EPIDEMIC PROPORTIONS

I couldn't comment on the career arc of Tom Cruise even if I wanted to – which is to say, even if doing so would not be an insipid waste of time – because as a rule I do not pay to see his movies. It is a personal boycott. Yes, I've seen bits of A Few Good Men because it is on cable basic every Saturday afternoon (apparently by law) and my dad took me to see Top Gun when I was six. In practice, however, Mr. Cruise's relentless public anti-psychiatry campaigning has earned him a place on my personal shitlist. I realize that he does not care. But like the anti-vaccine pinheads toiling away at the University of Google, this position does not merely make Mr. Cruise wrong. It also makes him dangerous. There are real people with real mental illnesses who are able to function thanks to the intervention of pharmaceuticals and psychiatry, and many more people who could benefit from doing so.

I mention this not to beat Mr. Cruise and his fellow cultists like the sad pinata of pseudoscience that they are. The point is that while I am many questionable things, I am not anti-psychiatry or -medicine. Re-read that sentence – multiple times if necessary – before you rush to the comments.

This must be good, right?

As a young faculty member there is both great value and great risk in listening to the Elders of academia. Much of their wisdom is invaluable; much of their complaining represents an unwillingness to change and/or a generational gap they are incapable of bridging. So it was with great hesitation that I engaged several older colleagues – not at my current university – bemoaning the over-medication and general over-diagnosing of the modern crop of undergraduates. The more they talked about it, the more I felt that there was a kernel of truth in it. Even the eight short years I have been teaching have been an eye-opening experience in this regard.

On the one hand this is an argument that should be treated with skepticism. An older person saying "We didn't have no 'ADHD' back in my day!" is foolish on the level of listening to old WWII veterans talking about how they didn't have PTSD back then. Of course they had it, they just didn't have a name for it. The treatment was alcohol, self-administered. Lots of problems exist long before medicine figures out how to diagnose and categorize them – postpartum depression, concussions, autism, and so on.

Once we reject that argument on its face and accept that the whole gamut of things we accommodate in the field of education – learning disabilities, developmental disorders, anxiety/depression, ADHD/ADD, and so on – are real, the question becomes more complex. We stop asking whether these things are real and start wondering how it is that suddenly every student in the educational system has them.

That is hyperbole, of course. But every year a larger percentage of the students I deal with, as is the case with other faculty as well, have various learning disabilities assigned to them. Often the student does not even have any idea what his or her disability is supposed to be; they know only that ever since they were in kindergarten, their parents and school administrators have been telling them that they are learning disabled. In the past ten years, conservative measurements show that the diagnosis of learning disabilities under the IDEA legislation has increased 40%.

Estimates vary widely, but something on the order of 15 to 20 percent of college undergraduates today are diagnosed with ADHD, and more than half (!!!) are taking Adderall or Ritalin without prescriptions either for fun or as a study aid. In graduate school and in my career I've met numerous academics who had legitimate addictions to these medications, and to a person they all stated that getting them legally from a doctor is as easy as walking into the office and saying "I have trouble focusing sometimes." Thirty seconds later they left with a prescription for amphetamines. (Check out this panel op-ed discussion of ADHD/prescription issues in education from the NY Times for more).

Of course you already know some of these statistics, just like you know that antidepressants, anxiety drugs, painkillers, and every other kind of medication on the planet is wildly over-prescribed in this country. But sometimes I stand in class and wonder that when we consider the recreational drug users (not a rarity in college, of course) with the students given pharmaceuticals by a doctor, are there any students left who aren't chemically altered by the time they get to me?

To hear the older faculty argue that back in the day, none of these things existed and somehow students managed to get through college anyway is misleading at best. Of course there were students with undiagnosed issues who never even made it to college or who failed because they couldn't study, couldn't focus, or couldn't do what was asked of them without some kind of necessary assistance. Despite that, I must admit that I wonder about the ratio of legitimate diagnoses to actual diagnoses in the student population. Doctors (especially the kind that gravitate to campus "health centers" and whatnot) will give pretty much anyone Adderall these days, but how many of those same students actually have ADHD? How many 18 year olds with diagnosed learning disabilities are simply reacting to the system (and Mom & Dad) telling them for the past ten years that they are disabled?

