The following guest post is by Susan Molchan, MD, one of our regular contributors, who has previously worked at the FDA. She tweets as @SusanMolchan.
If you think this sounds like the prelude to a drug commercial you’re not far off the mark. This NPR story reports on a short screening scale or test for adult attention-deficit/hyperactivity (ADHD) disorder as published in JAMA Psychiatry. The gist of the news was the researchers’ claim that “six simple questions” can reliably diagnose adults with attention deficit/hyperactivity disorder. And diagnose it they did: the researchers found that 8.2% of those sampled suffered from ADHD, almost double that found from a comparable study about 10 years ago.
I wish health journalists had asked one simple question in order to give their readers much needed context: Who funded the research? Just follow the money.
The study received funding from a variety of sources, including government (National Institutes of Health) and foundation grants, as well as five drug companies that market medications for ADHD. Its authors list financial relationships with at least twenty drug companies, many of which market ADHD drugs. It’s well known that studies with industry funding tend to come out in favor of the industry’s interests.
Here’s another problem: New diagnostic criteria may increase the likelihood of someone being tagged with a condition for which a drug treatment is approved. (And, in the US, these drugs often are familiar because they’re advertised online, in print, and on TV). That’s especially true for mental health conditions, for which we don’t have blood tests or brain scans that can confirm that our patient has an infection or has suffered a stroke, for example.
As psychiatrists and psychologists, our criteria for diagnoses overlap with the normal range of experience and behavior — they have fuzzy borders. This fuzziness makes it easier to sell someone on the idea that their procrastination or their poor performance might be the result of a “disease” that can be fixed with a pill.
More patients mean more business, hence the tendency in medicine to “medicalize” what people are going through. Many people have written about this: Alan Schwarz in ADHD Nation, Dr. Allen Frances in Saving Normal, Ray Moynihan and Alan Cassels in Selling Sickness, Dr. Nortin Hadler in The Last Well Person, and Dr. H. Gil Welch in Overdiagnosed.
As of 2015, almost 7% of school-aged children insured under a parent’s employer and over 12% of those on Medicaid were prescribed medications for ADHD; now corporations have turned to development of the adult market. This was made easier by the lowering of the bar for diagnosing the condition in adults, formalized in the latest edition of psychiatry’s diagnostic manual (DSM-5). Notably, most (78%) of the academics who were on the DSM-5 work group for designing the ADHD criteria were paid drug industry consultants .
Good health journalists know it’s important to get some perspective and commentary from someone not involved in the study that they’re reporting on. Dr. David Goodman from Johns Hopkins University served as an expert source of information in the NPR article, but readers are not told that he consults for numerous pharmaceutical companies. HIs bread is generously buttered by running studies for at least 14 such companies, according to disclosures in a recent paper published in the Journal of Clinical Psychiatry. He’s published only on adult ADHD for the past 10 years, at least as documented in PubMed. Adult ADHD is his life.
Most psychiatrists in universities have ties to drug companies. Such ties may or may not bias them, but reporters should inform their readers if potential conflicts exist. Health journalists can find sources without corporate entanglements from this list at HealthNewsReview.org (the list is in the process of being revised and may contain some outdated listings) and from the National Physicians Alliance, a group of about 10,000 physicians from all specialties.
The six questions refer to the Adult ADHD Self-Report Scale, which was developed in conjunction with Eli Lilly and Company and Shire, both purveyors of medications for ADHD. It’s not unusual for companies to develop scales: for example, pain assessment scales were developed by pharmaceutical companies in research studies of opioid medications.
Keith Conners, PhD, a long-time ADHD researcher who developed the earliest diagnostic scale, is horrified by this latest effort by the pharmaceutical industry – and the physicians it buys — to convince more people to take a medication that is essentially speed. Author and psychiatrist Frances quotes Conners in a blog post:
Adult ADHD is real and of great life importance, but quite rare and easily over-diagnosed. Beware the charlatans and fringe practitioners making a new assault to capture the drug market.
The NPR article, with its whimsical graphics, reads almost like a drug ad. Even worse, it came without the fine print of possible side effects. Adverse events can be substantial, especially in people with anxiety or mood disorders who can experience serious exacerbations that can tip them into panic episodes or mania. My cardiologist colleagues wonder what increased stimulant prescriptions will do to rates of arrhythmias and other heart disease. They will continue to wonder as little is known about the long-term use of these drugs in aging populations.
Whenever I see something that looks and smells and walks like an ad, I look at who’s paying. Much to my surprise and chagrin, I found that even NPR takes funding from drug companies. (Their list of supporters includes the Pharmaceutical Research and Manufacturers of America.)
Another bubble burst.