controlled substances, meaning they are considered to have a high potential for abuse, with their use “potentially leading to severe psychological or physical dependence.” Methamphetamine adverse effects can include convulsions, memory loss, severe dental problems and even death. “Cocaine and potent stimulant pharmaceuticals, such as amphetamines and methylphenidate, produce similar effects.” The effects of amphetamines are similar to cocaine but occur slower and last longer.

Chronic abuse produces a psychosis that resembles schizophrenia and is characterized by paranoia, picking at the skin, preoccupation with one’s own thoughts, and auditory and visual hallucinations. Violent and erratic behavior is frequently seen among chronic users of amphetamines and methamphetamine.

A 2015 study by Clemow and Walker reviewed the literature on ADHD medication misuse. The authors found that elevations in brain dopamine levels seemed to be necessary to both their efficacy in ADHD and in their potential for abuse. The data suggested ADHD medication misuse was a common health care problem for stimulant medications, “with the prevalence believed to be approximately 5% to 10% of high school students and 5% to 35% of college students, depending on the study.” Conversely, nonstimulant ADHD medications did not suggest a potential for abuse. “In light of these findings, the data suggest a need for close screening and therapeutic monitoring of ADHD medication us.”

And if that is not enough to raise concerns with the use of amphetamine and methylphenidate to treat ADHD, there is evidence that challenges their long-term effectiveness. The National Institute of Mental Health (NIMH) funded a nationwide, long-term study of the effectiveness of stimulants in treating ADHD by many of the long-time advocates of stimulant medication. In 2007 the authors finally published their evaluation of long-term effectiveness. The Jensen et al. study concluded: “By 36 months, the earlier advantage of having had 14 months of the medication algorithm was no longer apparent.” The Swanson et al. study said: “All five propensity subgroups showed initial advantage of medication that disappeared by the 36-month assessment.”

So where does this leave us with regard to ADHD? Is it even a valid diagnosis? In Debunking ADHD, Michael Corrigan said ADHD diagnosis in its current form is a diagnosis of normal, using eighteen very generic, commonly observed childhood behaviors to justify giving the medications. “Coincidentally or conveniently, ordained by the all-knowing creators of ADHD as proof of ADHD’s existence, these eighteen childish behaviors … seem to drive parents and educators crazy.” ADHD is a negative label that some want you to believe is real. Like the stories of about unicorns, fairies and leprechauns, “the diagnosis of ADHD is a brilliant work of fiction.” In Our Post Human Future, Francis Fukuyama also suggested ADHD wasn’t a disease, but rather, “just the tail end of the bell curve describing the distribution of perfectly normal behavior.”

Young human beings, and particularly young boys, were not designed by evolution to sit around a desk for hours at a time paying attention to a teacher, but rather to run and play and do other physically active things. The fact that we increasingly demand that they sit still in classrooms, or that parents and teachers have less time to spend with them on interesting tasks, is what creates the impression that there is a growing disease.

For more information on ADHD, see: “ADHD: An Imbalance of Fire over Water or a Case of the Fidgets?”

09/26/17

Demolishing ADHD Diagnosis

The Harvard psychologist, Jerome Kagan, sees ADHD as more of an invented condition than a serious illness. Further, he thinks it was invented for “money-making reasons” by the pharmaceutical industry and pro-ADHD researchers. He believes the drastic increase in the number of children diagnosed with ADHD has more to do with “fuzzy diagnostic practices” and relabeling. Fifty years ago, a 7-year-old child who was bored and disruptive in class was seen as “lazy.” Today he is seen as suffering from ADHD.

Every child who’s not doing well in school is sent to see a pediatrician, and the pediatrician says: “It’s ADHD; here’s Ritalin.” In fact, 90 percent of these 5.4 million kids don’t have an abnormal dopamine metabolism. The problem is, if a drug is available to doctors, they’ll make the corresponding diagnosis.

