October 16, 2000
|Lawrence Diller, M.D.|
Why are we seeing a rise in the use of these drugs?
It starts from the fact that we, as a culture--more than any other culture--seem to have accepted biology and the brain as the reason for maladaptive or poor behavior. American psychiatry had already begun to focus on the brain in the 1960s and 1970s. But it really wasn't until Prozac that the American public became interested in the brain for behavioral and emotional problems. Prozac will allow people, with far less side effects than earlier antidepressants, to improve their mood and become more resilient.
So, it became more acceptable and easier to take a psychiatric drug. Prozac was introduced in 1988. The explosion in Ritalin occurred in 1991. And I believe that Prozac paved the way, in terms of acceptability, for the use of Ritalin in children, though there are many other factors as to why Ritalin took off.
Besides the change in American psychiatry, and the public's view of behavior being brain-related, we had other things going on in the 1960s, 1970s, and 1980s. To begin with, you needed two parents to work to maintain the same standard of living than you did in the 1960s. That means that now we have institutional day care for children. We have many more latchkey kids. That's one factor, a major factor.
We have educational paranoia that began in the late 1980s with the downsizing of the white-collar middle class. With computers and stuff, if every child doesn't get a four-year-plus college education, they're not going to have any choices; they're not going to be successful. So what does that mean?
We have the expectations of three-year-olds learning their alphabet and their numbers. We have five-year-olds all learning to read in kindergarten. We have my eighth-grader learning algebra a year earlier than I learned it. This goes on all the way through the educational system. So we have more pressures on kids. And all through the 1970s and 1980s, we saw an expansion of classroom size.
So, not only are we expecting more from the children, but we're delivering less to them by their parents being at work, and by the teacher having more students per kid.
We have other factors going on. We have a continuing erosion of parental discipline that probably began 150 years ago. But we had the self-esteem movement in the 1980s that basically said that conflict is not good for children, that it further erodes their self-image. There was a misreading of Freud in the 1950s that said to reduce stress and your child will be neurosis-free.
All these things were going on through the 1970s and 1980s. And yet, Ritalin production remained stable all through the 1980s. And in 1991, it takes off.
The question is, what was the spark? If we look at the history, and we look at the data, the only thing that changed was the administrative change in the educational laws guiding our country's accommodations to children. In 1991, it began to include children with the diagnosis ADD or ADHD. And I think parents were genuinely trying to get help for their children.
But when they found out that they could get special services and accommodations by getting the diagnosis, they flocked to their doctors. Word spread, and along the way, you also got Ritalin.
Can you put that in specifics what that meant for an individual family? What kind of advantages did they get?
I don't want to disparage the families. If you have a child that's struggling in school, you would like to find a way of helping him. And under the disability laws in our country, specifically something call the [Individuals with Disabilities Education Act (IDEA)] and section 504, a child who's been diagnosed with ADHD is entitled to special services, such as getting an aide, getting reduced amounts of work given to them, having unlimited time to take an exam. These are all things that can happen for the child with that diagnosis.
And why has Europe had resistance to medication for treating ADHD, while its use in the US has exploded?
Western Europe has been targeted by the pharmaceutical industry as the next big market for stimulants, so we're seeing changes in using patterns. Traditionally, England, France, and Australia used one-tenth the rates of Ritalin that we do. They use a lot more minor tranquilizers like Valium, particularly in the elderly.
But now, we're starting to see English psychiatrists and a lot of interest in France about stimulants. They've heard from their American research brethren, virtually all of whom receive funding from pharmaceutical companies, that this stuff works. . . .
But in general, when you talk to English psychiatrists, they continue to feel that, unless there's extreme hyperactivity, that there are other things that can be done for the child in his or her environment.
And the French seem to just be much more tolerant of children's differences. Meanwhile, the French, as a people, use more pharmaceuticals than other country per capita in the world. And yet they haven't been using Ritalin.
In your view, what is ADHD?
First of all, it's basically a subjective experience of a child who has extra trouble with inattention, impulsivity, and hyperactivity.
"A subjective experience of a child." What do you mean by that?
Well, it depends on who's doing the deciding, and in what environment and culture these people are living in.
There is no test, unlike a blood test or brain scan that defines a gold standard for ADHD. That said, we see a very hyperactive kid running around the room, and usually they have other problems. They might have learning disorders, or might be mildly mentally retarded, or whatever. And you and I would have no problem agreeing there's something wrong with that kid. It's probably partly his brain.
But I tell you, the kids who I see who sit there like this, and they answer my questions beautifully, and they do really quite decently outside of school, or non-academic endeavors at home. And yet they're still struggling in school. Depending on the family, depending on the community, I might wind up giving that kid Ritalin.
Does he have ADHD? Well, it's an eye-of-the-beholder decision. There is no brain scan. There is no blood test that definitively says who has ADD and who doesn't. . . . The decision where to draw the line between abnormal and normal variance of behavior is an arbitrary one.
