I've alluded to the field of "behavioural economics" in other posts. I think this is a very interesting extension of social and motivational psychology.
I think that a broad analogy can be made between economics and psychiatry:
the phenomenon of an economy is similar to the mind, or to one's life, in a variety of ways:
1) there are engines which drive the economy, in the form of productivity. Economic productivity may be measured by goods or services generated by the population. Life productivity includes various tasks of developmental "work".
2) There is a relationship between "supply" and "demand" which changes the valuation and flow of productivity.
3) Currencies become symbolic short-cuts to exchange goods or services; emotional or behavioural "currencies" can be short-cuts in to obtain needs in the community or in relationships.
4) Problems in an economy could occur at many different levels in the system: productivity failure due to a technical, external problem (e.g. a natural disaster), a failure to exchange or trade freely, a symbolic or regulatory system which goes out of control despite integrity in the rest of the system (e.g. stock market crashes). In the economics of mind, there could be core external problems (e.g. a neurological disorder), but there could certainly also be problems "trading freely." Heightened neurotic defenses could be compared to a lack of "free trade," where healthy inner resources cannot be shared, not with other parts of oneself, nor with others. Such phenomena stunt an economy, even if the core capacity for productivity is strong. A "stock market" crash, similarly, could occur in the mind, if regulatory mechanisms in one's mind run wild, while losing touch with a moment-to-moment sense of self or present.
5) Borrowing could, one the one hand, be a powerful means to accomplish tasks that would otherwise be impossible (e.g. buying a house). Refusal to borrow limits capacity for growth. But if debt cannot be managed, it leads to an economic instability, reduced autonomy, and ultimate failure (bankruptcy). Similarly, in one's mind, risks need to be taken to grow, and one needs to borrow from others and from the community in order to develop oneself. Refusal to borrow limits what is possible. However, over-borrowing, and accumulation of social & emotional debts, leads to a cascade of chaotic effects.
6) Investing is a means of taking a risk of giving one's resources away, with the hope that the community will prosper as a result, and return the investment prosperously. Emotional and social investments are risks taken which, on the one hand, are immediately depleting, and which may cause permanent losses (e.g. with unfruitful actions are relationships) but which permit the possibility of substantial growth in one's own life, while also allowing resources for the community to grow (emotionally or socially) around you.
Much in the field of economics include sophisticated mathematical analysis of the energy dynamics in an economic system, accounting for the many variables at play. It would be interesting to apply some of this analysis to psychological dynamics. Behavioural economics is more psychology than economics, at this point. It would be curious to have more of the leaders in the study of mathematical economics apply some of their ideas to "psychological economics."
Wednesday, October 27, 2010
Psychiatry & Architecture
This is the first in a series of posts in which I'd like to discuss figurative or literal comparisons and overlaps between psychiatry and other fields of study.
Architecture could be considered a science and an art--a field with many technical elements, but with an over-riding importance given to esthetics, expressiveness, and community relationships.
Ideas in psychiatry could be considered "architectural" in the sense that it is important to have an overall sense of a plan, with a clear sense of purpose. Even with good technical skills (e.g. to relieve a symptom), work in psychiatry, or in life progress, may be unsatisfying if there is no attendance to the larger sense of purpose in the life's structure. Part of the purpose is "esthetic," but part has to do with identity, interaction with community, originality, and expressiveness. This is similar to the architectural considerations involved in planning and developing a new physical structure.
As in architecture, many very good ideas could be generated to develop one's life, but the ideas must also be technically sound, and supported by good engineering. Many life plans have dangerous weaknesses in the foundation, so to speak, or may be hindered by untreated symptoms. So, a sound architectural plan in psychiatry or in life management must include both esthetic or artistic elements, as well as good structural support.
Architecture could be considered a science and an art--a field with many technical elements, but with an over-riding importance given to esthetics, expressiveness, and community relationships.
Ideas in psychiatry could be considered "architectural" in the sense that it is important to have an overall sense of a plan, with a clear sense of purpose. Even with good technical skills (e.g. to relieve a symptom), work in psychiatry, or in life progress, may be unsatisfying if there is no attendance to the larger sense of purpose in the life's structure. Part of the purpose is "esthetic," but part has to do with identity, interaction with community, originality, and expressiveness. This is similar to the architectural considerations involved in planning and developing a new physical structure.
