What It Will Take to Decrease ADHD Rates, Part 1

I have nothing but respect for Dr. Allen Frances, who has done as much as anyone to raise awareness about the dangers of over-diagnosis and medicalizing normality. He had written extensively about the causes behind the rising rates of Attention-Deficit/Hyperactivity Disorder (ADHD). His recent blog post, My Prediction: The ADHD Fad Is About to Fade, surprised me with its optimistic tone.

First, Dr. Frances points out some of the forces that have led to the excessive diagnosis of ADHD and its treatment with stimulants, including big pharma with their lobbyists and deep pockets, perfectionistic parents, recreational users, chaotic schools, and ADHD experts who see only the benefits but not the risks of treatment. He then goes on to list his reasons for "making the long-shot bet that [the ADHD fad] will now begin to fade":

• The percentage of kids being diagnosed (11 percent overall, and 20 percent of teenage boys) is so absurdly high that reasonable people can no longer accept that the label is being applied with anything approaching sufficient care and caution.

• The astounding rate of stimulant use (6 percent overall, and 10 percent in teenage boys) shocks us into the realization that we are creating a generation of drugged kids.

• Studies show that stimulants are much less effective than we originally thought in improving long-term school performance.

• Some of the leading experts who developed the concept of ADHD and did the best research are speaking out about their surprise and dismay at the way it is now being misused.

• The press is now on the case, with frequent exposés of careless ADHD diagnosis and stimulant misuse. Alan Schwarz of The New York Times deserves special mention (and a Pulitzer prize) for his vivid, in-depth reporting, but this story is now receiving extensive international coverage and has long legs.

I hope that Dr. Frances is right. However, I am not nearly as hopeful as he is "that parents will now play an active role in curtailing the ADHD fad, protecting their kids from unwarranted diagnosis and potentially harmful medication treatment."

I certainly agree with Dr. Frances's first two points about the "absurdly high" rates of diagnosis and "astounding rate" of stimulant use. However, I am not convinced that statistics like this will lead to people clamoring for change. As the saying (apocryphally attributed to Stalin) goes, "A single death is a tragedy; a million deaths is a statistic." For example, the U.S. locks up far more of its adults than any other developed nation. Yet I do not detect much outrage, except among the minority populations that are disproportionately incarcerated. Even liberal Americans who are upset by the high rates of incarceration would probably not mind if someone who burglarized their house got the maximal sentence. Similarly, the average person reading about the skyrocketing rates of ADHD might be taken aback, but that feeling is unlikely to translate into action, especially if this person's child is falling behind in school or not behaving, and the doctor offers a pill as the standard treatment.

In my own experience, the rising rates of ADHD treatment have just made it a more acceptable topic of everyday conversation, so I sometimes have parents come to me saying that the child of an acquaintance of theirs was transformed by a medication, and now they want the same pill for their child as well. The parents I meet who would prefer not to have their child on a medication by and large know nothing about the rates of ADHD diagnosis and treatment; they just think it's wrong to give their child a brain-altering pharmaceutical.

As for the third and fourth points, I think the experts who are dismayed by the high rates of ADHD are still in the minority, while most ADHD experts tend to have views similar to those expressed in a recent JAACAP editorial:

Importantly, although rates of medication use have increased in the past decade, approximately 70% of children and teens with current ADHD are receiving medication treatment (6.1% divided by 8.8%). Although not every child or adolescent with ADHD requires medication treatment, the study documents a pattern of undertreatment. Because stimulant medication is the core evidence-based treatment for ADHD, undertreatment is an important take-home message from this study.

When academics such as these discuss the studies showing lack of long term benefit from stimulants, they tend to emphasize that that the children and adolescents studied were on too low of a dose (usually blamed on pediatricians and PCPs), or did not take the medication for long enough.

As for Dr. Frances's last point, I hope the media keeps up their coverage. However, I think back to circa 2008, when Senator's Grassley investigations put many big-name psychiatrists on the hot seat, and I wonder how much lasting change resulted from those news reports. It seems that the news cycle moved on, and unethical behavior and conflicts of interest continue to be pervasive amongst the top echelons of medicine and psychiatry.

While I may come across as quite pessimistic here, in a future post I will outline some things that I do think can eventually help decrease the over-diagnosis and treatment of ADHD.