In his interview with Spiegel Online, Kagan went on to say that the inflated diagnosis of ADHD and other so-called childhood mental health disorders means more money for the pharmaceutical industry, psychiatrists and the people doing research. “We’re up against an enormously powerful alliance: pharmaceutical companies that are making billions, and a profession that is self-interested.” As he said, he’s not the only psychologist who is saying this.

Parenting expert and family psychologist, John Rosemond, agrees with Kagan. In 2009 he co-authored The Diseasing of American’s Children where they argued that ADHD and other childhood behavior disorders “were inventions of the psychological-psychiatric-pharmaceutical industry.” They went further than Kagan in saying that ADHD does not exist; that it is a fiction. In his April 9, 2017 article, “ADHD Simply Does Not Exist,” Rosemond referred to Kagan’s declaration on ADHD, noting that he and other psychologists studied Kagan’s books and research papers on children and child development when they were in graduate school. In The Diseasing America’s Children, Rosemond said:

Science depends on verifiable, objective evidence and experimental results that can be replicated by other scientists. Where ADHD is concerned, neither verifiable, objective evidence nor replicable experimental results exist to support the claims of the ADHD establishment.”

Rosemond and his co-author, Bose Ravenel, believe that childhood behavior disorders like ADHD are manifestations of “dysfunctions of discipline and lifestyle” endemic to modern family culture. Once these problems are identified, they can be easily corrected. And once corrected, the errant behavior “usually recovers to a state of normalcy within a relatively short period of time.” They believe children do not need a psychologist when they misbehave, they need discipline—“firm, calm and loving discipline.”

In Debunking ADHD, educational psychologist Michael Corrigan said ADHD is a negative label that does not exist. “Not unlike the many wonderful stories about unicorns, fairies, and leprechauns, the diagnosis of ADHD is a brilliant work of fiction.” He noted that many of the common childhood behaviors (or supposed symptoms) associated with ADHD are also used to identify giftedness in children. When these behaviors are harnessed and focused, they can help children become “incredibly creative, insightful, and successful individuals in adulthood.” If children don’t learn to harness the power of the behaviors ADHD and giftedness have in common, “such behaviors when displayed might seem annoying and immature.” He said:

My biggest reason for writing this book is my desire to show you that the practice of medicating children for acting like children in the name of ADHD is, in two words, wrong and dangerous. Despite the grandiose claims of the mega-pharmaceutical companies selling ADHD drugs to concerned parents, prescribing pills to young children trying to learn how to become young adults is just a quick fix void of any long-term benefits.

Corrigan described eating lunch with a group of children who had just taken their ADHD medication at school. They were now supposedly “good to go” (sufficiently medicated) for an afternoon of learning. It was the longest lunch period he had ever experienced. “Comparing the kids at my table to others in the cafeteria, and slowly watching these playful, creative, energetic, and funny children go from kids being kids to near expressionless robot-like entities, made me sick to my stomach.”

The total number of children on ADHD medication “skyrocketed” from 1.5 million in 1995 to 3.5 million in 2011. “Sales of prescription stimulants quintupled from 2005 to 2015.” The rising rate of ADHD diagnosis has been described as “an unreal epidemic” and a “national disaster of dangerous proportions” by well-known professionals like Allen Frances and Keith Conners. Frances was the chair of the DSM-IV. Conners, now an emeritus professor of medical psychology at Duke University, “spent much of his career in legitimizing the diagnosis of ADHD.”

Allen Frances was one of four authors of an article in the International Journal of Qualitative Studies on Health and Well-Being, “ADHD: A Critical Update for Educational Professionals.” When the DSM-IV was published in 1994, the prevalence of ADHD was estimated to be 3%. Since then, parent-reported ADHD diagnosis increased to 7.8% in 2003; 9.5% in 2007; and to 11% in 2011. Nearly one in five high school boys had been diagnosed with ADHD and around 13.3% of 11-year-old boys were medicated for ADHD.