I have no answers to any of these questions. It's merely a set of observations. Despite all of these medical conditions being quite real and quite legitimate, I do not necessarily think my older colleagues insane quack-medicine theorists for questioning the rapid and substantial increase in the number of students so labeled in recent years. Those of you who have school- or college-aged children (or who are college-aged) are of particular interest to me here; what is your take on this? Is it the new moral panic – Druuuugs! Everyone's on druuuuuugs! Think of the childrennnn! – or is this a question we should spend any time thinking about?

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75 Responses to “EPIDEMIC PROPORTIONS”

  1. Andy Brown Says:

    I think our current levels of medication are probably overdetermined. And I think there is a lot going on there, from corporate profiteering to indulging anxious parents. But here is another way to think about it: an overarching push toward Standardization. It is one thing to standardize textbooks, institutions, curricula, etc. It is an entirely different thing to standardize the student body (and I mean that in multiple ways). Yet I think that's what this pressure is toward. Even a couple of generations ago, only a minority of students was expected to make their way through 14 or 16 years of academic, classroom instruction. Not everyone is cut out to find that a satisfactory existence for thriving within. Hence the effort to set our growing repertoire of chemical adjusters to the task.

  2. Andy Brown Says:

    In a complementary process, education is being molded into something that can process this much less differentiated mass. The reason that so many teachers dislike grade inflation is that they experience it as pressure to give everyone essentially the same grade. Paa(ABCD)aasssss.

  3. JohnR Says:

    Interesting. W/regard to the question of "kids today", I suppose there are two schools of thought on that. Changes may be real or imagined; we may over-react to real change and miss it because we're using a particular label promiscuously. Autism used to be very rare; now it's extremely common, and that doesn't even include Asperger's. Is that statement accurate, or have we started looking and diagnosing better? Beats the hell out of me. I do know that my wife's cousin has a boy with Asperger's, one of my two colleagues in the lab has twin boys with severe autism, and almost everyone I know has or knows someone who has an autistic kid. What does this mean? Is it mercury in sodas from the HFCS processing? Is it mercury-compound thimerosol in various things? Is it anything to do with mercury? Is it rising age of father at conception? Is it something else? The advent of Reaganomics, maybe? I haven't seen any clear indications. How about depressive disorders, including bipolar Type I and Type II and all the other varieties of depression. Are they more common than 30 years ago? 50 years ago? Beats the hell out of me. It wouldn't surprise me – overcrowding is associated with various stress-related problems in various other animals, but I don't know. Is the huge increase in diagnoses a function of a huge increase of psychiatrists needing patients? Beats me. So a lot of college kids are goofed up on one thing or another. Is that actually different from 30 years ago, or are we just talking about another in an endless string of "kids today" stories? Hell if I know. Anecdotal evidence is evidence, but what does it actually mean? I was diagnosed as bipolar 2 after college, and for a while used one of two different medications. One worked really great. One screwed me up very badly, and it took a long time to get over the side-effects. Back in college, I developed a pattern of delaying assignments because as the stress level increased, at some point I would go into a 'creative frenzy' where the stuff just poured out onto the page, and I couldn't stop writing. I had tunnel vision, couldn't sleep, couldn't not write. When I was done, I crashed for a day or so to recover. It felt great; it felt wonderful and when it stopped happening in my first year of grad. school I was devastated. I was suicidal for a while, but managed not to pull the trigger. Eventually I was diagnosed and put on a medication that was amazing – it was like the lights went on and the color came back; a lot like the first cup of coffee on a Monday. Anyway, medications wear off as you habituate to them; diagnoses are often less than accurate, as most docs aren't mind-readers, and even depressed people aren't always completely forthcoming. People use useful medication for unintended or unanticipated purposes. What a surprise! We're most of us screwed up one way or another; life's a pile of crap sometimes, and sometimes we just seem to want to make it worse. So? Human nature; we've been doing that for millennia if not longer. You can't help everybody, and a lot of us don't really seem to want to be helped anyway. Do the best you can to help the ones who want and need it the worst, and try not to get overwhelmed. Platitude, platitude, all is platitudes.

  4. DocAmazing Says:

    I'm a pediatrician, so I see a lot of this. First problem: kids whose behavioral problems might not be an issue in a classroom of 24 kids are going to be a problem in a class of 32. Teachers are overworked, and lean heavily on us docs for a chemical fix to the behavioral problem. Insurers won't pay for complex psychiatric testing to get to the root of the specific behavioral problem that the kid has, so they lean on us to make the ADHD diagnosis and begin stimulant treatment. Even getting a referral to a psychologist is an uphill battle.

