Adult ADHD Drug Use Skyrockets

A recent article reported that American adults now exceed children in ADHD drug prescriptions. In 2007, adults accounted for 39% of 37 million total ADHD drug prescriptions. In 2014, adults accounted for 53% of 63 million total ADHD drug prescriptions. Note that the total number of yearly ADHD drug prescriptions to both children and adults increased by 70% (from 37 million to 63 million) during this 7 year time period.

Why are so many adults taking ADHD drugs? While the official line from the psychiatry establishment is that previously undiagnosed adults are finally coming forward to doctors and getting diagnosed with ADHD, a New York Times article from a few months ago tells a different story. Many adults are obtaining ADHD drugs (legally via prescription or illegally from friends or dealers) not because they are ill, but because they want to perform better at work. They want to be able to get by with 4 hours or less of sleep per night. They want to knock out PowerPoint presentations to keep up with the competition.

The article opens with an example of Elizabeth, “a Long Island native in her late 20s”, who purchased Adderall from a drug dealer to do an all-nighter to complete a PowerPoint presentation. She was doing this presentation for investors in her health-technology start-up company. Why did Elizabeth feel compelled to purchase Adderall from a drug dealer, given the risks inherent in illegal drug sales, along with the risks of amphetamine use, such as anxiety, addiction, and hallucinations? According to Elizabeth, “not to take Adderall while competitors did would be like playing tennis with a wood racket.” Elizabeth also tried the legal route to obtain amphetamine, going to a psychiatrist and complaining that she could not concentrate on work. In 10 minutes, she received a diagnosis of ADHD and a prescription for Adderall. The article isn’t clear why she got Adderall from (illegal) drug dealers in addition to the (legal psychiatric) dealers. Perhaps her doctor wouldn’t prescribe enough Adderall for her to knock out all those PowerPoints.

I play tennis. I wouldn’t want to try to play with a wooden racket. But I don’t see how my playing with a modern racket is anyway comparable to popping Adderall to stay awake and focused. Modern tennis rackets don’t have any side effects. They’re not addictive. They don’t alter brain chemistry.

The article mentions the darker side of stimulant use. A young woman became hooked on Adderall while in college, getting the drug from classmates for $5 or $10 a pill. She began taking more Adderall while working after college. Becoming too wired to relax or sleep, she tried taking Xanax to calm down. After experimenting with alcohol, cigarettes, and other prescription drugs to try to stabilize her intense mood swings, she ended up in a treatment center.

Many times a brief chat with a doctor is all that’s needed to get an ADHD diagnosis and Adderall, Vyvanse, Concerta, or Ritalin prescription. A Houston lawyer increased his dosage from 20 mg of Adderall to 100 mg, twice the highest FDA recommended dose, by getting prescriptions from multiple doctors, a felony in Texas. His bosses and clients were thrilled with his productivity. This lawyer soon realized that there were negative consequences to his drug use: rapid heartbeat, sweating, acute anxiety, and sleep deprivation. His wife divorced him, he lost his job, and he spent six weeks at a drug treatment center.

In a Room for Debate follow-up article, three “experts” try to convince us that this use of ADHD drugs for workplace performance enhancement is a new trend of modern life. Titles such as “This Is the Probable Future”, “Equalizers in a Stressful World, If Used Properly”, and “A Symptom of Modern Life” suggest that we are facing something that represents a viable way to cope with the stress and demands of the contemporary workplace. According Julian Savulescu of Oxford University, “Ritalin and other stimulants improve impulse control,” and impulse control is one of the most important determinants of success in life.

Ritalin and other stimulants improve impulse control? Huh? They are highly addictive drugs. Taking an addictive drug for whatever reason, to get high, or to perform better at work, or to pull an all-nighter, is not an example of impulse control, but the opposite—a surrender of one’s long-term best interest to short-term gain (feeling high and energetic). That’s what the supposed experts in our society are advising us to do, but it doesn’t make it right.

These articles suggest that ADHD drug use is some new trend to cope with the twenty-first century workplace. This is inaccurate. ADHD drugs like amphetamines are nothing new. The amphetamine Benzedrine dates from the 1930’s, decades before first generation antidepressants and antipsychotics were introduced. The young people like Elizabeth who feel compelled to take amphetamines to perform better at work are making the same mistakes that many of their parents’ and grandparents’ generations made. Doctors who prescribe stimulant drugs today are making the same mistakes that doctors made decades ago, only for different reasons. While doctors in the mid-twentieth century prescribed amphetamine for people to lose weight, or treat mild depression or psychosomatic ailments, without knowing the adverse effects, doctors today cannot be ignorant about the abuse potential of these drugs. That’s the reason that they are Schedule II controlled substances in the U.S. The different today is that the alliance between Big Pharma and Psychiatry has fooled people and doctors into thinking that many children and adults have a disorder called ADHD that can be treated with stimulant drugs. They “prove” their case for the efficacy of the drugs based on short-term studies. There’s no question that the drugs improve short-term attention. The problem is long-term functioning. Since Pharma doesn’t need to prove long-term efficacy for drug approval, and Pharma provides most of the funding for studies, we know little scientifically about long-term efficacy.

My father was a habitual user of amphetamines for about 40 years. When he started with them as a young man for weight loss, little was known about their adverse effects. Although the pills may have helped him lose weight and perform better at work, he paid the price when he got older. He developed chronic severe depression and anxiety beginning in his fifties. He had a major depressive episode leading to a suicide attempt that landed him in a treatment center. After he was weaned off amphetamine and put on "safer" drugs like antidepressants and antipsychotics, he couldn't function at work and was forced to retire from a career he loved in his early sixties.

I have suffered from problems with attention as an adult. I briefly tried Ritalin after I convinced my psychiatrist to diagnose me with ADD, and found that the drug did improve my focus when studying difficult scientific subjects in school. I didn’t like the emotional-numbing and social withdrawal effects, however, and stopped taking this drug. Later I found alternative ways to improve focus, including meditation / guided imagery exercises, and behavioral changes based on my human magnetoreception hypothesis. Although what I’m doing may not work for everyone, I think doctors and scientists need to be open to alternative ways to control attention deficit / hyperactive symptoms. Mass-prescribing amphetamines and other stimulants is an old idea that is getting new traction due to the adult ADHD diagnosis fad.

The New York Times Criticizes the Medical Model of ADHD

The New York Times, the most prestigious and influential newspaper in the United States, has run a series of articles in the past year or two critical of the over-diagnosis and over-prescription of ADHD drugs (mainly stimulants) for children and adults. The Times doesn’t question that there is a disorder known as ADHD that can be effectively treated with stimulant drugs. What the newspaper criticizes is a biological interpretation of the rapidly increasing prevalence of ADHD, the increasing use of prescription drugs to treat this disorder, the excessive drugging of poor children on state assistance (Medicaid), and the refusal among many in the medical community to look at alternative treatments such as behavior and psychosocial therapy. For those who, like myself, want to see a reduction in the use of medication for ADHD, this is encouraging. Here are some examples of relevant articles:

• Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries (May 16, 2014): More than 10,000 American children ages 2 or 3 are being medicated for ADHD, according to data from the CDC. Toddlers covered by Medicaid are especially vulnerable to being put on stimulant medication. Diagnosing ADHD and prescribing drugs in children so young is against established pediatric guidelines. “It’s absolutely shocking, and it shouldn’t be happening,” said Anita Zervigon-Hakes, a children’s mental health consultant.
  
   “People prescribing to 2-year-olds are just winging it,” according to Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, CA. “It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.”
  
  The reason why pediatric guidelines don’t recommend diagnosing and treating ADHD in toddlers is that hyperactivity and impulsivity are developmentally appropriate at that age. Experts say that more time is needed to see if a disorder is truly present.
  
  The CDC data showed that about one in 225 Georgia toddlers covered by Medicaid is being prescribed drugs for ADHD. Extrapolating the Georgia data nationwide provides the 10,000 total number of toddlers being medicated for ADHD. An additional 4,000 toddlers covered by private insurance were also being prescribed stimulant drugs.
  
  Behavioral treatments, such as providing more structured environments for the children, are often ignored. “Some of these kids are having really legitimate problems,” Dr. Doris Greenberg, a behavioral pediatrician in Savannah, GA said. “But you also have overwhelmed parents who can’t cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse.”    


• Exercising the Mind to Treat Attention Deficits (May 12, 2014). This article talks about treating ADHD by strengthening the patient’s “cognitive control,” the ability to maintain focus on something while ignoring other impulses. A number of research studies have shown that it is possible for children and adults to improve their cognitive control via exercises in “mindfulness”. Noting a “growing disenchantment with the first-line treatment for [ADHD]: drugs,” and the fact that the beneficial effects of the stimulant drugs usually wane by the third year, or sooner, researchers have been looking for treatment alternatives to drugs. According to James M. Swanson, a University of California, Irvine psychologist, “There are no long-term, lasting benefits from taking ADHD medications. But mindfulness seems to be training the same areas of the brain that have reduced activity in ADHD. That’s why mindfulness might be so important. It seems to get at the causes.”
  
  ADHD isn’t unique to Americans, but the belief that only medication can treat it is. As an example, a study showed that the incidence of ADHD among Finnish teenagers is the same as the incidence of ADHD among American teenagers. The big difference between the two countries is that although most Finnish teenagers weren’t taking medication, most American teenagers were.
  
  Some attributes included in the concept “cognitive control” are delayed gratification, impulse management, emotional regulation, self-control, and suppression of irrelevant thoughts. Cognitive control increases between the ages of 4 and 12, then plateaus during the early teenage years. After about age 16, cognitive control increases again until people achieve adult levels.
  
  To improve cognitive control, therapists teach people to dispassionately monitor their thoughts and feelings. This is known as “mindfulness training.” If their attention has wandered, they are taught to renew their concentration. According to a recent study, adults with ADD given mindfulness training combined with cognitive therapy had improved mental performance comparable to that achieved by adults given medication.
  
  One consequence of mindfulness training is that it gives you “the ability to self-regulate your internal distractions”, according to Dr. Adam Gazzaley of the University of California, San Francisco. Gazzaley uses video games to help older adults improve their cognitive control.


