An article in the New York Times last week described the increasing use of stimulant medications such as Adderall and Ritalin among high-school students. Titled “The Risky Rise of the Good-Grade Pill,” the article discussed how 15 to 40 percent of students, competing for straight-As and spots in elite colleges, use stimulants for an extra “edge,” regardless of whether they actually have ADHD. In this blog, I’ve written about ADHD. It’s a real condition—and medications can help tremendously—but the diagnostic criteria are quite vague. As with much in psychiatry, anyone “saying the right thing” can relatively easily get one of these drugs, whether they want it or not.
Sure enough, the number of prescriptions for these drugs has risen 26% since 2007. Does this mean that ADHD is now 26% more prevalent? No. In the Times article, some students admitted they “lie to [their] psychiatrists” in order to “get something good.” In fact, some students “laughed at the ease with which they got some doctors to write prescriptions for ADHD.” In the absence of an objective test (some computerized tests exist but aren’t widely used nor validated, and brain scans are similarly circumspect) and diagnostic criteria that are readily accessible on the internet, anyone who wants a stimulant can basically get one. And while psychiatric diagnosis is often an imperfect science, in many settings the methodology by which we assess and diagnose ADHD is particularly crude.
Many of my colleagues will disagree with (or hate) me for saying so, but in some sense, the prescription of stimulants has become just like any other type of cosmetic medicine. Plastic surgeons and dermatologists, for instance, are trained to perform medically necessary procedures, but they often find that “cosmetic” procedures like facelifts and Botox injections are more lucrative. Similarly, psychiatrists can have successful practices in catering to ultra-competitive teens (and their parents) and giving out stimulants. Who cares if there’s no real disease? Psychiatry is all about enhancing patients’ lives, isn’t it? As another blogger wrote last week, some respectable physicians have even argued that “anyone and everyone should have access to drugs that improve performance.”
When I think about “performance enhancement” in this manner, I can’t help but think about the controversy over medical marijuana. This is another topic I’ve written about, mainly to question the “medical” label on something that is neither routinely accepted nor endorsed by the medical profession. Proponents of medical cannabis, I wrote, have co-opted the “medical” label in order for patients to obtain an abusable psychoactive substance legally, under the guise of receiving “treatment.”
How is this different from the prescription of psychostimulants for ADHD? The short answer is, it’s not. If my fellow psychiatrists and I prescribe psychostimulants (which are abusable psychoactive substances in their own right, as described in the pages of the NYT) on the basis of simple patient complaints—and continue to do so simply because a patient reports a subjective benefit—then this isn’t very different from a medical marijuana provider writing a prescription (or “recommendation”) for medical cannabis. In both cases, the conditions being treated are ill-defined (yes, in the case of ADHD, it’s detailed in the DSM, which gives it a certain validity, but that’s not saying much). In both cases, the conditions affect patients’ quality of life but are rarely, if ever, life-threatening. In both cases, psychoactive drugs are prescribed which could be abused but which most patients actually use quite responsibly. Last but not least, in both cases, patients generally do well; they report satisfaction with treatment and often come back for more.
In fact, taken one step further, this analogy may turn out to be an argument in favor of medical marijuana. As proponents of cannabis are all too eager to point out, marijuana is a natural substance, humans have used it for thousands of years, and it’s arguably safer than other abusable (but legal) substances like nicotine and alcohol. Psychostimulants, on the other hand, are synthetic chemicals (not without adverse effects) and have been described as “gateway drugs” to more or less the same degree as marijuana. Why one is legal and one is not simply appears to be due to the psychiatric profession’s “seal of approval” on one but not the other.
If the psychiatric profession is gradually moving away from the assessment, diagnosis, and treatment of severe mental illness and, instead, treating “lifestyle” problems with drugs that could easily be abused, then I really don’t have a good argument for denying cannabis to patients who insist it helps their anxiety, insomnia, depression, or chronic pain.
