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In 2017, the World Health Organization released as six question “test” for adult attention deficit hyperactivity disorder (ADHD). While even proponents of the questions warn that people should not self-diagnose with the “test”, there is the obvious question about the effectiveness of such a diagnostic method. After all, as others have noted, almost every adult seems to exhibit the symptoms that the questions ask about. For example, difficulty in concentrating, unwinding and relaxing seem to be the plight of most people. I first learned of a similar sort of diagnostic tool at a mandatory training session on learning disabilities and another faculty member commented on this tool by saying “by those standards, I think we all have ADHD.” Everyone agreed. Because of these concerns, doctors tend to agree that the simple screening test is not sufficient to diagnose adult ADHD. While using an unreliably method of diagnosing adult ADHD would be problematic, there are also important moral concerns about this matter.
Coincidentally enough, many of the doctors who served on the advisory panel for developing the screening method have enjoyed the financial support of the pharmaceutical companies who produce the drugs used to “treat” adult ADHD. Such payments to doctors by pharmaceutical companies is standard practice and drives much of how treatment works in the United States. Doctors who are not influenced by pharmaceutical companies as less inclined to prescribe the brand name products of companies, which is hardly surprising.
It is important to note that the fact that doctors are enriched financial by pharmaceutical companies that profit from ADHD drugs does not prove that the questions are not useful nor does it prove that they are wrong in expanding the number of people on ADHD drugs. After all, the possibility that a person making a claim is biased does not entail that the claim is false and to think otherwise would be an error of logic. That said, if a person is an interested party and stands to gain, then the relevant claims should be considered with due skepticism. As such, the doctors who are pushing the agenda of the pharmaceutical companies that enrich them should be regarded as lacking in credibility to the degree they are likely to be influenced by this enrichment. Which, one would infer, would be significant. As is always the case in such situations, what is needed are more objective sources of information about ADHD. As should not be surprising, those who are not being enriched by the industry are not as enthusiastic about expanding the ADHD drug market. This raises reasonable ethical concerns about whether the industry is profiting at the expense of people who are being pushed to use drugs they do not actually need. Given the general track record of these companies, this sort of unethical behavior does seem to be the case.
Since I am not a medical doctor specializing in ADHD, I lack the expertise to properly assess the matter. However, I can offer some rational consideration of adult ADHD and its treatment with pharmaceuticals. The diagnostic questions focus on such factors as concentration, ability to remain seated, ability to relax, ability to let people finish sentences, ability to not procrastinate, and independence in regards to ordering one’s life. As noted above, these are all things that all humans have difficulty with at one time or another. Of course, even the proponents of medicating people do note that it takes more than the usual problems to make a person a candidate for medication. But, of course, these proponents do have a fairly generous view of who should be medicated.
One reasonable concern is that there are non-pharmaceutical methods of addressing problematic behaviors of this sort. While, as noted above, I am not an ADHD specialist, I do have extensive training in methods of concentration (thanks to running, martial arts and academics). As such, I know that people can be trained to have better focus without the use of profitable chemicals. Since these drugs have side effects and cost money, it would be morally and practically preferable to focus on non-chemical methods of developing positive traits. Aristotle developed just such a method long ago: training in virtue by habituation. But, it can be objected, there are people who cannot or will not use such non-pharmaceutical methods.
This is a reasonable reply. After all, while many medical conditions can be addressed without drugs, there are times when drugs are the only viable options—such as in cases of severe bacterial infections. However, there is still an important concern: are the drugs merely masking the symptoms of an underlying problem?
In the United States, most adults do not get enough sleep and are under considerable stress. This is due, largely, to the economic system that we accept and tolerate. It is well known that lack of sleep and stress cause exactly the sort of woes that are seen as symptoms of adult ADHD. As such, it seems reasonable to think that problematic adult ADHD is largely the result of the American way of life. While the drugs mask the real problems, they do not solve them. In fact, these drugs can be seen as analogous to the soma of Aldous Huxley’s Brave New World. If this is true, then the treatment of ADHD with drugs is morally problematic in at least two ways. First, it does not really treat the problems—it merely masks them and leaves the real causes in place. Second, drugging people in this manner makes it easier for them to tolerate a political, social and economic system that is destroying them which is morally wrong. In light of the above discussion, the pushing of ADHD drugs on adults is morally wrong.
Probably the most salient point that you are making is that you are not a doctor, and you are not a specialist in ADHD. You have used the appropriate buzz-words (“Profit”, “Enriched”) to imply that in this country, doctors are lining their pockets with enough lavish contributions from big pharmaceutical companies to risk their medical licenses and betray their Hippocratic Oaths in order to freely distribute expensive controlled substances to an unwitting public that just allows themselves to be drugged into complacency.
I don’t think this is the case at all.
First of all, the six question “test” is not enough to warrant a prescription – it is enough to warrant a consultation with one’s doctor. And not just any doctor. In New York State, where I live, a general physician is not allowed to treat ADHD without extensive training – and I don’t know of any family doctors or internists or PCP who undergo that training. Rather, they will make a referral to a qualified psychiatrist.