Teachers and other school personnel are often the first to suggest a child might be “ADHD.” Research suggested teachers felt insecure about dealing with behavioral problems and hesitated to accept responsibility for students with special needs. Frances and his coauthors described six scientifically grounded issues that educational professionals should be aware of when they are confronted with inattention and hyperactivity in the classroom.

First: birth order matters. Several studies have shown “That relative age is a significant determinant of ADHD diagnosis and treatment.” The youngest children in the classroom are twice as likely to be diagnosed with ADHD and receive medication. They suggest teachers take the child’s relative age into account when judging the child’s behavior. “Seeing ADHD as the cause of inattention and hyperactivity is in fact a logical fallacy as it is circular.”

Second, there is no single cause of ADHD. “There are no measurable biological markers or objective tests to establish the presence or absence of ADHD (or any other given DSM syndrome).” ADHD is a description of behavior and is based on “criteria that are sensitive to subjectivity and cognitive biases.” Multiple factors have been associated with ADHD, without necessarily implying causality. Those factors include: divorce, poverty, parenting styles, lone parenthood, sexual abuse, lack of sleep, artificial food additives, mobile phone use and growing up in areas with low solar intensity. “All these factors and more may play a role when a particular child exhibits impairing hyperactive and inattentive behaviours, and there is no conclusive cause of ADHD.”

Third, most children exhibiting “ADHD behavior” have normal-looking brains. Studies that do show small differences in terms of brain anatomy do not apply to all children diagnosed with ADHD. Individual differences refer to slower anatomical development. “They do not reveal any innate defect as is illustrated by the fact that many people with an unusual anatomy or physiology do not experience ADHD related problems.” Also, the test subjects in many brain-related studies are rigorously screened and don’t represent all individuals diagnosed with ADHD.

The samples do not comprise an accurate representation of their respective populations, meaning an average child with a diagnosis of ADHD and an average “normal” child. This problem is particularly urgent since the DSM 5 has lowered the age of onset criterion, as well as the impairment criterion compared to the previous version, the DSM-IV. Alongside the lowered threshold, the potential to generalize earlier research findings has lowered as well.

Fourth, the claims of ADHD being inherited may be overestimated. The claims vary widely and are subject to debate because of methodological issues used in calculating the heritability coefficient in twin, familial and adoption studies. There is significant difficulty separating genetic influences from environmental ones, such as poverty, parenting styles and divorce, in these studies. “In genetic association studies that really analyse genetic material and that are more powerful when separating the influence of genetics from other etiologic sources, associated genes show only very small effects.” When combined, they explain less than 10% of variance.

This means they occur only slightly more often in diagnosed individuals than in controls, and they do not explain nor predict ADHD behaviours. For educational professionals, this is important to consider as an ADHD label might give a false sense of security with regard to the alleged (genetic) cause of a child’s behaviour and the preferred cure (medication).

Fifth, medication does not benefit most children in the long run. Follow up studies of the long-term effects of the MTA (Multimodal Treatment of Attention Deficit Hyperactivity Disorder) study showed a convergence of outcomes over time between medicated and non-medicated children. Other studies also report either no long-term benefits, or even worse benefits. “While medication may help a small group of children in the long run, most will not benefit from long-term pharmaceutical treatment.”

The sixth and final issue that educational professionals should be aware of when confronted with inattention and hyperactivity in the classroom is the reality that a diagnosis can be harmful to children. A CDC MMWR Report indicated only 13.8% had severe ADHD, with 86.2% having mild (46.7%) or moderate (39.5%) ADHD. The authors pointed out a DSM diagnosis opened the door for additional reimbursement to the school for treatment and school services, perhaps promoting a search for pathology in relatively mild cases. “The question is whether in these mild cases the merits of a confirmed diagnosis—such as acknowledgement of problems and access to help—outweigh possible demerits.” Some known disadvantages of a diagnosis are: lower teacher and parent expectations that turn into self-fulfilling prophecies, prejudice and stigmatization of diagnosed children, a more passive role towards problems, difficulties getting life and disability insurances later on in life, and others.