Perhaps we should ask physicians take a more rigorous approach to ADHD diagnosis, demanding interviews with parents and teachers, extensive neuropsychiatric testing, and (perhaps) neuroimaging before offering a script. But in a world in which doctors’ reimbursements are dwindling, and the time devoted to patient care is vanishing—not to mention a patient culture which demands a quick fix for the problems associated with the stresses of modern adolescence—it doesn’t surprise me one bit that some doctors will cut corners and prescribe without a thorough workup, in much the same way that marijuana is provided, in states where it’s legal. If the loudest protests against such a practice don’t come from our leadership—but instead from the pages of the New York Times—we only have ourselves to blame when things really get out of hand.
Thought Broadcast 
Thanks for the thought-provoking piece. It makes me ask – why not do what the surgeons did with plastic surgery, and divide your profession into psychiatrists treating illnesses vs. psychiatrists improving mental performance? That way people who want marijuana and adderall for their psychoactive properties could be dealt with on a different (non-therapeutic) level.
That would be an interesting solution. It seems to make a lot of sense to diversify the profession so that psychiatrists who want to treat the truly mentally ill, can do so more efficiently. The problem is that we, as Americans, don’t like change and everyone and their brother will have an opinion about it that will quickly turn into yet more talking points for Fox News, MSNBC, and CNN. The real issues would be lost in the noise, unfortunately. ~LyssaLee
I think this is a topic for many, besides psychiatrists, to think on. What is it about our society that makes so many think they need to be on a performance enhancer? And why should we live in a society where KIDS think they need to be on a performance enhancer?
ADHD is controversial because it is just so culture specific. I once read somewhere that there is an entire African tribe of people who qualify as having ADHD. I read that hunter/gatherer theory as well that has been floating around. ADHD is an evolutionary thing that came about because folks with ADHD make good hunters (they crave and seek out the stimulation of the hunt). And everyone else would be a gatherer.
What’s another culture specific one…pediatric bipolar disorder. I read that the United State is like a psychiatric freak accident. Nowhere else in the world has this many ADHD and Bipolar kids.
It may be time for everyone to settle down and rethink how we function as a society. Why are marijuana and psychostimulants so popular with kids and adults alike? Why are so many suddenly disordered? Something’s wrong
Unfortunately, since our current society doesn’t value ADHD symptoms and considers it detrimental, that means it is a disorder. If you’re living in a society that only values work that’s done behind a desk, you’re going to have a very, very hard time fitting in if you’re preoccupied with an overwhelming desire to hunt/gather. It’s kinda like with medications. When a medication does something other than what you might want it to do, it’s called a side effect. There are lots of medicines that make you drowsy. If you don’t want to feel drowsy, we call it a side effect. If you want it to make you drowsy, then it’s a sleeping aid. All of these disorders that keep popping up may indeed be a comment on the rigidity of our society vs the actual people’s ability to live in it.
@ Mara – Can you refer me to where you read about the hunter/gatherer theory? I am really interested in reading more about that. Thanks. ~LyssaLee
Steve, this post may be an argument for medical marijuana, but with a few tweaks you’ve made the libertarian case for public access to any substance without prescription.
Prohibition has never worked.
Back in the 20’s, alcoholsim was even MORE prevalent than now, that it’s legalized.
History and experience clearly show us that what people want, they will find a way to obtain, legal or not.And when something is illegal, it simply creates more problems for higher taxes to enforce and punish the “wrongdoers”.
Why not legalize weed, TAX it and at least make some neded public revenue from it.
Steve,
So I agree with everything you’ve said, and you could extend that. People request SSRI’s for anxiety which is not visible to others, then report they feel better, and they choose to remain on them because they feel more comfortable.
The one difference with marijuana is that it’s not “prescribed” like Adderall or Paxil, and it’s not monitored. You get a ‘Go’ card. At least with Adderall, the kid comes in monthly, you can check their pulse and blood pressure, and make sure you’re not harming them. You wanted Adderall because you can’t concentrate, you’re getting it, and you still have C’s, same as before, so it’s not changed anything, maybe you shouldn’t be taking it. With marijuana, if it induces an amotivational state, if the recipient is on disability (because it’s for all those cancer and chronic pain patients), you’re not seeing them to assess. I would have much less of a gripe with legalized marijuana or with marijuana prescribed like any other ‘medicine.’ Oh, I can’t believe you started me.
