Are ADHD medications overprescribed?

Posted by Karoli in ADHD, Parenting February 22nd, 2006

Shrinkette posted a shout-out over the weekend for child psychiatrists to comment on this question in response to nhsblogdoc’s post asking how many children really need meds. nhsblogdoc comes at it with a fairly balanced approach until the end of his post, where he links up the “death from ritalin” site, which I will not link to because of its hysterical and unbalanced approach to the question of ADHD medications. Another post entitled “Keeping Kids Happy” leads off with this:

It is not clear from the adverts why these children are so happy. Too much apple pie maybe? Or are they drugged up to the eyeballs. Should drug companies be promoting their wares in this fashion?

He then goes on to insert the following hypothetical marketing pitch, lifting a quote from “Brave New World”:

“By this time the soma Ritalin had begun to work. Eyes shone, cheeks were flushed, the inner light of universal benevolence broke out on every face in happy, friendly smiles.”

His conclusion: “Make no mistake. This is what we are doing to our children.”

No sir, Dr. Crippen. It is not what we are doing to our children. Not at all. It’s how you spin what we are doing.

On the other side of the debate, WebMD’s Dr. Richard Sogn responds by asking whether the issue is that stimulants are overprescribed or misprescribed.

Medications for ADHD are misprescribed in the same way that antibiotics for viral infections are misprescribed. Rather than doing a thorough evaluation and laboratory testing to differentiate a viral infection from a bacterial infection for someone with flu-like symptoms, it’s often easier just to write a prescription. Rather than doing a comprehensive evaluation of the child with difficulties paying attention or experiencing disruptive behavior, and then developing a comprehensive treatment plan that may or may not include medications, it’s sometimes easier for physicians with little time, training, or experience in evaluating and treating ADHD to simply write a prescription.

And on Grand Rounds this week, Difficult Patient is frustrated with those who question whether ADHD even exists. Difficultpatient and I share that frustration.

To me, all of this blog buzz feels like a lot of heat with very little light. I appreciated shrinkette’s measured response to Dr. Crippen’s articles, and Dr. Sogn’s rational analysis of what the real problem may be.

I own this: I am biased toward medications because I’ve seen them work.

I also understand what was involved at arriving at a true diagnosis and treatment plan. It really is important to me that if you’re reading my blog for the first time you understand that I do not support an off-the-cuff diagnosis and prescription. At the same time, to equate the benefits of stimulant medications in treating ADHD with a fictional account of mind control in Brave New World is at best fanciful and at worst irresponsible.

What do you think? Am I overreacting?

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    Dear Drums&Whistles,

    I came here via NHSDoc. I hope this is ok etiquette, I'm copying the coment I left on his site. I'm eager to share my experiences because this ADHD thing is such a big issue and I feel the conversation needs to be continually broadened. And, as you will notice, my own example, though neurochemical, is not in fact ADHD. However, there is a story. Also, nowhere in this comment do I address other interventions, eg. behavioural.

    Someone at Shrinkette referred to the "N=1" samples where people generalize from their own experience. With that in mind, I'd still like to offer a few thoughts on this topic. I've been involved in psychiatric and mental health nursing, both within and outside the mainstream for 30 years. I have also been "working on myself" for that long. For 20 years I was seeking not only to 'know myself', but to overcome a tendency toward emotional reactivity. This mostly manifested in relation to my spouse, but I could as easily say it only manifested in private, not over the counter of the local shops. Coming from a family of screamers, I'd clearly been conditioned into this pattern.

    Very early on I adopted a very healthy diet, seeking balance through moderation as well as meditation. I would eventually come to label myself 'high-strung', like grandmother, though some clever MD could conceivably attach an 'agitated depression' label to me. After 20 years of meditation and all relevant therapies, practices, diet, I hit an edge that had me in a doctor's office requesting Prozac. I'd been in India during Prozac's debut, had heard a few things about it, had used Valium a handful times in my past and hated it, but knew I needed something. Within an hour I thought it should go into the water supply: I felt good, I was no longer reactive to everything (also known as temper tantrums, or rage attacks), though the nausea was a bummer. Stayed on 3 weeks, got back to my inner practices. A year later, another crisis, and after 3 weeks unable to regain my balance, returned to Prozac. This time, unwilling to feel so edgy in an uncertain living situation, for 6 months. Until I developed a rash. The rash that came to stay. And morph and spread to the other side of the body. Read Prozac insert (discontinue if rash appears) , stopped the drug.Took months to quit the itching, eventually with acupuncture. But it was always ready to start up again. Now, 10 years later, I see that my immune system was compromised in a way that's never recovered.

