The Vatican, Ritalin, and a Canadian Study of Long-term ADHD Outcomes
Even so, there were, within that larger agenda, presentations on the prescribing of psychotropic drugs to children, with Marcia and Barry securing invitations for a number of people who have written critically about this practice. There were seven of us “critics” who were given 20 minutes each to speak. There were also several presentations by European psychiatrists and physicians who supported such treatments, speaking of them as a way to ease the suffering of ill children.
I was the first of the seven “critics” to speak, and prior to my moment on the stage, there had been two presentations on ADHD, both by speakers from Catholic institutions, who spoke of ADHD in biological terms and told of the importance of stimulants to treat it. The second such talk, by Professor Cinzia Dello Russo, a researcher at the Pharmacology Unit at the Catholic University of the Sacred Heart in Rome, was titled “Neuropharmacology: Current State and Prospects.” She told of how ADHD was a brain development disorder, and how stimulants might change the ADHD brain in ways that helped it develop more normally.
This seems to be the new story that is emerging in biological psychiatry. Whereas psychiatry once told of psychiatric drugs that fixed chemical imbalances, the field is now telling of how the drugs may be “neuroprotective,” protecting against some toxic disease process; or how they may stir the growth of new neurons in select areas of the brain, which is seen as helpful; or that, in the case of stimulants, they somehow counter abnormal brain development said to be common to youth with ADHD. All of these tell of how the drugs, in some manner or another, are good for the brain.
I then gave my talk. I had been assigned the topic of “The History of Psychiatric Drug Care: The Global Spread of Psychotropic Treatment,” and like all speakers, allotted 20 minutes. I spoke briefly about the conventional history, which is that the arrival of chlorpromazine in asylum medicine in 1954 kicked off a “psychopharmacological revolution,” this great leap in care. Then, in the late 1980s and early 1990s, a second generation of psychiatric medications came to market that were understood to be safer and more effective than the first generation, and which were also understood to fix chemical imbalances in the brain.
I then quickly reviewed three reasons to be skeptical about that story of progress. I told of the soaring number of people disabled by mental illness over the past 25 years in developed countries around the world; of the fact that the chemical imbalance theory of mental disorders had never panned out; and of how outcomes for major mental disorders—schizophrenia, depression, and bipolar disorder—had, if anything, worsened, in the modern era.
That was the first half of my talk, and at this point, I think–from the point of view of one of the moderators for my session—I was veering from the expected script. Next, I turned my attention to pediatric disorders, starting with the rise of ADHD. I told of how it came to be identified as a disorder in the American Psychiatric Association’s Diagnostic and Statistical Manual, and how this diagnosis spread throughout much of the developed world in the past 15 years. I then noted that long-term studies—such as the MTA study funded by the National Institute of Mental Health—had failed to find that the stimulants provided any benefit. And if that were so, I asked, where is the rationale for the long-term prescribing of stimulants? We know that these drugs can cause adverse effects, and if they aren’t providing a long-term benefit on any domain of functioning, then shouldn’t we worry that this practice is causing harm?
My time was about up, and so I hurried through a few more comments about the evidence base for antidepressants and antipsychotics in children. I spoke of how most pediatric studies of antidepressants had failed to find that the drugs provided even a short-term benefit over placebo, and of how, in the one longer-term study of antipsychotics in children, the TEOSS trial funded by the NIMH, only 12% of the youth were seen as benefitting from the drug by the end of 12 months.
While there were many in the audience who welcomed my talk, I think it is fair to say that one of the two moderators, Dr. Daniel Cabezas, who is a consultant to the Pontifical Council, was not particularly pleased with it. Later, as I thought about that, I could see why. I was following a presentation by a researcher in the pharmacology unit at the Catholic University of the Sacred Heart, and it was clear that my presentation directly challenged what she had said only moments before. In the conservative environs of the Vatican, I imagine that must have seemed a rather impolite thing to do. As David Cohen told me when I sat back down, my talk seemed very “American,” in the sense that I hadn’t tried to couch my words, but rather had honed in on the bottom line, and while some in the audience may have appreciated that approach, it probably wasn’t the usual way things were done there, in the halls of a Vatican conference.
Given that experience, on the way back home I kept wondering: is it possible to have a real exploration of the merits of psychiatric drugs? And then, when I arrived back in Cambridge, I received an email from Bonnie Kaplan, who writes on this website, that provided a link to a new study of long-term ADHD outcomes in Quebec, Canada. This study reminded me anew of the importance of keeping this question alive, even when doing so can seem so difficult.
The paper, authored by Princeton University economist Janet Currie and colleagues, was funded by the Canadian Institutes of Health Research, and published by the National Bureau of Economic Research, which is headquartered in Cambridge Massachusetts. It is titled: “Do Stimulant Medications Improve Educational and Behavioral Outcomes for Children with ADHD?”
The three researchers mined a rich data set from the National Longitudinal Survey of Canadian Youth to answer this question. In 1994, Canadian investigators first surveyed more than 16,000 children, ages 0 to 11, and then followed their progress through childhood, with follow-up surveys done every two years, through 2008. The final data set consisted of 9818 children, and, among other things, it provided information on whether the children had symptoms of ADHD (as determined in the survey questionnaire.)
Now, in 1997, Quebec greatly expanded insurance coverage for medications, and in the wake of that change, the diagnosis of ADHD and the prescribing of stimulants in the providence soared, to rates markedly above the rest of Canada. This allowed the researchers to assess whether, as the result of this expanded treatment, the outcomes for children with ADHD in Quebec improved.
Here is what the researchers found:
“The increase in medication use is associated with increases in unhappiness and a deterioration in relationship with parents. These emotional and social effects are concentrated among girls, who also experience increases in anxiety and depression. We also see some evidence of deterioration in contemporaneous educational outcomes including grade repetition and mathematics scores. When we turn to an examination of long-term outcomes, we find that increases in medication use are associated with increases in the probability that boys dropped out of school and with marginal increases in the probability that girls have ever been diagnosed with a mental or emotional disorder.”
From a societal viewpoint, the findings can be summed up this way: Increased treatment led to more unhappiness and depression, worsening relationships with parents, and a decline in educational outcomes. The increased prescribing of stimulants took a toll on Quebec society, in the form of worsening outcomes for children diagnosed with ADHD.
This study is a valuable addition to the long-term outcomes literature for ADHD. We already had the MTA study, funded by the NIMH, which failed to find that stimulants provided a long-term benefit on any domain of functioning. We already had a ten-year study by Western Australia, which failed to find any long-term benefit. Now we have this new Canadian study. The “evidence base” for long-term outcomes with stimulants is becoming ever more robust, and thus we come to the very question that I raised at the Vatican conference: If the drugs do not provide any long-term benefit, and we know they can cause adverse effects, then, over the long-term, isn’t this a story of harm being done?
The answer to that question, of course, is yes. And given that we are talking about a medical practice that is affecting so many children in the U.S. and around the world, if research is indeed showing a lack of long-term benefit (and thus of harm), then such findings need to be publicized. This is a pursuit of profound moral dimensions, and yet, having come back home from the Vatican conference, which I attended with such high hopes, I now see it more than ever as a task that is so very difficult to achieve.