What does Ritalin do in the brain?
If you're just curious what Ritalin does to the brain, we can tell you what we know. How it works, for sure, in ADHD, nobody knows. There isn't a single unifying concept for ADHD, probably because ADHD and ADD represent just a whole group of different problems that are put under one label. Ritalin, and stimulants in general, cause dopamine to be released in excess amounts. Dopamine is a neurotransmitter. It tells one nerve cell to tell the next nerve cell what to do. That's one way of putting it.
And what you get is this rush of dopamine between the nerve cells. And I use the word "rush" intentionally, because if you use this drug improperly, it will cause a euphoria similar to cocaine and methamphetamine.
So it is similar to cocaine and methamphetamine?
Well, again, I want to put in perspective. Used properly, these drugs seem very, very safe, at least in children. But no, they are very, very similar to cocaine and methamphetamine. And I heard some friends who used cocaine in the 1980s say that they would take a little and they'd be able to do their work. I think cocaine is different enough that it creates more euphoria.
Methamphetamine--and people don't know this--is in the Physician's Desk Reference for the treatment of ADHD. The trouble is, it's real expensive, probably because people want to get it illegally. And Ritalin and Dexedrine, and all these drugs, circulate illegally in the high schools and the colleges these days.
Ritalin is a nitrogen different from Dexedrine and Adderall, which is amphetamine. But again, used properly, used in the proper way in low doses, these drugs appear pretty safe.
You've stated that there's over-medication.
There's over-medication, and there's under-medication, depending on the community you assess, and your values for it. I generally feel that in the community I work in, which is a white middle- to upper-middle class community, there is over-medication.
And how dangerous is it? Is it a problem?
I think 60 years of experience with stimulants suggests it's pretty safe stuff. If we're choosing to medicate children who, if they had a smaller classroom size, or one parent could be home, or issues like that, that becomes a moral ethical decision, rather than one of physical safety. I think we have a pretty good track record. Three to five years' worth of Ritalin use is probably pretty safe.
We have no data on adolescents taking this drug for any length of time. And we have anecdotal data that if you don't abuse amphetamines too much, as an adult, it's probably safe. But it's not any kind of systematic data.
And what about the risks of under-medicating?
That's a good question. And the decision is to try to address other issues along the line of parenting, and the schools, and learning of the child, and the struggling. What if parents decide they still don't want to medicate? Or there's less access to these medications and systems? And there are data that show children with impulsivity do have more problems, both in terms of getting along with other kids, and in terms of finishing high school and avoiding substance abuse.
The question is, does giving them medication make a difference? Nobody knows.
It's enormously frustrating for a parent to face these kinds of answers, because there's no clarity. I don't know what to do. I'm a parent; I have children. I wouldn't know what to do after listening to what you said.
People want clarity. And that's the seduction of the biological model. And I can think that's one of the reasons why in our particular technological society, this has great attraction. But parents also worry. I think there are a couple of things that parents can do to try to stay sensible about this. If they're getting a prescription after 15 or 20 minutes of talking to the doctor, then they know that is going to be a very, very limited evaluation. And all the interventions that follow are going to be very, very, limited.
A good, decent ADHD evaluation takes a couple of hours. And almost everyone agrees with that. Now, can the parent get that without paying for it out of their own pocket? That's another question.
I think another thing that evaluators and families are often overlooking is the absence of participation of fathers--if they're associated with the children in the family, or still have a connection with the child. And I think too many evaluations go on with only the mothers involved. The likelihood of that medication being used properly goes way up when we have both parents involved in the process.
The other major problem in terms of an evaluation is what's been termed a structural divide--between schools and teachers, who make the complaints about the child--the doctors who prescribe the medications--and the parents, who are the couriers in between. Unfortunately, a lot is lost in both directions. Concerns that the teacher has, or views that the teacher has, get mediated through the parent's worries, or lack of worries. Ideas that the doctor has, both on medication and other interventions, don't get translated either. So there's this structural divide.
What role do the insurance companies and pharmaceutical companies play in the world of ADHD?
There's a suit going on right now in three states. It alleges that the major pharmaceutical company that makes Ritalin, the Novartis Company, along with the American Psychiatric Association, the main representatives of organized medicine in the ADHD movement, and the self-help group CHADD have conspired to dupe the American public into believing that there's such a thing as ADHD, and then thrust upon innocent children a potentially dangerous drug.
The suit alleges that there's a conspiracy. Now, there may be some legal definition that meets the conspiracy angle. But I don't believe that there's any conspiracy at all. We have what I call the "invisible hand" of Adam Smith at work. Adam Smith, as you know, wrote the fundamental textbook on capitalism. And we have market forces at major play here, getting people to think a certain way about medications, and then operating on the doctors and the patients to get them to take them first--often at the expense of other interventions that work.
As a doctor, how do you experience those forces?