    So I researched alternatives. The penny first dropped when I heard a psychologist say, "well, do we say that all these people have a Prozac deficiency?" Then what is deficient?? Found research suggesting high dose B vitamins had been effective in treating schizophrenia. Given that I'm just a 'normal neurotic', albeit high-strung, surely it must have some potential for me. Found info about amino acid l-tryptophan, including that it was withdrawn from the market weeks before Prozac was introduced, and never allowed back in the US since. (you'll find that story here: www.lightparty.com)

    The guts of it: Yes I and many others have ineffectual neurotransmitter systems. I believe early childhood stressors, plus genetics sealed my fate. Just as genetics plus Prozac sealed my fate when 6 years later, under severe stresses, my system collapsed leaving me with chronic fatigue immune disorder (CFIDS). But there is no evidence that I had a Prozac deficiency, just as there is no evidence that these kids have stimulant deficiencies.

    I wish I could speak with greater expertise and footnotes, but I can't. But I can tell you than I manage my nervous system with vitamins B3 (1-2g/day), B5 250 mg/day, B6 (200-400mg/day) + folic acid. (It's prudent to make sure B's are balanced, with a multi, or diet.) Plus, 200mg tryptophan/day. And more recently, when depression about my illness threatened to swamp me, 1/8 tsp tyrosine gave me back the capacity for joy. Magnesium finally helped me to sleep. Mineral and heavy metal levels were monitored by hair tissue analysis.

    In treating the CFIDS, once we switched my thyroid medication (I've been on replacement since 13 yo) to custom-compounded, my base condition improved. Except, as soon as I felt the slightest increased energy I could feel my nervous system ramping up again. I now know that this condition which i merely found unpleasant and inconvenient earlier has now become life-threatening. The confluence of hormonal shifts (I'm 56 yo), stress and this 'high-strung' nervous system have led me to such a profound depletion that it's clear something has to change.

    Bear with me, I'm almost there. So the next search was to calm my nervous system. My compounding chemist recommended GABA . Within a few days my nervous system calmed, heart rate lowered, sleep deepened, sense of feeling twitchy dropped. This is only in the last 2 weeks, so I'm not sure exactly where I go next, or if GABA will turn out to be The Thing. [GABA:gamma-aminobutyric acid, "the most important and abundant inhibitory neurotransmitter in the brain,it's actually an amino acid classified as a neurotransmitter. It helps induce relaxation and sleep. It acts as a "balancer" for the brain where excitation of the brain is balanced with inhibition. http://www.bodybuildingforyou.com/supplements-r...

    What I Know: Vitamins, minerals and amino acids are our basic building blocks. And yet we jump over the basics for the magic bullet pharmaceuticals. I know in my N=1 sample my process and choices are idiosyncratic. They are also customized. Prozac would be way cheaper. But I fundamentally believe in supporting the whole system, like properly preparing and feeding the soil before growing veggies. I know that similar approaches would work for many, many people. And my fervent hope is that there's enough suspicion at present about pharmaceuticals, particularly mind-altering substances, that this area of exploration grows and rapidly. And that one day health schemes subsidize such solutions (oh well, maybe that's psychotic thinking.)

    In Illinois the Pfeiffer Treatment and Research Center's mission is to 'increase an individual’s ability to lead a productive and rewarding life by focusing on the research, education and nutritional treatment of biochemical imbalances.' They're working with ADHD Also , who just hosted a first international summit for integrative mental health, with folk from the Pfieffer Instit. And the excellent site of my compounding chemist, www.custommedicine.com.au/brain-function. I am not affiliated with these or any other organization. Just out here finding people who are taking a new look at healing our brains.

    [ See the Light Party index for articles on tryptophan and 5htp. Also, this reference, (and millions of others via google)
    www.vrp.com/pdf/november2005news.pdf (pg 11 re tryptophan) I've seen one reference to tryptophan causing stomach cancer, but when I went to the source, it referred to doses of 10-12 grams (I take 200 mg.) Some doctors have thought that my dose is too low to work. They also don't believe that I felt the Prozac within an hour. And certainly they don't believe Prozac's the cause of my immune disorder.]
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    Hi nursenancy and welcome,

    I disagree with characterizing ADHD as a "stimulant deficiency". It is a neurotransmitter disorder which stimulants effectively treat, but doesn't necessarily mean one is deficient in stimulants. If you find natural alternatives that are working for you, I'm all for them.

