Bad medicine: adult attention-deficit/hyperactivity disorder
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7244 (Published 07 November 2011) Cite this as: BMJ 2011;343:d7244All rapid responses
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Adult ADHD: Bad medicine or Bad attitudes?
The BNF on my desk has 770 pages of pharmaceutical products, but only 54 (7%) of these are for mental disorders, at a time when the Department of Health1 estimates mental health problems are responsible for 22% of the UK’s “health burden” – hardly the “pharma goldmine” that Des Spence suggests. Like all of medicine, psychiatry suffers from distorted research priorities driven by the interests of the pharmaceutical industry rather than clinical need, but mental health in general remains under-researched2 and under-resourced in proportion to other areas of medicine.
Psychiatry “willingly medicates children”? Yes, and so do all specialities. Children with diabetes, asthma, leukaemia, epilepsy are quite rightly medicated, and no-one objects: to criticise when a mental disorder is treated is to perpetuate the stigmatisation and marginalisation of mental illness in comparison to physical illness. There are certainly concerns associated with overdiagnosis and treatment, but underdiagnosis and undertreatment of mental disorder remains a greater problem.
Diagnostic descriptions “include traits common to us all”? Yes they do – much mental disorder is dimensional rather than categorical in nature, again not unlike many physical illnesses. There is certainly a risk of medicalising normal experiences – and psychiatry has a shameful history of labelling difference as pathology – but the medical profession also has a history of ignoring the genuine suffering and unmet need resulting from mental illness.
Uncritical and unthinking prescription of stimulants for poorly defined ADHD is certainly bad medicine – but dismissing the real, and eminently treatable, needs of patients suggests a bad attitude to mental health that should not go unchallenged.
1 Department of Health. No health without mental health. 2011. http://www.dh.gov.uk/en/Aboutus/Features/DH_123998
2 Medical Research Council. Review of Mental health research: report of the Strategic Review Group. 2010. http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC006848
Competing interests: No competing interests
Re: Bad medicine: adult attention-deficit/hyperactivity disorder
We could not resist strongly disagreeing with the author’s views on Adult ADHD which are not only ill informed but add to the misperception of Adult ADHD within the medical profession and general population.
We really hope his views about Mental Illnesses are not reflective of the views of the large body of General Practitioners, particularly as General Practitioners are going to be in charge of most of the healthcare budget and this will significantly affect the recognition of mental illnesses in the frontline of healthcare. Even Depression which is now a well-established illness and widely accepted to be one of the leading causes of morbidity (1) was found to be recognised in less than 50% of patients by General Practitioners (2).
Moreover, in this case the author is clearly unfounded in his statements. Adult ADHD is an extremely debilitating and impairing condition and like many other Mental Illnesses is currently going through a phase of being misperceived, underdiagnosed and under treated.
It was also sad to see the quality of the studies he has quoted in defence of his views. There is now extensive international research in Adult ADHD (6) and not just “few specialists in Harvard”. The prevalence of Adult ADHD is now widely accepted to be between 2-4% in most studies including an international WHO study which had about 11,000 participants from 10 countries(3).
His point about the sample size of one study (146 patients) as being representative of the evidence is incorrect. In the same analysis Cochrane took into consideration 7 studies of amphetamines for Adult ADHD, totalling 1091 patients (4) and there is now extensive and growing data about the efficacy of psycho-stimulants and other medication as well(6).
Celebrities openly talking about their illnesses is by no means scientific evidence supporting or refuting the authenticity of any medical diagnosis. In fact it can at times serve an important role in increasing public awareness.
There is a large and consistent body of evidence that supports that psycho-stimulants are not abused widely and have much less potential of being used for their “euphoric” effects due their pharmacokinetic properties compared to other drugs of abuse(7). The side effects are also quite transient and much less troublesome compared to other Psychotropic Medication. On the contrary there is evidence to show that treatment of ADHD maybe a protective factor in substance misuse amongst patients (8).
Whist there is a much merit in the argument about pharmaceutical industry’s role in research and efforts certainly need to be made to stringently regulate this, the pharmaceutical industry’s role in investing in new innovations in pharmacological treatments cannot be underestimated. It is indeed a difficult balance which demands careful evaluation and discussion and should not be based on a conspiracy theories.
Regards
Dr A Vaze and Dr M Arif.
1. http://www.who.int/mental_health/management/depression/definition/en/
2. Mitchell, Alex J, Vaze, Amol, Rao, Sanjay: Clinical diagnosis of depression in primary care: A meta-analysis. The Lancet, August 2009, vol./is. 374/9690(609-619), 0140-6736 (Aug 22, 2009)
3. Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demyttenaere K, De Girolamo G, Haro JM, Karam EG, Lara C, Lépine JP, Ormel J, Posada-Villa J, Zaslavsky AM, Jin R. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br Journal of Psychiatry, 2007 May;190:402-9.
4. http://summaries.cochrane.org/CD007813/amfetamines-for-attention-deficit....
5. Faraone, Stephen V. PhD, Spencer, Thomas MD; Aleardi, Megan; Pagano, Christine; Biederman, Joseph MD. Meta-Analysis of the Efficacy of Methylphenidate for Treating Adult Attention-Deficit/Hyperactivity Disorder. Journal of Clinical Psychopharmacology: February 2004 - Volume 24 - Issue 1 - pp 24-29
6. Kooij et al. European consensus statement on diagnosis and
treatment of adult ADHD: The European Network
Adult ADHD. BMC Psychiatry 2010, 10:67.
7. Volkow ND, Swanson JM: Variables that affect the clinical use and abuse
of methylphenidate in the treatment of ADHD. Am J Psychiatry 2003, 160(11):1909-1918.
8. Wilens TE, Faraone SV, Biederman J, Gunawardene S: Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 2003,111(1):179-185.
Competing interests: Dr Arif has been a Consultant and Speaker for Janssen Cilag and Eli Lilly. Dr A Vaze has been a Speaker for Eli Lilly.