Will you write a post that dispels the myth that people with ADHD have paradoxical responses to stimulants? I still hear this one frequently. Anabolic steroids and Adderall address the exact same problem–humans vary in measured performances, and there will be a bottom 5 percent in everything. You see, I have a jumping and muscle mass deficit disorder that can be objectively verified to a degree psychiatry can only dream of. Disease-ridden, I march on. 100 percent of people taking Adderall will have improved academic performance. No disease, at any time, is every being “treated.” Students taking Adderall should be disqualified from receiving scholarships.
The educational system may be competitive, but education isn’t actually a competition. Some scholarship may be difficult to get, but they exist to help students afford higher education. Should a student be denied a proper education because they need to take Adderall? If you were dealt a bad hand, you shouldn’t feel bad about making things better for yourself. If a child loses an limb, a prosthetic arm or leg doesn’t disqualify them from playing sports.
Steve,
Is there really any difference between “drugs of choice” on the streets (or privately in homes) and psychiatric drugs?
Really.
C’mon.
Who are you docs trying to fools.
ADHD “medication” is amphetamine.
If Willie Nelson (love his music… grew up in Austin) wants to smoke grass on his tour bus at age 70 (give or take a year), who cares?
But to call these drugs “medicinal” is not only a “stretch”, it’s absurd.
To alter the mind with a drugs is to alter the mind with a drug.
Whether it’s legal, illegal, or a little bit of both.
Stop calling drugs “medicine”.
Stop calling psychiatry a “branch” of medicine.
Psychiatrists numb pain.
That’s all.
They do NOT get to the root cause of problems – physical, emotional, spiritual… You numb pain.
Drug dealers.
That’s what you do.
That’s who you are.
Duane
And to “prescribe” them to kids, outta be illegal.
Plain and simple.
At-ease, Dr. Z.
At-ease.
Duane
Steve,
When are you gonna make the clean-break, huh?
You’ve got far too much going for you…
You’re too bright a guy…
Make the clean-break.
Come over to the other side, where people speak in plain English, where the air is fresh-and-clean; where we help each other try to figure out what to do next.. now that psychiatry is dead.
Duane
Hi Duane,
Why don’t I make the “clean-break”? Well, partly because of people like Monika and her boyfriend (“I really believe psychiatry and its approach is not of the ‘drug dealing’ variety with him“). Psychiatry is a branch of medicine, insofar as many people who seek our help struggle daily with demons whose exorcism requires the care and dedication of a true healer.
But by “healer” I mean someone who, as you say, “gets to the root cause of problems,” and I agree with you: that’s not what most psychiatrists are today. Neither are we “enhancers” (to use Monika’s term), except in some cases, like those who prescribe stimulants ad lib to the Riverdale and Dalton kids in the NYT article.
Looking back at some of the comments on this post, it almost seems like psychiatry ought to take one of two paths: (a) we get rid of psychiatry as we know it and make all medications freely available to anyone who wants them, or (b) we re-establish psychiatry as a “cosmetic” specialty, prescribing whatever a patient requests (including MJ and the “legal speed” known as Adderall) to enhance performance, obtain social services, or any other outcome the patient desires.
Unfortunately, left in the middle would be people like Monika’s BF and countless other “true” psychiatric patients. These are neither the competitive college-prep kids looking to ace the SATs with Vyvanse, nor the inner-city disability malingerers looking to pick up a monthly $700 check with cannabis for “anxiety”– both of whom would be well-served by either alternative. No, those who truly suffer a disease that deserve our care would be left to pick up the scraps after the prep-school junior gets his Ritalin, the soccer mom gets her Abilify, the crackhead gets her Seroquel, and the inmate gets his Valium.
Dr. Steve,
The folks who are suffering most and with the least means are already the least likely to access care/treatment (regardless of the quality of that care). This is not limited to psychiatry. Regardless of whether Psychiatry “opens up” or rebrands itself as cosmetic (and I think these have both already happened in a lot of ways for all sorts of intentional and unintentional reasons) or does neither, people who are most “ill” are not getting good care. It would be great if folks who are interested in supporting these people have the capacity, funding, and evidence to do so well, but psychiatry research and practice priorities have already shifted away and don’t look like they are coming back.
