The impending globalization of ADHD: notes on the expansion and growth of a medicalized disorder

A Regional ADHD Center-Based Network Project for the Diagnosis and Treatment of Children and Adolescents With ADHD

OBJECTIVE

We aimed to define the sociodemographic, clinical, and prescription profiles of the participants enrolled in the Italian Lombardy ADHD Register.

METHOD

Data on patients evaluated by the 18 regional ADHD reference centers in the 2012 to 2013 period were analyzed.

RESULTS

Seven hundred fifty-three of 1,150 (65%) suspected patients received a diagnosis of ADHD. In 24% of cases, there was a family history of ADHD. Four hundred eighty-three (64%) patients had at least one psychopathological disorder, the more common of which were learning disorders (35%). Eighty-four percent of patients received a prescription for psychoeducational interventions, 2% received only pharmacological treatment, and 14% a combination of both. Compared with patients treated with psychoeducational intervention alone, patients with drug prescriptions more commonly presented values of Clinical Global Impressions - Severity scale (CGI-S) of 5 or higher ( p < .0001).

CONCLUSION

A continuous and systematic monitoring of patterns of care is essential in promoting significant improvements in clinical practice and ensuring an efficient and homogeneous quality of care.

ADHD prevalence estimates in Italian children and adolescents: a methodological issue

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is recognized as the most common, and most studied, developmental age disorder. Basic information, such as the most appropriate case definition and the best way to evaluate the disorder's prevalence rate, however, remains an open issue.

METHODS

A comprehensive meta-analysis on the epidemiology of ADHD in Italy, which was lacking from the literature, was therefore performed to attempt to estimate the actual prevalence rate of ADHD, highlighting conceptual and quantitative differences between clinical-diagnosis and survey-based symptoms studies. The Medline, Embase, and PsycINFO databases, and the grey literature, were searched up to January 2018. The review was laid out in three main sections: an overall prevalence estimate, an epidemiological profile of ADHD symptoms, and an attempt to define the actual rate of ADHD diagnosis, as emerged from Italian studies.

RESULTS

A total of 15 unique studies were included. These contributed to estimating the prevalence of ADHD in 67,838 subjects aged 5-17, representing 9 of the 20 regions (45%) of Italy. Overall, the pooled prevalence of ADHD was 2.9% (range: 1.1-16.7%). When distinguishing studies based on case definition, however, we found an average prevalence estimate, based on symptoms criteria, of 5.9% (range: 1.4 to 16.7%) and a best-estimate prevalence rate of 1.4% (range: 1.1 to 3.1%).

CONCLUSIONS

Following the case definition for epidemiological studies of ADHD, counting only subjects with an ADHD diagnosis performed and confirmed by clinical assessment would reduce the wide variability in prevalence estimates, and, above all, would both describe the real rate of subjects suffering from ADHD disorder and avoid misdiagnosis.

Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment

Knowledge about attention-deficit hyperactivity disorder (ADHD) is rapidly accumulating. Recent advances in diagnosis, genetics, neuroimaging, drug and non-drug treatments are considered, and the results are related to the critical attack on the ADHD diagnosis, which argues it a medicalising social construct, unhelpfully sustaining power relationships. The advances reviewed suggest that, while this attack can be conclusively dismissed as wrong and misleading, the phenomenological definition of ADHD is no longer sufficient for construct validity, though continues to be valuable as a guide for clinicians. The humanising and individualising concerns underlying the attack on the diagnosis could usefully be redirected to improving effective measurement of patient outcomes.

Risk of amphetamine use disorder and mortality among incident users of prescribed stimulant medications in the Veterans Administration

BACKGROUND AND AIMS

Non-medical use of prescribed stimulant medications is a growing concern. This study's aims were to ascertain the demographics of stimulant medication users compared with non-users, examine temporal trends of stimulant medication use and estimate risk factors for development of amphetamine use disorder (AUD) and mortality among new users of stimulant medications.

