Apr 27 2007
I have dedicated this week to discussing the complex topic of mental illness, specifically responding to those, like Dr. Fred Baughman, who deny that it is legitimate. In my final installment I will deal specifically with the issue of drug therapy, covering some general principles, as it applies to mental illness in general, and to ADHD in particular.
Rational pharmacotherapy is a critical and effective part of modern medicine. The bottom line is that drugs save lives, extend our lives, and improve our quality of life. Like any technology, they are a tool. Because they are a potent tool, however, they also have the ability to harm.
This duality is reflected in public opinion, that both desires the benefits of modern pharmacology, but also harbors a deep fear and mistrust of drugs and chemicals – words that are often used as pejoratives. This distrust extends to the pharmaceutical industry, which is also the target of much conspiracy and anti-corporate ideology. I am not going to discuss the vices and virtues of big pharma today – that’s for another time – but rather try to close the gap between how physicians think of and use drugs and the public perception of them.
Those, like Dr. Baughman, who are trying to make a case against drug therapy have a habit of decrying them as “poisons” and “toxins.” This is disengenuous. Everything potentially is a poison at high enough dose – even water and all the foods that we eat. And all poisons are safe at a low enough dose. So it is a bit of a false dichotomy to talk about substances as if some are safe and others are poisons.
Rather, the only important question is whether or not there is a dose range where the substance has a useful property but the risk of toxicity is low. In developing pharmaceuticals, that is a primary question, and studies are done to answer that question very precisely. Drugs are drugs because they have a therapeutic range. But even drugs with a therapeutic range have unwanted side effects – biology is complex and no drug is a “magic bullet.” So we also assess drugs according to their risks vs benefit. So generally drugs are deemed acceptable if they have a range of dose where they provide some medical benefit in excess of medical risk.
Drugs for mental illnesses are no different. Sometimes, for example with schizophrenia, the benefits might include the ability to live an independent and somewhat normal life. The side effects of drugs used to treat psychotic disorders, unfortunately, are significant, and may include sedation and movement disorders. Pharmaceutical technology is improving, like all technologies, and newer drugs are generally better, but at present the drugs we have available are useful but could be a lot better.
ADHD is perhaps the most controversial mental disorder, especially with regard to the issue of treatment with medication. There is the added emotional factor that medications are being used on children. The idea of “drugging children” easily provokes queasiness and this is exploited by Baughman and others to make the whole enterprise of mental health seem reckless and dangerous. But this is really just fear-mongering. The same principles of rational and safe pharmacotherapy apply. Therapy in the pediatric population does present new possible risks that have to be considered, such as the effect of medication on development. And this issue is actively researched.
A recent review of all the published literature by an American Academy of Pediatrics committee had this to say about the evidence for treatment of ADHD: “The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed.”
There are many complexities in the research, and there are many identified side effects of medication, but when all the evidence is looked at by relevant academic experts, it supports a positive role for the use of medication. Much of the criticism of medication use in ADHD, however, is ideological, and when I talk to patients and people about the issue they tend to base their opinion on a sense that it is just wrong to rely on drugs rather than simply good parenting, or that drugs are unnatural, or that drugs only treat symptoms and not underlying causes. But all of these objections are ideological – not evidence based.
In some children who meet the diagnostic criteria for ADHD there appears to be a biological cause in that parts of the brain, primarily involving the frontal lobes, that are responsible for executive function and attention are under active. Stimulants increase the activity in these brain regions, and allow these children to focus their attention better, with tangible benefits. Whether or not this is treating symptoms is a non-sequitur, and the claim is often based upon the false premise that the true cause is bad parenting (parenting obviously is a factor in overall behavior, and the degree to which it is a factor varies from child to child, but it is false to assume that it is the dominant factor in most or all cases). If the cause of ADHD in some children is neurological, well the only way to cure the underlying cause is to change the hardwiring and biochemistry of the brain. Since we do not have the technology to do this (yet) we must make due with the tools we have.
What has evolved over time in the clinical treatment of ADHD is what we typically see in most areas of medicine. Different treatments are tried, addressing all of the theoretical causes or contributor to a syndrome, and then we see what works. Often combinations of therapies are given. With ADHD stimulants have been tried in addition to other medications, parental training, behavioral therapy, and even dietary changes and less plausible interventions. This is a sensible approach – try everything and see what is the most safe and effective. The evidence supports stimulant medication as the most effective for addressing the core symptoms of ADHD. This does not mean that medication is the first or only treatment tried. Principles of good clinical practice must be applied to decide how it should fit into the overall treatment plan, individualized to the patient, and using outcome to guide ongoing therapy. Again, no different than managing any chronic illness.
What strikes me most about Baughman and other deniers is that they do not address the evidence to arrive at the best “evidence-based” practice. Rather they rely upon fear of “poisons” and big conspiracies to cast a sinister shadow over the entire enterprise of mental health.
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