The Allen Frances article linked above was the most accepting of ADHD as a legitimate “neuro-developmental disorder.” Yet it cautioned there was no single cause for ADHD, medications to “treat” ADHD did not have long-term benefits, and there was a problem with its over diagnosis. Jerome Kagan thought 90% children were wrongly diagnosed with ADHD because of “fuzzy diagnostic practices and relabeling.” Michael Corrigan, John Rosemond and questioned the validity of ADHD as a neuro-developmental disorder. Corrigan said it pathologized normal childhood behavior; and medicating these children was wrong and evil. It’s time to demolish the ADHD treatment empire.

Additional articles on ADHD can be found on this website here: “National ADHD Epidemic,” “Misleading Info on ADHD,” “Tip of the ADHD Iceberg,” and “Is ADHD Simply a Case of the Fidgets?” You can also read a longer paper: “ADHD: An Imbalance of Fire Over Water of a Case of the Fidgets?”

11/18/16

National ADHD Epidemic

The CDC published a study that found 11% of school-aged children in the U.S. between 2003 and 2011 had received an ADHD diagnosis. This statistic meant that 6.4 million children, 1 in 5 boys and 1 in 11 girls, were said to have ADHD. A different CDC report indicated the American Psychiatric Association (APA) estimated in their 2013 edition of the DSM, the DSM-5, that only 5% of children have ADHD. The rates of ADHD diagnosis are increasing over time, from an average of 3% per year between 1997 and 2006, to 5% between 2003 and 2011. The prevalence of children between the ages of 4 and 17 diagnosed with ADHD varied widely by state. In 2011, the lowest reported rates were in Nevada (5.6%); the highest rates were in Kentucky (18.7%). In contrast, the percentage of children diagnosed and medicated for ADHD in France is less than half of one percent—.5%!

You can see the CDC reports cited above here, here and here.

Writing for Psychology Today in 2012, Marilyn Wedge noted in “Why French Kids Don’t Have ADHD,” how the difference seemed to turn on how ADHD was conceived. In the U.S. ADHD is seen as a biological disorder with biological causes. So the go-to treatment method is stimulant medications. Dr. Wedge also pointed that French psychiatrists did not use the DSM system to diagnose childhood emotional problems. Instead they used an alternative classification system that focuses on the underlying psychosocial causes of a child’s symptoms.

French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating a child’s focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress—not in the child’s brain but in the child’s social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child’s brain.

She commented that the holistic, psychosocial approach of the French allowed for the possibility there could be nutritional factors that worsen ADHD symptoms. “In the U.S., the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children’s behavior.”

Psychiatrist Robert Berezin commented on Wedge’s report saying that it seemed American boys had contracted some contagion that spread ADHD exponentially. More seriously, he went right to the heart of the problem: if ADHD rates are so drastically different between the U.S. and France, how can ADHD be a brain disease? “Yes there can be symptoms of hyperactivity and concentration. But it is created by psychosocial causes, not biological ones. And the treatments should be appropriate to the cause.” He concluded that the French situation showed that so-called ADHD was a psychosocial problem, not a brain disease.

So if we accept this conclusion, where does this leave us in America with regard to ADHD and the aftermath of decades of conceiving and treating it as a brain disease? A recent investigative report by the Milwaukee Journal Sentinel and MedPage Today pointed out several areas of concern. First is the increase in the diagnosis of Adult ADHD. Twenty years ago ADHD was rarely diagnosed in adult Americans. Now, 1 in 23 adult Americans, around 10 million people, are said to have ADHD. And there has been a fourfold increase among adults 26 and older who use Adderall recreationally.