DESIGN

Cox proportional hazards regression in a retrospective cohort adjusted by baseline covariates.

SETTING

United States, national administrative database of the Veterans Affairs (VA) health-care system.

PARTICIPANTS

Adult incident users of stimulant medications (n = 78 829) from fiscal years (FY) 2001 to 2012.

MEASUREMENTS

Primary outcomes were time-to-event: (1) occurrence of AUD diagnosis and (2) death. Baseline covariates included demographic information, Food and Drug Administration (FDA)-approved indications for stimulant use, substance use disorders (SUD) and depression.

FINDINGS

Stimulant users compared with non-users were younger, more likely to be non-Hispanic white and female. Incident stimulant medication users increased threefold from FY2001-FY2012 and eightfold among adults aged 18-44 years. Nearly one in 10 incident users in FY2012 had a comorbid baseline SUD. Off-label use was common-nearly three of every five incident users in FY2012. Comorbid SUDs among incident stimulant medication users were risk factors for occurrence of AUD during follow-up, with adjusted hazard ratio (AHR) estimates ranging from 1.54 to 2.83 (Ps < 0.05). Increased mortality risk was observed with occurrence of AUD during follow-up [AHR = 1.55, 95% confidence interval (CI) = 1.13-2.14, P = 0.007], while on-label prescribing was protective against death (AHR = 0.686, 95% CI = 0.63-0.75, P < 0.0001).

CONCLUSIONS

In a US national cohort of adult incident stimulant medication users in the Veterans Affairs health-care system, measured from fiscal years 2001 to 2012, comorbid substance use disorders were common and were risk factors for development of an amphetamine use disorder (AUD). Increased mortality risk among incident users of stimulant medications was observed among both those who developed an AUD later and those whose use was defined as off-label.

Biases in Understanding Attention Deficit Hyperactivity Disorder and Autism Spectrum Disorder in Japan

Recent research has shown high rates of comorbidity between attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) and difficulties regarding differential diagnosis. Unlike those in Western countries, the Japanese ADHD prevalence rate is lower relative to that of ASD. This inconsistency could have occurred because of cultural diversities among professionals such as physicians. However, little is known about attitudes toward ADHD and ASD in non-Western cultural contexts. We conducted two experiments to identify biases in ASD and ADHD assessment. In Study 1, we examined attitudes toward these disorders in medical doctors and mental health professionals, using a web-based questionnaire. In Study 2, medical doctors and clinical psychologists assessed four fictional cases based on criteria for ADHD, ASD, oppositional defiant disorder, and disinhibited social engagement disorder (DSED). Diagnosis of ASD was considered more difficult relative to that of ADHD. Most participants assessed the fictional DSED case as ASD, rather than DSED or ADHD. The results provide evidence that Japanese professionals are more likely to attribute children’s behavioral problems to ASD, relative to other disorders. Therefore, Japanese therapists could be more sensitive to and likely to diagnose ASD, relative to therapists in other countries. These findings suggest that cultural biases could influence clinicians’ diagnosis of ADHD and ASD.

Methylphenidate clinically oral doses improved brain and heart glutathione redox status and evoked renal and cardiac tissue injury in rats