On Integrated Mental Health Care

The American Psychiatric Association sure seems to be pushing hard for integrated (a.k.a. "collaborative") care these days. They even commissioned a report on how integrated care would save the system billions, which the Psych Practice blog recently dissected. APA president Dr. Jeffrey Lieberman, who is nearing the end of his term, recently published this piece in Psychiatric News. The attitude is one of "change is coming, so we'd best prepare." In this post, I'd like to take a critical look at various aspects of integrated care, based on my own (admittedly limited) experience.

First, why is integrated care a good idea? Where I work now, many psychiatrists do not accept insurance, and it can take patients months to get in to see a psychiatrist. When they do see a psychiatrist, the psychiatrist and referring physician are often too busy to communicate with one another. In some places, primary care doctors are forced to handle psychiatric patients with severe illnesses like schizophrenia, as highlighted in this post by Dr. Maria Yang. With children, pediatricians with very little psychiatric training often end up counseling parents about behavioral issues and prescribing medications, due partly to the severe shortage of child and adolescent psychiatrists.

Just as the American health care system is not just one system, but a patchwork mostly local systems, integrated/collaborative mental health care is not one thing; it can be done in many different ways. Several years ago, I experienced integrated care first-hand when I worked as a consulting psychiatrist in several primary care clinics that mainly provided care for underserved populations. Not surprisingly, most patients I saw were over 40 and had multiple medical problems. Most were referred to me because of depression or anxiety, though a significant number had a personality disorder, bipolar disorder, or schizophrenia. I got to spend an hour for each new patient visit and 30 minutes for each follow-up. In some of the clinics, I was told I should try to refer the patient back to their primary care physician (PCP) after 6 visits with me, though they were generally flexible about that.

I have to say, it was overall a good experience for me. I got to focus on providing patient care and did not have to deal with insurance companies or pharmacy benefit managers, since the clinics mostly used a generic formulary for medications. I was also glad that I helped not only the patient, but fellow physicians as well. The primary care doctors were uniformly and sincerely appreciative of having a psychiatrist that they could quickly refer patients to, or quickly consult with on a "curbside" basis. The patients tended to show up consistently for their appointments and liked having more time to talk with me compared to their brief PCP appointments. In one of the clinics, where the patients were mostly refugees and immigrants, few of them would have sought out a therapist or psychiatrist on their own, but they were more comfortable going to their doctor's office to meet with me. This all seems to concur with the APA's view of things.

That being said, my experience with integrated care was far from perfect. I thought that the vast majority of patients I saw would have benefitted from psychotherapy, yet very few of the clinics employed therapists, and none had access to more intensive treatments like dialectical behavior therapy. Even in the clinics that did have therapists (usually LCSWs), they were usually full and could not readily see new referrals. Because of the therapist shortage, I often ended up prescribing a medication by default. And of course, other forms of integrated care may be much more compromised than what I experienced. For example, managed care organizations seem to focus much more on cost containment, screening using rating scales, and then using medications to get those numbers down. To quote Sandra Steingard's comment last month on the 1Boring Old Man blog:

I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like, "So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!"

I also get quite concerned when I read things like Dr. Lieberman's article, which reflects the thinking of the APA leadership. From his closing paragraphs:

The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.

There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.

Is the focus on improving patient care, or something else? I believe that most psychiatrists are secure with their professional identities, and it is the more biologically-oriented psychiatrists who feel that we must claim our rightful place amongst other medical professionals. It's clear that they fear that psychiatrists would just opt out of the system entirely and remain in solo practice or collaborate mostly with independent psychologists and therapists. This would open the door for people like prescribing psychologists or nurse practitioners to fill the unmet need of psychiatric prescribers in medical settings. So on some level, this is a political battle as the APA fights to retain the mantle of mental health leadership. Why else do you think they have prominent politicians like Bill Clinton and Joe Biden opening the APA annual meetings?

In my mind, the biggest unmet need in mental health right now for the insured population is increasing the numbers of providers of effective therapies like CBT, DBT, PCIT, and so on. Of course, the APA does not address this at all. Instead, what the biological psychiatrists tend to emphasize is that primary care doctors don't diagnose enough, don't use the right dosage of medication, and patients do not stay on medications for long enough. Thus, the relentless push for diagnostic inflation, mass screening so cases are not missed, medication algorithms so that doses are optimized, and tracking patients like they're widgets in a factory. If psychiatry changes in accord with this vision, it would profoundly alter who enters this profession (if it continues to exist at all). Most psychiatrists I know went into this field because of a desire to treat the whole person rather than just symptoms, not to "or at least oversee" treatment provided by someone else. This type of system would favor those whose interests lie primarily in numbers, charts, "huddling" with a team. Is this really what anyone other than the APA wants business interests of managed care want the future psychiatrist to be?

