wow, first child care and now psychoactive medication. It's fun when people in the blogosphere start talking about things I have profound interest in, either inherently or because I sort of fell into it through my work.
Psychoactive medication I have an inherent interest in.
CalPundit
says he likes a Virginia Postrel post that I found pretty dumb. Here is the TNR
article on ADHD that inspired Virginia Postrel.
The first half of this post is on ADHD, the second on depression.
I do think ADHD exists. But the way the TNR article blithely asserts that "even a cursory examination of the existing literature or, for that matter, simply talking to the parents and teachers of children with ADHD reveals, the condition is real, and it is treatable," is unjustified. I've performed more than a cursory examination of the existing literature, and the conclusion I came to was that it was real, but it was vastly overdiagnosed. "Simply talking to the parents and teachers of children with ADHD" wouldn't prove that ADHD exists. It might prove that their kids had serious problems, and even that Ritalin managed to alleviate them, but it wouldn't mean that the thing causing those problems was the lack of behavioral inhibition mechanism Russell Barkley describes (another thing that article does wrong is fail to identify its experts as people who make an excellent living treating, talking about, writing about, and selling videos about ADHD. I'm not saying they're corrupt, but journalists should describe the relevant details about their experts, rather than acting as if they're just citing a random authority, so readers can come to their own conclusions about their biases). Maybe the kids have an emotional disturbance that manifests itself in poor attention and inhibition (or whatever). It's sort of like how the fact that sometimes people forget abuse does not prove a repression mechanism (another thing that may not exist, or if it does is probably way overdiagnosed. People just forget a lot more than one would think). Since I do think ADHD exists, I'm not going to argue that point (though it's worth mentioning that some studies
have found as many as 28% of kids on Ritalin are also taking
two or more other psychotropic drugs, which might suggest that there's more of a behavioral problem stew than one isolatable disorder), but I think the author puts too much faith in his conversations, unless his conversations were systematic, large scale diagnostic interviews with kids, teachers, and parents.
The TNR article goes on: "Often the best diagnostic test for an ailment is how it responds to treatment."
Well, it's true that often sick people who respond to the same treatment have the same ailment, but if behavior was incorrectly pathologized in the first place, the fact that drugs change the behavior does not mean there was truly an ailment. My sobriety responds excellently to alcohol. The fact that alcohol gets rid of sobriety for both me and the next gal pretty much equally well indicates that we were both sober to begin with. It doesn't mean that sobriety was an ailment.
Yes, ADHD makes kids calmer and enables them to focus better. (Caffeine also improves focus unless taken in too great a does, and it possibly works in a similar way to Ritalin, but just because caffeine helps you focus does not mean your previous lack of focus was a disease.) Some of those kids were pathologically hyperactive and inattentive, and it's proper that they should be medicated. However, one of the problems with ADHD (and also with depression; Virginia Postrel tells the untruth that clinical depression is fundamentally different from something ordinary people experience--I'll get to that later) is that it almost certainly exists on a continuum. Everybody had problems with concentration and self control. In some people on the tail end of a bell curve, it's so bad that it will interfere with their life functions so much that we decide medication will make them a lot happier and more productive. The problem is deciding at what point on the bell curve it's bad enough to medicate--in the worst 1%? the worst 10%? The other problem--which the TNR article shrugs off when it says it doesn't matter that there's no way to objectively detect the presence of ADHD--is that the criteria for ADHD are incredibly subjective (this is a problem with a lot of psychiatric disorders). Persistent inattention? Frequent fidgeting? What is truly pathological? ADHD critics aren't just talking out of their asses when they worry that we are pathologizing ordinary childhood behaviors. When you read some of the percentages of children who are on medication in some schools, it's fair to wonder about the criteria we're using to define pathology. Here's an NIH
press release detailing results of a survey in which
15% of white boys had been diagnosed with ADHD, and 10% were being medicated. The NIH don't wonder if the children are being overmedicated, they just say, "Impact of Attention Deficit-Hyperactivity May Be Underestimated." If we find certain behaviors so troubling that they need to be medicated out of existence, but they are found in 15% of the white male population, that to me rings bells that we are overpathologizing difference, and maybe we need to be thinking about different ways to respond to some of these kids.
