Monday, May 23, 2016

Adult ADHD

In 2006, interest in attention deficit hyperactivity disorder (ADHD) reached new heights after a major study found that 4.4% of adults in America had the condition.

For decades, ADHD primarily had been a diagnosis in children, but the new study found it also affected as many as 10 million adults.

"It changed ADHD," said Peter Conrad, PhD, a professor of social sciences at Brandeis University who wrote The Medicalization of Society. "It became a lifespan disorder."

What happened next followed a familiar pattern: More research papers -- many of them based on research funded by drug companies -- were published.

The 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, relaxed the definition for adult ADHD.

The previous definition, in effect since 1994, said adults needed to have at least six of a possible nine symptoms from either of two categories. The symptoms include the inability to focus on tasks, fidgeting, and interrupting others. The new definition reduced it to five of the nine.

It also increased the age at which some of those symptoms first must have been present -- from before age 7 to before age 12.

Seventy-eight percent of those among the work group of experts who oversaw the changes had financial ties to the pharmaceutical industry, according to a 2012 analysis by the journal PLoS Medicine.

Psychiatrist Darrel Regier MD, MPH, a spokesman for the American Psychiatric Association, said financial conflicts were limited to $10,000 a year in income such as working as industry consultants, advisers, and speakers.

Regier, who served as vice chairman of the diagnostic manual's task force, defended the inclusion of adult ADHD in the document. He said that while it was once thought that children would age out of the disorder, for some, it remains in adulthood.

"Is it believable that this one mental disorder is one that kids would totally outgrow?" he said. "I think not."

Finally, the cumulative result of these factors was as expected: Prescriptions spiked.

And, since many of those drugs are amphetamines and stimulants that can lead to abuse, thousands more people began showing up in hospital emergency rooms.

At the same time, the growing focus on adult ADHD prompted questions from skeptics:

.How valid was the diagnosis?

.How many people are truly impaired?

.What role does promotion by drug-makers have in the rapidity of ADHD diagnoses?

.Has the spike in prescriptions for ADHD caused more harm than good?

"It is very easy to fake the symptoms of ADHD," said Daniel Carlat, MD, a psychiatrist at Tufts University School of Medicine and author of Unhinged: the Trouble with Psychiatry, a Doctor's Revelation about a Profession in Crisis.

A 2010 study found that 22% of adults tested for ADHD exaggerated their symptoms, exaggeration often made easier by the wide availability of online symptom check lists.

For years, the legitimacy of the adult ADHD was based on the belief that it was a condition that started in childhood and, for some, persisted into adulthood.

But last year that hypothesis was shaken by the publication of a provocative, long-term study that began in the early 1970s and followed more than 1,000 New Zealand children until age 38.

In that study Terrie Moffitt, PhD, a psychologist at Duke University, and her colleagues found that in childhood, 6% of those in the study had ADHD. At age 38, that number had dropped to 3%.

And the biggest surprise was the lack of evidence of significant overlap between the two groups.

Only 5% of those with ADHD in childhood still met the criteria at age 38. And only 10% of those who met the definition at age 38 were among those with the condition in childhood.

That, in turn, led the researchers to speculate that some of the adult patients were substance abusers who had attention problems stemming from drugs and alcohol, and that others may have had a personality disorder and were trying to game the system to obtain stimulants to abuse.

Moffitt noted that while childhood ADHD is considered a brain development condition, adult ADHD patients in her study scored normally on neuropsychological tests.

"It seems to be a different disorder," Moffitt said.

Adults with ADHD may have trouble completing tasks, prioritizing, and keeping appointments. Some research even shows a connection between the condition and higher rates of divorce, unemployment, and car accidents.

However, those only are associations, not proof that ADHD causes the problems or -- more importantly -- that ADHD drugs will prevent them.

In 2014, the pharmaceutical company Shire paid $56 million to settle a U.S. Department of Justice allegation that it illegally promoted Vyvanse and two other ADHD drugs, Adderall XR, and Daytrana.  

Between 2007 and 2010, according to the Justice Department, company sales representatives claimed Vyvanse would prevent car accidents, divorce, arrests, and unemployment.


  1. Drug industry exuberance for the budding adult ADHD market was highlighted in a 2008 report from the market research firm Datamonitor that serves the worldwide pharmaceutical industry.

    "Estimated to be twice the size of the pediatric ADHD population, the highly prevalent, yet largely untapped, adult ADHD population continues to represent an attractive niche to target," the report said.

    From 2008 to 2012, prescriptions of ADHD drugs to adults increased 53%, according Express Scripts, a national prescription benefit plan provider.

    Overall, ADHD drugs now are one of the most lucrative sectors of the U.S. drug market, totalling more than $10 billion in sales and 83 million prescriptions in 2014 , according to data from IMS Health, a drug market research firm.