I do also question your notion that you want to stay in your field because people in distress seek out doctors for help. That people do so is a byproduct of pharma-marketing, cultural norms of trusting doctors (uncritically), and the systemic elimination and belittling of other avenues of support that I believe was led by Medicine in the past half century. Perhaps evidence has been showing that what doctors offer is not all that helpful, particularly in light of the risks and costs associated with seeking help from doctors? Perhaps “healers,” including doctors who consider themselves to be, could be more honest and ethical and acknowledging limitations of what doctors can provide and support people in distress in finding other ways of addressing their “demons?”
The “other side”?
Mad in America –
http://www.madinamerica.com/
Duane
Duane,
I love what you say – but my bf has bipolar, and I really believe psychiatry and its approach is not of the “drug dealing” variety with him. But I have often carelessly referred to psychiatrists as the “drug dealers of medicine”, so we are more on the same wavelength that my opening would indicate.
I still think there are different professions at work here – one that tries to help people who have a problem, and one that tries to enhance people who don’t. Culture decides “problem” vs. “enhancement” (just like it decides medicine vs. recreation).
I know there is a philosophy out there (forgive me for no references, but it’s late) that there is a natural drive in humans to seek mind-altering, through drugs or yoga or what have you, the way we have a sex drive. I believe this is true to the extent that some people have no sex drive so some people have no mind-altering drive. But others have it in spades.
What do you all think about this? If that is a natural drive, marijuana vs. adderall vs. caffeine vs. cocaine is almost a moot point: fill-in-the-blank is always therapeutic for some, enhancing for others, some don’t even feel it, and others can’t tolerate it.
Sounds like all drugs, right? What’s different is how they are legislated.
not sure what to say
duane
Kind of as a side note commentary on Steve’s inner-city malingerers…I’m not inner-city. I’m chapparal, and wineries, and horses. But I know plenty of other SSI recipients…and I don’t think we “malinger” so much as we anticipate not getting the help we know we need. We’ve been let down a lot. Multiple diagnoses, innefective treatments, and docs with little faith in us. Even I feel pressured to fudge the truth, and I know I shouldn’t. I have a friend who I ABSOLUTELY believe deserves SSI. But she admitted to me that she was fudging the truth, making it look worse than it was, and whatnot so the PDoc evaluating her would say she was disabled. I’m sure he knew she was putting him on a bit. He told her it would be several diagnoses. But I know why she did it. She needs that money. And I need it too.
SSI is weird, because they handicap you in some ways and then help you in others. Free healthcare is helpful. But forcing me to have a representative payee, who is in charge of my money is not. If I insist on managing my own money, they actually sent me a letter telling me that I would be re-evaulated and possibly found not disabled because I can manage money.
Weirdly, they didn’t threaten to take away my benefits while I was getting my BA. They allow you to be educated and disabled, but not to manage your own finances and be disabled.
It’s a bizarre system. You never know what they will consider disabled or not. I was really surprised they still thought I was disabled while I was going through college.
Because I can pass College Algebra, but I can’t figure out how to manage SSI benefits…
I’m just saying, it’s a weird system. I don’t think a lot of us malinger because we are scam artists. We know we’re disabled, but docs haven’t a clue what is wrong with us (laundry list of diagnoses, many different drug families tried, etc). And we don’t often get psychiatric help that actually helps us. So we need the money. And if we don’t get it, then we will just end up with nothing, totally unable to support ourselves, and facing down homelessness…if that hasn’t already happened because SSI is not that much.
Mara,
Your comment and observations (all of which are entirely accurate) reflect the sorry state of affairs in medicine today, particularly in psychiatry. Most of what I do as a psychiatrist working in the public sector is to make hundreds of square pegs fit into (ever-smaller) round holes.
Some of my patients need money, some don’t. Some need help spending it, some don’t. Some want an education, others don’t (or can’t). And so forth. But everyone deserves care. It’s unfortunate that the care has to be doled out in such a specific way and according to such a precise formula, that it really removes any trace of “humanity” from what we do and makes the “care” essentially meaningless in the end.
“Malingerers” is a powerful word. Perhaps I shouldn’t have used it. The fact is that for every person who lies to get something they don’t deserve, there are dozens of others (myself included) who misrepresent the truth simply because it’s the only way to get what they do deserve.