Methylphenidate (MPH) is a first-line stimulant drug to treat attention deficit hyperactivity disorder (ADHD). Overdiagnosis of ADHD and MPH abuse lead to serious concerns about the possible long-term adverse consequences of MPH in healthy children and adolescents. We aimed to evaluate MPH effects in adolescent male Wistar rats (postnatal day 40) using an oral dose scheme (2 daily MPH doses 5 mg/kg in a 5% sucrose solution, 5 h apart, for 7 days) that mimics the therapeutic doses given to human adolescents. Twenty-four hours after the last MPH administration, rats were sacrificed and brain areas [cerebellum, prefrontal cortex (PFC), hippocampus, and striatum], peripheral organs (liver, heart, and kidneys), and blood were collected for biochemical and histological analysis. MPH treatment did not alter rats' body temperature or weight, neither food or water intake throughout the experiment. The ratio of reduced glutathione/oxidized glutathione (GSH/GSSG) significantly increased in the PFC and hippocampus of MPH-treated rats, meanwhile protein carbonylation remained unchanged in the brain. In the heart, the GSH/GSSG ratio and GSH levels were significantly increased, with decreased GSSG, while histology revealed significant damage, namely interstitial edema, vascular congestion, and presence of a fibrin-like material in the interstitial space. In the kidneys, MPH treatment resulted in extensive necrotic areas with cellular disorganization and cell infiltration, and immunohistochemistry analysis revealed a marked activation of nuclear factor-ĸB. This study showed that clinically relevant oral MPH doses improve the GSH redox status in the brain and heart, but evoke heart and kidney tissue damage to adolescent rats.

Attention Deficit Hyperactivity Disorder (ADHD): Controversy, Developmental Mechanisms, and Multiple Levels of Analysis

Controversy abounds regarding the symptom dimensions of attention problems, impulsivity, and hyperactivity, developmentally extreme and impairing levels of which compose the diagnostic category of attention deficit hyperactivity disorder (ADHD). I highlight causal factors, underlying mechanisms, developmental trajectories, and female manifestations of ADHD, integrating the psychobiological underpinnings of this syndrome with contextual factors related to its clinical presentation, impairments, and soaring increases in diagnosed prevalence. Indeed, despite strong heritability, ADHD is expressed via transactional patterns of influence linked to family-, school-, peer-, neighborhood-, and policy-related factors. Moreover, intervention strategies must take into account both pharmacologic and behavioral modalities if the goal is to enhance competencies, rather than symptom reduction per se. A comprehensive understanding of ADHD mandates multiple levels of analysis-spanning genes, neurotransmission, brain pathways, individual skill levels, family socialization, peer relationships, and educational and cultural forces-which must be integrated and synthesized to surpass reductionist accounts, reduce stigma, and maximize the impact of prevention- and intervention-related efforts.

Teachers' Experiences With and Perceptions of Students With Attention Deficit/hyperactivity Disorder

PURPOSE

The purpose of this research was to examine teacher experiences with and perceptions of students with attention deficit/hyperactivity disorder (ADHD). Teachers are integral in helping these children learn effectively and foster healthy relationships, yet little is known about their interactions with these children.

DESIGN AND METHOD

Semi structured interviews were conducted with a purposive sample of fourteen currently practicing or retired elementary and middle schools teachers in North Carolina and South Carolina. All interviews were audio-recorded then analyzed for common themes.

RESULTS

Participants obtained ADHD information from in-services or peer interaction, rather than formal education. Culture and gender influenced teacher perceptions, and ADHD classroom strategies were based on anecdotal experience. Teachers experienced guilt and worry while negotiating student needs, school system constraints, and family issues.

CONCLUSIONS

While teachers have developed effective coping mechanisms through informal means, formal education and support will help teachers better serve students with ADHD.

PRACTICE IMPLICATIONS

Pediatric nurses in many settings can benefit from better understanding how teachers perceive and interact with students who have attentional issues.

Evidence for overuse of medical services around the world

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

La Construcción Social de la Hiperactividad

El trastorno por déficit de atención e hiperactividad (tdah)es una afección frecuente, con alta variabilidad en su preva-lencia a través de contextos, y de interés por la repercusión que tiene sobre el desempeño escolar de quienes la padecen. Se exploraron las construcciones simbólicas que hacen diferentes actores acerca de niños diagnosticados con TDAH. Con tal fin se realizaron entrevistas abiertas de tipo semántico y episódico a 31 participantes bogotanos, distribuidos en grupos de maestros, padres y niños. Estas entrevistas fueron abordadas desde una perspectiva de análisis de discurso. Los resultados mostraron que el tdahse reconstruye, a partir de la perspectiva del observador y del contexto, en términos de problema hereditario y de fallas en las prácticas de crianza. Por su parte, para los niños, el diagnóstico es un evento importante en la construcción de su subjetividad.

