Sunday, May 19, 2013

Over Diagnosis or Undertreatment of ADHD?

Recently a front page article in the New York Times by Alan Schwartz described a case that caught the attention of millions of readers. He followed the prescription history of stimulant drugs such as Adderall for a promising young college pre-med student who committed suicide after being prescribed stimulant drugs by multiple doctors who never made a valid initial diagnosis of ADHD. This article was followed by another article about a case involving a lawsuit by parents against  Harvard college following their son's suicide after being prescribed stimulants by a nurse practitioner who allegedly had not followed standard approved diagnostic procedures.

Regardless of the merits of these and many similar stories--and the articles are careful to follow a balanced and non-biased view of these events--they raise the issue of whether the term "diagnosis" is being properly applied to ADHD; for since physicians or other authorized health care specialists  presumably must make a diagnosis in order to prescribe these drugs, (unless they are prescribing "wildly"), it is hard to account for the stupendous increase in prescriptions for stimulants over the past ten years. (According to a study in Pediatrics the increase in stimulant drugs for ADHD over the past ten years is more than 49 percent, second only to the increase in contraceptive prescriptions).

While the DSM-IV diagnostic criteria for ADHD have their limitations, there is little evidence to suggest that the criteria are being applied in a very large number of cases where stimulants are being prescribed. The bulk of prescriptions in fact come from primary care or pediatric physicians, not child psychiatrists. ADHD is a complex disorder requiring considerable time for the history, data gathering from parents and teachers, interviewing of the patients and their caretakers, evaluation of possible environmental or medical problems best accounting for the clinical picture and the application of behavioral or psychotherapeutic alternatives to pharmacotherapy. Unfortunately reimbursement policies and the lure of "quick fix" treatments may be responsible for a great number of individuals receiving drugs they do not need or which are being used illicitly. If there is a vast number of

prescriptions for people who have not been carefully diagnosed, what about those who have. The best epidemiology of ADHD shows that only about 2-4 percent of children and adolescents qualify for the diagnosis, not the nine to fourteen percent claimed by less than pristine methods such as telephone interviews in which the patient is never actually interviewed. Of those, who do qualify, perhaps a quarter never get the treatment most appropriate for their age and circumstances. In this sense there are a relatively small number who are getting illicit prescriptions when truly indicated by good medical practice. But clearly, as the New York Times reporting indicates, the most serious issue is the vast number of "shadow" diagnoses and drugs in the hands of many who abuse them seriously enough to die or become psychotic or addicted. a