• Report Says Medication Use Is Rising for Adults With Attention Disorder (March 12, 2014): An alternative title for this article that I came up with is: “Experts Fiddle While ADHD Drug Use Burns America.” The article refers to a study done by Express Scripts, the largest prescription drug manager in the U.S. The results of the study point to a disturbing and rapid increase in the number of prescriptions for ADHD, especially among young adults. The number of young American adults taking medication for ADHD nearly doubled between 2008 and 2012. In that same time period, the number of American adults of all ages taking ADHD medication rose 53%. Use of ADHD medication among American children rose 19%. In 2012, 7.8% of boys and 3.5% of girls between ages 4 and 18 were being prescribed ADHD medications. Almost 1 in 10 adolescent boys were taking ADHD medications.
  
  This explosion in ADHD drug use has occurred while experts fiddled, i.e. pretended that nothing was happening. The CDC last year did a telephone survey of 76,000 parents that reported a similar explosive increase in ADHD drug use. Experts dismissed the survey, similar to ones that were done every year since 2003, as lacking scientific rigor. The American Medical Association stated that these phone surveys “overestimated true prevalence” of ADHD diagnosis. Dr. Sanjay Gupta of CNN said that, “There’s not a lot of value in these studies.”
  
  It’s classic incompetence to dismiss reports of problems without doing anything. Couldn’t these “experts” have designed their own scientific studies to confirm or disprove the CDC data? According to Susanna Visser, the CDC’s lead epidemiologist for ADHD, the experts’ discrediting of the CDC survey data has been costly, not only in understanding the issue, but also coming up with solutions.
  
  One reason why the “experts” haven’t done anything is that many don’t think that increased drugging of adults for ADHD is a problem. According to Dr. Lenard A. Adler of NYU Langone Medical Center, “We still know that a majority of adults with ADHD are untreated.”


• A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs (December 29, 2013): A discussion of how the results of the Multimodal Treatment Study of Children With ADHD, which argued strongly for the benefits of medication over behavioral therapy, are being re-interpreted today. This expensive, independent study of about 600 children, which began 20 years ago, is widely considered the most influential study on ADHD. The authors found that medication reduced symptoms in 56% of children, while behavioral therapy only reduced symptoms in 34% of children. Combination therapy (medication + behavioral therapy) reduced symptoms in 68% of children, which the authors felt was only a small increase over medication alone (56%). The conclusion was that medication was superior to behavioral treatment by a considerable margin.
  
  This sanction of approval by a major study not funded by them gave pharma a powerful weapon to use in their marketing materials and doctor-education classes. According to Laura Batstra, a psychologist at the University of Groningen in the Netherlands, “the only thing we heard was . . . that medication is the answer.”
  
  There were problems with the study design that led to the medication-being-superior conclusion. According to researchers involved with the study, it was structured to emphasize the reduction of impulsivity and inattention symptoms, with less emphasis placed on improving children’s longer-term academic and social skills. Medication mainly addresses the former, while behavior therapy addresses the latter by creating less distracting and more organized learning environments. In other words, the study was designed to make medications look good and behavior therapy bad.
  
  An additional $10 million in government funding extended the study, and followed the children into young adulthood, making it a true longitudinal study. Results called into serious question the value of medication. I have already blogged about the follow-up results. One highlight is that more than half of the children stopped taking medication after an 8 year follow up. Another highlight is that children who were no longer taking medication at the time of the follow up were functioning as well as children who were taking medication.
  
  Many experts interpreted these findings as showing that the efficacy of medications dissipated over time. Pharma apologists argued that children did worse because they went off the medications. A balanced interpretation is that treatment type cannot predict long-term functioning, i.e. we cannot conclude that medication is superior or inferior to behavior therapy.
  
  The warped initial findings of the study are examples of psychiatry’s obsession with symptoms as opposed to overall functioning. This is the philosophy behind the DSM, the psychiatrist treatment manual. Not all experts agree with this symptom-based approach. According to Stephen Hinshaw, a psychologist at the University of California, Berkeley (and one of the study researchers), “My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing.”
  
  According to another co-author, Dr. Lily Hechtman (McGill University), “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”


• The Selling of Attention Deficit Disorder (December 14, 2013): I have already blogged about this article. It argues that pharmaceutical company marketing is a major culprit behind the explosion in ADHD diagnosis and treatment. The article also provides a detailed account of the various marketing tricks used to con doctors, parents, and patients into accepting the story that there are millions of undiagnosed children and adults with ADHD who would benefit from stimulant treatment.


• The The Not-So-Hidden Cause Behind the A.D.H.D. Epidemic (October 15, 2013): This article argues for a sociological interpretation of the rapid rise in ADHD diagnosis and treatment. ADHD reached “epidemic” status at about the same time as some important policy changes that incentivized diagnosis. In 1991, ADHD was included in the Individuals with Disabilities Education Act. For students diagnosed with ADHD, this allowed access to tutors, and more time to take standardized tests. By the late 1990’s, as public awareness of ADHD increased, its prevalence also increased. Another important policy change was the legalization of pharma marketing of controlled substances to the public that occurred in 1997. This allowed pharma to market stimulant drugs directly to consumers via print and TV ads.
  
  Stephen Hinshaw of the University of California, Berkeley found that in 2007, 15.6% of children ages 4 to 17 in North Carolina had received an ADHD diagnosis, while only 6.2% of children in California had this diagnosis. The reason for this geographical disparity is likely due to effects of state educational policies. North Carolina was the first state to adopt a program linking school financing to standardized-test performance, while California was one of the last. Hinshaw found a correlation between state’s implementation of these laws and ADHD prevalence. The No Child Left Behind Act was a federal program punishing or rewarding schools for standardized test scores, signed into law by President George W. Bush. The rates of ADHD diagnosis nationwide increased by 22% in the first four years after the act was implemented.
  
  Parents and educators obsessed with standardized tests results will look favorably on any intervention that improves a child’s ability to perform on tests, and prevents him from being a distraction to others. An ADHD diagnosis with medication treatment is such an intervention that has obvious short-term benefits (with less clear long-term benefits). This provides enormous pressure for the parent to have her inattentive / hyperactive child be diagnosed and drugged.
  
  The ADHD diagnosis explosion is part of a broader American trend of medicalization of traits the previous generations handled in different ways, according to Joel Nigg of the Oregon Health and Science University. Instead of punishing children who misbehave, we diagnose them with ADHD and drug them.


• A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise (March 31, 2013): I have already blogged about this article. 19% of American high school boys have received an ADHD diagnosis. 11% of school-age children overall have received the diagnosis. There has been a 16% increase in children between ages 4 and 17 being diagnosed with ADHD since 2007, and a 41% increase in the last decade.

The Marketing of ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is, like other psychiatric disorders, diagnosed based on symptoms, not biology. Although the symptoms described by the disorder have been known for centuries, it didn’t take its present name until the DSM III was published in 1980. ADHD had a treatment before it was ever conceptualized as a disorder. In 1937, Charles Bradley made a chance finding that the stimulant Benzedrine improved behavior and school performance in some children. These children had symptoms that we would now associate with ADHD, such as short attention span, hyperactivity, and impulsiveness.

Diagnosis of ADHD and medication treatment of it has skyrocketed in recent years. Last April, I blogged that almost 1 in 5 American high school boys are diagnosed with ADHD. There has been a 41% increase in diagnosis of ADHD in American children in the last decade. The increased diagnosis correlates with increased prescription of stimulant medications like Ritalin and Adderall. The number of children on medication for the disorder had increased from 600,000 in 1990, to 3.5 million today. Sales of stimulant medication in 2012 were nearly $9 billion, more than five times what they were ten years earlier. ADHD is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma.

I blogged last July that stimulant drugs don’t improve long-term academic outcomes in children with ADHD. There may be a short term boost in school performance, but when evaluated years later, children treated with stimulants don’t function better than untreated children. Then why are they being prescribed so widely?

A recent New York Times article talks about how pharmaceutical company marketing is a major culprit behind the explosion in ADHD diagnosis and treatment. It also provides a detailed account of the various marketing tricks used to con doctors, parents, and patients into accepting the story that there are millions of undiagnosed children and adults with ADHD who would benefit from stimulant treatment.

Marketing to Doctors

Marketing to doctors is the original and most effective method for drug companies to promote ADHD drugs. A common technique is the pharma-sponsored doctor meeting, in which a paid physician spokesman presents to other doctors. The New York times article gives an example of William Dodson, a psychiatrist from Denver, who presented to 70 other doctors in Pasadena, California, in April 2002. Dodson encouraged his audience to “educate the patient on the lifelong nature of the disorder and the benefits of lifelong treatment.” This statement contradicts scientific knowledge. Studies have shown that about half of children with ADHD do not have the disorder as adults. Little is known about the risks or efficacy of long-term medication use.

Dodson’s presentation asserted that stimulants aren’t “drugs of abuse” because people who overdose either feel nothing, or feel bad. Then why are these drugs classified among the most likely to be abused? Severe heart problems and psychotic behavior can result from an overdose.

A slide in the presentation also warned that later in life, children with ADHD risked “job failure or underemployment,” “fatal car wrecks,” “criminal involvement,” “unwanted pregnancy”, and STD’s. This may be true, but studies haven’t shown whether stimulant treatment decreased the later risks for these bad outcomes.

Dodson, who received $2000 for this talk from Shire, and earned $45,500 in speaking fees from pharma in 2010-2011, makes a new ADHD diagnosis in about 300 patients a year, and always recommends their taking stimulants for life. “If people want help, my job is to make sure they get it,” Dodson said.

Many scientific studies cited by Dodson and other drug company speakers involve Joseph Biederman, a Harvard child psychiatrist. Biederman’s research has had major pharma funding. Biederman also made $1.6 million in speaking and consulting fees. Findings from Biederman’s studies on ADHD and different brands of stimulants are cited by pharma posters and pamphlets.

We can conclude from Biederman’s research findings the following:

1. ADHD is underdiagnosed.
2. Stimulants are effective and safe.
3. Unmedicated ADHD results in risks of academic failure, drug dependence, auto accidents, and criminal behavior.

