Mental Health is not Fake News

Over the last few months, an article highlighting a very prominent psychologist, Jerome Kagan has been floating around, disputing the validity of ADHD as a medical diagnosis. Anytime the word “Harvard” appears behind a person’s name, it seems to give their argument almost automatic credibility, and after seeing it this week on my social media feed for the sixth time in two months, I felt the need to write about it.  From the article:

It may be very surprising to learn that he believes that the most modern diagnosis of ADHD is a mere invention rather than a serious condition.
“Let’s go back 50 years. We have a 7-year-old child who is bored in school and disrupts classes. Back then, he was called lazy. Today, he is said to suffer from ADHD (Attention Deficit Hyperactivity Disorder). That’s why the numbers have soared,” says Kegan in the interview.

When asked about his opinion on the disorder, Kegan told the Spiegel that he believes ADHD is an invention. He thinks that if a child is not doing well in school, the pediatrician gives that child Ritalin, since the cure is available to the doctors and they give the diagnosis.

According to Kagan, the fact that millions of American children who are inaccurately diagnosed as mentally ill because they think there is something fundamentally wrong with them is devastating.

Besides being a psychologist is determined to raise the alarm about this trend, Kagan and others feel they’re up against “an enormously powerful alliance: pharmaceutical companies that are making billions, and a profession that is self-interested.”

Kagan himself suffered from inner restlessness and stuttering as a child, but his mother told him that there was nothing wrong with him, only that his mind was working faster than his tongue.

I’m not going to even get into the fact that they misspelled his name.

First, going back 50 years and comparing rates of diagnosis to today is going to be fraught with problems. ADHD was identified as a disorder 75 years ago but did not enter into the DSM until 30 years ago. It’s not as if a light switch goes on and screening tools are developed, health care providers are trained, and the general public automatically knows how to identify or even have a basic knowledge of a diagnosis once it becomes “official.” Now, where did we see this before?  Ah, yes…

Autism provides a fair example of how dangerous taking an opinion from one doctor, perhaps out of context, can be. Numbers have also soared with autism in the last few decades. On the surface, the numbers are so dramatic that it implies something must be making a lot more people autistic than there were just a few decades ago. The real reasons why the numbers have changed? Better screening tools and culture shifts in schools and health care that occurred over time to detect and intervene, as well as the removal of the stigma associated with the disorder, which works to help folks be more open to discussing autism.  Scientific American did an excellent piece on this last year and I highly recommend reading it, if you haven’t already.

Second, it’s not clear what the term “invention” (a term used by the article, not Jerome Kagan) means as it relates to the diagnosis of ADHD. The DSM (Diagnostic and Statistical Manual of Mental Disorders- the manual that houses mental health diagnoses and their criteria) is developed by hundreds of professionals over the course of years, taking into account research and best practices. Many of these professionals come from Harvard as well. In fact, there are 19 pages in the DSM-5 filled front to back with the names of highly regarded professionals in the fields of medicine, psychology, social work and public health who have contributed to one of the most vetted and research-based versions of the DSM to date. The creation of the DSM is an often contentious process that involves criticism and philosophical differences. The DSM-5 was the product of the most open process in the history of the manual.

I love the tidbit about “millions” of children being “inaccurately” diagnosed and believing there is something “fundamentally wrong with them.” I don’t think there is anyone in the field that I know of who would use the term “fundamentally wrong” as a means of explaining a mental health diagnosis. Viewing and describing mental health issues in this manner as a culture will certainly have a devastating impact.

According to the CDC, 21.4% of teens between the ages of 13 to 18 meet the criteria for a severe disorder. Not mild or moderate but severe, so if we were to just focus on that criterion alone, the number is in the millions. Are these the millions to whom Jerome Kagan is referring? What does he imagine should happen?