Yeah, there are lots of people who I am sure are pure 100% malingerers. But I think a lot of us are just semi-malingerers. We have real issues, but we tend to get shamed a lot by everyone. We’re told we need to pull ourselves up by our bootstraps or whatever. Poor mental health doesn’t have the same credibility with a lot of people that asthma or cancer does. So maybe we ham it up a little (because we are so used to being disbelieved, told that we’re lazy, we have some kind of spiritual crisis, whatever) in an attempt to show the illness in a way that is more obvious for the doc to see.
I just think malingering comes in different forms. There’s outright lies…and then there’s hamming it up because you need help and you want the doc to believe it.
Interestingly, I’m following a discussion elsewhere in which doctors are explaining how they misrepresent patients’ complaints in correspondence with insurance companies, in order to get approval for medications without the time and hassle of completing prior authorization requests on a monthly basis. Sort of like the way I’ve been told by supervisors not to give an “NOS” diagnosis– even on the first visit– because the clinic won’t be paid for it.
The system makes liars out of all of us, we’d be hypocrites to think that patients aren’t doing the same.
make the clean-break, steve
sure, it will be frightening (at first)
but you can do it
duane
@Duane: Don’t encourage him to make the clean break. Psych patients still need him to manage our meds. If Steve ever moved to SoCal, or I ever moved to NorCal, I wouldn’t mind using him for med management. Bright psychiatrists who give this much of a crap about the patient are hard to find. And I’m difficult to medicate, so I don’t know that I would trust anyone but a psychiatrist to attempt medicating me with psych meds. Some of us need psychiatrists…especially ones who won’t ruin us with five different meds at once and who treat us like a science experiment.
Mara, Steve,
There’s so much truth to both of your brave, candid comments that they bring me down to my knees.. Lacking ways to fight the whole system (yet), and not wanting to abandon the people who need us the most (in the hands of “five different meds at once” type of providers), the fight needs to go on.
Thanks for the kind words, Mara. The fact is that every patient is a “science experiment.” (Even those we don’t medicate– you could call them “social science” experiments, I suppose.) And just as scientists differ not just in their fund of knowledge but also in the way they design experiments, some psychiatrists simply provide more informed consent, patient/subject autonomy, and, for lack of a better term, “human subjects protection,” than others. 🙂
Why are we giving our kids stimulants and gifted education to advance them. Where are they going? With some advanced placement a talented kid can spend five relaxed/intense years at a first rate state University and come away experienced and educated deeply. Compare that to four frentic years at Harvard with professors who have no time for any but the absolutely destined to be first rate.
Suggestion—admission to med school requires a year of public service or the equvilant–driving a truck, selling programs at a circus. Any activity in which days go by without achieving anything.
They could also choose another way to practice some true doctor skills during other ways. Here is a possible one: http://www.forbes.com/sites/tomiogeron/2012/06/28/healthtap-adds-micro-transactions-for-remote-doctor-chat/
Just saw the article and felt it fits perfectly!