In 2006, Biederman said, “If a child is brilliant but is doing just O.K. in school, that child may need treatment, which would result in their performing brilliantly at school.”

According to Richard M. Scheffler, professor of health economics and public policy at University of California, Berkeley, “[Biederman] didn’t have a balance. He became totally convinced that [medicating ADHD is] a good thing and can be more widely used.”

Pharma advertises heavily for ADHD drugs in medical journals, the same journals that published pharma-sponsored research supporting the use of the drugs. The Journal of the American Academy of Child & Adolescent Psychiatry, the most prominent publication in the field, went from no ADHD med ads from 1990-1993 to about 100 pages per year a decade later. Almost every full-page color ad was for an ADHD drug.

Drug sales reps promote ADHD drugs to doctors in person. Brian Lutz, an Oakland, CA-based Shire salesman for Adderall XR from 2004-2009, said he met with 75 psychiatrists in his territory at least every 2 weeks. He showed the doctors posters and pamphlets that emphasized the medicine’s benefits. Side effects or possible abuse were played down. Lutz would refer only to the small print in the package insert or offer Shire’s phone number for additional information about risks.

Marketing to Parents, Teachers, and Children

The relaxing of federal regulations in the 1990’s allowed pharma to market controlled substances directly to the public. Drug companies took advantage of this to target ADHD drugs to parents, especially mothers. A magazine ad for Concerta had a mother saying, “Better test scores at school, more chores done at home, an independence I try to encourage, a smile I can always count on.” A 2009 ad for Intuniv had a child in a monster suit take off his hairy mask to reveal his wonderful smiling self. The text read, “There’s a great kid in there.”

The Food and Drug Administration (FDA) has repeatedly instructed drug companies to withdraw these types of ads, and has sent many warning letters. The FDA claims that the ads are false and misleading, or exaggerate the effects of the medication. Last February, Shire agreed to pay $57.5 million in fines for improper advertising and sales of several ADHD drugs, including Vyvanse, Adderall XR, and Daytrana.

Susan Parry of Mercer Island (outside Seattle) said that in the 1990’s, teachers pushed her into having her son Andy evaluated for ADHD. One teacher said that her own twins were doing great on Ritalin. A school psychologist gave her a pamphlet, which said that “parents should be aware that these medicines do not ‘drug’ or ‘alter’ the brain of the child. They make the child ‘normal.’” A pharma sales rep provided the pamphlet, which had a Ciba-Geigy logo, to the school district. Parry put her son on Ritalin for 3 years, but took him off when he had sleep problems and heart palpitations. Parry’s husband said that he “definitely felt seduced and enticed [by the Ciba-Geigy pamphlet]. I’d say baited.”

If we believe that pharma has any scruples, this is belied by their direct marketing to children. Pharma is not above marketing a controlled, highly addictive drug to children. Shire, manufacturer of Adderall and the longtime ADHD drug market leader, recently paid for 50,000 copies of a comic book. In this book, superheroes tell children, “Medicines may make it easier to pay attention and control your behavior!”

Marketing to Potential Adult Patients

Estimates of the prevalence of adult ADHD in the U.S. have typically ranged from 3 to 5 percent. Since adults outnumber children, the adult market could be potentially twice as large as the child market. Pharma has taken note of this and ramped up marketing to adults. Nearly 16 million prescriptions for ADHD meds were written for people ages 20 to 39 in 2012, almost triple the 5.6 million just 5 years before. This corresponds to an estimated 2 million patients.

William Dodson, the paid pharma psychiatrist spokesman mentioned above, in 2004 authored a booklet marketed to doctors. Sponsored by Shire, the booklet said that, “about 10 percent of adults have ADHD, which means you’re probably already treating patients with ADHD even though you don’t know it.” The 10% adult prevalence figure doesn’t reflect research findings. The booklet contains a quote from Dodson’s patient named Scarlett. “If you give me a drink or a drug, I’ll abuse it, but not this medication. I don’t consider it a drug. Drugs get abused. Medication helps people have satisfying lives.”

A Shire print ad for adult ADHD showed a happy couple’s wedding photo with “DIVORCED” stamped on it. The intention was to suggest that untreated ADHD leads to divorce. It cites a Biederman study which showed higher rates of divorce for adults with ADHD. This ad was misleading, because the study didn’t evaluate whether stimulant treatment had any effect on divorce rates.

Web searches for ADHD bring up short quizzes that can encourage normal people to think they might have the disorder. I tried the quiz on http://www.everydayhealth.com/ownyouradhd, and got a “ADHD Possible” result. I have some inattention symptoms, but don’t fit the (DSM-V) diagnostic criteria because they weren’t present before age 12. It’s easy for someone who doesn’t have the disorder to answer the 6 questions and get an “ADHD Possible” or “ADHD May Be Likely” result. In fact, in a NY Times-sponsored nationwide telephone poll, almost half of over 1100 adults in the poll scored in the possible or likely ADHD range (remember that true ADHD adult prevalence, as measured by scientific studies, is in the range of 3 to 5 percent). These tests influence many patients and doctors to see the disorder when it doesn’t in fact exist.

Tyrone Williams, a psychiatrist in Cambridge, Mass, thinks that these tests are misleading. “I do think that there are some people out there who are really suffering and find out that maybe it’s treatable. But these symptoms can be a bazillion things. Sometimes the answers are so simple and they don’t require prescriptions – like ‘How about eight hours of sleep, Mom, because four hours doesn’t cut it?’ And then all their ADHD symptoms magically disappear.”

My Own Experience With Stimulant Drugs

I have some of the symptoms of the inattention subtype of ADHD, such as difficulty holding attention on tasks, disliking sustained mental effort, being easily distracted, and forgetful. I have little problem with hyperactivity or impulsivity. I don’t fit the ADHD diagnostic criteria because these symptoms started after age 18. Nevertheless, at age 34, while struggling to keep up with schoolwork in biology, I talked my psychiatrist into prescribing me Ritalin. I was thus an example of an adult who was prescribed stimulants off-label for inattention symptoms. Pharma marketing wasn’t a major factor in influencing my decision to experiment with Ritalin. Being knowledgeable about neuroscience and psychopharmacology, I thought that Ritalin might be useful in my struggle to keep up with undergraduate science classes.

I found that Ritalin helped me somewhat with academics. It wasn’t a large boost, but it did help me concentrate and focus. The reason why I had to quit taking it after about 6 months, however, was that I felt it increased emotional suppression and decreased desire for socialization. Emotional suppression and social difficulties had been problems for me for many years, and I didn’t like the fact that Ritalin made it worse. I also felt addicted to Ritalin, getting a minor “high” every time I took a pill. I didn’t want to sell my soul to the pharma devil, to become a Ritalin addict, to sacrifice what little emotions and social life I had, to get slightly better grades.

Other people with normal emotions and social skills, but with inattention and hyperactivity symptoms, may not be as sensitive as I was to these side effects. But I think these effects are important and should not be overlooked, especially for children. As children grow, not only their academic skills, but social and moral skills need to be developed. Ritalin and other stimulants may help with academic performance over the short term, but “growing up” isn’t only about doing well in school. Children need to acquire habits of self-discipline, social skills, control over emotion, and responsibility. These habits cannot be found in a pill. This is probably the reason for the lack of long-term improvement in functioning of children with ADHD who are on stimulants, as compared to not taking stimulants. Parents sell their child’s soul to the pharma devil in order to placate teachers and make the child fit in the classroom environment, but the child is stunted in his long-term development.

Comparison With Autism

It’s interesting to compare ADHD with autism. The prevalence of both ADHD and autism has skyrocketed in recent decades. Autism spectrum prevalence is now approximately 1%, a 20-fold increase over the last 3 decades, and 78% increase between 2002 and 2008. Compared to 15% of school-age boys diagnosed with ADHD, the 2% of boys diagnosed with autism spectrum is tiny, but the point here is that prevalence in both ADHD and autism spectrum has greatly increased in the last few decades. One major difference between the two is that although ADHD has a (short-term) effective pharmacological treatment, there is no medication to treat the core symptoms of autism. While many children with autism are prescribed antidepressants, stimulants, and antipsychotics, these medications don’t treat the symptoms of social and communication impairments that define autism. So we can’t blame pharma marketing for the increase in autism prevalence.

It’s likely that the increase in autism prevalence is due to a combination of changes in diagnostic practices, increased public awareness, and actual increase in true frequency of autism. The increase in ADHD prevalence is probably caused by the same factors as with autism, except that pharma marketing must also be added in.

Environmental Risk Factors For ADHD and Disruptive Behavior

ADHD, like most behavioral disorders, is caused by a combination of genes and environment. The rapid increase in ADHD prevalence in recent decades is likely not a result of a major population genetic change, since these changes occur over much longer periods of time. Environmental factors (in addition to the ones mentioned in the previous paragraph) are involved in this prevalence increase. To explain this, any proposed environmental factors must have increased in intensity the past several decades. This excludes some common proposed environmental factors such as lead contamination, cigarette and alcohol use during pregnancy, and low birth weight. Lead paint has been outlawed, cigarette use among adults has declined in half from 1965 until 2011, alcohol use has declined slightly over the past 25 years, and many more women abstain from drinking when pregnant than before. Birth weights in the U.S. increased during the second half of the 20th century, but have declined in the last several decades. The decline is under 2%.

The American diet has changed significantly in the past 50 years, mostly in negative ways. The contribution of diet to obesity is well known and has an obvious causal connection. The connection of diet to ADHD is less obvious, but has been proposed and extensively researched. The idea that refined sugar may make children hyperactive makes some sense, but research doesn’t support it. A trendy theory is that food additives is a contributing factor for ADHD. There is little research support for this, although it’s possible that some artificial food colorings may increase hyperactivity in some children.

