The Score at Medscape: Meds 9 and the Rest of the Universe 1by Robert A. Yourell, MA | May 26, 2008
I’m never surprised at the power big pharma has over the media, especially media directed at physicians. For once, I’d like to talk back. Here’s a perfect opportunity! I’m going to talk back at an article recently posted to MedScape.com — a source of very informative, thoughtful, brainwashing, and useful information for physicians. This article is about individualizing adult ADD treatment:
To review the latest clinical thinking in this field, Medscape’s Randall F. White, MD, spoke with Richard H. Weisler, MD. Dr. Weisler, a busy clinician and researcher, is adjunct professor of psychiatry at the University of North Carolina at Chapel Hill, and adjunct associate professor of psychiatry at Duke University Medical Center in Durham, North Carolina.
… so long as the “latest clinical thinking” gives short shrift to anything but medication.
… some in the general public worry that ADHD may be overdiagnosed. When you look at the diagnostic criteria, they require impairment in multiple areas, such as school or work, and also in relationships or at home. If significant impairment exists in these areas, I believe that treatment is indicated.
But we won’t address the fact that there are regions where ADD diagnosis is at extremely high levels, and how diagnostic and systemic biases cause this. And don’t get me started on how we have abandoned the educational system and it’s need for adequate integrated counseling and mental health staffing.
Medscape: In your opinion, who are the 10.9% of adults with ADHD receiving treatment, and why are they getting treatment whereas the others are not?
Dr. Weisler: Some selection bias exists related to resources that people have, such as insurance coverage and maybe access to care in some regions. Certain places have a shortage of mental health professionals, and although primary care physicians may be comfortable in making a diagnosis of major depression or generalized anxiety disorder, almost half feel uncomfortable making a diagnosis of adult ADHD. They likely will refer the person to a psychiatrist for evaluation, if possible.
So only 10.9% of adults have adequate insurance or income and access to a psychiatrist or other mental health professional who would guide them properly? That’s the explanation? What about the extreme drop out rate among those who get medication for ADD? How about actually thinking this through? No. That would spoil the bias!
Medscape: Once the diagnosis is established and a decision is made to proceed with treatment, how should the clinician and patient arrive at the treatment goals? And what’s the best way to monitor progress?
At this point in the article, something good happens. Dr. Weisler talks about tracking real-life symptoms in order to monitor progress, and talking to people in the person’s life to get a more balanced and realistic view of what’s going on.
But he mentions something akin to denial:
If a person has somehow managed for 15, 20, or 30 years, he or she thinks that’s just the way it is.
Sometimes, but sometimes they have a lifestyle that does not challenge them in their symptom areas, and they are functioning well enough that they would rather not take the risks that are involved in taking medication. All medical decisions are, after all, a tradeoff involving risk, even if it’s relatively small. Or, perhaps the person is in a safety-sensitive job, such as being a pilot, and they don’t want to destroy their careers after performing safely and effectively for years.
At this point, Weisler takes the position that you should treat affective symptoms of problems such as depression before ADHD, but leaves room for individuality and points out that control of ADHD symptoms can improve abstinence by increasing life stability.
Then he recognizes the world outside of his office, which I wish more clinicians would do. He says that, since the most impaired people with ADHD are also the least likely to comply with medication, that people in the person’s life should be involved in their treatment. It would be nice if he had emphasized what kind of problem solving and problems with the medication take place. When medication has good odds of working, I agree that spouses should ask, “Are you taking your medication today?” even though it sounds like an unbalanced relationship. Even if it is, it’s still a relationship. He also points out advantages to once-a-day versions of stimulant medication.
He comes to a naive conclusion about a study on compliance. He mentions a study in which a medication management system showed that persons with cocaine dependence tended to take out their stimulant medication just before coming in to see the doctor, and lie about it, saying that they took the medication. He makes it sound like they were just disorganized and need a helpful spouse to remind them. But if they’re lying and addicted to cocaine, they are probably selling. After all, you have to take special measures to offset the cost of cocaine! But let’s not think this though, it would spoil the bias!
