View Full Version : ADHD Overtreatment/undertreatment


Kunga Dorji
07-15-14, 10:52 PM
Here is an interesting article from The Lancet:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961146-6/fulltext

There may be issues for non Health Practitioners in gaining full access, so I will highlight the main point that I wanted to draw attention to:


The new President of the Royal College of Psychiatrists, Simon Wessely, recently signalled his concerns about overmedicalisation in children. In an interview with The Times newspaper in the UK, he said that “Medicalisation is not often done by doctors…Now we see a huge rise in support groups, we see pressure brought to bear to bring in labels…You get obvious pressure from parents…It's psychiatry which is against the medicalisation of normality.” Specifically in relation to attention-deficit hyperactivity disorders (ADHD), he went on: “It's the same with Ritalin. It's probably over-prescribed, but it's also under-prescribed because we don't have good enough services.”


My take on this is that it is fair comment. I have found that getting control of my ADHD has been hard work over a number of years, and I have often required treatments that cannot be accessed through health insurance or our Australian Medicare.

I am concerned at the way the system pretty much forces very heavy relaiance on medication because more comprehensive therapy is largely inaccessable to most patients due to cost.

Amtram
07-16-14, 09:14 PM
This is what I took away from it:

ADHD can be a controversial diagnosis. But it is clear that some children and young people do have substantial social and educational difficulties because of ADHD. In some cases, problems with attention and impulsivity might be helped by pharmacological treatment. This approach should always be only one part of a holistic management plan developed in the context of the family and social environment. The new guidance from the American Academy of Pediatrics is therefore very helpful. And we also agree with Simon Wessely that mental health services for children and young people need to be substantially strengthened.

Flory
07-16-14, 09:27 PM
You need to put this in the context of it being in the uk..... We probably have under ten adult ADHD services for the entire adult population of the uk, you'd be more likely to get a boob job or gastric bypass/obesity surgery with the Nhs than you would the diagnosis of a condition that is so massively impairing....

Treatment medicalisation etc etc is a debate for another time but so far pretty much all of the highest regarded specialists would agree that medicine is the best first line treatment for ADHD full stop...

daveddd
07-16-14, 09:33 PM
You need to put this in the context of it being in the uk..... We probably have under ten adult ADHD services for the entire adult population of the uk, you'd be more likely to gets bloody boob job or stomach staples with the Nhs than you would the diagnosis of a condition that is so massively impairing....

Treatment medicalisation etc etc is a debate for another time but so far pretty much all of the highest regarded specialists would agree that medicine is the best first line treatment for ADHD full stop...

medicine is ok, and it does help, especially in the short term


it seems though, and i see it everyday on the forum, people who rely strictly on medication are still constantly miserable

i understand the defensive stance in a way, i guess

does something other than pills helping us make us a bad person?

most specialists would not recommend meds alone

Amtram
07-16-14, 09:37 PM
No specialists worth seeing recommend medication alone.

As for seeing unhappy people, well, they're more likely to come online looking for support than happy ones, right? That doesn't mean that they actually outnumber the happy ones, though.

daveddd
07-16-14, 09:44 PM
No specialists worth seeing recommend medication alone.

As for seeing unhappy people, well, they're more likely to come online looking for support than happy ones, right? That doesn't mean that they actually outnumber the happy ones, though.

ill be honest, I'm an obsessive hobbyist just like you
except in psychology instead of genetics

the numbers don't lie, most won't do well on medication alone

i didn't see KD take issue with meds, thats why i questioned the defensive stance, he admits to taking them

why else was an argument made that specialists says meds are best?


i read meds should be made a part of treatment, nothing about them being bad

Flory
07-16-14, 09:45 PM
I meant first line as in try medication in combi with behavioural therapy services as opposed to the routes taken with other conditions such as strictly talkin therapy.

