In 2011, approximately 50 million prescriptions for medications that treat ADD and ADHD were given out by pharmacies all around the United states, which is up from about 20 million in 2007. How did this disorder, which first appeared as ADD in 1980 (the first time it was labelled ADD was in the DSM-III) grow so fast? Has this disorder become an epidemic among American kids? This paper will explore the increasing number of ADD and ADHD diagnoses in the United States, and examine the immoral practices of the pharmaceutical companies that sell drugs to treat the disorder.
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While the agreed upon definitions of ADD and ADHD are relatively recent, the roots of the disorder can be traced three centuries back. Melchoir Adam Weikard, a German-Russian physician, is widely credited with the first description of ADD/ADHD symptoms in his 1775 medical textbook. Weikard describes children and adults with the disorder as easily distractible, inattentive, and lacking impulse control. Weikard’s eighteenth century definition mirrors some of the current descriptions of the disorder. A more recent explanation of the condition is found in the DSM-II, where it is referred to as Hyperkenetic Reaction of Childhood. Only in more modern editions of the DSM is it referred to as ADD/ADHD or include the different criteria. The current definition states that someone with the disorder must display six or more symptoms persistently which interfere with normal life. These criteria include making careless mistakes, difficulty sustaining attention, not listening, inability to complete tasks, unorganization, reluctance to engage in tasks that require focus, often loses things, easily distracted, and forgetful. If you find yourself suffering from any of those symptoms, or even if you just tell a doctor you do, you will likely be diagnosed and prescribed some sort of medication or treatment plan.
While the causes of ADD and ADHD are still being researched, there are some ideas about what might cause it. Researchers have figured out that genetics most likely plays a role in the presence of ADD/ADHD, but they are still studying how other factors such as alcohol and tobacco use during pregnancy, injury, and prematurity. One thing all researchers and doctors can agree on is that environmental factors such as diet, screen time, and parenting do not cause ADD or ADHD, but may make the symptoms appear worse. A major characteristic of ADD/ADHD is an underactive frontal cortex, which is responsible for decision making, thinking about consequences, and impulse control. That can affect all areas of life, and a person without treatment may find it difficult to even hold down a job.
Once a child or adult is diagnosed with ADD or ADHD, there are multiple types of treatment they can receive. One of those is behavioral therapy, which is a drug free form of treatment that some opt for. The goal of behavioral therapy is to teach the child what behavior is disruptive and what behavior is good. Therapy will strengthen the good behavior and train the child to recognize bad behavior such as disruption or inattention. Studies have shown that therapy that trains both children and parents to correct bad behavior is beneficial for both, as it creates a stronger bond between the two and helps with the disorder. While behavioral therapy has been shown to help, the more common course of treatment is medication. The two classes of drugs used are stimulant and nonstimulant, and they work by increasing dopamine levels in the brain which affect motivation, attention, and satisfaction. While these drugs have helped the majority of patients suffering with attention disorders, they also come with major side effects. A paper in The New England Journal of Medicine says that there might be a link between cardiovascular problems and ADD medications which raise blood pressure and heart rate. In another study, children from ages 6-13 taking the ADD/ADHD medication Concerta are shown to be, on average, an inch and three pounds smaller than those who were not on the drug. Another negative aspect that comes with ADD drugs like adderall is that they are very hard to get off of. With long term use, these drugs can permanently impact the brain’s reward pathways. This is damaging because it doesn’t allow your brain to produce adequate dopamine without increasing the dosage of the medication you are taking. When the drug is no longer taken, it can cause mood swings, depression, and irritability. A study done on rats has also shown that long term stimulant use can permanently damage reward pathways, causing less reaction to positive stimuli such as food and sex. While reaction to positive stimuli lessened, the rats reaction to stressful situations increased. Another area of concern for physicians comes when comparing the drugs used on children to treat ADD and stimulants like cocaine and meth. Both of these drugs boost energy and suppress dopamine transporters. This is supported by a study done on rats where some received cocaine and other received methylphenidate, a drug used to treat ADD/ADHD commonly known as Ritalin. After long term use, cocaine and methylphenidate similarly remodeled the brains of the rats, who experienced the growth of tiny spines on the end of neurons with dopamine receptors.
ADD is not alone in its misdiagnosis and treatment, doctors have long known that management of mental health in the US is and has been deteriorating. Leon Eisenberg, an influential child psychiatrist, was one of the more outspoken doctors who advocated for treatment rather than medication. His essay, Were we all asleep at the switch?, outlines the downfall of American mental health treatment from the mid 1900’s to the early 2000’s. In 1956, there were 550,000 beds in American hospitals for psychiatric patients. Many doctors at the time predicted that number would increase, but the opposite happened. Treatment of mental health shifted from inpatient treatment to outpatient centers, medication, and even jail. Additionally, in the 1970’s, the majority of patients visited psychiatric offices for therapy with no prescription, but that number has plummeted to less than 10 percent. Most patients visit for the sole purpose of getting a new prescription.
While doctors may seem like the ones at fault for prescribing copious amounts of drugs, the drug manufacturers are a large part of the problem. In 2004, federal prosecutors issued subpoenas for some major manufacturers for a pattern of financial incentives given to doctors. One doctor said he received a ten thousand dollar check from pharmaceutical manufacturer Schering- Plough (now Merck). Additionally, Schering-Plough gave doctors up to $1500 in order to prescribe a particular drug to their patients. These payments are covered up by being labelled as ‘consulting fees’, and they ensure doctors continue to prescribe their drugs. These payments are not limited to Merck though, because in 2015, almost half of all physicians received payments from pharmaceutical companies, adding up to about 2.4 billion dollars. In 2010, Congress passed the Physicians Payment Sunshine Act to try and limit these damaging payments. This act forced manufacturers of drugs and devices to make any payments or grants given to physicians public. The Sunshine Act promoted transparency among both doctors and pharmaceutical companies, but it also made damning information available to patients and civilians. Before 2010, most companies gave doctors money and labeled it as consulting fees, but after the act passed, the manufacturers began doing something different. They began to treat doctors to over the top meals at outrageous prices. Pharmaceutical company, Roche, was fined $75,000 for breaking code that says hospitality for doctors should be ‘simple and modest’. Roche took two doctors out in Sydney where they spent approximately $215 dollars per person. Incidents like this are not irregular, and marketing to doctors has exploded over the last twenty years from 17.7 to almost 30 billion dollars from 1997 to 2016. About 60% of pharmaceutical marketing budgets go directly into the pockets of doctors in one way or another. This is a frightening statistic for consumers, because they may be prescribed a medication that is not necessarily right for them simply because their physician received monetary incentives to do so.
Another aspect that affects the prescription of medication are advertisements to patients. Pharmaceutical companies spent over six billion dollars in direct to consumer advertising in 2016, up from just over one billion in 1997. Additionally, these companies also put out advertisements to create awareness for a disease, one of which was mental health, which emphasized ADD and ADHD. In 2009, Mylan Pharmaceuticals Inc. spent nine million dollars on an attention deficit disorder awareness campaign to promote their drug Intuniv. The scary part about these campaigns is that there are no regulations. In 2004, the FDA stopped monitoring awareness campaigns, and as of now, there are no fines from the FDA for misleading or incorrect information in these campaigns. In addition to these campaigns, Pharmaceutical companies have also started pushing drugs aimed at treating adult ADD. Vyvanse and Concerta were both cleared by the FDA for treatment of adult ADD, and companies are advertising them as a solution to mild attention issues.