As in architecture, many very good ideas could be generated to develop one's life, but the ideas must also be technically sound, and supported by good engineering. Many life plans have dangerous weaknesses in the foundation, so to speak, or may be hindered by untreated symptoms. So, a sound architectural plan in psychiatry or in life management must include both esthetic or artistic elements, as well as good structural support.
Making tasks fun improves motivation & self-control
Juliano Laran and Chris Janiszewski recently published a study in Journal of Consumer Research (Vol. 37, electronically published Aug. 24, 2010, entitled "Work or Fun? How Task Construal and Completion Influence Regulatory Behavior."
It is an example of a simple research study in an evolving literature about self-control.
A prevailing notion is that the work involved in any self-controlling action is depleting; therefore, repeated difficult acts of self-control, even if successful, increase the chance of self-control failure shortly thereafter, because of the depletion of inner self-control resources.
The authors in this study hypothesize that there are several variables which affect the dynamics here:
1) individuals vary in their capacity for self-control
2) individuals who engage in actions which are inherently satisfying (fun) are not depleted by these actions, and do not experience a decrement in self-control afterwards
3) individuals for whom these same actions are merely work, and not fun, are depleted by their actions, and have less self-control afterwards
4) Activities which are incomplete have a neutral effect on subsequent self-control
5) Activities can be "reframed" as work, or as fun, and this reframing affects whether the activity is depleting or not.
The experiments described in this paper are, like many brief psychological studies of this sort, somewhat amusing to read about, and could certainly be criticized as somewhat shallow, cross-sectional portraits of a complex behavioural dynamic, with quite limited generalizability. The measure of "self-control," for example, involves measuring how much candy the subjects eat following a written exercise.
Yet, the results did support the hypotheses, allowing the following conclusions:
1) One's attitude towards a task has a very strong influence upon how the completed task will affect you afterwards. If tasks are perceived and experienced as work, as tedious, as unenjoyable, then they will leave you "depleted," and substantially more prone to unhealthy behaviours afterwards. If an attitude can be nurtured of tasks being enjoyable or fun, then the completion of these tasks leads to an increased sense of vitality, without any experience of depletion. .
2) While there may be mood or personality states or traits which influence these attitudes towards tasks, it is possible to reframe the activities in a beneficial way.
3) If some tasks cannot be reframed as "fun," than a neutral alternative could be to frame the activity as ongoing, and therefore never complete. Incompleted tasks, according to this study, have a more neutral effect upon self-control depletion. In the management of obesity, for example, nutrition management tactics, even if not subjectively enjoyable, would best be framed as a permanent lifestyle change, rather than a temporary "diet." An unpleasant "diet" is much more likely to cause regulatory failure after completion; this is certainly the almost invariable experience of all those who have managed their weight using spartan "diets." Yet, I would emphasize that something better than neutrality should be sought after, which, in the case of nutrition management, means that one's permanent nutritional habits should also be enjoyable, rather than simply a self-care chore.
It is an example of a simple research study in an evolving literature about self-control.
A prevailing notion is that the work involved in any self-controlling action is depleting; therefore, repeated difficult acts of self-control, even if successful, increase the chance of self-control failure shortly thereafter, because of the depletion of inner self-control resources.
The authors in this study hypothesize that there are several variables which affect the dynamics here:
1) individuals vary in their capacity for self-control
2) individuals who engage in actions which are inherently satisfying (fun) are not depleted by these actions, and do not experience a decrement in self-control afterwards
3) individuals for whom these same actions are merely work, and not fun, are depleted by their actions, and have less self-control afterwards
4) Activities which are incomplete have a neutral effect on subsequent self-control
5) Activities can be "reframed" as work, or as fun, and this reframing affects whether the activity is depleting or not.
The experiments described in this paper are, like many brief psychological studies of this sort, somewhat amusing to read about, and could certainly be criticized as somewhat shallow, cross-sectional portraits of a complex behavioural dynamic, with quite limited generalizability. The measure of "self-control," for example, involves measuring how much candy the subjects eat following a written exercise.
Yet, the results did support the hypotheses, allowing the following conclusions:
1) One's attitude towards a task has a very strong influence upon how the completed task will affect you afterwards. If tasks are perceived and experienced as work, as tedious, as unenjoyable, then they will leave you "depleted," and substantially more prone to unhealthy behaviours afterwards. If an attitude can be nurtured of tasks being enjoyable or fun, then the completion of these tasks leads to an increased sense of vitality, without any experience of depletion. .
