My last blog warned that Attention Deficit Disorder has become an overused fad diagnosis, with resulting excessive prescription of stimulant drugs. In the past 15 years, rates of ADD have tripled and stimulant use has doubled. For kids with severe and clearcut ADD, the medicine is often essential and enormously helpful. But loose diagnosis and aggressive drug company marketing result in frequent mislabeling and a quick trigger to starting medication when it may not really be needed.
Martin Whitely offers a proven public health cure for this false "epidemic" of diagnosis and treatment, one that has already worked wonders in his native state of Western Australia. Mr. Whitely is currently a member of Parliament, was previously a teacher, and has always been a crusader for safe and effective mental health services. He describes the taming of ADD in Perth -- the world's first hotspot to see a massive downturn in child prescribing rates.
Mr. Whitely writes:
"When I was elected to the Western Australian Parliament in 2001, my state's ADD per-capita prescribing rate was approximately 3.5 times the Australian national rate and exceeded the U.S. rate."
"The numerous committees that had previously reviewed diagnostic and prescribing practices had been heavily influenced by 'ADD experts' -- usually themselves frequent prescribers who had commercial ties to the pharmaceutical industry. Not surprisingly, these reviews consistently found no basis for concerns about possible harms and even concluded that ADD was under-diagnosed and the drugs used to treat it were under-prescribed. Their recommendations usually encouraged the further prescription of ADD drugs (without a scientific basis other than the consensus of the experts on the review committee) and predictably were followed by further increases in ADD prescribing rates."
"The most obvious problem (and opportunity for intervention) was the fact that frequent prescribers were largely exempt from accountability requirements. I advocated for much tighter, case by case, quality control administered by clinicians known to prescribe far less frequently. The resulting more rigorous and independently administered accountability resulted in a dramatic and sustained (60-70 percent) fall in child ADD prescribing numbers since 2003. Western Australia's child ADD per-capita prescribing rate is now marginally below the national average and is decreasing relative to other Australian states."
"Loose ADD diagnosis and the overprescribing of stimulants had also led to a big drug abuse problem. In 2005, 5.5 percent of Western Australian high school students had abused a diverted prescription stimulant within the last year. An amazing 45 percent of high school students who had ever taken dexamphetamine or Ritalin were not prescribed the drugs by a doctor and 27 percent of those who had been prescribed these drugs either gave away or sold them."
"Over the same period that child prescribing rates fell 60-70 percent, the number of teenagers abusing amphetamine dropped 51 percent. Far from supporting the commonly-made assertion that medicating for ADD prevents illicit drug abuse (by reducing self-medicating among untreated ADD sufferers), Western Australia's experience confirms the common-sense proposition that over-prescribing amphetamines legally facilitates their illegal abuse."
"Unfortunately old habits die hard among the ADD generation that was overmedicated in the 1990s. Western Australia's prescribing rate for adults is the highest in Australia -- far too many of our young adults still abuse prescription ADD amphetamines, particularly when binge drinking."
"The good news is that at least for the next generation of Western Australian children, the cycle of diagnosis, prescription and ongoing abuse has, to a significant degree, been broken. Our experience shows that rigorous and independent controls over prescribing can end the pattern of 'regulatory capture' by vested interests and thereby slash both the number of children legally on ADD drugs and the rates of illegal amphetamine abuse.
For more details see www.speedupsitstill.com."
Well done to Mr. Whitely and to Western Australia. I hope this example can be generalized wherever ADD diagnosis and treatment have gotten out of control. Fads in psychiatric diagnosis have been common throughout history. They usually begin suddenly, spread quickly to epidemic proportions, and then disappear in a fairly sudden death.
There are two potential tools that would allow us to tame the current ADD fad: 1) narrowed and more carefully applied diagnostic criteria, and 2) rigorous quality controls over stimulant prescription. DSM-5 will lead us in just the wrong direction on the first; Mr. Whitely shows us the way on the second.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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