The concept of medicalisation reassessed

Medicalisation has been an important concept in sociological discussions of medicine since its adoption by medical sociologists in the early 1970s. Yet it has been criticised by some sociologists, in part because it seems too negative about medicine, and modified or replaced by others with concepts deemed more relevant like biomedicalisation and pharmaceuticalisation. My aim in this paper is to reassess the concept and consider whether it still has value in exploring significant aspects of the role of medicine in present-day society. I start with an archaeology of the concept's development and the different ways it has been used. This covers some familiar ground but is essential to the main task: examining criticisms of the concept and assessing its value. I conclude that the concept continues to have a crucial and productive place in sociological analyses of medicine and that the process of medicalisation is still a key feature of late-modern social life and culture.

ADHD, Lifestyles and Comorbidities: A Call for an Holistic Perspective - from Medical to Societal Intervening Factors

The review examines Attention Deficit Hyperactivity Disorder (ADHD in its Child and Adult form) and its various presentations (Hyperactive Impulsive, Inattentive, and Combined) with a particular focus on environmental (incl. social factors), lifestyles and comorbidities. It is argued that ADHD is best understood in a holistic and interactive context and a vast empirical literature is presented to illustrate the point: Environmental factors include stress in general as well as exposure to toxins (phthalates, bisphenol A). Social factors are illustrated by effects of social deprivation and seduction to unhealthy lifestyles. Maternal lifestyle during pregnancy is pointed out (particularly her exposure to nicotine, alcohol, caffeine, and drugs, even seemingly benign medications like acetaminophen), which all tend to be related to ADHD. Family environment is discussed with respect to protective effect of (mainly authoritative and autocratic) parenting styles. Societal factors include mainly economic and political issues: income inequality and poverty (low SES is an ADHD risk factor) and a growing moral dilemma between a humanistic effort to globally spread the knowledge of ADHD and the medicalization and commercialization of the disorder. The second part of the review is devoted to ADHD related lifestyles and resulting comorbidities (e.g., food addiction and obesity, substance abuse, electronic media dependencies and conduct and personality disorders). Although ADHD is a neurodevelopmental disorder, its assessment and treatment are also linked to environmental, behavioral and social factors and their interactions.

Child Health in Elementary School Following California’s Paid Family Leave Program

We evaluate changes in elementary school children health outcomes following the introduction of California’s Paid Family Leave (PFL) program, which provided parents with paid time off following the birth of a child. Our health outcomes--overweight, ADHD, and hearing-related problems--are characterized by diagnosis rates that only pick up during early elementary school. Moreover, our health outcomes have been found to be negatively linked with many potential implications of extended maternity leave--increased breastfeeding, prompt medical checkups at infancy, reduced prenatal stress, and reduced non-parental care during infancy. Using the Early Childhood Longitudinal Studies (ECLS) within a difference-in-differences framework, our results suggest improvements in health outcomes among California elementary school children following PFL’s introduction. Furthermore, the improvements are driven by children from less advantaged backgrounds, which is consistent with the notion that California’s PFL had the greatest effect on leave-taking duration after childbirth mostly for less advantaged mothers who previously could not afford to take unpaid leave.

Peer influence as a potential magnifier of ADHD diagnosis

The prevalence of Attention Deficit and Hyperactivity Disorder (ADHD) is growing in America, but its cause is unclear. Scholars have identified many environmental factors that can cause or confound ADHD diagnosis, but epidemiological studies that try to control for confounding factors still find evidence that rates of ADHD diagnosis are increasing. As a preliminary explanation to ADHD's increasing prevalence, this article examines whether core ADHD diagnostic traits are subject to peer influence. If ADHD diagnosis can be confounded by peer influence, there are several mechanisms that could have caused increased rates of diagnosis. With data drawn from two schools across three waves in the National Longitudinal Survey of Adolescent Health (n = 2193), the author uses a stochastic actor oriented model to estimate the effect of peer influence on inattention, controlling for alternative network and behavioral causes. Results indicate that respondents have a strong likelihood to modify their self-reports of inattention, a core ADHD trait, to resemble that of their friends.

