Ritalin: Is Drug Shortage or Drug Excess the Problem?

Today's New York Times features an opinion piece by Dr. J. Alan Sroufe, emeritus professor of psychology at the University of Minnesota and expert on child development:
http://www.nytimes.com/2012/01/29/opinion/sunday/childrens-add-drugs-dont-work-long-term.html

Dr. Sroufe starts by noting that the news has lately been full of reports of serious drug shortages, leaving frantic parents and teachers worried that kids with attention deficit disorder will be unable to get their Ritalin (methylphenidate). Dr. Sroufe then offers the argument that instead of worrying that these kids might not be able to get their meds, we should be worried that far too many kids are getting medicated for ADD despite good evidence that any benefit from drugs is probably limited and short-term.

The piece basically falls into two parts. One addresses the actual evidence about the benefits of stimulant drugs like Ritalin in ADD. The other discusses the likelihood that ADD is not an inborn chemical imbalance and may be at least partly environmentally triggered, suggesting that a more complex approach is needed rather than just prescribing drugs. (Since psychiatrists tend to prescribe drugs for behavioral problems and psychologists tend to downplay the value of drugs and suggest various other forms of therapy and prevention, I fully expect to read angry psychiatrists attacking Sroufe's article in coming days.) And Dr. Sroufe defends his bona fides by noting that early in his career, he did research on Ritalin and helped show that it seemed to have benefit. Anyway, the first part of the article is what I choose to focus on as most pertinent to this blog's agenda.

Basically Dr. Sroufe disputes the initial claims that ADD kids have messed up brain chemistry because of an inborn problem, so that stimulant drugs have a paradoxical effect on them and settle them down instead of revving them up. There's no paradox, he says--anyone given stimulants, and then assigned to do boring, repetitive tasks (presumably like much schoolwork is) will be able to do the tasks better. The real issue is whether in the long run ADD kids improve on Ritalin, in terms of learning or life adjustment, and he claims that long-term studies show no difference and that any presumed benefit to stimulants disappears after a few years as the body develops tolerance. Because the body develops tolerance, kids do worse when the drug is stopped, so studies showing worsening of ADD symptoms on drug withdrawal hardly support the actual benefits of the drugs.

What these assertions have to do with our concerns is:

• Stimulants, like many drugs used in mental health, look very good so long as you do your study for a 4-8 week period, and never look at long term outcomes. For this reason it is increasingly worrisome that so many studies of psychoactive drugs are roughly 4-12 weeks' duration. From an industry viewpoint this is good for two reasons--such studies are cheap and quick, and as noted their outcomes are much more likely to be positive. The rest of the world (the FDA included) needs to take note that such studies are also virtually uninformative about any drug intended to be used chronically.


• To repeat a basic theme, drug marketing does not simply try to sell us drugs. Marketing tries to sell both physicians and the general public a way to think about drugs. We have recently discussed the popularity as well as the scientific defects of the low-serotonin theory of depression (http://brodyhooked.blogspot.com/2012/01/npr-forget-serotonin-theory-of.html). Telling guilty and frazzled parents and teachers that the child has an inborn brain disease is reassuring, while saying that something in the environment may be making them act that way just ramps up the guilt. So the public (and the physicians trying to reassure them) readily grab for a biochemical story to tell about ADD. So long as that story sells pills, Pharma wants to be sure we keep believing it, even if the science refuses to accommodate them.


• We are also seeing here more signs of the worries raised in Robert Whitaker's controversial but probably mostly-on-target book, Anatomy of an Epidemic (http://brodyhooked.blogspot.com/2010/05/whitakers-anatomy-of-epidemic.html). Whitaker paints a bleak picture of modern psychopharmacology, while admitting that for the small population of people with really severe psychiatric symptoms, drugs are far better than no drugs. He claims as a general point about psychoactive drugs that the human body seeks to restore homeostatis, a fancy way of saying that if you give a drug that (say) raises your serotonin, the body thinks this is making things go out of kilter and sooner or later tries to lower its own serotonin production in response. If you then go off the drug for a while, you are left with a brain that is producing serotonin at even lower levels than normal, and you might well see withdrawal effects, which psychiatrists interpret as more evidence that you really need the drug and dare not stop it. So the bottom line is that we've gone way overboard in prescribing drugs that have dangerous and often unknown long-term consequences for people who have such mild symptoms that they would be much better off with no drug treatment--Sroufe notes that we now prescribe 20 times more stimulants for ADD than we did 30 years ago.