Medication: The smart-pill oversell

Características das prescrições de metilfenidato em ambulatório de neuropediatria

RESUMO O metilfenidato não é disponibilizado pelo Sistema Único de Saúde (SUS), pois não faz parte da Relação Nacional de Medicamentos Essenciais. Todavia, o metilfenidato 10 mg é disponibilizado pela rede pública em Maringá-PR de acordo com a Política da Assistência Farmacêutica do município. Objetivou-se analisar as características das prescrições médicas de metilfenidato para crianças em ambulatório de neuropediatria vinculado ao SUS no município. Estudo transversal observacional retrospectivo de caráter quantitativo, realizado por meio da coleta de dados dos prontuários cadastrados no Sistema Gestor da rede pública de saúde do município, pelo ambulatório de neuropediatria na Unidade Básica de Saúde, Zona 7, entre janeiro de 2017 e novembro de 2019. Analisaram-se os dados por frequência relativa e absoluta. Emitiram-se 339 prescrições pelo neuropediatra responsável do ambulatório para 107 pacientes de 6 a 11 anos. Notou-se distribuição geográfica desigual das crianças atendidas conforme bairro da cidade, o que denota influência socioeconômica na prescrição de medicamentos. Ressaltam-se picos de prescrições coincidindo com o período do ano letivo escolar. Concluiu-se que o acompanhamento especializado adequado é premissa para o tratamento, não dispensando a rede longitudinal de assistência. Ademais, evidencia-se o impacto das condições socioeconômicas, tanto na prescrição como na aquisição do medicamento.

Where to find accurate information on attention-deficit hyperactivity disorder? A study of scientific distortions among French websites, newspapers, and television programs

Attention-deficit/hyperactivity disorder is the most frequent mental disorder among school-age children. This condition has given rise to a large mediatic coverage, which contributed to the shaping of the lay public's perceptions. We therefore conducted two studies on the way attention-deficit/hyperactivity disorder was portrayed in the TV programs and the lay-public press in France between 1995 and 2015, but the growing part played by the Internet required an additional study to analyze and compare the scientific material which is available to the French lay public depending on the source of information used. We studied the 50 first French websites dedicated to attention-deficit/hyperactivity as indexed by Google^® search engine using a structured quantitative content analysis for the web. We illustrate our results with excerpts derived from the websites. The conceptions of attention-deficit/hyperactivity disorder available on the Internet are essentially biomedical and comprise an important level of scientific distortion. Findings concerning other mass media such as television programs and the press also demonstrate massive and systematic distortions caused by the role of experts and the pharmaceutical industry. Furthermore, the most consulted media present the highest level of scientific distortions.

What stops practitioners discussing medication breaks in children and adolescents with ADHD? Identifying barriers through theory-driven qualitative research

National and international guidelines on the treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents call for annual reviews to assess continuing need for medication by considering brief periods without medication, referred to as 'Drug holidays'. However, drug holidays are reactively initiated by families, or recommended by practitioners if growth has been suppressed by medication rather than proactively to check the need. There is little evidence of planned, practitioner-initiated drug holidays from methylphenidate. The aim of this study was to identify what stops practitioners from routinely discussing planned drug holidays from methylphenidate with children, adolescents, and their parents. Practitioners involved in shared-care prescribing for children and adolescents with ADHD in one UK County were included. Interviews with 8 general practitioners (GPs) and 8 Child and Adolescent Mental Health Service (CAMHS) practitioners were conducted. Transcripts were analysed qualitatively against the components of the Capability-Opportunity-Motivation-Behaviour (COM-B) model. Possible interventions for increasing prescribers' engagement with planned drug holidays were considered in response. Multiple barriers to practitioner engagement in planned drug holidays from methylphenidate were identified. Capability, in terms of knowledge and skills, was not a barrier identified for CAMHS practitioners but was for GPs. Opportunity was a main barrier for both groups, who reported lack of time and the absence of educational material about drug holidays. Motivation was more complex to define, with CAMHS practitioners questioning the need for drug holidays and GPs being more accepting due to worries about long-term medication side effects as well as cost savings. 'Education' and 'enablement' interventions were identified as key activities targeting all three components, which could feasibly increase uptake of practitioner-initiated planned drug holidays from methylphenidate. The application of the COM-B system identified a number of key barriers to practitioner engagement with drug holidays in children and adolescents with ADHD. Accordingly, a number of interventions could be developed to facilitate change. For example, educating and training GPs about ADHD management and drug holidays, and developing a decision aid to help families make informed decisions about whether or not to implement drug holidays could be used.

How French media have portrayed ADHD to the lay public and to social workers

Two models of attention deficit hyperactivity disorder (ADHD) coexist: the biomedical and the psychosocial. We identified in nine French newspapers 159 articles giving facts and opinions about ADHD from 1995 to 2015. We classified them according to the model they mainly supported and on the basis of what argument. Two thirds (104/159) mainly supported the biomedical model. The others either defended the psychodynamic understanding of ADHD or voiced both models. Neurological dysfunctions and genetic risk factors were mentioned in support of the biomedical model in only 26 and eight articles, respectively. These biological arguments were less frequent in the most recent years. There were fewer articles mentioning medication other than asserting that medication must be combined with psychosocial interventions (14 versus 57 articles). Only 11/159 articles claimed that medication protects from school failure. These results were compared to those of our two previous studies. Thus, both French newspapers and the specialized press read by social workers mainly defended either the psychodynamic understanding of ADHD or a nuanced version of the biomedical model. In contrast, most French TV programmes described ADHD as an inherited neurological disease whose consequences on school failure can be counteracted by a very effective medication.

