Last time I talked about how reshaping our conceptions towards the idea that the self is dynamic and changeable – with awareness, desire, and perseverance – can lead us all on a path to betterance. This time round, I want to show how pharmaceutical giants have pushed a culture of overdiagnosis and overmedication of ADHD onto us, harming our children and our society all in the pursuit of profits.
Mental health remains surprisingly stigmatised in the 21st century, and services across the Western world (e.g. UK (by 8% – £600m), Australia, Canada, US) have been particularly vulnerable to scathing cuts in the wake of the financial crisis. Resources are insufficient on a global scale, and spending on mental health (UK – 11% of NHS budget) lags significantly behind the proportion of burden of disease mental health problems account for (UK – 23%). But even within these limited confines, there are serious problems in the way many mental disorders are diagnosed and treated, perpetuating this stigma and freezing the dynamic hopes and ambitions of millions.
In particular, I want to talk about Attention Deficit Hyperactivity Disorder (ADHD). In the US, 7.8% of 4-17 year olds were diagnosed with ADHD in 2003. By 2007, this figure was 9.5%, and by 2011, 11%. That’s 1 in 5 boys and 1 in 11 girls, adding up to 6.4 million children, just in the US. These are conservative figures, based on voluntary parent reporting – practitioner surveys produce estimates as high as 18%.
There is no doubt that for at least some sufferers, ADHD is a neurological disorder with genetic roots and one characterised by clear functional impairments in the brain. But this avalanche-like rise in diagnosis despite there still being no clear utilisable biological markers of the disorder cries out that something isn’t quite right.
When you examine the breadth of evidence, it is impossible to ignore that socio-environmental factors play a significant role in diagnosis. For example, white children are disproportionately diagnosed with and treated for ADHD despite lower average symptom levels than black and Hispanic children, and the lowest socio-economic status children have 45-79% higher predicted ADHD rates than high SES children, but are only 14% more likely to be diagnosed, and less likely to be treated with stimulant drugs. What is even more troubling is that boys born in the last month of the school year are 30% more likely to be diagnosed than those born in the first month, and the equivalent figure for girls is a shocking 70%. This surely means that many diagnosed with ADHD do not have any underlying biological markers of the disorder – addressing the issue of school age alone, 20% of kids are likely to have been misdiagnosed.
socio-environmental factors play a significant role in diagnosis
That’s 20% of kids merely displaying signs of natural immaturity, the majority of whom are prescribed methylphenidate (Ritalin), a drug that boosts dopamine concentrations in an attempt to improve planning, reasoning, and the ability to inhibit behaviours. Ritalin also substantially raises heart rate and blood pressure, stunts growth for long after treatment ceases, increases the risk of psychotic and manic symptoms and perhaps even depression, and has to be labelled with the FDA’s strongest “black box” warning upon prescription. Long-term follow up studies examining children 8 years after prescription find no advantages on any outcomes compared to non-medicated children, and symptoms may in fact be exacerbated. It is a Schedule II drug in the US and a Class B in the UK, and its effects when snorted are highly similar to cocaine, with a similarly high potential for psychological and physical dependency.
These kids are diagnosed at an average age of seven. Seven. I have serious reservations regarding the wisdom of tampering with the dopamine circuitry of a brain whose stucture and function is still not even yet half formed. Especially when there is cold hard evidence to suggest that the aforementioned brain pathology associated with ADHD may in fact be caused by the medication and not the disorder itself.
So what is responsible for this rise in diagnosis? Three letters – DSM. The Diagnostic and Statistical Manual of Mental Disorders, the primary diagnostic tool for psychiatrists in the US, by its very structure encourages categorisation into a psychological box from which many may never escape. Six or more symptoms of inattention, six or more symptoms of hyperactivity and impulsivity, and there’s your diagnosis. Symptoms from the most recent version, DSM-V, include:
- Often talks excessively
- Often has trouble waiting his/her turn
- Is often “on the go” acting as if “driven by a motor
- Often interrupts or intrudes on others
- Often unable to play or take part in leisure activities quietly
- Is often easily distracted
- Often does not seem to listen when spoken to directly
- Often fails to give close attention to details or makes careless mistakes in schoolwork
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time, such as schoolwork or homework
I don’t know about you, but I don’t know many kids who seek, like, and are excited to perform such tasks. There are numerous environmental causes that can explain some of the common DSM symptoms, but these are given nowhere near enough attention before medication is deemed necessary. Caffeine (Adult RDA = 85mg, 500ml Red Bull = 160mg), aspartame, and food preservatives all cause hyperactivity, and these substances are endemic to Western (and particularly American) society.
Sleep deprivation, stress, passive rather than active learning (a cornerstone of English and American education), school overcrowding, and poor parenting are all also strong contributors to ADHD-like symptoms. Tallulah, a long-time psychiatric social worker, told me she had all too often seen children who are “products of the divorce from hell” being taken to psychiatrists by their parents who insist their child’s inability to focus must be ADHD. In fact, there is even concern that UK families might be pushing for prescriptions because an ADHD diagnosis makes a family eligible for Disability Living Allowance – which journalist and author William Sutcliffe eloquently equates to ‘living in a state that effectively pays parents to drug misbehaving children’.