    I tried the 'natural thing', psychotherapy, hypnosis, and just about everything else before coming to an understanding that what worked -- really worked -- was the medications. Do I think they should be prescribed without careful research by parents and adult patients beforehand? Absolutely not.

    I am open to new research, but what annoys and deeply concerns me is the current 'anti-medication' bent that seems to be getting all the press. As Terrence over on The Republic of T says in his post here:
    Maybe I’m overreacting to this, but it just seems to me that the one group of people getting pretty much left out or brushed aside in these discussions lately are those who have benefited from these medications. That only makes sense. After all, why spend much time listening to people who claim to have a condition that you’re pretty certain probably doesn’t exist. Sure, they benefited from medication, and maybe they have better lives than they had before medication and treatment, but that’s only because they weren’t willing to try harder and they weren’t punished enough. So, if they end up having a harder time getting medication, that might actually be good for them. Maybe a giant step backwards can also be a giant step forwards.

    Maybe I’m skeptical because I’m one of those people who benefited from stimulant medication, after trying just about everything else and finding that they either didn’t work or that they had side effects that I couldn’t live with. I understand that these medicines aren’t necessarily for everyone. Some people can’t tolerate the side effects and/or don’t want to take the medications, and no one should have to take them.

    So, if there are alternative treatments or “non-drug interventions” that work for some people, I’m all for them. But why make it harder for people who can and do benefit from these medicines to get them? Because that’s where the current trend seems to be headed.


    A clinically depressed patient should not rule out medications as part of the treatment, and the same is true for kids and adults with attention deficit disorder. It should not be looked upon as some kind of evil form of mind control but approached with a clear and informed mind, armed with facts.
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    Medications do work for some people, but there's not enough emphasis on their detrimental side-effects. There's also not enough being said about doctors pushing meds as magic pills that cure people of their problems. Because not all people are the same there should more variety in how doctors are handling these cases.

    It seems people with AD/HD find solutions in one of the following ways:

    a) Medications
    b) Medications in tandem with coping strategies
    c) Coping stategies
    d) Denial
    e) Disinterest in finding solutions to their problems

    Most doctors I have had experience with push solution a because they have good intensions and ultimate faith in the pharmaceutical industry. They don't emphasize learning how to live and cope with AD/HD, or even use it as an asset. I wonder if there was more emphasis on points b & c if we wouldn't see so many cases of a which are setting off the extremists and fueling the fires of phobia and ignorance.

    ~Douglas
    -=-
    The Splintered Mind - Overcoming Neurological Disabilities With Lots Of Humor And Attitude
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    Hi Douglas and welcome,

    I disagree with the remark that there's not enough emphasis on 'detrimental side effects'....it seems like that's ALL we hear about these days. Rarely is there any balance in the reporting, which is what I'm after.

    I'm glad you stopped by -- you have an interesting blog and I plan to keep reading it!

    DnW
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    Well, when I was researching medications 14 years ago nobody discussed side-effects. If the doctor had told me that one possible side-effect of desoxyn was Touerette's syndrome I would have run screaming from the office. Instead, he didn't say a thing and I became damaged after only 2-3 weeks on the medication. These days there have been enough law suits and malpractice suits that all you hear during a drug commercial is "Our drug will solve all your problems...unless you take it on Tuesday following a rain storm during March, and if you are allergic to photons, and if you find it difficult coughing up blood. Our drug may cause your intestines to explode, your left hand to fall off, yada yada yada..."

    What I was was referring to was the media. They hardly ever mention the detriments to taking medication. You get one of two types of articles. Those proclaiming the new medicated millennia is upon us for a happier, better world and those that claim that we're a bunch of hypochondriacs overmedicating our children. Always just two sides.

    Well, that's true of most issues, but it rankles most for me when AD/HD is involved. I'd like to see more informed reporting. Not just the crib notes version from whatever press release they're basing their report on.

    I'm glad you liked my blog. I look forward to reading more of your comments. ;)

    ~Douglas
    -=-
    The Splintered Mind - Overcoming Neurological Disabilities With Lots Of Humor And Attitude
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    Douglas,

    Yes, we do agree on that -- the reporting is far too one-dimensional and sensationalistic. Personally, I think the TV and print ads for medications should be banned. They are, by definition, slanted and far too broad. While consumers have resources to research and learn about meds, the ads carry far too much weight and promise way too much.

    Take care

    DnW
 

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