The reporters cited a 2010 study where 22% of the adults tested for ADHD had exaggerated their symptoms. This finding underscores how college-aged adults increasingly use ADHD medications as “study aides.” A 2013 study found wastewater samples collected near college dormitories in Tacoma Washington were eight times higher for amphetamines during final exams week than during the first week of classes. Although FDA adverse events indicated there were more reports for children, the adults were reporting more serious adverse events. “Adults accounted for just over one-third of reports, but made up more than half of all hospitalizations and 85% of deaths.”

Experts question whether adult ADHD is truly a widespread condition that needs treatment with the array of FDA-approved prescription medications. A medical historian, Nicolas Rasmussen, was quoted as saying that amphetamines are grossly overused; and that “the streets are awash with Adderall.”

Drug companies counter that ADHD is a real and treatable medical condition that effects millions of Americans. Charles Catalano, a spokesperson for Shire, which manufactures two ADHD medications, Vyvanse and Adderall, said the drugs have been approved by regulators around the world and are safe to use. “Our medications are proven to be effective when used according to prescribing practices of a licensed, trained health care professional.” A spokesperson for Novartis, the manufacturer of Ritalin, said it has been used safely and effectively for more than 60 years. “If used inappropriately, the results could be serious, just like with the misuse of any other medication.”

The DSM-5, published in 2013 by the APA, relaxed the criteria for diagnosing adult ADHD. Previously adults needed to have six of nine possible symptoms. Now they only need five of nine symptoms. Seventy-eight percent of the panel of experts who approved the changes had financial ties to drug companies. The APA minimized the potential conflicts of interest by stating no panel member had made more than $10,000 a year working as industry speakers and consultants.

Moffitt et al. published the results of a forty-year study of individuals in New Zealand in The American Journal of Psychiatry. The study found that found 90% of adult ADHD cases did not have a history of childhood ADHD. “The findings raise the possibility that adults presenting with the ADHD symptom picture may not have a childhood-onset neurodevelopmental disorder.” The authors added that if the findings were replicated, adult ADHD’s place in the DSM should be reconsidered and that research needs to investigate the etiology of adult ADHD.

It also appears that using ADHD medication leads to addiction and abuse problems with some individuals. Some of this is simple common sense. All ADHD stimulant medications are Schedule II controlled substances, meaning that the DEA considers them to have the same addictive potential as cocaine. Yet the research literature presents conflicting accounts. Some studies report that untreated ADHD is a significant risk factor in developing substance use disorders. Others suggest there is no compelling evidence that treating children with ADHD medication leads to an increased risk of later substance use problems.

A Medscape article concluded that the bulk of evidence suggested that treating ADHD with stimulant medication did not increase the risk for developing a substance use disorder, nor did it decrease to risk. At the very end of the article this comment appeared: “This activity is supported by an independent educational grant from Shire.” The author of the article had also received grants and served as a paid consultant for Shire.

On the other hand, Peter Breggin and others have noted there is a high abuse liability with stimulant medications. A 1995 DEA report indicated there was an abundance of scientific literature on the abuse potential of Ritalin and other Schedule II stimulants. A 1998 NIH conference on the “Diagnosis and Treatment of ADHD” stated: “An extensive scientific literature spanning more than 30 years of research unequivocally indicates that MPH [Ritalin] has a high abuse liability.” A 1995 study by Nora Volkow and others found that cocaine and MPH had similar effects on the brain when given intravenously. Breggin commented in his discussion of the study in his book, The Ritalin Fact Book, that the main difference was the longer lasting effect of Ritalin. This was speculated to be why Ritalin was less subject to abuse than cocaine. Breggin said:

What does all of this mean in plain English? Ritalin’s biochemical mechanism of action is essentially the same as that of cocaine, and therefore Ritalin produces similar effects to cocaine. In fact, all of the stimulants, including Ritalin and cocaine, jack up dopamine, serotonin, and norepinephrine chemical messengers in the brain, producing a variety of similar mental abnormalities. If given intravenously, the “high” is the same for all of them.