    In 2010, a commentary in the journal BMJ asked: "Is ADHD a valid diagnosis in adults?"

    One of the authors, British psychiatrist Joanna Moncrieff, MD, said there may be a small number of adults who are hyperactive and find it difficult to concentrate.

    But, she added, "Diagnostic criteria are so loose that anyone could qualify."

    More importantly, Moncrieff said, there is not good evidence that using stimulant drugs does any more than provide modest improvement on rating scales of how users rate their performance on measures such as concentration and organization. She noted that any benefit likely is influenced by the fact that the drugs also make people feel good.

    Moncrieff, of University College London, said the boom in adult ADHD cases increases the likelihood of a repeat of the prescription stimulant epidemic in the 1960s, when the pills were marketed for weight loss.

    For decades, stimulants have been known for the ability to improve alertness and focus for users ranging from pilots to college students.

    But they also are powerful enough to produce a sense of euphoria in adults, making them a popular for drug abusers.

    In 2014, about 1 million people 26 and older used prescription stimulants for nonmedical purposes, which includes using a drug without a prescription or using a drug for the feeling it causes, according to data from the most recent National Survey on Drug Use and Health survey...

    Between 2005 and 2010 -- more recent numbers were not available -- emergency room visits involving ADHD drugs more than doubled, from 13,379 to 31,244, according to data from Substance Abuse and Mental Health Services Administration.

  2. However, California psychiatrist Lawrence Diller, MD, author of the book Running on Ritalin, argues the official definition in DSM provided a vague justification for overprescribing. He said he believes amphetamines, which have been around since the 1930s, are "dangerously over prescribed" in adult ADHD.

    "If you don't study history, you are doomed to repeat it," he said. "We have had multiple waves since 1929 of doctor prescribed stimulant abuse epidemics."

    Diller said there is little doubt ADHD has caused impairment for some adults, but says many others -- including two of his former patients -- have been able to get diagnosed because they feel they need the drugs to attain some career goal.

    One was a man in his 50s who worked for a Wall Street firm and felt he needed the drugs to keep up with new job responsibilities. He took the drugs for a while, but eventually retired and stopped using them.

    Another was a young man who wanted to get a law degree, but because he had a reading problem he felt he needed the drugs to study. He ended up quitting law school and eventually became a successful salesman without the drugs.

    Others may turn to the drugs to help them meet expectations to maintain a job and salary that allows a higher standard of living, Diller said.

    "That's what it comes down to," he said. "I call the condition 'American achievement anxiety disorder.'"

    The number of published papers on adult ADHD increased dramatically from 2006 through 2010, reaching 100 or more in 2 of those years, according to a tally published in 2011 in The Psychiatrist. Moncrieff co-authored the paper.

  3. Joseph Biederman, MD, a psychiatrist with Harvard Medical School, was a co-author of the 2006 study that put the prevalence rate at 4.4% of adults, or about 10 million people. He has since published many more papers, all more or less supporting the findings of the 2006 study.

    He bristled at the idea adult ADHD was largely a concocted disorder.

    "The conspiracy theory of ADHD and other equally nonsensical ideas should be better asked from the Church of Scientology and not from a researcher clinician like myself," he wrote in an email.

    Biederman, who also works for Massachusetts General Hospital, declined to be interviewed by phone and only answered a few questions by email.

    In a report from a 2008 U.S. Senate Committee on Finance investigation, Biederman said he had received $1.6 million from drug companies, most of which was not reported to Harvard and Massachusetts General.

    He would not respond to questions about the lack of disclosure of his financial ties to the drug industry.

    In addition, there were no financial disclosures listed in his 2006 paper, which was published in the American Journal of Psychiatry. That paper was partially funded by Eli Lilly. Two years later, Lilly received an FDA warning letter, which chastised the company for alleged misleading claims about its popular ADHD drug, Strattera.

    The 2006 paper relied significantly on Biederman's research, citing 14 papers in which he was an author.

    The conclusion that 4.4% of adults having ADHD was based on 3,199 interviews were conducted among 18- to 44-year-olds by nonmedical personnel.

    Since attention deficit disorder (ADD) with or without hyperactivity was initially recognized as a disorder in children in 1980 and since then there has been a steady diagnosis creep to encompass adolescents and finally adults.

    "If we are not careful, we are going to get geriatric ADHD," Conrad, the Brandeis professor and author said in an interview.

    That already may be happening.

    A 2012 study by researchers in the Netherlands found ADHD rates of up to 4% in people ages 60 to 94. The study was funded by Shire -- manufacturer of the top-selling ADHD drug in the United States.