Here’s where I have the biggest problem, verging on disgust. Catch this:
More directly relevant to ADHD is a study by Capone and colleagues that examined monthly persistence on medication. They found that even after just a few months, half the people weren’t taking their medication. Adherence dropped to 20% after a year or so. Unfortunately, it’s not all that different from what we see with bipolar disorder, depression, or other psychiatric disorders.
How does he address this critical issue? He wanders off, briefly, into how children’s stimulant use goes down in the summer, and then veers into the awful things that are likely to happen to people with ADHD, such as job loss, divorce, and traffic violations.
In other words, he doesn’t answer the question, and distracts us with some fear mongering intended to emphasize the importance of medication. No solution is in sight, other than the clinician becoming more strident with the patient.
Or, as Medscape puts it, without alluding to any direct evidence:
So poor adherence could have deadly consequences.
Could be. More likely, the greatest threats to well-being are from developmental issues that medication cannot treat in adults. At best, medication might make an adult more successful in treatment directed at those developmental issues. But, in this case, the medication would be adjunctive. But let’s stick with the illusion of things being more clear-cut, don’t spoil the bias!
Weisler also points out that regular treatment (he always says treatment instead of stimulant medication treatment, as you would say if you were acknowledging the importance of other treatment modalities) reduces the initial side effects that can reduce medication compliance. In my experience, people who complain about side effects, whether they are taking stimulant medication or have discontinued it, complain about enduring side effects. I rarely hear of complaints about the initial effects.
Medscape: Aside from extended-action medications, what other pharmacologic characteristics affect treatment adherence?
Dr. Weisler: With ADHD, just as with other diseases, people will have idiosyncrasies as to what effects are unacceptable.
They have “idiosyncrasies,” because calling them personal preferences (like being upset about losing their appetite or sleep difficulties) is too, well, personal!
Oh boy, now we’re going to hear about something besides medication!
Medscape: What role do psychotherapy or other psychosocial interventions play in treatment of adult ADHD and promoting medication adherence?
Dr. Weisler: I think that psychotherapy can play a significant role. If you’ve lived with undiagnosed ADHD for many years, your self-esteem is likely to be low. You may well have some depression or be anxious in certain situations because you are worried about what people think of you. I think that cognitive therapy can make a big difference for both depression and anxiety.
Why are some people so good at diminishing a topic down to a token, and sounding as though they’re really talking about it? And how about the value of having a more specialized approach? It that too managed care unfriendly?
Dr. Weisler: Patients can learn techniques that will help them cope with their limitations better. Professional coaches can assist people, and simple techniques such as wearing sound-canceling headphones while they’re trying to work in a noisy environment can make a difference.
Sure, ADD people just need a few simple techniques. They are vulnerable to deadly things like traffic accidents, drug use and fights (well, the article says so), but this is because of impulsiveness (well, the article says so), and that’s taken care of by the meds (well, the article says so), so a couple simple techniques from a coach, and some counseling for self esteem and mood will take care of the rest. I’m starting to like the Weisler Universe. It’s so much tidier and simpler than the one with developmental issues and numerous reasons for medication noncompliance (such as the serious limitations of the medications themselves) that you have to deal with in the Unprocessed Universe.
Dr. Weisler: In my experience, adherence is clearly improved with psychotherapy. It doesn’t necessarily get people better faster, but it makes them more likely to stick with treatment, and it’s another way of addressing difficult issues.
Ugh. No comment. I’m done.
1,606 words about meds, and 156 about everything else. That’s just under 10%. It doesn’t take Noam Chomsky to see the pattern at Medscape.
Mind you, I’m not anti-medication. I’m just anti-brainwashing.
Weisler, R.H., White, R.F. (2008). Managing Expectations and Individualizing Treatment for Adults With ADHD: An Expert Interview With Richard H. Weisler, MD. Medscape Psychiatry & Mental Health.
No future articles scheduled.
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