I’ll propose a different hypothesis about environmental risk factors for ADHD. I’ll begin by combining the so-called “disruptive behavioral disorders” (ADHD, Oppositional Defiant Disorder, and Conduct Disorder) into one entity. Not including predominantly inattentive ADHD, I’ll call this entity “disruptive behavior”. The DSM separates out the components of this psychiatric triad on the basis of symptoms and treatments, with the idea that ADHD is a biological-based disorder that can be treated by stimulants, and Oppositional Defiant Disorder (defying authority, noncompliance, tantrums) and Conduct Disorder (delinquent and criminal behavior) are separate entities, with different causes and treatments. They frequently co-occur, however, and this separation is unwarranted. It’s like separating depression and anxiety. Although depression and anxiety have different symptoms and treatments, they frequently co-occur, and this separation can hinder the search for causes.

Disruptive behavior occurs much more frequently among boys than girls. Difficulty paying attention, hyperactivity, impulsivity, defying authority, and noncompliance are defining characteristics. Untreated, this condition can turn into more serious delinquent and criminal behavior. There are sociological factors that have radically increased in the U.S. in the past half century, and that can logically be connected to disruptive behavior. The defining characteristics of these factors are:

• Instability
• Lack of structure
• Lack of discipline
• Lack of positive role models

In an unstable environment, one which lacks structure and discipline, one in which authority figures are weak or nonexistent, it’s reasonable to expect disruptive behavior. Specific factors include single parent families, permissive parents, lack of discipline in the home and school, unstable, dangerous neighborhoods, lack of male role models, delinquent peers, and a permissive, nonjudgmental wider society. Single parent families are archetypes of problem environments associated with disruptive behavior. Single parents families are unstable, a result of unmarried or divorced parents having split up. They don’t have the structure of a two-parent family. They are usually headed by females, who aren’t effective in disciplining male children. The absentee father puts a void in what should be a male role model. The number of children living in single parent households has nearly doubled in 50 years, with one in three children raised without a father.

Most of these environmental risk factors have become much worse in the U.S. in the last 50 years, at the same time of skyrocketing ADHD diagnoses. There is correlational evidence tying them to disruptive behavior, along with a logical connection. We’ve been in effect undergoing a real-life experiment. The research question is whether it’s possible to socialize children in the absence of stability, structure, discipline, and positive role models. Some children do OK in this environment: most girls and some boys. The boys who don’t do well have a certain genetic predisposition, one that can lead to problems, but that can also lead to creative achievement and leadership. The experiment has failed for these boys. This was obvious 30 years ago, and more obvious now. Every new boy diagnosed with ADHD and prescribed stimulant drugs is evidence of this failure.

None of these sociological factors are easy to change, certainly not for an individual therapist or doctor. The problem is so widespread it’s impossible to hold anyone accountable. It’s easy to blame the single moms, but they are single for a reason, and many times the reason has to do with problems with the father: he abandons the family, he abuses substances, he’s unemployed, he’s abusive, or he’s in jail. People from just about every walk of life have been responsible for the social changes that have led to the current predicament: parents, educators, lawyers, politicians, intellectuals, businessmen, artists, musicians, etc.

The psychiatric-pharma alliance has come to the rescue, offering drugs to control these boys’ behavior. The drugs will help boys do better in school, stay out of trouble, accomplish more. That was the marketing slogan. But the reality is that children with ADHD who take medication don’t do any better in the long term than children with ADHD who don’t take medication. Another reality is that boys are not accomplishing as much as girls. They perform worse at school, drop out of school more, and attend college at a lower rate (42 men versus 58 women). While it’s wonderful that girls are doing so well, it would be even more wonderful if boys kept up.

Example scenario

Let’s take an example of Laura, a stressed-out single mom with a boy named Mark who’s misbehaving and not paying attention in elementary school. Laura yells and screams a lot at Mark, but otherwise has no concept of proper discipline or authoritative parenting skills. She sees TV commercials for stimulant drugs showing smiling medicated boys with ADHD. She hears from Mark’s teacher that she should consider medicating Mark. In the old days, Mark would have gotten disciplined in school for his behavior, but in our brave new world of education that’s no longer allowed. Pharma sends pamphlets to schools promoting ADHD drugs, and the teacher gives Laura a pamphlet. It’s hard to find an available child psychiatrist, so Laura brings Mark to his pediatrician. After a 10 minute examination of Mark, the doctor prescribes a stimulant med. Mark’s pediatrician has been visited by pharma reps selling ADHD drugs, and has been to a pharma-sponsored seminar promoting stimulant drugs. It’s difficult to blame Laura for making the decision to fill the prescription and drug Mark for his ADHD.

Policy Recommendations and Conclusions

Stimulants are already controlled substances, so we need to tighten the controls. One policy change would be to not allow primary care doctors to prescribe stimulants for ADHD. They don’t have the training or time to make a proper psychiatric diagnosis. We can outlaw direct pharma marketing of stimulants to the public. Even better would be to require proof of long-term efficacy before allowing stimulants to be prescribed for ADHD in children.

We need to address the environmental risk factors for ADHD. Discouraging single parenting, training parents in authoritative parenting skills, restoring discipline to schools, improving neighborhoods, having positive role models for boys, and promoting positive, ethical behavior in the media can help reduce the prevalence of ADHD and juvenile delinquency.

ADHD Drugs Don’t Help Kids Perform Better in School

I blogged last April that almost 1 in 5 American high school boys are diagnosed with ADHD. According to Consumer Reports, 59% of children get prescribed medications immediately after an ADHD diagnosis. Approximately 2.7 million children were taking medication for ADHD in the U.S. as of 2007, according to the Centers for Disease Control and Prevention. Millions of children are being diagnosed and treated for a psychiatric condition that impairs their ability to function in school. This is a positive thing, right? It would be if ADHD drugs (stimulant medications like Ritalin or Adderall) actually improved school performance. But the evidence base is growing that these drugs don’t improve academic outcomes in the long term, according to a recent Wall Street Journal article.

One study examined medication usage and educational outcomes of nearly 4,000 students in Quebec.  It found that medication use was associated with increases in emotional problems among girls, and reductions in educational attainment among boys. Princeton economics professor Janet Curie, an author of the study, said that "the possibility that [medication] won't help them [in school] needs to be acknowledged and needs to be closely monitored."

The lack of long-term benefits of medication for children with ADHD is a conclusion from a major U.S. government-funded study known as the MTA. In this study, 579 children with the condition were randomized to one of three different kinds of treatment (medication alone, psychosocial/behavioral treatment alone, a combination of both) or to routine community care (control group) for 14 months.

Initial results of the study, published in 1999, indicated that 8- and 9-year old children who received medication and a combination treatment saw greater improvements in ADHD symptoms than the other two groups. Kids taking medicine also exhibited some improvement in educational outcomes in that first year.

The benefits of taking medication dissipated by the third year, however. The most recent set of assessments, the eight-year follow-up published in 2007, indicated that there were no differences in symptoms or functioning among the youths assigned to the different treatment groups as children. Some other conclusions from the follow up study were:

• Youths with ADHD had more academic, social, and conduct problems, more depression, and more hospitalizations than their peers without ADHD.
• Youths with ADHD who responded well to treatment and maintained their gains for 3 years functioned the best after 8 years.
• 61.5% of the children who were medicated at the end of 14 months had stopped taking their medication by the 8 year follow-up. The reason for so many children stopping their medication is unknown.
• Children who were no longer taking medication at the 8 year follow-up were functioning as well as children who were still medicated.

It’s interesting that more than half of the medicated children stopped taking their medication by the 8 year follow up. Is it because they outgrew their ADHD? Or is it because the families couldn't find enough of a benefit in continuing the drug? The study results showed that children who stopped taking their medication did as well as children who were still medicated. Also children who were randomized in the initial study for no medication did as well after 8 years as children who were randomized in one of the drug groups.

From the Wall Street Journal article, “One way of interpreting the findings is that the medicine proves effective on immediate classroom behaviors like sitting still and interrupting the teacher less, but it doesn't help with other factors important to successful completion of homework or test-taking, like family encouragement.”

There’s certainly no evidence in the above studies supporting the use of stimulant drugs for ADHD. Children are being exposed to dangerous side effects, and parents, insurance companies, and the taxpayers are purchasing drugs that have no proven long-term benefit.

Due to the fact that 15% to 30% of ADHD drugs end up being used by children who don’t have ADHD, do the drugs benefit these children in any way? Although children without ADHD believe that stimulants enhance their cognitive ability, a recent study that examined objective measures like episodic memory, working memory, inhibitory control, intelligence, and scholastic achievement could find very little cognitive benefit from the stimulant Adderall. These children without an ADHD diagnosis are getting high and being exposed to dangerous side effects from stimulant drugs they obtain from friends, but the drugs are not helping them perform better in school.

The burden of proof is on the drug companies and doctors to show any long-term benefit of stimulant drugs for ADHD. The evidence presented in this article clearly indicates little to no benefit. In the absence of any benefits, prescribing these drugs to children should be banned.

Getting Drug Companies to Release Clinical Trial Data

There’s a tension in our society between openness and confidentiality. On the one hand, we celebrate openness and full disclosure. Men like Julian Assange and Edward Snowden who allegedly break laws and release confidential or classified information are lauded as anti-establishment heroes. The media doesn't allow politicians, celebrities, and other people in the public eye any privacy. On the other hand, laws like HIPAA restrict our ability to acquire health care information about other people. I recently blogged about the inability of parents to find out about their children’s mental health treatment.

A change has been occurring regarding public access to pharmaceutical clinical trial data. A recent New York Times article talks about the efforts of researchers to push drug companies to release unpublished clinical trial data.

The article profiles Peter Doshi, a M.I.T.-educated researcher, and Dr. Tom Jefferson, a British epidemiologist. They collaborated to determine if the anti-flu drug Tamiflu was effective. Jefferson had earlier concluded that Tamiflu reduced the complications of flu. His review was based on a study that pooled the results of 10 clinical trials. Only 2 out of these 10 trials had been published in medical journals, however. Taking another look at the data, Jefferson approached Roche, the manufacturer of Tamiflu, for the results of the 8 missing trials. Roche declined to cooperate, citing Jefferson’s refusal to sign a confidentiality agreement.

Due to the missing data, Jefferson’s team published an article in the British Medical Journal that concluded that Tamiflu was only moderately effective against influenza-like symptoms, and cannot be shown to reduce complications of influenza (e.g. pneumonia and hospitalization). The journal also did its own investigation, concluding that Roche had hired ghost writers to author some of the articles involving Tamiflu, pressuring the writers to highlight positive aspects of the drug.