  4. Asherson P, Adamou M, Bolea B, Muller U, Morua SD, Pitts M, Thome J, Young S. Is ADHD a valid diagnosis in adults? Yes. BMJ. 2010 Mar 26;340

    From the article:

    Using the Washington University diagnostic criteria, the National Institute for Health and Clinical Excellence (NICE) reviewed the validity of the system used to diagnose ADHD in children and adults.

    Symptoms of ADHD are reliably identifiable. The symptoms used to define ADHD are found to cluster together in both clinical and population samples. Studies in such samples also separate ADHD symptoms from conduct problems and neurodevelopmental traits. Twin studies show a distinct pattern of genetic and environmental influences on ADHD compared with conduct problems,and overlapping genetic influences between ADHD and neurodevelopmental disorders such as autism and specific reading difficulties.7 8 Disorders that commonly, but not invariably, occur in adults with ADHD include antisocial personality, substance misuse, and depression...

    ADHD is an established childhood syndrome that often (in around 65% of cases) persists into adult life. NICE guidelines are a milestone in the development of effective clinical services for adults with ADHD. Recognition of ADHD in primary care and referral to secondary or tertiary care specialists will reduce the psychiatric and psychosocial morbidity associated with ADHD in adults...

    •Competing interests: All authors have completed the Unified Competing Interest form at and declare (1) No financial support for the submitted work; (2) PA, MA, BB, UM, JT, SY were consultants for Janssen-Cilag. PA, SY, and JT were consultants for Eli-Lilly. PA and SY were consultants for Shire. PA was a consultant for Flynn Pharma, PA has received grants from Shire, Wellcome Trust, US National Institute of Mental Health, National Institute of Health Research, and Janssen-Cilag. UM has received grants from Janssen-Cilag, Medical Research Council, and Wellcome Trust. PA developed educational programmes for Janssen-Cilag and Shire. PA and SY gave educational talks at meetings sponsored by Janssen-Cilag, Shire, and Flynn-Pharma. UM gave educational talks at meetings sponsored by Bristol-Myers Squibb, Eli-Lilly, Janssen-Cilag, Pharmacia Upjohn, and UCB Pharma. JT has given educational talks at meetings sponsored by Janssen-Cilag and Eli-Lilly. SDM received travel expenses from Janssen-Cilag. PA and SY were members of the NICE guideline development group for ADHD. PA, SY, JT, UM, BB, MA, and MP are board members of the UK Adult ADHD Network (UKAAN), a non-profit organisation providing support and training for UK clinicians in the delivery of clinical services to adults with ADHD. SDM acts in an advisory capacity to UKAAN and is a user representative who runs a local and national support group. All authors declare that they have no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work.

  5. Moncrieff J, Timimi S. Is ADHD a valid diagnosis in adults? No. BMJ. 2010 Mar 26;340:c547.

    From the article:

    A major driver behind the increased popularity of diagnosing adult ADHD is the idea that it responds to treatment with stimulant drugs. Studies in children show that stimulants can improve attention and reduce activity levels in the short term, but that they have little impact on quality of life or academic performance and initial beneficial effects are not sustained on long term follow-up. Even the NICE guidelines recommend restricting stimulant use to children with the most severe symptoms, or those in whom other treatments have failed. NICE, however, recommends stimulants as first line treatment for everyone with adult ADHD. This recommendation was made on the basis of three randomised controlled trials, two of which were conducted by a group at Harvard, which was found to have substantial conflicts of interests...

    A recent meta-analysis of a larger group of methylphenidate studies found no significant difference between drug and placebo in studies that used the generally superior parallel group design (effect size 0.36, 95% confidence interval −0.17 to 0.88), as opposed to crossover studies. It also showed that trials by the Harvard group reported substantially higher effects than others. The only long term drug trial yet published (atomoxetine) was negative for its main outcomes at six months. With regard to risks, stimulants are known to increase heart rate and blood pressure, and prolonged recreational use can result in myocardial infarction and stroke.

    Physical and psychological dependence are a further potential problem, and in countries with high rates of stimulant prescribing, much is diverted on to the black market. Popularising the diagnosis of adult ADHD also encourages people to regard longstanding behavioural problems as amenable to a quick fix, thus introducing, undebated, a form of cosmetic psychopharmacology that fits into our increasingly hyperactive lifestyles but at a price of distancing us from our own psychosocial resources and abilities.

    The speed with which the diagnosis of adult ADHD has been accepted, its vagueness, and the lack of evidence for the usefulness of specific treatments indicate that it is the latest of several medical and psychiatric fashions, which have been fuelled by the interests of the drugs industry. More research and debate is needed before the diagnosis is embraced and widespread stimulant prescribing becomes the norm, otherwise we may face a scandal similar to the overprescribing of benzodiazepines...

    Both authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: 1) no financial support for the submitted work; 2) no relationships with any companies that may have an interest in the submitted work in the past three years; 3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; 4) they are members of the Critical Psychiatry Network.