The rehabilitation research matrix: producing knowledge at micro, meso, and macro levels

PURPOSE

EU policy documents and health scholars point out that in order to understand the complexity of modern health systems, as well as to devise appropriate policy responses, considering micro, meso, and macro levels is indispensable. This article aims to develop an analytical framework for how rehabilitation as an interdisciplinary field can be framed in such a three-level framework.

METHODS

This is a conceptual paper based on recent contributions to the development of a theory of rehabilitation. The paper applies sociological theory to build an analytical framework for a holistic understanding of rehabilitation.

RESULTS

Three groups of agents in the field of rehabilitation are identified: individuals with disabilities, professionals, and governmental authorities. The paper systematizes how these agents are positioned and act at micro, meso, and macro levels. In the intersection between the three levels of society and the three groups of actors, a nine-cell table emerges. In the cells of the table, key examples of important social processes to study in the field of disability and rehabilitation are identified. At the micro level, individuals experience a daily life relevant to rehabilitation, professionals ask what works in therapy, and policy authorities promote a strong work ethic. At the meso level, individuals with disabilities act as service user groups, professionals develop organizational designs and the policy authorities ask for cost-effective services. At the macro level, organizations representing people with disabilities lobby, professionals negotiate authorization issues, and the policymaking authorities must identify what can count as just distribution of services. The nine cells of the table are elaborated on by presenting relevant current studies exemplifying each cell.

CONCLUSION

To systematize societal levels and agents involved is to enhance the understanding of rehabilitation as an interdisciplinary field of research. Implications for rehabilitation Rehabilitation practice and research must relate to different levels of society and identify different social agents. Service users are not only individuals receiving therapy, but also organized agents influencing the organization of rehabilitation services as well as priorities made at the level of policy development. Both the results produced by health professionals doing a clinical trial and political scientists studying rehabilitation policy disputes will improve when placed in a wide frame of knowledge production.

Psychological Symptom Amplification: Are Psychological Symptoms Subject to "Somatization"-Like Processes?

Many patients demonstrate amplified somatic symptom experiences that are felt by providers to cause excessive distress and functional impairment, and that can be diagnostically misleading. Terms attached to these presentations include somatization, medically unexplained symptoms, and, most recently, somatic symptom disorder. The analogous amplification of psychological symptoms has not been considered. Accordingly, this column makes a case for discussion and investigation of psychological symptom amplification (PSA), a process made possible by the medical legitimization of certain types of human suffering. As various forms of psychological suffering gain greater medical legitimacy, PSA becomes increasingly relevant. Circumstantial evidence suggests that unrecognized PSA may distort research findings and clinical efficacy in psychiatry. The largely symptom-based nature of psychiatric diagnosis makes PSA a challenging, but necessary, object of further scientific and clinical scrutiny.

Medicalización más allá de los médicos: marketing farmacéutico en torno al trastorno por déficit de atención e hiperactividad en Argentina y Brasil (1998-2014)