2) While there may be mood or personality states or traits which influence these attitudes towards tasks, it is possible to reframe the activities in a beneficial way.
3) If some tasks cannot be reframed as "fun," than a neutral alternative could be to frame the activity as ongoing, and therefore never complete. Incompleted tasks, according to this study, have a more neutral effect upon self-control depletion. In the management of obesity, for example, nutrition management tactics, even if not subjectively enjoyable, would best be framed as a permanent lifestyle change, rather than a temporary "diet." An unpleasant "diet" is much more likely to cause regulatory failure after completion; this is certainly the almost invariable experience of all those who have managed their weight using spartan "diets." Yet, I would emphasize that something better than neutrality should be sought after, which, in the case of nutrition management, means that one's permanent nutritional habits should also be enjoyable, rather than simply a self-care chore.
Friday, October 22, 2010
Medications for ADHD: newspaper headline
I have just looked at a front-page newspaper article by Carolyn Abraham in The Globe and Mail (Tuesday, October 19, 2010).
The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.
This is a very serious, important question. It warrants careful analysis of the issues, and a balanced evaluation of evidence.
Unfortunately, the article bothered me greatly, because of its bias. Here are some quotes from the article:
The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns. The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next. The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.
But the article did not give a balanced presentation of evidence.
It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment, all their lives. Often times, they, or their parents, have been strongly opposed to the idea of taking medications. Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence. Therefore, they have often not been able to achieve the goals which are reasonably available to them. There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time. A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).
Treating ADHD with medication does not increase substance abuse. Rates of substance use in an untreated ADHD population are substantially higher. Here is a reference to a research article demonstrating this: http://www.ncbi.nlm.nih.gov/pubmed/18838643 It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs. The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown. Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks.
In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants. Such an analysis would fairly establish that risks are present, but of low incidence. For example, the risk of stimulants causing heart problems.
But a fair assessment of risk must include consideration of the risks of non-treatment! The obvious risks in an ADHD population are higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour. The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle). Here are a few references evidence about this:
http://www.ncbi.nlm.nih.gov/pubmed/19739058
http://www.ncbi.nlm.nih.gov/pubmed/18815438
http://www.ncbi.nlm.nih.gov/pubmed/10790000
It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms. The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well. In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence.
The idea of accepting that "that's what boys do," etc. is important to consider. But imagine, as an adult reader, that you are transported to elementary school again. Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails? Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour. The issue is not just about the individuals with so-called ADHD, but also about peers and community. Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either. Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life: home, friendships, community, work, etc. This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some.
The article seems to suggest that male teachers would be preferable. What does this have to do with anything? Where is the evidence?! Is this claim not an insult to female teachers? And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers. In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.
I do agree that there are learning or educational styles which could suit some individuals much better. And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids." One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem. But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe, and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention. Band saw + ADHD! Do you see any problems there?
Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade. I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.
I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals. But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence.
One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude: ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity. These could be considered traits, and each of these traits could be considered useful, positive, and "normal" in some ways, as well as negative or deleterious in others. Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD). The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases. So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms. Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families. There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.
I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies. This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating.
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.
The article attempts to discuss the issue of whether medications are prescribed too often, for treating supposed attention deficit disorder, particularly in male children.
This is a very serious, important question. It warrants careful analysis of the issues, and a balanced evaluation of evidence.
Unfortunately, the article bothered me greatly, because of its bias. Here are some quotes from the article:
Boys: Fixing with a pill is easier than counselling [this was a heading]
There's a desire for the quick fix...the idea that - 'oh, we'll fix this with a pill' - rather than spend a few months in counselling, is pretty appealing. [this was a quote attributed to Gordon Floyd, the CEO of Children's Mental Health Ontario]
What are we drugging? Female teachers who don't understand boys like to run and jump and shout - that's what boys do. [this was a quote attributed to Jon Bradley, an education professor at McGill University]
Prescription rates for ADHD drugs, which like cocaine, are psycho-stimulants...
Mr. Floyd feels counselling stands a better chance of getting to the root of the problem with children, rather than using drugs for years to dull symptoms. Research shows, he says, that talk therapy can be very successful for kids with ADHD.
stimulant drugs may be dangerous for those with underlying heart problems - and those who do not actually have ADHD.