I experience them, first of all, by this unbelievable advertising barrage that has hit me first, and now is hitting the consumer directly. I think Novartis has acted quite responsibly, relatively speaking, because I think Ritalin represents a drop in the bucket to them in terms of the kind of money they make. They're much more worried about their bio-engineered foods these days than they are about Ritalin.
On the other hand, the makers of Adderall have presented what I consider to be the most disingenuous, elaborate campaign I've ever experienced. Adderall has passed Ritalin in terms of trade medication written for ADHD. I've been offered $100 if I will sit and listen to someone talk about ADHD, funded by Adderall, for 15 minutes on the telephone, and then fill out a five-minute questionnaire.
And now, with the loosening of controls on the pharmaceutical industry by the FDA, there is this direct marketing to families. You see this picture. Well, it doesn't say that it's for Concerta. It says, "Learn more about ADHD." And it's this picture of this smiling boy who has a pencil in his hand, and on either side of him, his parents are beaming. And underneath, it says something like, "They're happy, because now they know his ADHD is being treated."
What's the problem with that? The problem is it pushes people to only one way of thinking about the problem--that this is a biological problem, and that it needs a drug. . . .
The other major way economics plays a role here is in the managed care phenomenon of the United States, which was a legitimate attempt to address costs spiraling out of control. What managed care did, pretty much, was only make worse the pressure on doctors, particularly on pediatricians and family doctors, to diagnose quickly and to do something quickly.
Since Ritalin works on everyone, as I said, it becomes even a higher incentive. The doctor loses money if he spends time with the kid. The American Academy of Pediatrics recently offered guidelines for the diagnosis of ADHD. And my letter to the American Academy of Pediatrics in their journal said if doctors followed this model, they'd go broke.
Well, it's horrible for a parent for a parent to just think of this as a debate. For them it's a major life issue, and it's not a debate.
. . . I wish we could have a balanced discussion on this. . . . It quickly tends toward exaggeration and hyperbole that Ritalin is the best thing since sliced white bread, or Ritalin is the devil's drug. And it's neither. Yet, as a phenomenon, it got this 700 percent increase in the use of the stuff in our country, and we use 80 percent of the world's Ritalin. Why?
Is there an imbalance in how much money goes to studying the efficacy of drugs versus the efficacy of other things?
Yes. That's the other way that the market forces are operating here, in that virtually every ADHD researcher, now, because of previous cutbacks and because there is money out there, takes money from the pharmaceutical industry to do their research. And whether or not you're a doctor in the local hospital or you are one of the editors of the New England Journal of Medicine, we all know that research gets influenced by the funding source.
And this is not impugning these men. It's just how it works. They don't publish negative findings. The studies are tilted more toward counting symptoms and pills, rather than looking at the bigger picture. And if you look at a very narrow picture, if you just ask very narrow questions, you will get answers that miss the big picture. . . .
Dr. Peter Jensen, a respected authority in this field, says that, in the case of children's psychiatric medications, that it's not true; that the research money . . . comes from the government, because the pharmaceutical companies are afraid of litigation, and they don't want to go there.
That was the case. It was difficult to fund pharmaceutical research in children, particularly psychiatric pharmaceutical research in children, because there was seen to be no market until the 1990s. The government added this rider, where the pharmaceutical company will get an extra six months of patent protection if they study the drug in children. So what we're going to get, and what we're getting, is a flood of pharmaceutical research money directed toward children. And one could be very glad for that in some ways.
But again, if we only ask questions about how many symptoms does the kid have, and how many pills should he take, we are going to get a very, very narrow group of answers of what ails the kid, and what should be done about it.
So we are entrusting the research on our children's mental health and the solutions for their problems to pharmaceutical companies with vested interests?
You got it. It's clear to all of us, even those of us who do receive medication pharmaceutical money, which I don't. And I would like to, because I have to pay for my own trips. But the moment I do, I'm potentially influenced by that money.
How much money are we talking about here?
I think I've heard the stimulant market these days is getting close to a billion dollars. That's the legal stimulant market, because the illegal stimulant market, I think, is in the order of tens of billions of dollars.
Why did you write the book Running on Ritalin?
I wrote the book Running on Ritalin to deal with my own professional ethical dilemma. As a physician, my job is to heal and to ease suffering. So, after addressing the child's family life, particularly the parenting, and if it's appropriate with the child's temperament, and looking at the school and learning environment, I'll prescribe medication, because it will allow that octagonal, or round-peg child, primarily, to fit in that square educational hole.
But I also have a role as a citizen. And my role as a citizen demands that I speak out about the larger social, cultural, and economic forces, that come into play here with the diagnosis of ADHD. And if I don't speak out about those forces, then I become complicit as a physician, because I'm making money, I'm prescribing this medication, with factors and values that I think are bad for children and families. That's why I wrote Running on Ritalin, so I could go to bed at night and sleep better.