    When easy, less-expensive chemical solutions are available, they will be used, appropriately or otherwise, unless someone's riding herd on the insurers and providing other options.

  5. JazzBumpa Says:

    I need to run so I'll get back to read comments later. It's absolutely a question we should spend more time thinking about. And not just in that demographic.

    My mother in law is 84 and in an extended care facility. We recently changed her doctor and he reduced her drugs dramatically. She had become psychotic, paranoid and aggressive – on anti-psychotics, anti-paranoics, and trancs. Her turn around was miraculous.

    How many old people are in that condition – over medicated and left out to dry? It's a damned good thing my lovely wife has been a staunch advocate for her mother.

    There are a few lessons here. One is to not simply think MD's have any god damned idea what they're doing when they throw meds around. Another is that 3 drug interactions never get studied and lots of people are on a dozen or more, so nobody has any fucking idea what that does to anyone. Another is that drug reactions are individual – it might not o to me what it does to you.

    Most importantly – if anyone you care about is in an institution or hospital, you have to watch like a hawk, ask every question you can think of, get advice from others, and don't think anyone there is going to give a shit about outcomes. [Even though some of them do, obviously – but they also have 100 other patients to think about.]

    This is literally life and death, and you can make a huge difference.

    JzB

  6. mothra Says:

    I don't know a thing about this, but I do know that there is a woman I work with who needs medication. Woman probably has some kind of personality disorder in addition to having severe ADHD. God, she's impossible.

  7. protected static Says:

    @lofgren & Middle Seaman – country of service makes a difference. The Brits have much lower rates of all kinds of psychiatric complaints among combat troops coming back from Afghanistan compared to their American counterparts.

  8. Strangepork Says:

    Cool thread, and everyone has been pretty cool and respectful. It's always interesting to hear other's experiences with psychiatry and meds, etc. I was diagnosed with MDD as a teenager in the 90's and institutionalized for a bit. When I was inside, I met a little kid named Mike H., or Mikey Hyper. He talked so fast you could only make out every other word. He literally couldn't look you in the eye for more than 10 seconds while you were talking to him before he was staring at the crack in the ceiling, or your shoes, or that bird over there. You learned to talk in 3 word sentences to him, because he'd be gone down the hall by the end of a 4th. Alternatively, if you really needed to make sure he processed what you were saying, you could hold onto his cheeks and touch your forehead to his while you talked so that you were the only thing he could see. He was also the most excellent human cannonball — a "game" where you ran down the boy's wing as fast as possible and jumped at the grate over the windows, which would bounce you back down the hallway…we were bored.
    Anyway, whenever anyone suggests that ADHD doesn't exist, my memory of Mikey begs to differ.

  9. Trapclap Says:

    @Mothra, There's an old saying that's appropriate here: Mental illnesses have a tendency to come in threes. Browse around some ADD communities and you'll see an alarming tendency for people to have AD/HD along with bipolar and even autism. As someone with ADHD, I can't imagine a worse combo.

    The drug cocktails these people take are the craziest thing. Mixing antidepressants with stimulants and who knows what else in a lifelong struggle to find some kind of balance in your life must be a bit of a nightmare. On the one hand, it's easy to wonder whether they really need the drugs. On the other hand..Can you imagine being unable to focus on any one thing at a time while also having a tendency to rapidly shift emotions? Have some sympathy and respect for those with mental illnesses. They can be hard to work with, but you get to be away from that for most of your day. They don't.

  10. hardcastle Says:

    Given the NIMH statistics (~8% for 18-29yo) regarding the prevalence of attention deficit disorders, I find the "overmedication" hype to be incredibly overblown, self-satisfied dick waving by the same type of people who get all wigged out about "sexting."

    My mom runs a counseling agency and views on AD[H]D and medication in general vary widely between different counselors, but they frequently deal with people taking various medications for mental health issues and thus have to remain pretty neutral in their practices. Growing up around this might have skewed my view a little, but I think the perception that drugs are just casually doled out all the time is extremely flawed. It happens, obviously. But it certainly does not represent the majority of cases.

    Most of the clients who are on some sort of medication did not get it by walking into a doctor's office and saying "I have trouble focusing." The prescription usually follows a history of behavioral problems/trauma/emotional upset/etc that eventually leads the person to see a counselor. The counselor will try to help them process through their issues without medication, but will refer them to a psychiatrist if it becomes apparent that meds might be needed. The client, the counselor, and the psychiatrist all communicate about the process the entire time and everything is documented and monitored.