Fumento could stand to talk to some actual clinicians who dissent from his Ritalin boosterism. This paragraph is very flawed:
Barkley and Rapoport say research backs her up. Randomized, controlled studies in both the United States and Sweden have tried combining medication with behavioral interventions and then dropped either one or the other. For those trying to go on without medicine, "the behavioral interventions maintained nothing," Barkley says. Rapoport concurs: "Unfortunately, behavior modification doesn't seem to help with ADHD." (Both doctors are quick to add that ADHD is often accompanied by other disorders that are treatable through behavior modification in tandem with medicine.)
It's been a while since I've read the MTA study, but
this article does a good job of summarizing the results. Yes, it's true that a higher percentage of kids who are only on meds normalize than of kids who only get behavior modification treatment (but many kids in the behavioral modification group did improve). Medication only outpaced behavior modification in improving the primary ADHD symptoms--inattention and hyperactivity. They were equally effective in treating aggression and defiance, etc. As time passed, however, the positive effects of behavioral modification maintained, while the effects of medication diminished a little. But one of the most important things this paragraph leaves out is that combination behavioral/medical treatments are better than medication alone, and it's a little bit silly that Barkely criticizes behavioral interventions as having no lasting effects, because the only reason drugs have lasting effects is because kids keep taking them! There's no evidence of improvements that last even if the medication is discontinued (if drugs are used alone, without other therapies) for any psychotropic drug that I know of. (I could be wrong, but I've never heard of one.) Finally, another huge piece of information about treatment this paragraph omits is that the dropout rate was a higher in the medication alone groups than it was in either the behavior modification or the combined treatment group, and parents and teachers reported higher levels of satisfaction with those treatments. This is a typical (sometimes willful) mistake people make in interpreting the results of treatment studies: they don't consider the dropout rate as part of the overall failure rate of the treatment, even though if people can't stick with the treatment protocol, it doesn't do them much good. I don't have a copy of the study with me, so I can't look at the raw numbers and see whether behavioral treatment becomes more effective than just medication if you consider the dropout rate, but it's a possibility. What to conclude? That combined treatment is probably best in most cases, but in all cases the individual needs and responses of the child and family should be considered, and that Fumento is publishing this simplistic near-advertisement for Ritalin is not just bad journalism, it's socially irresponsible.
The article goes on (I could fulminate all day) to brush off statistics about communities where Ritalin prevalance is huge, not by actually refuting these stats, but by saying that there are also communities where it's underprescribed. Yes it's bad (and not particularly surprising) that the poor and minorities have less access to medical care, including psychiatric care. I'll stipulate that there are probably kids who could benefit from Ritalin but don't get it. Fumento does not demonstrate enough intellectual honesty to do what I just did--acknowledge that if there are communities where 20% of white boys are being drugged (!) that is a huge problem. And sentences like this are just absurd: "A report in the January 2003 issue of Archives of Pediatrics and Adolescent Medicine did find a large increase in the use of ADHD medicines from 1987 to 1996, an increase that doesn't appear to be slowing. Yet nobody thinks it's a problem that routine screening for high blood pressure has produced a big increase in the use of hypertension medicine." But there is a difference between ADHD and hypertension. Hypertension you can measure, so you can be pretty sure you're not giving medicine to people don't need it. And despite what the "it's chemical" brigade will tell you, there
is a difference between physiological and psychiatric disorders. There's usually not a danger of doctors unjustly pathologizing one end of normal when treating physiological disorders (well, sometimes there is, like when endocrinologists give little girls infertility-causing hormones because they're afraid they'll grow up to be too tall). The diagnosis of psychiatric disorders is usually much more subjective and therefore much more subject to error, or to becoming a tool for the imposition of cultural norms on healthy people. I'm not saying I'm a Szaszian who believes psychopathology doesn't exist, but I do believe in actively critiquing the psychiatric establishment, which has a time-honored tradition, from Freud to the present day, of abusing its power to determine what is disease and what is not.