Non-diagnostic based approaches to helping children who could be labelled ADHD and their families

Mental health services are not always good for you. There are some troubling facts to confront such as the increase in the use of diagnostic based approaches and psychotropic medications for children and young people being associated with poorer rather than better outcomes. In this article I will outline some of the evidence around outcome as a result of treatment for young people diagnosed with attention deficit hyperactivity disorder (ADHD) and for those who are prescribed long-term stimulants. I will then discuss clinical approaches that move beyond a focus on symptom management that diagnostic paradigms encourage. This includes clinical models that take account of the diversity of contextual and relational issues that young patients present with and the possibility afforded of engaging in more positive and hopeful therapeutic approaches such as the Relational Awareness Programme (RAP).

Attention Deficit Hyperactivity Disorder Symptoms and Low Educational Achievement: Evidence Supporting A Causal Hypothesis

Attention Deficit Hyperactivity Disorder (ADHD) and educational achievement are negatively associated in children. Here we test the hypothesis that there is a direct causal effect of ADHD on educational achievement. The causal effect is tested in a genetically sensitive design to exclude the possibility of confounding by a third factor (e.g. genetic pleiotropy) and by comparing educational achievement and secondary school career in children with ADHD who take or do not take methylphenidate. Data on ADHD symptoms, educational achievement and methylphenidate usage were available in a primary school sample of ~10,000 12-year-old twins from the Netherlands Twin Register. A substantial group also had longitudinal data at ages 7-12 years. ADHD symptoms were cross-sectionally and longitudinally, associated with lower educational achievement at age 12. More ADHD symptoms predicted a lower-level future secondary school career at age 14-16. In both the cross-sectional and longitudinal analyses, testing the direct causal effect of ADHD on educational achievement, while controlling for genetic and environmental factors, revealed an association between ADHD symptoms and educational achievement independent of genetic and environmental pleiotropy. These findings were confirmed in MZ twin intra-pair differences models, twins with more ADHD symptoms scored lower on educational achievement than their co-twins. Furthermore, children with ADHD medication, scored significantly higher on the educational achievement test than children with ADHD who did not use medication. Taken together, the results are consistent with a direct causal effect of ADHD on educational achievement.

Recent Trends in Stimulant Usage

OBJECTIVE

In the last decade, dramatic changes have occurred in stimulant medication prevalence and in patterns of stimulant treatment. The resultant trends merit analysis.

METHOD

Usage patterns of stimulant medication, specifically amphetamine and methylphenidate, were analyzed for trends. The data were obtained from datasets including pharmacy claims, aggregate production quotas, bulk distribution to counties, pharmacy prescription sales, parent surveys, and physician visit surveys. Stimulant medication trends were organized by drug subclass, year, age group, gender, country, prescriber specialty, diagnosis, and expenditures.

RESULTS

Major recent trends are as follows: amphetamine medication usage has prominently surpassed methylphenidate, total stimulant prescription sales to adults have surpassed those for youth, and more adult women are prescribed stimulants than adult men.

CONCLUSION

Stimulant medication treatment-particularly of amphetamines-is rapidly expanding in the United States. Off-label use is reported to be at least 40% of total use and appears to be more common in adults. (J. of Att. Dis. 2016; 20(6) 471-477).

Stimulant Medications and Cognition, Behavior and Quality of Life in Children and Youth with HIV

BACKGROUND

Limited empirical investigation exists into longitudinal changes in cognition, behavior or quality of life (QOL) in children with perinatal HIV who are prescribed stimulants.

METHODS

This study was an analysis of longitudinal data from children age 3-19 years, with perinatal HIV infection, with and without prescriptions for stimulant medications [prescription (PG) and comparison (CG) groups, respectively], matched on age, availability of CD4% and outcome measures of cognition, behavior and QOL. Generalized estimating equation models were used to evaluate effects of stimulant exposure on change in measured outcomes over 3 years of follow-up, adjusting for baseline levels of outcomes and relevant covariates.

RESULTS

Children in both the PG (n = 132) and the CG (n = 392) obtained mean verbal and performance (nonverbal) intelligence quotients (VIQ and PIQ, respectively) in the low-average range for age. At baseline, those in PG demonstrated more frequent signs of hyperactivity, impulsivity and conduct and learning problems than those in CG (P ≤ 0.003 in unadjusted analyses). At follow-up, after adjustment for baseline functioning and other relevant covariates, there were no significant changes from baseline in VIQ or PIQ. Stimulant prescription use, however, was associated with worsening symptoms of hyperactivity (P = 0.01), impulsivity (P = 0.04), learning problems (P < 0.001) and worsening of perceived health status (P < 0.001).

CONCLUSIONS

The results suggest expectations for behavioral improvement may not align well with long-term effects of stimulant prescription use on behavior and QOL in children with HIV. Further research is necessary to determine if there are subsets of children who may benefit from stimulant therapy.

Addressing the problem of ADHD medication as neuroenhancements

The prevalence of attention deficit hyperactivity disorder (ADHD) diagnoses is rising. ADHD is closely linked to its treatment with medications such as methylphenidate and amphetamines, which have popular appeal as neuroenhancement drugs by persons without a neurological disorder. The three main reasons for the increase in ADHD medication demand, production, and consumption are a) the inclusion of milder ADHD diagnoses; b) the vast marketing of ADHD medications by the pharmaceutical industry; and c) the illegal diversion of controlled ADHD medication to consumers seeking stimulants as neuroenhancements. Rapidly rising rates of any neurological disorder - especially a behaviorly-defined disorder closely linked to potent medications currently prescribed to more than 5% of the population - deserves ongoing scrutiny. Major social and ethical problems arise from vague-symptom medicalization, neurological disorder trivialization, medication overuse, and controlled substances diversion to healthy persons for nonmedical purposes. We argue against the 'spectrumization' of ADHD in an effort to curtail further diagnosis creep.