Thursday, 10 December 2015

Cochrane does methylphenidate for ADHD

'Cochrane does' in the title of this post refers to the Cochrane Library and the sterling work that is done by the Cochrane Reviews to analyse the collected peer-reviewed evidence on various aspects of health and wellbeing and provide a sort of 'state of the evidence' address. It's something that has graced this blog before (see here).

This time around attention has turned to the paper by Ole Jakob Storebø and colleagues [1] (open-access) who started with the objective to: "assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD [attention-deficit hyperactivity disorder]." Methylphenidate, more readily known by the brand names Concerta or Ritalin is one of the management tools of choice for some people diagnosed with ADHD as part of a suite of stimulant medicines indicated for the condition. As what can happen with quite a few medicines in the medicinal chest, methylphenidate is also becoming a nootropic of choice in these days of so-called cognitive enhancers or smart drugs and particularly with reference to the academic rat race that many people find themselves in.

The paper from Storebø et al surveyed the peer-reviewed research literature on the topic of methylphenidate (MPH) and ADHD up to February of this year (2015) identifying some 185 trials: "randomised controlled trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD." They concluded that there was some evidence that MPH was a useful medicine for improving things like teacher-rated ADHD scores and parent-reported quality of life among children and young adults with ADHD. Serious, life-threatening side-effects were also fairly rare based on the data inspected. Good news indeed.

But... as per some other write-up of the study findings (see here), the picture was not universally rosy when it came to MPH use and ADHD in the research literature. So: "The most common non-serious adverse events were sleep problems and decreased appetite. Children in the methylphenidate group were at 60% greater risk for trouble sleeping/sleep problems..., and 266% greater risk for decreased appetite... than children in the control group." Such findings even within the context of requiring better designed trials to assess MPH, are slightly worrying and are perhaps the reasons why the BBC headline on this study read: "Experts call for caution over Ritalin." Other recent research has also come to similar conclusions [2].

Bearing in mind my oft-cited caveats on this blog about not giving anything that looks, sounds or smells like clinical advice, I have a few things to add to the Storebø report based on my reading of some of the research literature in this area. First and foremost is the fact that outside of something like MPH (and a few other medicines) science and medicine have not got a great deal of other therapeutic options to offer when ADHD is diagnosed. Yes, behavioural interventions can be implemented; indeed, even something like sleep interventions have been discussed with ADHD in mind (see here). But surprisingly little else is available unless one considers that some of the more 'complementary' interventions might also be useful for some (see here).

Second, as per quite a bit of professional opinion these days, childhood developmental disorders such as ADHD really need to be tackled in the younger years in view of the 'risks' attached to their perpetuation into adulthood. Take for example the emerging research suggesting that ADHD might 'prime' for something like psychosis or schizophrenia in later years (see here) (albeit with other important variables potentially playing a role) and one has a taste of what future enhanced risks might be associated with the label. Even some of the authors from the current Cochrane review have some previous research form in this area [3]. This also covers other more societal risks too (see here).

Finally is the idea that whilst no-one particularly likes the idea that children and young adults are being dispensed quite powerful medicines, things like MPH with appropriate medicines management, can make a real difference to people's lives. With my autism research blogging hat on and acknowledging how autism and ADHD show some significant 'overlapping' (see here) the peer-reviewed research confirms such 'positive effects' [4] at least for some. And yes, we need to know more about who the potential best and non-responders are likely to be.

Further research is of course indicated in this area including that related to the mechanism of effect from something like MPH (see here). As part of a suite of intervention options for labels like ADHD (including something as simple as promoting physical activity), MPH continues to have a place subject to the idea that the use of such medication should be treated as a time-limited experiment with an N=1 and appropriate monitoring for side-effects.

Music: Where's Your Car Debbie - Slaves.

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[1] Storebø OJ. et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). Cochrane Database of Systematic Reviews. 2015; Issue 11. Art. No.: CD009885.

[2] Kidwell KM. et al. Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis. Pediatrics. 2015 Nov 23. pii: peds.2015-1708.

[3] Storebø OJ. & Simonsen E. The Association Between ADHD and Antisocial Personality Disorder (ASPD): A Review. J Atten Disord. 2013 Nov 27.

[4] Posey DJ. et al. Positive effects of methylphenidate on inattention and hyperactivity in pervasive developmental disorders: an analysis of secondary measures. Biol Psychiatry. 2007 Feb 15;61(4):538-44.

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ResearchBlogging.org Storebø OJ, Ramstad E, Krogh HB, Nilausen TD, Skoog M, Holmskov M, Rosendal S, Groth C, Magnusson FL, Moreira-Maia CR, Gillies D, Buch Rasmussen K, Gauci D, Zwi M, Kirubakaran R, Forsbøl B, Simonsen E, & Gluud C (2015). Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD). The Cochrane database of systematic reviews, 11 PMID: 26599576