On to Virginia Postrel. I can't permalink, but
scroll down the the post entitled "mental treatments." People who suffer from mental disorders often claim some kind of special credibility on the subject, when in fact their diagnosis often motivates them to talk about the disorder in a certain way, and they actually have less credibility, or at the very least, no more credibility than a non-sufferer who chooses to educate herself. This paragraph is just wrong:
I don't know much about ADHD, although the anecdotal experience I've heard from parents backs Mike's case. But I do know about depression, and it's completely distinguishable from ordinary sadness. The paralyzing despair it induces has absolutely nothing to do with anything happening outside your head. You can have a perfectly happy life and be depressed and, conversely, a miserable life with no depression.
No, actually, clinical depression is not completely distinguishable from ordinary sadness. It's different in its severity and its duration, but it's not a completely different phenomenon. Depression is often (perhaps even in a majority of cases--I really need access to some full text psyc journal databases) triggered by an external event. What distinguishes clinical from nonclinical depression is simply the sufferer's resistance to improvement. If profound feelings of sadness (or anhedonia--loss of pleasure) along with some other behavioral, cognitive, and somatic symptoms persist for two weeks, then the DSM IV says you're clinically depressed. In fact, clinical depression, like ADHD, probably exists on a continuum of human experience, with happiness being on one end of the affective scale, normal sadness being in the negative range, and severe depression being on one end.
Here are the DSM IV diagnostic criteria for clinical depression. For those of you who think you have never been clinically depressed (I think I'm in that category), but have felt very upset for some sustained period in your life (say, a week), I would ask: were you irritable during that period? did your appetite change? did your sleep patterns change? were you fatigued?\\ (probably as a result of your answer to the last question)? did you feel guilty? have trouble making decisions or concentrating? Your answer to some of those questions is probably yes. Mine was yes to all of them. The very fact that the diagnostic criteria specify that these symptoms only indicate depression if it's not a natural response to a major trauma, like the death of a loved one, is an indication that clinical depression is not something utterly distinct from what normal people experience. Because depression, like ADHD, probably exists on a continuum, as with ADHD we have the difficult question of deciding what to pathologize, what to medicate. That last sentence of Virginia Postrel's is either badly written, or nonsensical, or both. Does she mean that the external circumstances of your life can appear happy to the outside observer and you can become depressed? That might make more sense. You can't be happy and depressed however. You just can't, and if you are clinically depressed, you won't be able to function well enough to maintain the appearance of having a happy life either.
VP is motivated to say that clinical depression is something fundamentally, qualitatively different from what ordinary people experience to justify to herself that she takes drugs to alleviate it. I don't think it's wrong that she takes drugs; I don't know enough about her psychological health to be a judge of that. I do think it's wrong if she takes drugs without at least periodic therapy. People who pop pills in place of (instead of addition to) real psychological work have a tremendous incentive to believe their depression is nothing more than a physiological disease, and they are taking the medicine to correct it. But "it's chemical" is a nearly meaningless statement when talking about depression or any other psychiatric disorder. Unless you believe in a soul or some other supernatural explanation for human consciousness, which of course, many people do; I, however, am not one of them, every mental state is chemical. Love, despair, jealously, and genius are all reducible to the position of cells and molecules in our brains. Yes, taking a drug can change the composition of chemicals in your brain and make you feel better. For some people, it is absolutely necessary to their life function and I would not deny them medication. However, learning to think differently, to examine your own motivations, to behave in ways that make you more creative or that let love into your life, to learn to be kinder and more generous towards others also will alter the position of cells and molecules in your brain, and they will also make you feel better. And I am a liberal who is not at all unsympathetic to the suffering of the mentally ill or the merely neurotic, but yeah, it bothers me that people in this society use drugs as a substitute for the hard work of self examination and self improvement. Never, absolutely never should drugs be a substitute for (good) therapy, and Virginia Postrel is full of shit when she says that "biological treatments...undermine the claims of therapists;" they do nothing of the kind, for reasons I just stated: that a mental state has a biological underpinning does not mean that therapy cannot also alter the chemical composition of your brain. And when you do it through therapy (or through religious counseling, or whatever) rather than with drugs alone, you've actually changed your values, your actions, your self concept in a way that you accomplished yourself and that can last even when you're not in direct treatment, which no medication for depression can claim to do. New research is revealing that even schizophrenia, which is the stereotypical example of the highly heritable "biological" disease, is treatable with cognitive therapies that allow people to recognize their delusions and function much better than they can with medication alone.