A study by Schrantee et al. published in the September issue of JAMA Psychiatry found there was a distinct effect of methylphenidate (Ritalin) on the brains of children and young adults. A discussion of this study in an article on Mad in America indicated the lead researcher of the study’s team, Liesbeth Reneman, said given that maturation of several brain regions are not complete until adolescence, drugs given during the sensitive, early phases of life could effect “neurodevelopmental trajectories” and have profound effects later in life.

The adolescent brain is a rapidly developing system that maintains high levels of plasticity. As such, the brain may be particularly vulnerable to drugs that interfere with these processes or modify the specific transmitter systems involved.

The mesolimbic dopamine system (MDS), the reward pathway of the brain, is one of those later maturing brain regions. Incidentally, the MDS is probably the region of the brain where drugs produce dependence. In his book, The Science of Addiction, Carleton Erickson said neuroscientists believe that when the functioning of certain MDS neurotransmitter systems are disrupted from genetic “miswiring” and/or long-term exposure to a drug, “chemical dependence as a brain disease” can develop.

The Schrantee et al. study is the first evidence that using ADHD medications can alter brain development. So studies of the long-term consequences need to be completed. But one of the questions that should be investigated is does the long-term use of stimulant medications effect changes to the MDS of the brains of adolescents and young adults and are those changes related to a greater risk of substance abuse. Hopefully we’ll have some answers before prescription stimulant drugs compete with opioids as a national drug epidemic.

07/1/16

Misleading Info on ADHD

Three Swedish researchers did a study on the information published online by the National Institute of Mental Health (NIMH) on ADHD. What is intriguing about their study is that they were looking at how the NIMH document sought to persuade its readers to take action to address their child’s ADHD problem. They suggested there was a circular argument wherein ADHD was defined according to the presence of certain behaviors, which the diagnostic label of ADHD was said to explain. They also pointed out how ADHD is presented as legitimate medical disorder, despite the fact that “diagnostic criteria are subjectively interpreted from the behavior of the child.”

The authors, Erlandsson, Lundun and Punzi, linked this Easy-to-Read NIMH document on ADHD in their study. However, their citations appear to be from this NIMH document, “What is Attention Deficit Hyperactivity Disorder (ADHD, ADD)?” They noted where the image of ADHD as a legitimate medical disorder was established by the first sentence of the article, “ADHD is one of the most common childhood disorders [and can continue through adolescence and adulthood].” This is word-for-word in the latter article, where the Easy-to-Read one is slightly different: “ADHD is a common mental disorder that begins in childhood and can continue through adolescence and adulthood.” The bracketed phrase was not quoted by Erlandsson, Lundun and Punzi, possibly because they were looking at ADHD in children; or when they examined the document in October of 2015, it wasn’t there.

Erlandsson et al. noted how the repeated use of the term “disorder” (at least 15 times) and a number of references to brain imaging and brain chemicals gave the impression of a chronic, long-term disability. The rhetoric is clearly suggestive that ADHD is a brain disorder. And yet, because symptoms vary from person to person, the ‘disorder’ can be difficult to diagnose. The so-called ‘key behaviors of ADHD’ are also found in all children—inattention, hyperactivity, and impulsivity. “But for children with ADHD, these behaviors are more severe and occur more often.” They have to be present for at least six months, and be present to a degree “that is greater than other children of the same age.” Erlandsson et al. said:

In fact, as shown in the document, there are no biological markers, environmentally defined categories, or objective tests to distinguish “ADHD” as a discrete condition. Rather, diagnostic criteria are subjectively interpreted from the behavior of the child: “No single test can diagnose a child having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment.” Professionals as well as teachers and parents are involved in the evaluation and examination process, and subsequently in the diagnostic process.