After the British Medical Journal articles appeared, Roche turned over partial copies of study reports. The European Medicines Agency also turned over documents from 19 trial reports to Jefferson and colleagues. These documents allowed researchers to discover the importance of clinical study reports, which are thousands of pages long, and contain details such as descriptions of trial protocol and design, and ingredients of placebo pills. This April, Roche further relented, agreeing to make available clinical study reports for all Roche-sponsored trials of Tamiflu.

“All these years later, and we still don’t know if Tamiflu is effective,” said Dr. Harlan Krumholz, a Yale cardiologist. “It’s perplexing to have a billion-dollar drug, and you’re not willing to share everything you’ve got to know whether this thing is effective and safe.”

Prodding from Doshi and others led the pharmaceutical company GlaxoSmithKline to announce that it will share detailed data from all company-sponsored trials dating to 2000. This would amount to more than 1000 trials involving more than 90 drugs. Due to past misdeeds, Glaxo needed an image rehabilitation. Last year, it pleaded guilty to criminal charges and agreed to pay $3 billion in fines. It had been accused by the U.S. Justice Department of failing to report safety data about its diabetes drug Avandia, and publishing misleading information about the antidepressant Paxil. The settlement, which also involved civil penalties over marketing of other drugs, was the largest ever involving a pharmaceutical company.

Publication bias of studies involving antidepressant drugs is a topic in Irving Kirsh’s book The Emperor's New Drugs (which I review here). Kirsh had used the Freedom of Information Act to obtain unpublished clinical trial studies of antidepressants from the FDA.

Not everyone in the pharmaceutical industry is happy with the new openness. The Pharmaceutical Research and Manufacturers of America (PhRMA), a major industry group, and other drug companies oppose releasing clinical trial data. John J. Castellani, chief executive of PhRMA, said that “[i]f you dump onto the sidewalk all the data and you include commercially protected information, then you’re essentially giving to competitors what we invested billions of dollars in.” U.S. federal law restricts what information can be released, especially data that can reveal personal or commercially confidential information.

My view is that the public has a right to know all the results of studies of a particular drug, both positive and negative. It’s the pharmaceutical company’s obligation to provide this data. They certainly have a right to withhold commercially protected information, and private research participant data, but they don’t have the right to only publish positive studies, and hide negative studies. I applaud Doshi, Jefferson, Kirsh and others who have helped push drug companies to release clinical trial data.

Bipartisan Push for Better Mental Health Care Won’t Be Helpful

In the aftermath of the shootings at Sandy Hook Elementary School, with memories of the Aurora movie theater shooting, the Gabby Giffords shooting, and the Virginia Tech shootings still in mind, people demanded that the U.S. Congress do something. These shootings, along with many others, were perpetrated by mentally ill individuals. Liberals wanted more gun control. Conservatives wanted more armed guards and armed civilians to take down the shooters. The divided congress was unable to pass a gun control measure. But apparently liberals and conservatives were able to agree on one thing, according to a recent New York Times article: better care for the mentally ill. According to the article, “[t]he emerging legislation would, among other things, finance the construction of more community mental health centers, provide grants to train teachers to spot early signs of mental illness and make more Medicaid dollars available for mental health care.” There would also be support for children who faced trauma, and suicide prevention initiatives. Approximately 1.5 million additional people with mental illness would be treated each year.

This is a good, thing, right? What’s there to complain about more mental health treatment? There’s nothing to complain about, if one believes in the current drug-based model of care. Treatment in this context will be primarily psychoactive drugs. The community mental health center will recruit and encourage people to see a doctor and get a prescription for a psychotropic medication. Teachers will spot early signs of ADHD, depression, and bipolar disorder in children, and put the children on the road to chronic stimulant, antidepressant, and antipsychotic drug treatment. Medicaid is notorious for drugging up the children who rely on it for health care. Suicide will be prevented by prescribing antidepressant drugs. The vast majority of the 1.5 million additional treated people will be prescribed drugs.

After reading Anatomy of an Epidemic (which I review here), I stopped believing that psychotropic drugs are an effective long-term solution for most mental disorders. The evidence is just not there. Some drugs, such as antipsychotics and benzodiazepines, are effective short-term solutions to psychotic or anxious symptoms. The problem is that they don’t help the patient function better over the long term. While the evidence isn’t clear that drugs caused the explosion of debilitating mental illness in recent years, they certainly haven’t helped prevent it. Drugging of children in particular (for ADHD or bipolar disorder) has likely led to poor long-term outcomes, including mental (psychotic disorders, increased suicide rate, rapidly-cycling bipolar) and physical (extreme weight gain and type 2 diabetes for children taking atypical antipsychotics).

I would have preferred to see congress pass a gun control measure. The mentally ill and guns go together like North Korea and nuclear weapons. People with mental illness should not be allowed to purchase firearms. They should not have access to them in their homes. Adam Lanza’s mother was tragically irresponsible for having guns in her home. Her son used these guns to kill her in her home, then 26 people at Sandy Hook Elementary, including 20 children.

I have lived with serious mental illness for some 30 years. Mine has been under better control than many people. I have never been hospitalized for mental illness. I have never had to quit or leave a job due to mental illness. But I would never trust myself with owning or having possession of a gun. The reason is that there are times when my emotions become extreme or difficult to control. In those times, I don’t want access to a gun. It only takes one mistake for a personal or public tragedy to occur.

Gun sales and ownership should be banned for anyone who has been treated for a psychiatric disorder—I mean anyone treated at any time in their life. This would be a major change from current American law, and would require confidential records being unsealed, but it is for the greater good. Anyone living with someone who has been treated for mental illness should be required, if they own a gun, to keep it locked and inaccessible. The NRA will be furious and scream that we are becoming Nazi Germany, but tough. The NRA’s refusal to consider any type of gun control legislation, and their control of most Republican legislators, have allowed these preventable tragedies to happen.

If the government wants to spend money, what should it spend it on, if not treating mental illness? What about research? The problem with research is that the biochemical / drug paradigm still dominates psychiatric research, decades after it’s been clear that the chemical imbalances that drugs supposedly treat don’t exist. The drugs themselves cause chemical imbalances, but after millions of dollars and decades of research, no one has been able to show that any psychiatric disorder is caused by a chemical imbalance. Any government research money will be wasted on new drugs, new brain imaging, new tests, and other things that won’t do anything to improve the lives of the mentally ill. Research on alternative treatments would be more promising, but only a tiny fraction of any allocated funds would go into this type of research.

I’d like to see the government spend its money on providing a solution to the homeless problem. Current policy is to leave the homeless to their own resources. If they want to live on the street, or in a public park, fine. Short-term treatment with medication is useless, since they go off the medication as soon as they leave the hospital or treatment center. Many homeless are afflicted with mental illness and substance abuse. The fact that they are living on the streets is an indictment of the entire drug-based psychiatric paradigm. Deinstitutionalization began in the 1960’s, a half-century ago. Drugs were supposed to provide the severely mentally ill the stability and mental resources to live outside the hospital. But, as I've said above, drugs are not an effective long-term solution for most mental disorders. Thus many deinstitutionalized patients were not able to control their problems, and live independently on their own. Those without financial or family resources to fall back on ended up on the streets. They are the government’s responsibility, and the fact that they are still on the streets decades after deinstitutionalization began is a sign of abject public policy failure.

I have a recent personal experience with the homeless problem in Salt Lake City. On a rainy night, I stopped in at the city library. The Salt Lake City Library is an architectural masterpiece. Here are some pictures of it:

The city library may be a masterpiece of modern architecture, but it’s a leaky masterpiece. There were many containers filled with leaking water that rainy night. This indicates that beautiful and practical architecture are not equivalent. More relevant for the current discussion is that on every floor of this spectacular library there were homeless people. They were sitting on the chairs, using the Internet, and using the bathrooms. One of the homeless guys camped out in the handicapped stall, prompting a man in a wheelchair to complain. The city library is basically a homeless shelter. This is an insult to the taxpayers who support it, to the patrons who want to enjoy its resources, and to the homeless themselves. They should have a permanent home, and the government should provide it.

During most of my lifetime, American homelessness was largely a problem of mentally ill and substance abusing people. Recent years has seen more short-term economic homelessness. What we need to do is to separate out those who are capable of being employed, and those who aren't. Programs for the short-term economic homeless should focus on getting them a temporary residence, and preparing them to get a job. Even better, prevent them from being homeless in the first place by having available state-supported short-term housing for them if they become evicted from their homes. The long-term homeless, those who are too physically or mentally disabled to work, should have permanent state-subsidized housing. This housing must provide care for their disabilities. They should not have the option to be homeless. If they don’t like the state-subsidized housing, let them show that they can independently live in regular housing, or can live with friends or relatives.

Commitment laws need to be changed. This doesn't mean that mentally ill people should be committed to short-term hospitalization, to undergo forced drugging. It means that homeless mentally ill people should be committed to long-term housing. In some cases, those who are most impaired, this will mean state hospitalization.

This change to our homeless policy will be expensive. It can be paid for with reduced entitlement spending (Medicare and Social Security), reduced defense spending, and increased taxes. The benefits will be enormous—we can reclaim our public spaces, our libraries, parks, and streets, and the homeless will no longer be homeless. It would be a much better use of state funds than expanding mental health drug treatment.

19% of American High School Boys Diagnosed with ADHD

A recent New York Times article reported the disturbing fact that 19% of American high school boys have received an ADHD diagnosis. 11% of school-age children overall have received the diagnosis. There has been a 16% increase in children between ages 4 and 17 being diagnosed with ADHD since 2007, and a 41% increase in the last decade. The increased diagnosis correlates with increased prescriptions to stimulant medications like Ritalin and Adderall. These medications, while offering short-term increased concentration abilities in children with true ADHD, also have risks of side-effects, including addiction, anxiety, and occasional psychosis. Evidence that stimulants improve long-term outcomes in children with ADHD is lacking.