Yet these environmental factors were officially forgotten by DSM-III, which marginalised consideration of context and life events in symptom presentation, and meticulously divided mental illness into clearly defined, narrow categories, raising diagnostic rates for each slice and mingling the worries of everyday life with mental illness. The number of identified disorders has steadily increased in subsequent versions, the publishing of which has earned the American Psychological Association (APA), a supposedly neutral organisation with the field’s best interests at heart, over $100m.
Delving deeper, the story becomes even more sickening. Half of the authors who defined DSM-IV have had financial relationships with the pharmaceutical industry at some point, and this figure rose to a staggering 69% for DSM-V. Perhaps it is no surprise then that in 2013, the DSM criteria for ADHD were revised so that the need for ‘clinically significant impairment’ has been replaced with a less stringent threshold, leading yet another raft of people to pay for medication they don’t need.
Make no mistake about it – lack of resources aside, Big Pharma is the biggest challenge facing mental health of our time, and its one that’s all too hard to bring to the surface. In this article, I had planned to reference a paper by Joseph Biederman of Harvard University before I learnt that he had earned £1.02m in consulting fees from drug corporations. Likewise, Dr Frederick Goodwin reportedly earned at least £0.84m for marketing lectures to doctors on behalf of similar companies. And who is Dr Goodwin? The former director of the National Institute of Mental Health.
The story of how this happened is enough alone to make you want to pop a few pills. Psychiatrist and chairman of the DSM-IV task force Dr Allen J. Frances elucidates that drug companies aggressively courted doctors with perks in the wake of DSM’s initial publishing, hired the most beautiful drug reps to push their products, and used celebrities to advertise directly to consumers. Companies received fines in excess of $1 billion for their behaviour, but these were the equivalent of a slap on the wrist in the context of the profits they were and are still making. In the US, sales of ADHD drugs more than doubled between 2007 and 2012, from $4 billion to $9 billion, so those extra 20% of misdiagnosed and medicated cases earnt them $1.8 billion. For one disorder. Well worth it.
The sad thing is that it doesn’t have to be this way. Countries such as France, Italy, and Finland consider ADHD a predominantly psychosocial phenomenon, use more stringent diagnostic systems, and treat the disorder behaviourally with an active consideration of the child’s social context – and medication a last resort. 0.5% of kids have ADHD in France according to their classification system, but using DSM, the estimate is 3.5%. The fact that this estimate is still three times lower than US prevalence makes clear the snowball effect a culture that actively seeks to pigeonhole its people can have – the more visible an illness is, the more inclined you are to use it as an explanation, and with sufficient marketing, the more likely you are to think, or be told, that you need medication.
DSM estimates of Finnish ADHD prevalence are 8.5-12.6%, but 0.64% of Finnish kids used medication in 2007. Rather than popping pills, Finland is developing specially designed video games where success is dependent on individually tailored patterns of thought, altering brain connectivity in the long-term. It’s early days, but $900,000 funded this. Imagine what $9 billion could do.
As Tallulah puts it, thanks to pharmaceutical companies, today’s generation of parents have been indoctrinated with the notion that no matter the illness, ‘there’s a pill for that’. One in four women and one in seven men in America now take a psychiatric medication, with similarly worrying figures for the UK. Psychiatric drugs send 90,000 people a year to emergency rooms in the US, and fatalities from prescription drugs outnumber those from heroin and cocaine combined. Surely there comes a point when we have to ask ourselves: is throwing drugs at our problems really the best solution?
Together, DSM and Big Pharma have successfully pathologised everything adults don’t like about normal juvenile behaviour and disease-mongered American people into thinking they need help, at a cost of $1000 a year per patient. And while ADHD diagnosis and drug treatment is still largely an American problem, academics are warning that it is rapidly becoming a globalised phenomenon. As the US market for ADHD drugs becomes saturated, and drug patents near expiration, pharma companies have started expanding to international markets in Western Europe, as well as Brazil, Mexico, and Japan. Despite resistance, scholars are predicting little can be done to combat the impending forces that want to push pills down the throats of our children. Indeed, despite much lower ADHD prevalence in the UK (3.62% of boys and 0.85% of girls), attributed to the more stringent ICD-10 classification system and marketing restrictions, the number of Ritalin prescriptions in the UK has increased sixfold between 1999 and 2014 to almost a million.
We need to do all we can to prevent corporate pharmaceutical interests from pushing harmful drugs down children’s throats when not absolutely necessary. Ditching DSM and even ICD in favour of person-centred approaches, regulating pharmaceutical companies, and monitoring doctors’ prescription rates are but a few of the changes we as a society should be making to combat the impending pathologisation of and medication for the struggles of daily life. At the very least, stepped diagnosis should be introduced – Dr Allen rightly points out that psychiatrists see children on the worst day of their lives, with symptom presentation at its most extreme. And as for you? Please sign one or both of these petitions to bring these atrocities to the government’s attention. There was no pre-existing petition in the UK before, so I’ve started one from scratch – please help it to get off the ground by signing and sharing!
The power is with us; we just have to exercise it.