The limits of psychiatry
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1523 (Published 22 June 2002) Cite this as: BMJ 2002;324:1523All rapid responses
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Sir
Although I have known of ADHD being treated with drugs with some
success, those same drugs are now under serious legal scrutiny in the USA
- and the companies supplying them - as certain legal bodies believe that
a conspiracy exists to deploy said drugs amongst the child population
through the creation of a 'syndrome' (ADHD) by the purveyors of those
drugs. I expect we are all aware of this and await the outcome with
interest.
Where was ADHD 20 years ago?
I have experience of children recovering from various forms of
illness, including 'psychiatric illness', through the removal of chemical
and electromagnetic pollutants from their immediate environment; isn't
that a more suitable form of intervention than any drug-based therapy?
Until we come to terms with the serious effects chemical and
electromagnetic field exposures pose to our youngsters at home and in
schools we will remain in the dark ages; medication should never be a
priority until chemical and/or electromagnetic or other environmental
pollutants are ruled out - but what physician can ensure this is the case?
The same pollutants, if present in toxic amounts at home, may affect one
or both parents and possibly other siblings.
We tend to forget that children who need attention, for such adverse
symptoms as those seen in ADHD, only seek help from physicians; whereas
nowadays, to climb out of the dark ages, the most appropriate first line
of enquiry ought to be the environmental scientist, and a physician the
later port of call. Our environment left the dark ages some time ago, it's
now time for medicine to make a similar move.
Regards
John H.
Competing interests: No competing interests
I am surprised that there is still a belief that methylphenidate may
be no more effective than placebo in the treatment of ADHD. A cursory
MEDLINE surch will provide over 100 articles showing benefit. It is not
the only treatment but even the Scottish guidelines (as opposed to NICE)
indicate that is the the first line treatment for core symptoms. It is
also true that environment is importent but remember, this is a genitic
condition. Research is starting to show that we cannot effectively treat
ADHD without recognizing that one of the adult carers may be affected and
also need treatment. It is time to get out of the dark ages and open our
eyes to the reality of these problems.
Competing interests: No competing interests
I did not say nor did I mean to imply that people with ADHD are lazy,
unmotivated and irresponsible. I have no wish to blame people with ADHD or
their families for the disorder. I was merely arguing for more
understanding of the disorder in the context of family and school life.
Statements about the causes of human behaviour can rarely demonstrate
one-to-one correspondence. The reasons for human action are usually more
multi-dimensional. Attributions of blame may not make much sense unless
they are consciously motivated. Terms like "lazy, unmotivated and
irresponsible" imply a moral or ethical judgement. I was merely proposing
more understanding of the reasons why children become inattentive and
hyperactive.
Not that I wish to fight shy of moral and ethical judgements if these
are appropriate. There has tended to be an avoidance of considering the
role of the family in producing mental disorders for fear the parents will
be blamed. However, let's start with considering what the family factors
might be before we move on to consider blame.
Nor did I say or mean to imply that ADHD is a hoax. The symptoms of
ADHD are a real problem. I just do not think that ritalin is always the
best solution. Not that it may not help. But so may a placebo help. The
question is whether ritalin is any better than a placebo. I agree such
questioning may be seen as unduly sceptical, but scepticism can be
healthy.
Competing interests: No competing interests
Re: Misunderstanding ADHD: The reality of the efficacy of methlphenidate
Larry Martel accuses me of being overly sceptical about the evidence base for the effectiveness of methylphenidate. He also states that ADHD is a genetic condition, and maybe I should challenge him to provide the evidence.
Let's not get too carried away by prejudices and biases about the evidence for the effectiveness of methylphenidate. Admittedly, the NICE guidelines do suggest methylphenidate is effective at reducing hyperactivity, inattention and impulsiveness in the short-term, and possibly in the longer-term.1 A systematic review conducted for the US Agency for Health Care Policy and Research2 identified 77 RCTs, 48 with a crossover design and 29 with a parallel group design. Overall, the quality of the methodological reporting of the trials was poor, and hence there is a relatively high probability of bias. Only 18 of the 77 RCTs were given 3 or more points on the Jadad methodological quality scale. Scores of less than 3 have been shown to be more likely to exaggerate treatment effects.3 The best quality Multimodal Treatment Study of Children with ADHD (MTA)4 did not include a placebo group and thus strictly cannot be used to assess the efficacy of medication.
I know it is easy to impeach clinical trials for their poor methodology, and it is simpler to reach definite conclusions about efficacy. However, the history of medicine is the overinterpretation of the placebo effect.5 I hope we are not misinterpreting the bias in trials of methylphenidate as an indication of effectiveness.
Competing interests:
None declared
Competing interests: No competing interests