These numbers are making some academic psychiatrists concerned. James Swanson is a professor of psychiatry at Florida International University, and one of the primary ADHD researchers in the last 20 years. According to Swanson, “There’s no way that one in five high-school boys has A.D.H.D. If we start treating children who do not have the disorder with stimulants, a certain percentage are going to have problems that are predictable — some of them are going to end up with abuse and dependence. And with all those pills around, how much of that actually goes to friends? Some studies have said it’s about 30 percent.”

Think about this—30% of stimulant medication is going to children who don’t have any disorder. They are using it to focus, to stay awake, and to improve their grades. Parents, doctors, and pharmacists are essentially giving normal children access to speed. Maybe these children will do better at school in the short term. But they are risking a life of drug abuse and dependence. Sure, grades are important, but are they really that important?

Dr. Ned Hallowell, a child psychiatrist and author of best-selling books on the disorder, is another psychiatrist who has changed his viewpoint on ADHD. For years Dr. Hallowell would reassure skeptical parents by telling them that Adderall and other stimulants were “safer than aspirin.” He now says, “I regret the analogy” and “won’t be saying that again.” Halloway still thinks that many children with ADHD continue to go unrecognized and untreated, but wants more rigorous diagnostic procedures. “I think now’s the time to call attention to the dangers that can be associated with making the diagnosis in a slipshod fashion,” he said. “That we have kids out there getting these drugs to use them as mental steroids — that’s dangerous, and I hate to think I have a hand in creating that problem.”

Regarding rigorous diagnostic procedures: proposed changes to the DSM, to be released soon in the DSM-V, allow for more adolescents and adults to qualify for the disorder. Some of the proposed changes include increasing the age of first symptoms from 7 to 12; examples, such as repeatedly losing one’s cell phone, that are applicable to teenagers; and a change in the requirement that symptoms cause “impairment” to symptoms simply “impacting” daily activities.

Pharmaceutical companies predictably use their marketing power to persuade parents and doctors to get more children an ADHD diagnosis and prescription for stimulant medication. An example of this is a pamphlet for Vyvanse from its manufacturer, Shire. In the pamphlet, a parent looks at her son and says, “I want to do all I can to help him succeed.”

The stimulant drugging of our youth is a national crisis that needs to be addressed. It is unlikely that psychiatrists and pharmaceutical companies will reform themselves without outside pressure. Left alone, the corrupt pharmaceutical-psychiatric establishment will diagnose and drug more children, as evidenced by the numbers mentioned above, and proposed changes in the DSM-V. The government needs to be involved in the solution. Some needed changes include the outlawing of off-label prescribing to children, tightening the diagnostic standards of ADHD, restricting the prescribing of stimulant medications to children, encouragement of using non-drug alternative solutions to ADHD, encouraging  research in alternative treatments for ADHD, outlawing drug company advertising to the public, outlawing drug companies’ bribes to doctors, and expelling from school any children found with stimulant medication that is not prescribed to them, or any children sharing their medication with other children. There also need to be more long-term studies done of the effects of stimulant medications on children with or without ADHD.

A Psychiatrist Criticizes His Own Profession: A Review of “Unhinged” by Daniel Carlat

It’s not news that the profession of psychiatry is in a crisis state. I’ve talked about problems with psychiatry on this blog, and there have been many books, articles, and blogs written criticizing psychiatry. There’s no shortage of things to criticize. The fact that there is little understanding of the neurobiology of psychopathology, that there are no diagnostic tests for psychiatric disorders, that drugs have become widely prescribed with little evidence supporting their long-term efficacy, that most psychiatrists have become exclusively pill pushers, eschewing the need to understand and connect to their patients beyond a 15 minute med check, and that many psychiatrists have allowed themselves to be corrupted by drug money, are some of the problems with contemporary psychiatry.

Daniel Carlat, in his book Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis, provides an insider’s look at the problems with psychiatry. Carlat was motivated to pursue a career in psychiatry because of his depressed mother’s suicide. He begins his book by giving an account of his medical training. Much of what he learned from the medical school curriculum and clinical rotations was useless in his later practice. Psychiatrists don’t perform surgeries, don’t order lab tests (except to rule out rare physical problems), and (usually) don’t order brain scans. They diagnose based on symptoms, which is what all doctors used to do before the twentieth century, but which is only a minor part of medical diagnosis today. Psychiatrists, like other doctors, prescribe drugs, so they need to understand psychopharmacology, but as Carlat describes in his book their decisions about medications are usually subjective.

Carlat did his residency at Massachusetts General Hospital (MGH), beginning in 1992, after the introduction of second generation antidepressants like Prozac. Although his supervisors were divided between therapy and drug advocates, Carlat admits that “the main thing you learn in a psychiatric residency, then or now, is how to write prescriptions” (p. 34). After completing his residency, Carlat, like most psychiatrists of his generation, specialized in psychopharmacology, i.e. prescribing drugs. He saw patients for 15 to 20 minute medication visits. The reason why he and other psychiatrists did this was that it was more profitable. Seeing three patients an hour for med checks allowed him to make about $180 an hour minus expenses. Seeing one patient an hour for therapy allowed him to make between $80 to $100 an hour, which is about 50% less. Carlat blames managed care companies for forcing psychiatrists into becoming pill pushers. But managed care companies can’t force psychiatrists to do something that they don’t believe in. The “key opinion leaders” in psychiatry, those leading academic psychiatrists who set the direction of their profession via their research and publications, are fanatical advocates of the biochemical/drug paradigm. This advocacy is quite profitable for them, as Carlat describes in his book.

Carlat talks about his experiences as a “hired gun,” someone who is paid (i.e. bought out) by drug companies. Carlat worked for Wyeth Pharmaceuticals to promote the antidepressant drug Effexor to primary care doctors. He made $750 per talk. He describes that although he was officially an “expert consultant,” in reality he was basically a highly-credentialed salesman. Sales reps attended his talks, and they communicated to him via body language and other feedback whether he was doing what they expected of him, i.e. to promote their product. When he tried to be more balanced and neutral, they criticized him. He eventually gave up his hired gun position.

Although Carlat was a minor figure among the drug company hired guns, he assumes that the same thought processes and corruption happened among the more famous and successful psychiatrists. He discusses the Senator Grassley investigations of several key opinion leaders in psychiatry, including:

• Melissa DelBello, a researcher who was paid $180,000 by AstraZeneca to promote the antipsychotic drug Seroquel.
• Joseph Biederman, Timothy Wilens, and Thomas Spencer of MGH, who were paid a combined $4.2 million by drug companies over a 7 year period. These men also received taxpayer money in the form of NIH research grants, which explicitly disallows such large drug company income. Biederman and colleagues pioneered the diagnosis of bipolar disorder in toddlers, which has led to thousands of preschool children receiving drug cocktails including powerful antipsychotics.
• Alan Schatzberg of Stanford, president of the American Psychiatric Association, controlled more than $4.8 million of stock in Corcept Therapeutics, a company he cofounded to test a drug to treat psychotic depression. He was also the principal investigator of a huge NIH study to test the same drug. This combination represented a major conflict of interest.
• Charles Nemeroff, chairman of the department of psychiatry at Emory University, earned $2.8 million from consulting arrangements, but failed to disclose at least $1.2 million. Some of this money was from the drug company GlaxoSmithKline, whose drugs Nemeroff was studying with $3.9 million of taxpayer money.

Carlat describes the insidious methods that drug companies use to market their products to psychiatrists. He used the epilepsy drug Neurontin as an example. The evidence in favor of Neurontin’s effectiveness for treating psychiatric disorders was poor, and did not meet the FDA’s criteria for effectiveness. Warner-Lambert, the drug company that introduced this drug, decided to illegally market it off-label for various disorders, including bipolar disorder, pain, and anxiety. The company bribed doctors to prescribe Neurontin, and hired marketing firms to ghost-write articles pushing this drug. It also paid doctors to allow drug reps to shadow them during their patient visits. These drug reps persuaded some doctors to prescribe Neurontin off-label. The sleazy techniques paid off, earning Warner-Lambert $2.7 billion in 2003 Neurontin sales, almost all of them from off-label uses.

Carlat describes his own experiences with the pharmaceutical marketing machine. One experience was a lavish party put on by Janssen, the manufacturer of the antipsychotic drug Risperdal, during the 1999 American Psychiatric Association annual meeting. Janssen rented the entire Smithsonian Air and Space Museum, with live jazz band, buffet food, and free drinks, all for the benefit of psychiatrists whom they wanted to prescribe Risperdal.

Another experience was with Valerie, his Ambien rep. Ambien, marketed by Sanofi-Aventis, was the first in a new category of non-benzodiazepine sleeping pill. Since Ambien was going off patent soon, Valerie tried to sell him Ambien CR (“Controlled Release”), a longer-acting drug than the original. Carlat was skeptical of the science behind the new pill. Valerie knew that he wasn’t prescribing much Ambien CR. She had access to this information since pharmacies have been selling their prescribing data to drug companies since the 1990’s. Valerie was persistent, offering a free medical textbook as a gift. Carlat prescribed Ambien CR to a patient, subconsciously or consciously reciprocating Valerie’s gift. The patient didn’t like the drug due to a hangover side effect. Carlat didn’t tell his patient that he prescribed Ambien CR as a favor to a drug rep.

Carlat criticizes the chemical imbalance theory. This theory, i.e. that depression is caused by a deficiency of the neurotransmitters serotonin and norepinephrine, and that schizophrenia is caused by too much dopamine, came about from discoveries of the pharmacology of antidepressant and antipsychotic drugs. It’s now known that antidepressant drugs block the reuptake of serotonin and/or norepinephrine (thus increasing the amount of these neurotransmitters in the synapse). Antipsychotic drugs block dopamine receptors. The chemical imbalance theory took as a given that the drugs were effective, and that they were not just treating symptoms, but treating the biochemical cause of mental disorders.

There has been no direct evidence in favor of the chemical imbalance theory. Part of the problem with verifying the theory is that scientists can only indirectly measure neurotransmitters via breakdown products in the blood, urine, or cerebrospinal fluid, or post-mortem exams. The studies utilizing these techniques have been inconclusive for both depression and schizophrenia. The result is that since virtually all biological psychiatric research in the past several decades has been based on the chemical imbalance theory, “the shadow of our ignorance [of psychiatric disorders] overwhelms the few dim lights of our knowledge” (p. 80). Carlat admits that with the lack of a scientific basis for drug choice, prescribing is more of an art than a science. “To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep” (p. 83).