My name is Kylie. I’m 26 years old and have had attention deficit disorder all of my life. My parents didn’t just throw me on amphetamines because they didn’t want to be bothered. They waited until I was in high school when they realized my condition wasn’t just because I was being your average “kid”. We first tried non stimulant ADHD medications to no avail. They made me extremely mean and obsessively focused. I could not hold down jobs, get homework done, or even listen to an entire lesson in the 50 minutes I had in each of my high school classes. I would come home crying because all I really ever wanted to do was to be able to stay focused enough to have a shot at living a normal life. Finally, we tried adderall for my issue at a very low dose and ever since I have been living my life and succeeding at all of the things I’ve always wanted to be focused on. To fully understand how amphetamines affect the brain of an individual with ADD…you first have to understand the human brain in basic general knowledge. People that are depressive have a lower than average level of seratonin in their brains creating the sad and hopeless feelings they are plagued with. With that being said, ADD is a lower than average level of a different brain chemical called Dopamine. To say that people are “enhancing” themselves and should not receive scholarships…is like saying anyone who is handicapped and is in a wheel chair is also “enhancing” themselves. It’s incredibly ignorant to imply that someone with any form of a disability that attempts to treat themselves medically…is therefore unnecessarily enhancing themselves and should not be allowed to have a normal life with the normal benefits that everyone else is entitled. You can’t allow hard work, whether done from someone without ADD and unmedicated or someone with ADD taking medication to function normally, to allow you to cold heartedly assume they havent used sweat, blood, and tears to get there. I’m a wonderful person!!! I am the founder of a non profit organization for bullied children because I was bullied horribly when I was younger, I am the owner of a photography business, and I help my father run the family business as well. People with ADD are creatively inclined…and some researchers swear they are, by far, one of the most intelligent groups of individuals in functioning society because they live by their own rules and use both sides of their brains. In example, Albert Einstein is said to have had a severe case of attention deficit disorder. He was also known to use Cocain every day (probably due to its similar effects on the brain as amphetamines). With that being said, never underestimate us…
Ode- Arthur O’shaughnessy
We are the music makers,
And we are the dreamers of dreams,
Wandering by lone sea-breakers,
And sitting by desolate streams;—
World-losers and world-forsakers,
On whom the pale moon gleams:
Yet we are the movers and shakers
Of the world for ever, it seems.
I also forgot to include for “Discover and Recover” and “()Gary” that I feel very sad for how bitter and opinionated the both of you are. I pray that down the road when you’re diagnosed and seek treatment for something debilitating as you both grow older, that people show you the same type of “kindness and empathy” you exert towards people who are different than you and seek treatment. Whether you are in wraiting pain from cancer and need pain management therapy or you fall and have a brain injury that requires SSRI therapy. I hope you both reflect back to this day and learn a valueable lesson; You do not pick the hand you are dealt…you just play the cards and pray you have a hand good enough that you don’t lose to every other player. NO ONE has the right to dictate how you play your hand…only the person holding the cards. None of the other players know exactly which cards you have been dealt…therefore…should not call out blind moves for anyone on that basis. Whether its amphetamine or marijuana treatment.
@ Dr Steve
Since Abilify works on dopamine could it also help people who have ADD and who don’t want to take stimulants?
ps: I know someone who took abilify (among other antipsychotics) and now developed dyskinesia and the neurologist said it could come from abilify. Can abilify cause dyskinesia?
Dr. I just want to say “thank you” for your thoughtful post on ADHD and end the diagnosis. As a single father (resulting from divorce) I have been marginalized in the decision making process for my son. I find my son to be a typical 7 year old, but his mother insists he has ADHD and wants him on Focalin. She also uses Adderall herself despite never being diagnosed with anything. My son does extremely well in a demanding private school and I have not given him the Focalin in over a year, but his mother gives it to him on her custody days. My opinion is that ADHD is an excuse in many cases and the children are prescribed these highly addictive medications when there is only downside for them (terrible side effects…). I thank you for caring enough about your profession and the patients to state our opion!
This excellent website really has all of the info I wanted about this subject and didn’t know who
to ask.
Hi there, just wanted to tell you, I enjoyed this post. It
was practical. Keep on posting!
If some one needs expert view regarding blogging and site-building then i propose him/her to pay a
quick visit this weblog, Keep up the nice work.
I do consider all the ideas you’ve introduced on your post.
They are very convincing and will certainly work. Still, the
posts are too quick for newbies. Could you
please prolong them a bit from next time? Thank you for the post.
Wonderful blog! I found it while surfing around on Yahoo
News. Do you have any tips on how to get listed in Yahoo News?
I’ve been trying for a while but I never seem to get there!
Thanks
Excellent blog! Do you have any suggestions for aspiring writers?
I’m hoping to start my own blog soon but I’m a little lost
on everything. Would you recommend starting with a free platform like WordPress or go for a paid option? There are so many choices out there
that I’m completely overwhelmed .. Any recommendations?
Cheers!
Hey, I think your site might be having browser compatibility issues.
When I look at your blog in Chrome, it looks fine but when opening in Internet Explorer,
it has some overlapping. I just wanted to give you a quick heads up!
Other then that, excellent blog!
What’s up to all, because I am in fact eager of reading this webpage’s post to be updated on a regular basis.
It consists of nice data.
Good readingg