Thursday, November 15, 2012

ADHD - The Scientific Evidence versus the Political Hype

I attended a day long seminar by Russell Barkley, PhD.  It is part of my ongoing mission of seeing the experts in person who I have read and collected in my library over the past 30 years.  My earliest exposure to Dr. Barkley's work was the book Hyperactive Children that I acquired while I was in Medical School and used when I was treating children in the first clinic I worked in as a psychiatrist.  Interestingly he was working at the same medical school I had attended.  Dr. Barkley has an impressive surveillance system for current literature and in the seminar was presenting work that had literally been published or put into prepublication the day before.  His scholarship is impressive and he is one of the most widely published authors in the field.  He has a clear scientific approach and does not recommend treatments that have not gone through randomized and blinded clinical trials.  He gave many examples of ADHD treatments that seemed effective until the raters were blinded to the treatment or the methods were used by researchers who had no vested interest in the outcome.

All of his information was presented on PowerPoint as is the standard.  His PowerPoint slides were information dense, frequently presenting dimensions and data points from several studies on the same line.

A few of the highlights that you will not read in the New York Times:

1.  On the "overdiagnosis" issue - at this time about 40% of kids and 10% of adults with the disorder are treated.
2.  On the DSM issue - the categories of ADHD are going away.  Like categories of schizophrenia and autism spectrum disorder they are not unique entities.   This of course runs counter to the usual DSM criticism that there is a proliferation of diagnostic categories   Another positive was that the age of onset criteria is changing from age 7 to age 12.  Barkley points out that an age cutoff for a developmental process is arbitrary and suggested a further change to "onset in childhood or adolescence".  On the other hand, it does appear that the committee in charge is responding to political pressure from the government and insurance companies to not make any changes that would increase the prevalence of the disorder.  He presented clear criteria that would improve the diagnosis of ADHD in adults that will apparently not be included or possibly on a parenthetical basis.
3.  The problem with the treatment of children is not overtreatment, but that fact that most children who need treatment discontinue their medications as teenagers.
4.  The resulting complications of untreated ADHD are significant from an educational, public health, and psychiatric perspective.  As one example, untreated ADHD is associated with high risk of dropping out of school.  Every person who drops out and does not complete school represents a cost of $450K to the community.
5.  Stimulant medications have a 40 year record of use and there have been over 350 studies documenting the efficacy and safety.  They have the greatest effect size of any psychiatric medications and that includes up to 90% response rates across all stimulants.
6.  Response to treatment is robust and the best of any psychiatric disorder.  Evidence based studies show that patients treated with stimulants show improved outcomes across 20 parameters and that treatment with atomoxetine is associated with improvement across 23 parameters.
7.  These medications have an unprecedented safety record.
8.  There is a potential steep cost in many areas of not adequately treating the disorder.

It is very disappointing to hear that the DSM committee may be yielding to political pressure when it comes to implementing new evidence based DSM criteria particularly give the poor quality of these arguments.  A professional organization should be above political influence when it comes to scientific findings and this revision of criteria was supposed to be based on science.  The APA does have a long history of not providing any resistance to the managed care industry or government initiatives to reduce the quality of psychiatric care in favor of the managed care industry.  If true it will be ironic that the ADHD section of the DSM5 will be be directly influenced by the usual managed care forces and that they are aligned with all of the media rhetoric about the proliferation diagnoses and increased prevalence.

So the usual media hype is wrong - psychiatrists and pharmaceutical companies are not plotting to put more people on medication.  The government, managed care companies, and the anti-biological antipsychiatrists are trying to keep them off even when they are indicated.  In that political divide - the science is left out.

George Dawson, MD, DFAPA

Dr. Russell A. Barkley, PhD.  Official Web Site.

Dr. Russel A. Barkley, PhD.  Professional Workshop on ADHD.  ADHD Across the Life Span: Diagnosis, Life Course, Management, and Comorbidity.  Minnetonka, Minnesota.  Thursday November 15, 2012.

International Consensus Statement on ADHD (excerpt) - read this statement signed by scientists explaining that this diagnosis is not controversial and that the percentage of patients treated is about the same in the past decade.

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