My mother started taking Zoloft, I don't know, maybe a year ago. When I heard this I told her, "Mom, I think you're doing this as a substitute for addressing the ways your life is fundamentally unfulfilling." She said, "I know. That doesn't bother me." My mom lives in a small, very religious town where it's hard for her to find friends who truly share her values. She's totally given up on finding a romantic partner. It's actually pretty hard for me to imagine her finding a romantic partner, at least one that she would be willing to be reciprocally attracted to (given what I've heard her say), but she could have definitely changed her life so she lived in an area where she could have had friends she related to, and where she could volunteer for causes she cares about, like environmental activism, population control, and reproductive rights (which she really can't do in half Catholic, half born again Los Banos, CA). I've heard her talk frequently about how much she likes Santa Fe. I asked her over and over again why she didn't try to move there, and she was just convinced that it would be financially devastating, that she'd go back to the bottom of a pay scale. But she's bilingual, which is already an asset, and she didn't even try to look into her options, like getting a Special Ed credential, or finding a job as an educational administrator--or something, I don't know. My point is she didn't look, because she has a very pessimistic self-denying personality (and I hope to god I don't turn into her. sometimes she says she was like me when she was young and that scares the fuck out of me). So instead of trying to do the best thing for her life, she takes Zoloft, which takes the edge off. her doctor just gave it to her when she asked for it. Asked her a couple of questions and then got out his pad. Didn't suggest she see a therapist at all. Forgive me if I find this a little, well, depressing. When she visited me in New York at one point I made some offhanded comment about "depressing suburban life." "Not all suburban life is depressing," my mom retorted. "My suburban life isn't depressing." "Mom," I said. "You're on Zoloft. I don't think you get to be the poster child for emotional fulfillment in suburbia." "Oh yeah," she said. Then she sort of giggled. "It's a low dose." In contrast, my friend Susan takes Zoloft. She is prone to very bad depression, and I don't doubt that she needs it. But Susan also has a lot of problems with the way she thinks about herself and the way she interacts with others (problems very similar to mine, actually, but more severe). She's in therapy to deal with these problems. She's doing the work my mom isn't, and she every day aspires to a better life than the one she's living. Yes, some people are genetically predisposed to feel really bad some of the time, and sometimes that lasts long enough to be clinical depression. But not a single one of these people does not have problems with the way they see themselves and the world that need to be addressed in some sort of counseling. Not one. Some people's depression is untraceable, at least in proportion, to anything that happened in their past. But there's no such thing as depression that does not have cognitive, affective, and behavioral components (that's why it's a mental disorder!) that need to be addressed with cognitive, affective (in addition to medication), and behavioral treatments. And if you're not doing the work, you're lazy. The drug that makes it all okay is all you're willing to invest in. You're living the unexamined life, and even if you've improved your affect enough so that you're life feels happier, Socrates would say that your life is still not worth living.
That was harsh. But I meant it. I've written too much, but I feel strongly about this. Now I must go to bed.