There is a clear bias in presenting ADHD as a biomedical problem. While saying scientists aren’t sure what causes ADHD, NIMH then said many studies suggest genes play a large role. Twin studies show ADHD runs in families. “Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention.” But the differences were not permanent and as the children with this gene grew up, the brain developed to a normal level of thickness and the ADHD symptoms improved. As Erlandsson et al. commented: “The biomedical discourse assumes that there is a consensus among professionals on how to interpret the behaviors of the child, which means that pharmacological treatment is the preferred intervention.” But this is not the case.

In “ADHD: an Imbalance of Fire over Water or a Case of the Fidgets?” I reviewed several different sources questioning whether ADHD was a biochemical disorder. Psychiatrist Peter Breggin said the search for a genetic and biological cause for ADHD would never succeed because the researchers are looking in the wrong place. Neurologist Fred Baughman said:

Despite regular pronouncements that its biologic roots have been discovered, no proof of a definite physical or chemical abnormality is ever found. All such research and all such claims … have been a sham, meant to create illusions of science and disease while proving nothing.

The NIMH material also did not mention there was a lack of consensus on the safety of using medication to treat children. Rather, medication is said to be a safe treatment: “Under medical supervision, stimulant medications are considered safe.” The potential for substance abuse or dependence is downplayed, saying: “there is little evidence of this.” ADHD stimulants are classified as Schedule II controlled substances, which have “a high potential for abuse, with use potentially leading to severe psychological or physical dependence.” See “ADHD: an Imbalance of Fire over Water or a Case of the Fidgets?” for more information on ADHD medications and addiction.

The consequences of a biomedical view of ADHD were addressed in a recent study by the CDC of ADHD treatment among children between 2 and 5 years of age. While the American Academy of Pediatrics and other organizations recommend behavior therapy ahead of stimulant medication for children under 5, only 53% of children had received behavior therapy in the year prior to the survey, while 47% had received stimulant medication during the previous week. Between 75% and 78.5% of children aged 2-5 with ADHD received one or more ADHD medications.

ADHD is a highly prevalent condition that can lead to poor health and social outcomes. Despite 2007 and 2011 guidelines recommending behavior therapy as first-line treatment for children aged <6 years with ADHD, during 2008–2014 only about half of children aged 2–5 years with ADHD received psychological services. To effectively mitigate impairments associated with ADHD and minimize risks associated with ADHD medications, it is important to increase the percentage of young children with ADHD who receive evidence-based psychological services, especially parent training in behavior therapy.

Around 30% of children aged 3-5 experienced adverse effects from ADHD medications. The most common ones were appetite suppression and sleep problems. But other commonly reported side effects were: abdominal pain, emotional outbursts, irritability, lack of alertness, repetitive behaviors and thoughts, social withdrawal, and irritability when the medication wears off. In one large study, of methylphenidate (Ritalin or Concerta) over 10% of children 3-5 had to stop treatment because of adverse effects. They were also 20% lower for height and 55% lower for weight. Anne Schuchat, the CDC’s Principle Deputy Director, said:

We are still learning about potential side effects of long-term use of ADHD medicine on young children. Until we know more, the recommendation is to refer parents for training in behavior therapy for children under 6 years of age with ADHD.

We recognize that these are not easy treatment decisions for parents to make. We know that behavior therapy is effective, and the skills they learn through behavior therapy can help the whole family be successful. Building these skills in parents and children both empowers families and helps young children with ADHD live up to their full potential.

An article in The Washington Post, “CDC Warns that Americans May Be Overmedicating Youngest Children with ADHD,” addressed this concern as well. The long-term effects of the drugs of choice for treating ADHD, Adderall and Ritalin, were not well studied. An estimated 2 million of the 6 million children diagnosed with ADHD were so labeled between the ages of 2 and 5. While ADHD medications don’t work for everyone, in many cases they take effect almost immediately. In contrast, behavior therapy can take several months to have an impact. However, it can be long lasting; and has no side effects.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: ADHD