Resumen Desde un análisis crítico de los estudios de la medicalización, y como un aporte a estas perspectivas, describimos y analizamos los modos en que la industria farmacéutica transnacional penetra en diversos espacios sociales, con diferentes estrategias de marketing, interviniendo en la consolidación de procesos medicalizadores en Argentina y Brasil. Se analizan dos modalidades de expansión de los procesos de medicalización, y se desarrollan aspectos y tendencias específicas del diagnóstico y tratamiento del TDAH en ambos países: la incidencia de la industria farmacéutica en los grupos de apoyo en Brasil y las estrategias de marketing farmacéutico orientadas a actores no médicos en Argentina. Estas dos modalidades se caracterizan por no involucrar sólo al profesional médico. La metodología incluye datos de investigaciones conducidas en Argentina y Brasil entre 1998 y 2014, con sede en la Universidad de Buenos Aires y la Universidade Estadual do Rio de Janeiro, orientadas al estudio de los procesos de diagnóstico y tratamiento del TDAH y el consumo de metilfenidato en ambos países. Se emplearon técnicas de entrevista semiestructurada individual y grupal a profesores y profesionales de salud, estadísticas oficiales y de organizaciones profesionales, y revisión de bibliografía general y especializada nacional e internacional. Concluimos que los fenómenos documentados en Argentina y Brasil ponen de relieve la importancia de efectuar investigaciones que contemplen aspectos singulares de los casos empíricos, y sus múltiples vinculaciones con entramados más amplios y en tensión de saberes, dispositivos, normativas y actores involucrados en la medicalización en el siglo XXI.

Beyond medicalization: Self-injuring acts revisited

For too long, medical/psychiatric and psychological studies, with focus on emotional sensitivity, personality traits, and correlation with psychopathology, have dominated research on self-injuring acts. The phenomenon thus has been defined as a predominantly medical issue. However, a large body of community prevalence studies show self-injuring acts to be a common phenomenon in society, and most of those who self-injure are unknown in psychiatric or other clinical settings. This article describes and analyzes the medicalization of self-injuring acts and argues a need to move research on self-injuring acts out of the medical paradigm. There is a need to explicitly explore the impact of social, cultural, structural, and gendered factors surrounding and influencing self-injuring acts. A non-medical approach, beyond the limits of the medical perspective, would feed research forward and create a more nuanced view on this widespread social phenomenon.

Geographic analysis of the variation in the incidence of ADHD in a country with free access to healthcare: a Danish cohort study

Background

The prevalence of citizens diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) has risen dramatically over the past decades in many countries, however, with large variations. Countries such as Denmark with centrally organized well fare systems, free access to health services and individual tracking based on unique personal identification may in particular contribute to our understanding of the reasons for this increase. Based on Danish registers we aimed to examine the geographical patterns of the distribution of ADHD diagnosis and medication use and explore the association with access to diagnostic services, diagnostic culture, neighbourhood socioeconomic status and municipal spending on health care for children.

Methods

We combined information on registered diagnosis of ICD-10 Hyperkinetic Disorder and ADHD medication use in a Danish register-based cohort of children born between 1990 and 2000. We mapped incidence proportions of diagnoses and medication use within the 98 Danish Municipalities. Global and local clustering of ADHD was identified using spatial analysis. Information on contextual factors in the municipalities was obtained from national registers. The associations between the incidence of ADHD and contextual factors were analysed using Bayesian spatial regression models.

Results

We found a considerable variation in the incidence of ADHD across the municipalities. Significant clustering of both high and low incidence of ADHD was identified and mapped using the local Moran’s I. Clustering of low incidence of diagnosis and medication use was observed in less populated areas with limited diagnostic resources and in contrast clustering of high incidence in densely populated areas and greater diagnostic resources. When considering the spatial autocorrelation between neighbouring municipalities, no significant associations were found between ADHD and access to diagnostic services, different diagnostic culture, socioeconomic status at municipality level or the municipal spending on health care for children.

Conclusions

A large geographical variation of ADHD in the municipalities was observed despite tax-financed and free access to healthcare. Although not statistically significant, results indicate that accessibility to diagnostic resources might explain some of the variation in ADHD incidence. In contrast to US studies the observed variation was not statistically associated to contextual factors in terms of SES, municipal spending on health care for children or differences in diagnostic practices.

Childhood: a suitable case for treatment?