    Maybe I'm harping on something that's beside the point, but I really hate the "overmedicating" perception because it has led some clients to avoid medications that they probably need. It CAN be easy/effortless to get psychiatric drugs to abuse, but promoting that image just compounds the mental health stigma. I liken it a little bit to the image of the Welfare Queen, because yeah, we all have a fuckload of examples that fit the stereotype, but in the end it's just anecdotal evidence and is not a good representative of the broad picture.

    I know tons of people who have gotten Adderall when they really didn't need it. It's certainly a thing and it probably should not be happening, but I honestly do not believe that there are enough of those people to represent anything close to an "epidemic of overmedication." It might seem that way because A) we are saturated with advertising for prescriptions, which is really screwed up, and B) confirmation and memory biases make the Adderall addict stand out in our minds over the other, much larger group of people who really need it to function and acquired it legitimately.

    As far as the increase in diagnosis of learning disabilities, I would guess that's just a side effect of us figuring out that there is no one-size-fits-all when it comes to human learning and development. Slapping a diagnosis on a kid in a society that heavily stigmatizes mental illness is probably one of the shittier ways to deal with it, though.

  11. matthew Says:

    Here's a blog post that goes deeper, if you want to get past anecdotes.

    Here are some headings:
    Progressive Increase in Required Dosage
    THE PATIENT WANTS STABILITY TOO
    The Short-Term vs The Long-Term
    Drug Withdrawal as Proof That It Works

  12. Elle Says:

    The Brits have much lower rates of all kinds of psychiatric complaints among combat troops coming back from Afghanistan compared to their American counterparts.

    Given the culture around mental health in the UK, and the relative inaccessibility of mental health services, I think that underdiagnosis should be considered as a likely cause of at least some of that difference.

  13. Anonymouse Says:

    @Strangepork ("Anyway, whenever anyone suggests that ADHD doesn't exist, my memory of Mikey begs to differ."): absolutely, and just in my neighborhood, I know two children who absolutely need ADHD meds. They're fine when on them, completely unable to focus when not.

    @DocAmazing ("kids whose behavioral problems might not be an issue in a classroom of 24 kids are going to be a problem in a class of 32. Teachers are overworked, and lean heavily on us docs for a chemical fix to the behavioral problem. Insurers won't pay for complex psychiatric testing to get to the root of the specific behavioral problem that the kid has, so they lean on us to make the ADHD diagnosis and begin stimulant treatment. Even getting a referral to a psychologist is an uphill battle.") I couldn't agree more. In my child's case, just getting material to learn that he hadn't mastered 3 years before did the trick. Engage the mind, and the child stops fidgeting. But the overworked teacher couldn't engage the mind of one child out of 32 when she had to get the Down Syndrome child to pass the No Child Left Untested debacle every year. Every other child's needs came last in the face of the one who was never going to pass anyway.

  14. Ed Says:

    I had one of those 'angry and distant' fathers in the 50s and 60s. Got 3 brothers and two of them are broken, can't say for the third, he abandoned the family. Pharmacology can help, but it also destroys and distorts. Pills without additional treatment are a tragic mistake. You'd think that with as much mental illness as we have, it would be better treated, but no. Big Pharma rules the day. Roll those pills, patient turn over is the goal in medicine, not healing. Doc has to see 50 patients today, no time for humans, just hustle the bodies and file those claims.

  15. Kate Says:

    Ivy League law student here.

    I really enjoyed reading this discussion thread. While I have nothing other than anecdotal evidence of observations from the law library to add to the discussion, I would guess that at least a third of my classmates are on some kind of study-drug. Mostly prescribed.

    I think a big part of it is stress… we all know that there's not a much of a market for the JD we're sinking ever-deeper into debt for. If you see everyone else working 12-hour days to beat the curve, there's a lot of motivation to find something that lets you do that too. And you need drugs for that – humans simply aren't meant to sit at a desk and read for 80+ hours a week.

  16. protected static Says:

    @Elle – it seems to have far more to do with how the UK rotates their troops out of combat zones, as these screenings are being done by the MoD. At the end of a deployment, the entire unit is given leave, together, but not in the UK. The entire unit gets to decompress together, away from their families and friends and stressors of everyday life. In the US, we typically just dump our troops back into their daily routines and expect them to instantly transition back to 'normal' as soon as they return.