This post was edited to more accurately reflect what I meant to say. Thanks, Dr. Dawson!

Book Review: Slow Getting Up

Over the weekend, I read Nate Jackson's Slow Getting Up: A Story of NFL Survival from the Bottom of the Pile in almost one sitting, a rare thing these days with my attention span getting ever shorter. Jackson was an unlikely success story, someone who beat the odds by making it to the NFL and playing for six seasons despite not being drafted after playing for a Division III college.

Jackson very vividly captures the bravado of the professional athlete: the pride in his extraordinary physical prowess, the adrenaline rush of stepping onto the field, the agony of being in the purgatory of NFL Europe, the fear of appearing weak, the drunken cash-burning Vegas partying, the frenzied testosterone-fueled cracking of helmets.

The book is wickedly funny in parts, such as when Jackson described having to be at practice early because he was part of the special teams unit:

Forty-five minutes later the rest of the team shows up. Starters don't come to special teams meetings. They're happy not to play during the ritual sacrifice of kickoffs and punts, but maybe they're also a bit envious. We're a tight-knit group. We know things the other guys don't. We know about fifty-yard dead-spring head-on collisions. We know about snot bubbles. We look at the game differently. [p. 101]

The gallows humor pervades much of the book, but the most jarring passages are when Jackson quotes from his own extensive medical record. The dry technical language belies the horrible ravaging that his body has suffered. From one of his later injuries:

MRI findings:

High-grade complete tear and stripping of proximal left adductor longus and brevis, with distal retraction and about 5cm tear defect gap with intervening edema and hemorrhage. Strain of the adjacent pectineus and obturator externus and gracilis muscles and attachments.

Moderate proximal hamstring tendinosis and/or strain and scarring are seen, with longitudinal thinning and possible tearing of the proximal deep margins at the ischial tuberosity attachments bilaterally. [p. 185]

From my viewpoint, Jackson's interactions with the team doctors take on a surreal quality. They ostensibly warn him of the risks and benefits of procedures such as steroid or NSAID injections, but it's a foregone conclusion that he would do whatever might get him back onto the field the fastest. Of course, the doctors were serving the team more than the players: one passage describes how Jackson's injuries were first reported to the team's management and the coach before he himself found out what was going on. The long-term health of the player did not factor much into the equation.

Ultimately, what I got out of the book is that the NFL is a profit-generating industry, which like all others, seeks to maximize its profits. It treats the players as replaceable cogs in a machine, parts that can easily be replaced when broken. Sure, coaches and general managers are frequently hired and fired as well, but it is the bodies and minds of the players that pay the ultimate price for our entertainment. Yet at the same time, players enter into this arrangement willingly (at least in the beginning), attracted by the money, the glory, the desire to be compete with the best in the world.

And that brings me to perhaps why I wrote this post today. There was an article in The Daily Beast making the rounds: How Being a Doctor Became the Most Miserable Profession. The article highlights a litany of woes, including the high suicide rate amongst doctors, the fact that 9 out of 10 doctors would discourage others from joining the profession, and how doctors have to see so many patients now that "the average face-to-face clinic visit lasts about 12 minutes."

Just as the NFL uses its players for profit maximization with little regard for their well-being, the healthcare system uses doctors in the same way. I tend to believe that what keeps most doctors in the profession is not the quest for money or status, but a sense of duty, of wanting to help patients and not abandon them. So in this way, doctors might actually be worse off than NFL players. There's no collective bargaining agreement. Doctors – in the U.S., at least – don't go on strike. The associations that are supposed to represent doctors often seem to collude with the business forces of medicine rather than look out for the interests of practicing clinicians. Doctors are not so easily replaced, and since there's already a big doctor shortage in the U.S., we've been sucking up physicians from the rest of the world's supply.

Compared to primary care, psychiatrists have it relatively good. Many are still in solo private practices, not on insurance panels and seeing a manageable number of patients per day. Others work in public-sector roles. Yet with every passing year, the system creeps closer to requiring psychiatrists to participate, ostensibly to help contain costs with measures like integrated care. What can be done to change it for the better? The current path is clearly not sustainable. Cost containment is clearly being targeted at the wrong level. How about containing costs here, or here? Now that would be a great start!