I think if it were possible that a lot more needs to be put in in terms of teaching coping mechanisms and other non pharma assistance but I would say that on a personal level medication for me is necessary....I've been in this system from childhood and had various non tablet treatments.... I think that more research into non med approaches needs to be done be it as a combination treatment with meds or as a sole treatment in people for which meds aren't appropriate

Amtram
07-16-14, 09:50 PM
The point KD was making is that he wants people to be treated for ADHD with chiropractic, acupuncture, and other things that have been shown to have no measurable benefits in the treatment of ADHD. The things that work, medication and therapy, don't need to be supplemented by things that do nothing.

Flory
07-16-14, 09:53 PM
I kin of have my own theory about the miserable on medication at least with regards to this forum but I don't know if this thread is the place for it ;)

daveddd
07-16-14, 09:54 PM
I kin of have my own theory about the miserable on medication at least with regards to this forum but I don't know if this thread is the place for it ;)

make a thread


sounds fascinating

Kunga Dorji
07-17-14, 09:30 AM
This is what I took away from it:

ADHD can be a controversial diagnosis. But it is clear that some children and young people do have substantial social and educational difficulties because of ADHD. In some cases, problems with attention and impulsivity might be helped by pharmacological treatment. This approach should always be only one part of a holistic management plan developed in the context of the family and social environment. The new guidance from the American Academy of Pediatrics is therefore very helpful. And we also agree with Simon Wessely that mental health services for children and young people need to be substantially strengthened.

Yes - we are finally starting to see more balance in the arguments coming to the public.

Kunga Dorji
07-17-14, 09:47 AM
The point KD was making is that he wants people to be treated for ADHD with chiropractic, acupuncture, and other things that have been shown to have no measurable benefits in the treatment of ADHD. The things that work, medication and therapy, don't need to be supplemented by things that do nothing.

No Amtram- that was not the point that I was making- and you should be careful not to impute implications that were not stated.
The point was very well made by Prof Alisdair Vance at the Royal Children's Hospital that treatment needs to be multimodal.

The majority of families dealing with children with ADHD have a very hard time handling their children. ADHD children can be highly oppositional and family dynamics within families with children with ADHD are often destructive to the emotional well being of children.

Even Russell Barkely says that although parenting should not be regarded as a cause of ADHD, that superlative parenting is needed to help ADHD children progress and mature adequately.

Have a close look at his book "Taking Charge of ADHD" and you will find he is in fact laying out a program of very thorough and structured "Parental Effectiveness Training".

The real point that Dr Wessley was making, and I was concurring with is that we need to do more with ADHD than just throw drugs at it.

Look at any of the major protocols for ADHD and you will find they all emphasise the need for behavioural interventions as well as medication.
The catch is that these behavioural interventions are not funded.

It might surprise you to know, but I spend a good deal of time inclose liaison with senior figures within a number of major patient support groups within Australia-- and all bemoan the fact that they are forced to over advocate for medication, because there is simply no money made available for the kind of behavioural interventions that are needed to alter ADHD.

This is much harder in the US- because there is such bitter and systematic opposition to publicly funded medical care.

The hard truth though, is that ADHD is an extremely "financially impairing condition" and unless the state is prepared to fund adequate comprehensive treatment of ADHD in children- the state will be saddled with the end effects of untreated ADHD- which is an adult who often cannot earn enough to support him self or control his impulses well enough to stay out of jail.

That was Wessley's main point, and that is what I was highlighting.

Kunga Dorji
07-17-14, 10:04 AM
I meant first line as in try medication in combi with behavioural therapy services as opposed to the routes taken with other conditions such as strictly talkin therapy.

I think if it were possible that a lot more needs to be put in in terms of teaching coping mechanisms and other non pharma assistance but I would say that on a personal level medication for me is necessary....I've been in this system from childhood and had various non tablet treatments.... I think that more research into non med approaches needs to be done be it as a combination treatment with meds or as a sole treatment in people for which meds aren't appropriate

My broad comment here would be that without medication, most ADHD patients cannot "attend" well enough to learn anything from behavioural interventions or talking therapy.

My basic model of ADHD is really very close to the conventional wisdom:
it is a developmental disorder in which there is a failure to achieve expected levels of self regulation of attention, emotion, (and alertness- to borrow from Thomas E Brown's "executive function model").

