Are ADHD Medications Being Overprescribed? .pdf version
by Ernest J. Bordini, Ph.D. All rights reserved
Executive Director, Clinical Psychology Associates of North Central Florida, P.A. CPANCF.COM
2121 NW 40th Terr. Suite B,
32605 (352) 336-2888 02/22/09
The question of whether or not Attention-Deficit Hyperactivity Disorder (ADHD) medications including stimulant medications are being overprescribed is often asked with concern. This was the subject of a recent interview with a radio reporter from AM 850, our local University-based radio station in Gainesville, Florida.
Stimulant medication such as Ritalin, Adderal, Concerta, Methadate and others are medications commonly used to treat ADHD. Generally, these as well as most psychiatric medications are recommended for use with what is termed multi-modal treatment: the combination of pharmacotherapy with individual and/or family psychotherapy and other interventions such as accommodations in school, studying and organizing help, parent training, educational approaches, and skill based programs such as group social-skill training.
Generally, response to medication is successful in 70% or more of the cases. This raises one of the first points that the question of over-prescription raises. Would we be asking this if we found a heart medication that was successful in 70% of cases? In short, sometimes the question itself belies negative attitudes about psychiatric medication and the stigma of mental illness (in this case a common neurodevelopmental brain-based disorder). ADHD can have serious negative consequences on achievement, learning, self-esteem, conduct, and peer relationships.
Having a successful approach and a variety of medication alternatives that can simplify dosing and help reduce side effects has benefitted many children and adults. None of the fancy diet preparations, vitamins and over the counter snake oil remedies often pushed by the anti-medication folks have come close to repeating the success of these medications in scientific random assignment double-blind studies. ADHD can occur with or without some of the more disruptive symptoms and can vary a great deal in severity. Some children with the disorder may with accommodations and other interventions respond adequately without medication. Some children may eventually need medication but are not suffering such severe immediate consequences that a trial of other interventions without medication would be appropriate, while others may be so severe that interventions and other efforts are likely to fail without medication.
As with all medical decisions an appreciation of where your child falls is important to understand in considering risks, costs and benefits. One previously unknown benefit, and risk of not taking medication, was reported in a recent study which found better neurological development in terms of dendritic branching in brain regions believed to be hypoactive in ADHD in treated versus untreated children with the disorder. This was not sufficient to alleviate need for the medication, but highlighted a risk associated with likely chronic brain hypoactivity in those regions.
Risks are well known, usually temporary and often manageable. Medication is often needed throughout school, though some children’s neurological system matures more than others and allows for some teens to discontinue successfully in adolescence. For other bright ADHD adolescents who could power their way through without medication in earlier grades, the increased demands of middle school may mean a decision to try medication. Same for college. Some adults with ADHD will continue to need the medication based on the severity of their ADHD and/or job demands.
According to a Health Affairs 2007 article, global use of ADHD medications increased threefold from 1993-2003. Interestingly, developed countries saw a much larger increase in the use of often more expensive long-acting forms of stimulant medication. Often, these are quite appropriate as they reduce need for multiple doses, and tend to have fewer side effects due to more even levels of the medication through the day. The fact that many ADHD children do well with very inexpensive twice daily dosing of the short-acting generic medication must be balanced with risks of side effects which may convince parents the medications are “bad” and discontinue or fail to try alternative medications or dosing.
Despite the increase in these prescriptions, the rates of prescription are generally in line with the estimates of the number of people who likely suffer from ADHD. Approximately 1-6% of population uses stimulants in the and there is approximately a 3-5% prevalence rate for ADHD. However, it is known that there are large variations by race, geography, and socioeconomic status. There are some population groups where it is very likely that stimulant and other ADHD medication is being under-prescribed.
Over-prescription occurs for a variety of reasons. These include misdiagnosis, failure to have licensed psychologist perform psychological testing, off-label use, advertising, and shortcuts, failure to try interventions and psychotherapy prior to prescription in mild cases, costs of specialty care, and the influence of inadequate insurance and managed care disincentives for specialty assessment and care.
Off-label use involves use of medication for conditions that the medication has not been FDA approved for. This is not uncommon and often appropriate in attempts to treat other disorders when more conventional treatments fail and when there is some research support for off-label use. This also includes more controversial use of the medications for enhancement of performance, subjective complaints, general behavior problems or psychosocial problems. Advertising has created an impact on prescription medication requests to physicians. If you do some spring cleaning and paint your bedroom walls, the commercials suggest there must be something wrong with you - seek medication from your doctor.
Overmedication, when it occurs, also is likely partly due to short physician appointment times, poor or limited insurance, and managed care plans tend to emphasize medication over specialty diagnosis and psychotherapy. This brings to mind an old memory of the brief period I was on a still very large and successful “mismanaged care” panel. I was told that testing for attention was not approved since their doctors prescribed medication just by watching the children in the waiting room! One would be naïve to doubt such attitudes and practices still exist.
Another issue the general question about possible ADHD medication over-prescription raises involves the use of stimulant medication for performance enhancement. Stimulant medications are amphetamines. As such, they do reduce fatigue, appetite, increase heart rate, increase alertness and vigilance in individuals without ADHD. This is a good reason not to rely on backward diagnosis – they help, so therefore the diagnosis of ADHD must have been correct.
The wisdom of using or prescribing a controlled substance with abuse potential when there is not a diagnosis to support the prescription is, at best, a controversial practice. When an individual who does not have ADHD seeks out such medication, the prescriber is well-advised to consider the possibility of substance abuse or diversion as these medications, unlike most antidepressants, are sought out on the streets.
A disturbing finding is that 56% of children without ADHD who were prescribed ADHD medications were prescribed the medication in the first visit. Prescription to those who do not have the disorder or have another disorder is usually caused by lack of a thorough psychological assessment including testing for ADHD, possible co-occurring disorders, and possible other disorders which can cause many of the symptoms of ADHD which are not unique to the disorder. Some clinics use shortcuts of ADHD rating scales or have individuals not licensed as psychologists conduct often arbitrary combinations of psychological tests for ADHD. Often, if only ADHD is tested for, only ADHD will be diagnosed. To avoid over-prescription and misdiagnosis there is no substitute for careful psychological assessment.
Visit the CPANCF.COM and ADHDASSESSMENT.COM website for more details on co-occurring disorders and what is involved in a comprehensive neuropsychological approach to ADHD assessment.
Further Perspectives on the Issue of ADHD Medication Overprescription:
Marguerite R. Lombardo (2004) Though the Correct Lens: Understanding Overprescription of Stimulant Drugs, Their Abuse, and Where the Remedies Lie
Gretchen B. LeFever, Andrea P. Arcona, and David O. Antonuccio (2003) ADHD among American Schoolchildren: Evidence of Overdiagnosis and Overuse of Medication
WebMD (2006) Are Stimulants Overprescribed or Misprescribed?
The books and links below are for educational purposes only and CPANCF, P.A. and the author of this article does not endorse or make other representations about such material