Carlat talks about the overdiagnosis of psychiatric disorders, which is caused by a combination of lack of scientific understanding of mental disorders, and greed. The DSM-IV, the “bible” of psychiatry, classifies mental disorders based on a list of symptoms. If you have five of the symptoms it mentions, you have depression. If you only have four, you don’t have depression. Since this symptom-based diagnosis is ultimately based on subjective or arbitrary factors, there is no way to prevent multiplication or redefinition of disorders. One of the criticisms of the upcoming revision (entitled “DSM-V”), is that new definitions of disorders would make it too easy to diagnose patients. An example is the proposed “prepsychotic” category, attempting to identify individuals who might in the future develop schizophrenia. In the words of Allen Frances, who was the chair of the DSM-IV committee, these broadened categories “would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment” (p. 65).

The problems with the DSM also affect clinical practice. For example, bipolar disorder is a diagnosis in the DSM based on symptoms such as alternating manic and depressive episodes. This diagnosis was intended for adults, although sometimes older teenagers have these symptoms. Joseph Biederman and his colleagues at MGH decided to expand the diagnosis of bipolar disorder to toddlers. In 1996, Biederman published a paper reporting that nearly a quarter of children he was treating for ADHD also met his criteria for bipolar disorder. Since preschool children don’t have mania or depression, how could they have bipolar disorder? Biederman decided that irritability was a defining attribute for mania in young children, even in the absence of euphoria or grandiosity. How could he make this diagnostic change? It wasn’t based on science, since the neurobiology of bipolar disorder in adults or children is unknown. Biederman was able to do this, and get a lot of other psychiatrists to follow his lead, because he was a full professor at Harvard, next to God, in his own words, on the psychiatric prestige scale. His diagnostic change led to a forty-fold increase in the number of children and adolescents treated for bipolar disorder. These children have been prescribed powerful drug cocktails, including antipsychotic drugs. The antipsychotic drugs have side effects such as sedation and weight gain that are much more harmful to children than adults. As I mentioned above, Biederman and colleagues received over $4 million dollars from drug companies, which was certainly a powerful incentive to expand diagnosis (and drug treatment) of bipolar disorder to children.

What is Carlat’s prescription for change in his broken profession? Carlat wants psychiatrists to go back to providing therapy, which can be balanced with medications. 15 minute medication checks are not sufficient to get to know a patient, to know what makes him tick. Sometimes changes in symptoms are not due to medications but life changes or stresses. Since most psychiatrists don’t have time to inquire about anything other than symptoms and medications, they are blind to what is going on in their patients’ lives. Carlat changed his own practice from exclusively 15-20 minute med checks, to somewhat longer medication sessions (20- 25 minutes), alternating with 45 minute therapy visits. He doesn’t use traditional psychodynamic therapy, but instead “a version of supportive therapy that I now try to weave into the fabric of all my sessions with patients, whether they are seeing me primarily for medications or for therapy” (p. 199).

Carlat also wants to see an alternative to medical school for training psychiatrists. He feels that medical school, in addition to be largely useless to future psychiatrists, indoctrinates these students into an excessively biomedical viewpoint. It also makes them feel inferior to other doctors, since psychiatry is in such a primitive state compared to the rest of medicine, and makes them feel superior to other mental health professionals, since psychiatrists have a medical degree. Carlat would like to see a new training program modeled on the “Doctorate in Mental Health” experiment in San Francisco in the 1970’s and 1980’s. This program combined two years of medical and psychological classes with three years of on-the-job training similar to a psychiatric residency. This shaved three years from the standard medical training, but unfortunately fizzled when psychiatrists successfully lobbied to prevent its graduates from being licensed. This program can be revived, and serve as a way to train new practitioners who would be better able to integrate drugs and therapy.

Carlat assumes that drugs are effective. In his book, he gives a number of case examples of patients who he says were helped by medications he prescribed. But how does he know that? His conclusions about drug effectiveness are based on his own clinical observations, which derive from 15 to 25 minute appointments. How can he, or any other psychiatrist, make any conclusion about effectiveness based on such short patient visits, and in the absence of any objective lab tests? Many people with mental disorders are in a complete state of denial about their condition. They are unable to recognize when they’re behaving strangely or irrationally. Family members and friends can usually notice changes, but they don’t always accompany a patient to a psychiatrist doctor visit. Even if they do, they may not speak up.

I have a personal example to support this. I have a relative who for years has been in denial about his depression, anxiety, paranoia, and OCD. When he went for his 10 minute medication visits (which was every month or every other month), he would tell his psychiatrist that everything was fine. His psychiatrist didn’t have time to ask probing questions or to try to make some independent observations. My relative's wife, who would drive him to the appointment and usually not go into the doctor’s office, was afraid to speak up. She was afraid because if she did speak up, my relative would become extremely angry, paranoid, and hostile, and blame her for triggering his bad mood, which would persist sometimes for days. So in the absence of any contradicting information, the doctor would usually tell him that he was doing great, and refill his prescriptions. This is pill pushing, not medicine. But it is the current standard of care in psychiatry.

I can give an example of where a 15 minute appointment would represent quality medical care. Let’s take a hypothetical example of Mary, who has diabetes. She is in denial about her condition. When she goes to the doctor, she tells him that she feels fine. He looks at her lab tests, however, and sees that her blood sugar is elevated. He tells her that she’s not fine, and then discusses possible causes for the elevated blood sugar, and prescribes a treatment plan. The doctor has an independent, objective source of information to balance Mary’s account of how she feels.

A psychiatrist doesn’t have any objective lab tests to balance a patient’s testimony. He needs more time to make an accurate diagnosis of the patient’s current state of mind. I think that an hour a patient is a bare minimum, even if the psychiatrist is only prescribing drugs, and not doing any therapy. In an hour, the psychiatrist has more time to observe and hear the patient, and ask questions. While it’s easy for a disturbed patient to put on an act for 15 minutes, it’s a lot harder do maintain this for 50 minutes. If a family member is present, it would also give the psychiatrist time to interview the family member away from the patient.

Psychiatrists, including Carlat, blame managed care companies for forcing them to have such short patient visits. But it is psychiatrists who set the standard of care for their profession. If leading psychiatrists said that they needed to see patients for a longer time, that 15 minute visits represented poor patient care and shouldn’t be reimbursed at all, and they lobbied the government, Medicare, and managed care companies to reimburse them at a higher rate for longer visits, then these changes would get made. Psychiatrists are not helpless pawns in the face of powerful entities, they have significant power themselves and can use that power to improve patient care.

Carlat doesn’t question the basic effectiveness of psychiatric drugs. His prescribing habits seem conventional, including prescribing drug cocktails. He gives an example of James, whom he calls a “typical success story of modern psychopharmacology” (p. 70). Carlat prescribed James five different medications, including Celexa for depression, Ativan for anxiety, Ambien for insomnia, Provigil for fatigue (a side effect of Celexa), and Viagra for erectile dysfunction (another side effect of Celexa). Is this a success story, even if James reported feeling happier? Carlat compares James to an old pickup truck, held together with baling wire and duck tape. Is turning patients into fragile jalopies a good thing?

Drug cocktails make it impossible to identify what drug is responsible for what side effect or reaction. How does one know if the patient’s fatigue or agitation is due to Drug A, Drug B, Drug C, the interaction between Drug A and Drug B, the interaction between Drug B and Drug C, or the interaction between Drug A and Drug C? This is for only 3 drugs. If a patient is on 5 drugs, as is James in the case mentioned above, then there are 10 possible interactions to consider. (The number of drug interactions can be expressed as [{n*(n-1)}/2], where n is the number of different drugs).

Drug interactions aren’t the only thing to worry about. There is also the question of dose sizes. Maybe Drug A is causing problems because it’s at too high a dose. But with the drug interactions and the effects of Drugs B and C, it’s not easy to identify Drug A’s dose as the problem. Also, drugs have different long-term effects from short-term effects. If a patient is on three different drugs, and suddenly develops severe anxiety, how does one know if this anxiety is due to the long-term effect of a drug? More likely, the doctor will add another drug to the regimen, or increase the dose of the anti-anxiety pill. But the better solution would have been to reduce or eliminate the drug that is causing the reaction, a drug that is impossible to ascertain because the patient is on too many drugs.

I emphasize these problems with drug cocktails because of my own personal experience with psychiatric drugs. I avoided drug cocktails, usually talking no more than two drugs at a time. With two drugs, there is only one interaction to worry about. For a period of time, the two drugs I took were the antidepressants Anafranil and Zoloft. After two years on this combination, I had an attack of severe anxiety. Rather than allowing my psychiatrist to prescribe an anti-anxiety drug, which would have been the typical response to this problem, I discontinued taking Zoloft. I had been on Anafranil for 3 years before I started Zoloft, and I didn’t think that Anafranil was the problem. The anxiety abated, and never returned to the level it was. If I were taking three or more medications, it would have been harder to identify the drug that was the problem.

Psychiatrists, including Carlat, have a knee-jerk reaction to add more drugs when there is a problem, rather than take drugs away. This is how drug cocktails come into being. Drug cocktails represent a type of off-label prescribing, because the individual drugs in the cocktail were never clinically tested or approved as part of a cocktail, only when taken individually. They are part of what’s wrong with psychiatry today, something that Carlat doesn’t acknowledge.