So the questions to me are
1) What interventions are necessary to train in these "executive skills"?
(calling them "executive skills" rather than "executive functions" highlights the now proven fact that these skills are trainable- given the correct approach).
2) What are the conditions required to facilitate training in these skills?
The answers to the latter really fall into 2 main categories-
i)improve attention enough to allow new learning
ii) do whatever is necessary to de-stress and unload the individual to also facilitate new learning.
This step is very important-- inattention creates an enormous burden of chaos in our lives- and most people I see are so overburdened with debt, with parking fines, with failing academic careers that they are utterly overwhelmed, and are not in a position to take on any new learning.

You might not know the whole story here - but the consequences of my ADHD created a situation where I was forced out of the workforce for nearly 2 years. I was extremely lucky that my disability insurance saved me from financial oblivion- because that 2 year period became an opportunity for me to virtually rebuild myself from the ground up.

I personally have gone through a series of transitions- but while I started on 50mg dexamphetamine a day my required dose has collapsed to the occasional stat dose of 15mg-- maybe 2-3 times a week, and my attention is better than ever. I am doubting that I will even need to ask for another prescription once my current one has run out (I am 1/3 way through my last 1 month prescription--- 3 months after filling it). Honestly I would rather not have to ask for another script-- because most psychiatrists I have dealt with are judgmental jerks-- and I would rather not be beholden to them or their opinions.

However, that tangent aside, I am well aware that part of the process of mastering our ADHD involves creating enough space in our lives for personal growth.

Kunga Dorji
07-17-14, 10:06 AM
medicine is ok, and it does help, especially in the short term


it seems though, and i see it everyday on the forum, people who rely strictly on medication are still constantly miserable

i understand the defensive stance in a way, i guess

does something other than pills helping us make us a bad person?

most specialists would not recommend meds alone

Unfortunately in many cases the demands of insurers for "high throughput medicine" have minimised the amount of time that many psychiatrists spend with their patients. I have encountered situations in Australia where some psychiatrists will issue a prescription for 6 months medication without even seeing the patient. NOT good practice by any standards.

Flory
07-17-14, 10:17 AM
I agree with you really personally I feel and through my own trials and tribulations that I do need medication I was trying to play devils advocate a little in suggesting that we do need other treatments researched and made more readily available however in no doubt that really where necessary medication is currently the best first line treatment we have!

Kunga Dorji
07-17-14, 10:18 AM
.................................................. ....................but so far pretty much all of the highest regarded specialists would agree that medicine is the best first line treatment for ADHD full stop...

That is not consistent with the major consensus protocols.
Current consensus emphasises, especially in children, an initial trial of behavioural interventions first, with early consideration of medication if there is not a prompt improvement. The "NICE" protocols from Europe are a good starting point.

It is also helpful to look at the Draft NH& MRC guidelines from Australia.
These are available online. They are reasonably current.
Unfortunately they have not been formally adopted as the scandal around Dr Biedermann's financing by drug company money derailed the political process necessary for these guidelines to be accepted.

Flory
07-17-14, 10:18 AM
Kunga, do you not have a law regarding these mass prescriptions for controlled drugs in th uk we can only receive a 30 day supply

Fuzzy12
07-17-14, 10:29 AM
I agree that (in the UK at least) medicalisation for ADHD is not commonly done. If at all the UK seems more conservative in regards to both diagnosing ADHD and prescribing stimulants.

Based on what I've read, the most effective approach is to use both medication and ADHD-specific therapy but therapy on its own has shown to be not very useful. I guess, the problem is that in its natural state our ADHD brain cannot easily and effectively use what we have learnt in therapy.

If we had to choose between either meds or therapy, I'd choose meds as I can (slowly and with lots of struggling) acquire in other ways the skills and strategies that therapy can teach me.

I think of the meds being similar to a car (sorry, silly example, but I can't think of anything else right now). You can learn how to drive a car but without a car you can't drive. Similarly, you can own a car and but just ownership of the car won't make you be able to start driving. However, once you have the car you can try to learn, even on your own, how to drive it and probably at some point you will figure it out. You'd be quicker with a professional instructor (and your driving skills might be slightly haphazard or of lower quality) but it can be done on your own.

