Friday, 5 May 2017

Trends in ADHD medication use in the US and Europe: is this a bad thing?

I don't want to dwell too much on the findings reported by Christian Bachmann and colleagues [1] observing that in five Western countries - Denmark, Germany, the Netherlands, the United Kingdom (UK) and the United States (US) - ADHD (attention-deficit hyperactivity disorder) medication use between 2005/2006-2012 was on the increase. But I do think it is important to mention some of the implications from such figures and some of the positives and negatives associated with such generated data.

OK, first things first. The general consensus is that the prevalence of ADHD in many parts of the world is on the up compared with say a decade or two ago. We can um-and-ah about whether this is a true increase in cases or whether through changes to the way ADHD is diagnosed for example, the figures are artificially inflated (see here). Indeed, whether for some - not by any means all - a diagnosis of ADHD is merely a means to an end (see here). Suffice to say that many studies either looking directly at rates of ADHD or via analysis of medication prescribing patterns suggest that more cases are being diagnosed these days. And that includes the use of ADHD as a comorbid diagnosis in relation to labels such as autism for example (see here) on the back of the important discussions about autism not typically presenting in some sort of diagnostic vacuum (see here).

The use of medication prescribing patterns to track estimated ADHD prevalence is the preferred method employed by Bachmann et al who concluded that: "ADHD medication use prevalence increased from 1.8% to 3.9% in the Netherlands cohort (relative increase: +111.9%), from 3.3% to 3.7% in the US cohort (+10.7%), from 1.3% to 2.2% in the German cohort (+62.4%), from 0.4% to 1.5% in the Danish cohort (+302.7%), and from 0.3% to 0.5% in the UK cohort (+56.6%)."

So, the positives from the Bachmann data. Well, accepting that ADHD is a label that, in the longer term, has been associated with heightened risk for all-manner of adverse life events (see here and see here for examples) I don't think anyone would argue that with the availability of good, safe, reliable treatment options (see here) and that such management avenues should be properly utilised. I know some people might be a little reluctant to want to medicate children for example, but the data from the various collected studies on something like methylphenidate use (typically indicated for ADHD or the presentation of ADHD-type behaviours) generally regards the medicine as safe and well tolerated albeit with monitoring and good medicines management implied. And by saying that I'm not suggesting that medication is/should be the only management option when it comes to ADHD (see here and see here for other examples). My reading of the Bachmann data is that prescribing clinicians are doling out more prescriptions for managing ADHD but this is a reflection of (a) greater recognition of ADHD and ADHD behaviours and/or (b) the value of prescribing such medicines to things like quality of life of recipients and their families.

The negatives... well, it wouldn't be difficult to suggest that with the realisation that quite a few ADHD medications have a good overall safety/response profile, clinicians perhaps become a little more 'comfortable' with their prescription over a wider range of presenting behaviours without necessarily looking at other options first. The fact for example, that Bachmann et al observed: "ADHD medication use was highest in 10-14-year olds", a special time when quite a few biological changes are on-going, could be interpreted as such medication use being a pharmacological 'crutch' during such a period. I don't know enough about ADHD to comment on whether its presentation is 'enhanced' as and when puberty hits but if it's anything like other labels [2]...

Reiterating that medication is not the only intervention option when it comes to ADHD and that one still needs to be cautious about the use of psychoactive substances typically being part of ADHD pharmacotherapy, I am airing on the more positive implications of the Bachmann findings rather than the negatives. Like many other discussions about medication use under various different circumstances (see here for example) it's easy to say that such medicines use is growing because of inappropriate or over-zealous use and should be curbed. But such medications often afford a real increase in quality of life when it comes to ADHD and, bearing in mind those enhanced risks typically associated with the label of ADHD, I can't in all honesty say that greater medication use is specifically detrimental to individuals personally or in a wider context...

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[1] Bachmann CJ. et al. Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012. Eur Neuropsychopharmacol. 2017 Mar 20. pii: S0924-977X(17)30184-0.

[2] Gillberg C. & Schaumann H. Infantile autism and puberty. J Autism Dev Disord. 1981 Dec;11(4):365-71.

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ResearchBlogging.org Bachmann CJ, Wijlaars LP, Kalverdijk LJ, Burcu M, Glaeske G, Schuiling-Veninga CC, Hoffmann F, Aagaard L, & Zito JM (2017). Trends in ADHD medication use in children and adolescents in five western countries, 2005-2012. European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology PMID: 28336088