The “medication is evil” nonsense is a lot like the vaccine boogeyman, and it’s something that I’m tired of fighting. Medications work. They save lives. Are they imperfect or ineffective at times? Yes – no one is arguing that they are a panacea, they have side effects and some folks simply don’t respond well but they present as a much greater good and it’s not just Big Pharma saying so

In contrast to the industry-sponsored trials, depression trials funded by the National Institute of Mental Health (NIMH) (N=2) are characterized by many methodological strengths, lower placebo response rates (30%-35%), and meaningful between-group differences (25%-30%) that support antidepressant efficacy. The NIMH-funded trials, taken together with the demonstrated efficacy of the serotonin reuptake inhibitors for childhood-onset obsessive-compulsive disorder and the anxiety disorders, suggest a broad and important role for antidepressant medications in pediatric internalizing conditions.

The study, while showing a lack of diligence on the part of Pharma in conducting trials, still demonstrates medications as having a statistically significant benefit in the treatment of mental health issues when stronger protocols are applied. This study received far less media attention than a significantly more methodologically vulnerable study published over a year earlier in the Lancet that demonstrated contradictory findings.

I don’t have a problem with healthy skepticism. We should always question and always look for better answers. I certainly don’t have an issue with studies that cause us to rethink our thinking. My beef is with lopsided reporting and exposure — especially when it involves little evidence and a significant departure from a much larger body of evidence and expert opinion.  My problem is with a poorly written and sourced article citing one quote, potentially out of context, going viral as legitimate evidence.

What I haven’t seen, are the articles that thoroughly debunked Jerome Kagan’s quote soon after it was published.  From Science-Based Medicine:                     

At this point there is no reasonable disagreement about the fact that ADHD is a disorder of brain function. Children who meet the strict diagnostic criteria are demonstrably different, in consistent and predictable ways, than children who do not (controlling for other possible factors). They have impaired executive functions, and we can see this in changes to the relevant parts of the brain. We still have a lot to learn (again, the brain is complex) but a consistent picture is emerging.

Read the full article here.

Pediatricians, at least in my experience, are cautious when prescribing medications, and the evidence points to the issue being more about under-utilization. Time Magazine addressed this issue squarely five years ago during another “Ritalin Scare”. From the article:

The researchers, led by Kathleen Merikangas, senior investigator and chief of the Genetic Epidemiology Branch in the Intramural Research Program at the National Institute of Mental Health, reviewed data that focused specifically on teen medication use and mental health history that was gathered in 2004 by the National Comorbidity Study: Adolescent Supplement, a huge, nationally representative, face-to-face survey.

Eager to investigate anecdotal and media reports of American teens taking meds for trivial, even trumped-up causes, they compared rates of psychotropic medication use to the prevalence of mental illness in their sample, using criteria from the diagnostic “bible,” the DSM-IV, to assess symptoms and their severity. They then looked specifically for medication overuse (i.e., the prescribing of meds to teens who don’t actually have mental disorders) and medication misuse (the prescribing of meds to treat disorders for which they’re not indicated).

According to the results, some overmedication did exist — just under 2.5% of teens without a diagnosable disorder in the past year reported having received meds nonetheless — but the authors cautioned that these teens either had neurodevelopmental disorders, lingering signs of previously diagnosed mental disorders, or “subthreshold conditions” that didn’t rise to DSM-IV standards but nonetheless caused them “psychological distress or impairment.” Yet the general picture suggested much more under-medication than excessive use. An earlier analysis of the same survey data, which drew together in-depth diagnostic interviews of teens with parent interviews to ascertain what sorts of services they’d accessed for their kids’ care, had shown that 20% of the young people surveyed had, at some point in their lives, suffered from a mental health disorder severe enough to affect their ability to function. The new data, which looked specifically at how that sub-population of kids had fared in the 12 months prior to being surveyed, found that only 14.2% of the teens with a diagnosable disorder had received medication for it.

My hope is that Jerome Kagan’s remarks were taken out of context. Either way, the article is one example in a long history of mental illness being delegitimized as a real and authentic problem. As highly regarded as Kagan is, his opinion does not really hold in light of the evidence. The larger issue is that this quote is streaming through social media,  posted by folks who may or may not have the foggiest notion of whether ADHD is real.

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