Flory
07-17-14, 10:30 AM
Coined it miss fuzz :)

My written language isn't always great despite a high verbal iq I tend to ramble and get distracted but fuzzy has pretty much nailed it ^

Kunga Dorji
07-17-14, 11:53 PM
Kunga, do you not have a law regarding these mass prescriptions for controlled drugs in th uk we can only receive a 30 day supply

The Law in Australia allows for prescribing up to 6 months worth of any controlled substance at a time-- ie a month's prescription and 5 repeats that can be issued without seeing the patient.
I would suggest though that encouraging more regular review allows the opportunity to ensure that the ADHD patient is getting enough help with the behavioural/coaching interventions.

Kunga Dorji
07-17-14, 11:55 PM
I agree that (in the UK at least) medicalisation for ADHD is not commonly done. If at all the UK seems more conservative in regards to both diagnosing ADHD and prescribing stimulants.

Based on what I've read, the most effective approach is to use both medication and ADHD-specific therapy but therapy on its own has shown to be not very useful. I guess, the problem is that in its natural state our ADHD brain cannot easily and effectively use what we have learnt in therapy.

If we had to choose between either meds or therapy, I'd choose meds as I can (slowly and with lots of struggling) acquire in other ways the skills and strategies that therapy can teach me.

I think of the meds being similar to a car (sorry, silly example, but I can't think of anything else right now). You can learn how to drive a car but without a car you can't drive. Similarly, you can own a car and but just ownership of the car won't make you be able to start driving. However, once you have the car you can try to learn, even on your own, how to drive it and probably at some point you will figure it out. You'd be quicker with a professional instructor (and your driving skills might be slightly haphazard or of lower quality) but it can be done on your own.

How can you do any therapy if you can't concentrate on it?
Medication is often a necessary precondition to allow therapy to commence.

Fuzzy12
07-18-14, 02:08 AM
How can you do any therapy if you can't concentrate on it?
Medication is often a necessary precondition to allow therapy to commence.
yes, that was my point.

Chicky75
07-18-14, 03:47 PM
I am concerned at the way the system pretty much forces very heavy relaiance on medication because more comprehensive therapy is largely inaccessable to most patients due to cost.

I apologize if I'm taking this off topic, but this reminded me of a discussion I recently read on a Linkedin group for therapists. I think they are mostly in the US, but I would be surprised if the overall trend they mention of insurance company policies pushing them more toward only private pay clients and emphasizing medication over therapy is completely unique to the US though the healthcare systems are obviously different. http://linkd.in/1oS47aw

Kunga Dorji
07-19-14, 01:05 AM
I apologize if I'm taking this off topic, but this reminded me of a discussion I recently read on a Linkedin group for therapists. I think they are mostly in the US, but I would be surprised if the overall trend they mention of insurance company policies pushing them more toward only private pay clients and emphasizing medication over therapy is completely unique to the US though the healthcare systems are obviously different. http://linkd.in/1oS47aw

No- it is quite an appropriate comment.

There is actually a huge issue that the insurance companies are distorting the system.

Psychiatrists are actually becoming deskilled in the art of talking to patients.
The one I see for medication supervision is blunt to the point of rudeness - I know many orthopedic surgeons with a better bedside manner. Thankfully it looks like I am close to completely outgrowing any need for medication.

I have also been seeing a psychotherapist (qualified psychiatrist - originally a child psychiatrist) twice weekly to weekly over 2 and 1/2 years- so quite a few sessions.

He is really concerned at the de-skilling of the psychiatric profession in talking therapies.

He makes a good point- I took a good deal of psychological harm secondary to other peoples' reactions to my ADHD behaviours- and talking through all that stuff has made a huge difference to my happiness and functionality.

I am lucky to have had that opportunity, and even luckier to have found a real master therapist (and it troubles me that such therapy is not more widely available).

However, many psychiatrists are so rushed and limited for time that the only tool they have at their disposal is medication.

- and to a man with a hammer--- everything is a nail.

I know I am