  17. Elle Says:

    @Protected Static

    I don't mean to do down the measures that the UK forces take to maximise the mental wellbeing of servicepeople, and it's entirely possible that the decompression you describe is enough to process the trauma of combat. I haven't read the paper referenced on this page on the armed forces and mental health, but it seems possible that the higher incidence of alcohol misuse than the general population might be attributable to self-medication for otherwise underdiagnosed mental health problems.

    Of course, I could be quite wrong.

  18. amil666 Says:

    A propos: http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

    Professor of Psychiatry and Chair of DSM-IV Task Force complains that DSM-V is just going to exacerbate the over-diagnosis problem.

    Choice quotes:

    "This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don't follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense."

    "The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good. Yesterday's APA approval makes it likely that DSM 5 will start a half or dozen or more new fads which will be detrimental to the misdiagnosed individuals and costly to our society.

    The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their's is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed)."

    He then goes on to list ten problematic changes that will lead to over-diagnosis (including of ADD).

  19. Eric Titus Says:

    There's two issues. The first is that while medication will do many people a lot of good, there's a tendency to see normal productivity (i.e. the ability to do 12hours of schoolwork, not have occassional days lost to lethargy, etc) as the goal rather than the more difficult task of figuring out how drugs can make you more well-adjusted and happy on your own terms. It's healthy to have a dialogue about whether psychopharmaceuticals are too tied up to some cookie cutter version of productivity and normalcy.

    There's also plenty of problems with the drug-based approach to treating mental issues. As @Trapclap points out you end up getting multiple diagnoses and "bizarre drug cocktails." The problem is the diagnostic tools: since disorders are not so clear-cut as the DSM makes them out to be, chances are that a disorder+some "normal" personality quirks will leave you with multiple potential diagnoses. On the less serious side, periods of reduced productivity are not unusual, but can easily result in an ADD diagnosis if you are (consciously or subconsciously) predisposed in that direction. The thing is, it's also not "natural" to be in school from 8-4 for 12 years of of your life (or more). So I do think that the diagnostic tools we have definitely make for plenty of "false positives". Psychiastrists know that it's somewhat discrediting them, but the problem is that most of them don't have the expertise to exit the diagnose-prescribe framework.

  20. protected static Says:

    @Elle – my understanding (which is as a layperson married to a researcher in this field) is that cultural norms and expectations play a greater role in drinking to excess than does self-medication. In the US, that's been difficult to study because active duty military personnel have few rights to privacy even as research subjects.

  21. Elle Says:

    @ Protected Static

    The cause of the alcohol misuse rate in the UK armed services being twice that in the general population isn't known. The defense select committee of the House of Commons recommended to the MoD in 2011 that it needed to do more work to explore this.

    The Committee itself, having heard evidence, posited that it might be a response to combat stress, or not.

    I guess at this point, we don't know.

  22. Jane Says:

    Parent of a 22 year old here. She and her friends take less "medication" than I did at her age.

    It seems that more young people are seriously unhappy now than they were in the mid 1980's, at least here in Sweden. There are excellent statistics available. (http://www.fhi.se/PageFiles/12031/R2011-9-Kartlaggning-av-psykisk-halsa-bland-barn-och-unga-2.pdf) – mostly in Swedish, sorry.

    This is serious and real and a large effect, and doesn't have to do with overmedication or competition with drug enhanced peers.

  23. mclaren Says:

    Clearly from the tone of your post, you suffer from affective disorder and need to be prescribed massive amounts of ritalin, chlorpromazine, risperidone, aripiprazole, olanzapine, quetiapine, and ziprasidone. If improvement is not visible within 10 to 14 weeks, stereotaxic surgery to burn out the affected areas of the brain may be indicated.

  24. Robert Says:

    I can speak from my experience as a parent. My husband and I adopted our two sons (now 15 and 11) from foster care. Each were five when adopted. They have both been receiving psychiatric AND psychological counseling since, along with medication for multiple psychiatric diagnoses. The meme of 'mommy says you're ADHD, so let's drug you into catatonic submission' truly chaps my hide. It took professional evaluation by multiple mental health professionals before either of them were given 'drugs'. I am convinced that they would have had to have been institutionalized without the care they've received.

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