It’s unlikely that Carlat would accept Irving Kirsch’s thesis in his book The Emperor’s New Drugs (which I review here) that antidepressants are no better than placebos, or Robert Whitaker’s more radical thesis in his book Anatomy of an Epidemic (which I review here) that psychiatric drugs do more long-term harm than good. The reason for this is that Carlat has spent his entire career prescribing drugs. For him to acknowledge that they are placebos with dangerous side effects, or that they harm patients long-term, would be for him to admit that his life’s work was a failure. It’s similar to getting a district attorney who, after years of prosecuting and convicting an innocent man, to admit that he made a terrible error. There are not many district attorneys who can make this admission. In the case of psychiatrists like Carlat, most will not admit that they have made a terrible error and harmed patients by prescribing drugs. Thus Unhinged, while a call for change in psychiatry, doesn’t go far enough in questioning the efficacy of drugs. Such questioning usually comes from people outside the profession, such as a clinical psychologist (Irving Kirsh) who treats patients via psychotherapy, and a journalist (Robert Whitaker) who isn’t a mental health practitioner.

In conclusion, Unhinged is a well-written, honest account of systemic problems in psychiatry written by someone with an insider’s perspective on the profession. Carlat does an excellent job describing the drug money corruption in psychiatry, in the overmedicalized view of a complicated phenomenon such as mental illness, and in the need for psychiatrists to better know their patients and provide some of them with therapy. He fails, however, to go far enough in questioning drug (and drug cocktail) efficacy.

How Greed and Ideology are Endangering America’s Financial and Mental Health

I just watched the excellent documentary Inside Job about the financial crisis. Its main point is that the 2008 crisis and subsequent Great Recession were a consequence of deregulation of the financial sector. This deregulation (primarily in the United States, but also in other countries like Iceland and Ireland) led to an explosion of trading in risky investments like CDO’s, that in turn led to the housing bubble and crash. The tragic thing about this crash is that if we had kept the regulations in place that came about after the 1929 crash and Great Depression, we would never have had the recent crisis. Protections such as separation of savings and investment banks, restrictions on leverage, and enforcement by the SEC and other regulatory agencies of securities and fraud laws were stripped away in recent decades. Also, the financial services industry created new exotic “financial weapons of mass destruction” and successfully lobbied to keep them unregulated.

How did this unstable and risky situation develop? Inside Job argues that a combination of greed and free market ideology led to the housing bubble and bust. The greed came about from the enormous profits generated by the deregulated post-1980 financial services industry. This money flowed to traders in the form of multi-million dollar bonuses, to politicians in the form of lobbying and campaign contributions, and to academic economists in the form of consulting fees. The free market ideology, promoted by right-wing think tanks, politicians, and academic economists, provided a rationalization for the government to deregulate the financial services industry. This ideology argued that allowing an unfettered financial services industry to generate incredible amounts of wealth, and to make riskier and riskier investments, was good for the economy. This attitude is best summarized by Gordon Gekko’s memorable line in the first Wall Street movie: "Greed, for lack of a better word, is good."

While the free market ideology is seductive, and I admit that I was once an enthusiastic follower, it clearly failed as a rationale for financial services deregulation. While it’s easy to blame the government for everything bad that happens, and the government did promote home ownership for people who should have been renting, the leaders of the Wall Street investment banks were the main culprits. They knowingly and deliberately invested their client’s savings in risky mortgage securities, sometimes while simultaneously betting against the securities (i.e. betting that their own clients would lose money). It was Wall Street money that bid up housing prices, that promoted subprime mortgages, that paid the ratings agencies to give ridiculously high ratings to what was basically junk, and that led to the worst financial crash and recession since World War II. Some foreign banks also were to blame, as they did the same thing that the Wall Street banks did. Ireland and Iceland are two egregious examples of investment banks destroying their economies. The executives in charge of the investment banks got greedy, and even after their companies lost billions and needed to be bailed out, they got to keep their multi-million dollar bonuses and salary. The most disgusting thing is that not one of them has been prosecuted (in the U.S.) for fraud or securities violations.

When an ideology fails in the real world, people who believe in it have two options. One is to accept reality, and stop believing in the ideology. The other is to continue believing in the ideology, and abandon reality. Most Democrats, who in the past (especially in the Clinton administration) joined with Republicans in eagerly stripping away financial services regulation, realized after the crash that they made a grave error. When they were in charge of Congress, they passed the Dodd-Frank bill to improve regulation of Wall Street. These regulations, while inadequate, were better than doing nothing. These regulations are now law, but as Paul Krugman writes in an article, they are in danger of not being enforced. The reason for this is that Republicans have chosen to keep their free market ideology, while abandoning reality. Republicans are now in charge of the House, and Republicans don’t believe in regulation in any form. Since they control the funds, Republicans can prevent the SEC and other agencies from doing any regulating and investigating. Wall Street will then be free to create more bubbles and more crises.

Why do people continue believing in an ideology when it has clearly failed? To answer this, consider the historical example of Communism. Within a few years after the 1917 Bolshevik revolution, it was clear that Communism was failing in its ability to provide goods and services that people wanted. That’s when the scapegoating started. It wasn’t Communism’s fault, it was the fault of the capitalists (or the kulaks, or the imperialists, or the fascists, etc.). That scapegoating continued for decades, until finally no one believed the ideology any more, and all that was left was greed and corruption.

In the case of Republicans, the scapegoat is the government. Wall Street didn’t do anything wrong, it was government intervention in the economy that caused the crash and recession. The fact that the financial services companies made many risky investments and bad decisions, not just in the U.S. but also overseas, is also a result of U.S. government intervention. If the government hadn’t provided guarantees and bailouts, the companies wouldn’t have made these risky investments.

In the context of a mixed economy, with an internationally-linked market, the government needs to regulate the financial markets. If Republicans get their way, and repeal or refuse to enforce the new regulations, another crash will happen. We’ll then be in the same situation in which the choice will be government bailouts or a second Great Depression. Blaming the government for all our problems is similar to the Communists blaming the capitalists for all their problems. The free market ideology has failed the reality test vis-à-vis financial regulation, and continuing to adhere to it is a sign of either delusion or greed. Regarding the latter motive, Wall Street continues to utilize its vast wealth to lobby politicians to weaken and gut regulations.

Now let me turn to mental health and psychiatry. While watching Inside Job, I was struck with the parallels between the financial services industry and the psychiatric-pharmaceutical industry. While the free market ideology is used by the financial services industry to justify deregulation, the chemical imbalance ideology is used by psychiatists to justify their prescribing drugs to patients. The chemical imbalance ideology states that schizophrenia is caused by too much of the neurotransmitter dopamine, and that depression is caused by too little serotonin. These imbalances can be treated by antipsychotic and antidepressant drugs, respectively. Patients who take their drugs restore balance in their brains, become symptom free, and function better than patients who are unwilling or unable to take drugs.

This chemical imbalance ideology doesn’t fit the facts. As Robert Whitaker describes in his book Anatomy of an Epidemic (which I reviewed in a previous blog post), after many millions of dollars of research money, and enormous time and effort spent, this theory remains unverified. Scientists haven’t made much progress in understanding the cause or pathophysiology of mental illness. Diagnosis is still based on symptoms due to a lack of any reliable or valid lab tests. Drugs that seem to help patients in the short term, have a much more problematic long-term outcome. As newer drugs began to be prescribed more frequently, patients seemed to function worse than they ever did before, many of them becoming permanently disabled and unable to work.

Just as the free market true believers identify the government as an all-encompassing scapegoat, the chemical imbalance true believers come up with their own scapegoat: the disease. The reason why juvenile bipolar disorder prevalence skyrocketed, why so many children were being diagnosed and treated with drugs, and becoming permanently disabled, wasn’t due to drugs they were being prescribed. It was due to something else in the environment causing a psychiatric epidemic. It’s almost comical reading Whitaker’s description of how bipolar disorder was “discovered” in children. Before psychiatric drugs were widely used, children never got bipolar disorder. The fact that stimulant and antidepressant drugs induce manic episodes, and that many more children were taking stimulants and antidepressants than ever before, was conveniently ignored. Since many children taking antidepressant drugs became bipolar, some researchers argued that the drugs were an effective diagnostic tool, unmasking the bipolar disorder that was hidden underneath. Diagnostic boundaries for juvenile bipolar disorder were expanded to include irritable and antisocial children, and these children were given drug cocktails that led to functional impairment and serious physical and mental side effects.

Another similarity between the financial services industry and the psychiatric-pharmaceutical industry is greed. When the ideology has cracks, fill in the gaps with cash. Just as academic economists receive thousands of dollars from the financial services industry in consulting fees, academic psychiatrists receive thousands of dollars from the pharmaceutical industry. This money provides an incentive for economists to spout free-market/deregulation dogma, and psychiatrists to promote drugs.

This ideology-greed connection becomes self-perpetuating. Academic economists promote deregulation and free markets, which leads to more profits for Wall Street, which means more consulting fees, which means more economists promote deregulation, etc. Academic psychiatrists promote the chemical imbalance theory and drug treatments, which means more profits for the pharmaceutical industry, which means more consulting fees for the psychiatrists, which means more psychiatrists promote drugs, etc.

What can be done to emerge from these vicious circles of greed and failed ideology? Reform from within isn’t an option. Both the financial services and psychiatric-pharmaceutical industries are too hopelessly corrupt to reform or regulate themselves. The only institution powerful enough to take on the economic and ideological might of these two industries is the federal government. But the government is itself corrupted by Wall Street and Big Pharma money. The government must be spurred into action by grassroots advocacy groups.

Any advocacy group needs to have a clear, specific goal in mind. The American Tea Party had a vague goal of opposing big government and bailouts. It has now been hijacked by libertarian/free market extremists.

The group that takes on Wall Street should have these goals: Phase 1 should be to pressure the government to fully fund all the regulatory agencies involved in enforcing Dodd-Frank. In addition, the government should prosecute bank and financial executives who committed fraud and securities violations during the housing boom and bust. Phase 2 should be to make even more ambitious reforms to curb the power, influence, and money of the financial services industry.

The group that takes on Big Pharma should begin with pressuring for congressional hearings. Robert Whitaker and other people who criticize the psychiatric-pharmaceutical industry should be allowed to speak, along with academic psychiatrists, drug company representatives, and parents and patients. If it turns out that there’s not enough evidence to demonstrate that drugs do long-term good (the burden of proof is on the pro-drug people to show that they work), then Phase 2 should be a major overhaul of psychiatric drug regulation. This can include banning drug advertising, banning off-label prescribing, banning prescribing the drugs to children, and extending clinical trials to several years (from the current 6 weeks).