Further, the six-question test is not designed to increase the rate of self-diagnosis for the purpose of selling drugs. At the end of the article you cite, the authors state that there is a proliferation of all kinds of “screening” tests all over the internet. “Most of these questionnaires” they report, “are not standardized or scientifically validated and should not be used to self-diagnose or to diagnose others with ADHD.” In other words, the WHO has gotten involved NOT to “line the pockets of prescribers who are beholden to Big Pharma”, but rather to put accurate information out there that is specifically differentiated from the inaccurate, unsubstantiated, un-validated information that is more likely to be produced by those who seek to profit by it.
“Using data from the National Comorbidity Survey, the authors found that the six questions appear to reliably, and specifically, screen for ADHD in adults. That could allow primary care physicians who have limited time with each patient to quickly and easily determine whether to recommend patients for further psychiatric evaluation, or even to prescribe medication.”
Again – PCP physicians, at least in New York, are not qualified to prescribe medication – they must make the referral to a qualified psychiatrist. And not just any psychiatrist – this specialist has to have a sub-specialty in treating ADHD, which means not only training and additional coursework, but ongoing professional development AND state scrutiny in dispensing controlled substances. By “controlled”, I of course mean that every prescription has to be monitored by the state regulatory agencies who keep track of things like opioids and amphetamines.
You are also conflating terms in an inaccurate way. “Adult ADHD” is not the same as “Adult-ONSET ADHD”. There is no such thing as the latter. ADHD is a largely a genetic disorder, although there are some environmental factors (pesticides, lead paint, etc) that can lead to it. A true screening by a qualified psychiatrist goes way beyond the six-question questionnaire, and takes a deep dive into one’s childhood – school records, achievement tests, IQ tests – there is a whole gamut before a doctor makes a determination.
It is true that our society is stressful and that we are overworked, and that there are many, many reasons for an adult to have symptoms that might appear on the surface to be ADHD – but that is why we are not allowed to self-diagnose, and that is why our doctors are not allowed to diagnose us; it is why ADHD medications are controlled substances and why those physicians who have specialized in this treatment are monitored closely for prescriptive abuses.
As for the “enrichment of doctors” at the hands of the pharmaceutical companies – I would suggest that you re-read the article you cite. The article deals mainly with restrictions of pharmaceutical companies’ access to physicians – but does not make the case at all that doctors are inclined to make unnecessary or incorrect prescriptions to patients who do not need the medication at all simply because they are being paid by the vendors. Rather, the article is very clear about the pharmaceutical companies’ influence over brand-name vs. generic medications only.
I am not suggesting that problems do not exist. I am certain that there are unethical physicians in this country who prescribe controlled substances in an uncontrolled manner because there is profit in that – but I would suggest that this is an exception to the rule, not the norm.
Michael LaBossiere says
The evidence of the influence on some doctors by the pharmaceutical companies is well documented. I am not claiming that even most of them are consciously in their pockets, just that they are being influenced in ways that are not in the best interest of the patients.
But you are making two completely separate arguments here.
I would cautiously agree with your second one – that some doctors are influenced by pharmaceutical companies, and in some cases, this may not be in the best interest of the patient. However, in other cases it may actually be in the patients’ best interest. With regard to one study (BMJ 2016;354:i4189), the authors of the study caution that their findings do not necessarily suggest that payments by pharmaceutical manufacturers are harmful for patient care:
“Patients may benefit from physicians being made aware of newly approved, effective treatments that may have fewer adverse effects, reduce the need for monitoring tests, or improve adherence,” they wrote
You have made the claim that the evidence of this is well-documented, and to a degree I think it has been – but the evidence points only to brand-name vs generic drugs. A comparison is made between specialists and GPs, the former being a more likely target of largess on the part of the pharmaceutical companies, and their being more likely to prescribe brand name drugs. (We must, of course, be very cautious about the fallacy of correlation and causation here, though. In fact, in the above-cited study, the authors say specifically that “As a cross sectional, ecological study, we cannot prove causation between payments to physicians and increased prescribing).
Nowhere that I have seen does anyone make the case that the prescription itself – i.e., to treat with drugs or without drugs – is influenced by corporate gifting or perks.
That is the implication of your essay, and it is that that I have a big disagreement with.
I am entirely willing to accept any additional evidence you want to put forth, and will certainly reconsider my point of view in light of this evidence – but none of the authors of the studies I have read (about seven or eight, prompted by this discussion) make the accusation that you make – that doctors will prescribe drugs for treatment of conditions that are better treated without them.
In the case of ADHD, I will stand by my argument. The documentation behind the WHO six-question screening test indicates that its purpose is NOT to reward the pharmaceutical companies that have bestowed lavish gifts upon them, but rather to put forth documented, fact-based information on the Internet to combat the plethora of false information that exists.
The six-questions are a SCREEN, not a diagnostic tool. As I said in my first answer, a patient must see a trained practitioner who specializes in ADHD (at least in NY State), and because the medications for this ailment are considered controlled substances, the physician must provide substantial documentation as to the diagnosis, the medication, and the dosage to state regulatory agencies.
I see this as no different from pictures of moles in the back of Reader’s Digest – “If your mole looks like this, see your doctor immediately”.