We examine the contemporary debate on attention deficit hyperactivity disorder, in which concerns about medicalisation and overuse of drug treatments are paramount. We show medicalisation in attention deficit hyperactivity disorder to be a complex issue that requires systematic research to be properly understood. In particular, we suggest that the debate on this disorder might be more productive and less divisive if longitudinal, evidence-based understanding of the harms and benefits of psychiatric diagnosis and misdiagnosis existed, as well as better access to effective, non-drug treatments. If articulation of the values that should guide clinical practice in child psychiatry is encouraged, this might create greater trust and less division.

Prevenção quaternária: um olhar sobre a medicalização na prática dos médicos de família

A medicalização é um fenômeno social complexo e disseminado no qual estão envolvidos diferentes agentes e instituições, tais como a indústria médica/farmacêutica, governos, profissionais/sistemas de saúde e cidadãos. Por sua vez, médicos e profissionais de saúde desempenham importante papel na reprodução e no enfrentamento da medicalização haja visto que a medicina e os cuidados em saúde podem gerar tanto danos como benefícios. Médicos de família lidam diariamente com a sobremedicalização e seus fenômenos associados (i.e. sobrediagnóstico, sobretratamento, comercialização de doenças) por desempenharem função-filtro nos sistemas de saúde. Por serem o primeiro ponto de contato, esses profissionais e suas equipes acolhem as demandas e necessidades sociais trazidas pelas pessoas e comunidades sob seus cuidados, que comumente estão influenciadas por uma perspectiva médica intervencionista e pelo marketing da saúde. Este artigo discute alguns conceitos principais da medicalização e seus determinantes, em especial as contribuições da ciência biomédica e suas bases epistemológicas para o fenômeno. Ele também desenvolve, sucintamente, algumas reflexões sobre a medicalização na prática do médico de famíliae comunidade, no contexto brasileiro. Por fim, analisa o enfoque da prevenção quaternária acerca da medicalização, que propõe mudanças de objeto e de atitude na prática médica, evitando, assim, intervenções desnecessárias e protegendo os pacientes dos excessos da medicina.

Quaternary prevention, an answer of family doctors to overmedicalization

In response to the questioning of Health Policy and Management (HPAM) by colleagues on the role of rank and file family physicians in the same journal, the author, a family physician in Belgium, is trying to highlight the complexity and depth of the work of his colleagues and their contribution to the understanding of the organization and economy of healthcare. It addresses, in particular, the management of health elements throughout the ongoing relationship of the family doctor with his/her patients. It shows how the three dimensions of prevention, clearly included in the daily work, are complemented with the fourth dimension, quaternary prevention or prevention of medicine itself, whose understanding could help to control the economic and human costs of healthcare.

Taking pills for developmental ails in Southern Brazil: The biologization of adolescence?

In the late 1990s researchers in Pelotas Southern Brazil began documenting what they considered to be unacceptably high rates of licensed psychotropic use among individuals of all ages, including youth. This came as a surprise, since the vast majority of psychiatrists in Pelotas draw on psychoanalytic theory and approach pharmaceutical use, especially for children and adolescents, in a consciously tempered way. Drawing from a longitudinal ethnographic sub-study, part of a larger 1982 birth cohort study, this paper follows the circuitous trajectories of emergent pharma-patterns among “shantytown” youth over a ten-year period, exploring the thickly layered and often moralized contingencies in which psychodynamic psychiatrists' intention to resist excessive pharmaceuticalization both succeed and crumble. I juxtapose these trajectories with the growing salience of an “anti-biologizing” explanatory framework that psychiatrists and researchers are using to pre-empt the kind of diagnostics-driven “biopsychiatrization” so prevalent in North America. My analysis suggests that psychiatrists' use of this framework ironically contributes to their failed attempts to “resist” pharmaceuticalization.

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Biopsychiatric logics are often implicated in the global rise of psychotropic-use.

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In Brazil, psychotropic-use prevails despite therapists' resistance to such logics.

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This resistance obscures the moral and social contingencies of pharmaceuticals.

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Attempts to resist biopsychiatric logics ironically contribute to psychotropic-use.