I have often wondered why no real connection has been made between the over-medicalization of our children and the increasing prevalence of illicit drug use in our society. When we give kids the message that they can be 'fixed' by popping a pill, it hardly seems surprising to me that they would later seek to solve their problems by using other available substances. [a quote attributed to Judy McGuire, a "Globe Catalyst"]
The article mentions important issues of concern, including the role of pharmaceutical marketing in changing medication prescription patterns. The diagnosis of ADHD, and the use of medications, appears to vary substantially from one locale to the next. The phenomenon of teachers coercing parents to seek medication treatment for their children is certainly problematic.
But the article did not give a balanced presentation of evidence.
It is more common, in my experience, to encounter young adults who have struggled with ADHD symptoms, without any medication treatment, all their lives. Often times, they, or their parents, have been strongly opposed to the idea of taking medications. Many of these young adults are very intelligent, but often have been unable to sit through the intellectual tasks required to develop their intelligence. Therefore, they have often not been able to achieve the goals which are reasonably available to them. There is really no way around the fact that reading, for example, is necessary to develop one's mind in the modern world; reading requires one to sit still and focus for extended periods of time. A great deal of the discipline required to develop one's intellect requires prolonged focus, often with tasks that are initially perceived to be uninteresting (with discipline, intelligence, and imagination, any so-called "boring" subject can become interesting--but if individuals are unable to focus during the initial "boring" introduction to a subject, this deep interest and engagement may never be found).
Treating ADHD with medication does not increase substance abuse. Rates of substance use in an untreated ADHD population are substantially higher. Here is a reference to a research article demonstrating this: http://www.ncbi.nlm.nih.gov/pubmed/18838643 It is certainly my clinical experience, that subjects with untreated ADHD have much higher rates of substance use, including cigarettes, alcohol, cannabis, and harder drugs. The belief that treating ADHD with medications somehow increases risk for substance abuse, is simply unfounded--the opposite effect has been clearly shown. Exceptions exist, of course, in individual cases where adolescents may be abusing their medication, selling it, etc. Also, in many cases "ADHD" is not the only issue or problem; there may be antisocial behaviour, mood disorders, severe family or psychosocial problems, etc. which also obviously affect risks.
In terms of dangers or risks, it is of course important to examine negative side-effects or toxicity from stimulants. Such an analysis would fairly establish that risks are present, but of low incidence. For example, the risk of stimulants causing heart problems.
But a fair assessment of risk must include consideration of the risks of non-treatment! The obvious risks in an ADHD population are higher risks of accidental injuries, car accidents, sequelae from substance abuse, and reckless interpersonal behaviour. The risk pertains not only to those with untreated ADHD, but also to peers (for example, passengers in a vehicle). Here are a few references evidence about this:
http://www.ncbi.nlm.nih.gov/pubmed/19739058
http://www.ncbi.nlm.nih.gov/pubmed/18815438
http://www.ncbi.nlm.nih.gov/pubmed/10790000
It is also, of course, very important to consider whether counseling or other types of therapy could be helpful for ADHD symptoms. The prevailing evidence shows that there can be small effects with existing therapy styles--this is certainly worth pursuing--but counseling often doesn't work very well. In cases where there are multiple other problems going on (e.g. anxiety, mood, family conflicts, etc.) then of course some type of external counseling support would be preferable to simply obtaining a stimulant prescription. The notion that "a few months of counseling" would make much of a difference for most kids with ADHD symptoms is absurd, and entirely unsupported by any evidence.
The idea of accepting that "that's what boys do," etc. is important to consider. But imagine, as an adult reader, that you are transported to elementary school again. Would it be a pleasant and rewarding situation for you to be in a classroom where the attitude "that's what boys do" prevails? Similar philosophies, in the adult world, have been used to justify various types of antisocial behaviour. The issue is not just about the individuals with so-called ADHD, but also about peers and community. Rambunctiousness need not be pathologized, but a desire for sustained attentiveness need not be pathologized either. Most people with ADHD histories have had serious difficulties not just in classroom settings, but in all spheres of life: home, friendships, community, work, etc. This issue is not just about artificially forcing people into the constraints of a boring, quiet classroom, although admittedly a sedate classroom environment could be a very unhelpful factor for some.
The article seems to suggest that male teachers would be preferable. What does this have to do with anything? Where is the evidence?! Is this claim not an insult to female teachers? And, in my memory, I don't remember male teachers being any better at managing a classroom of rambunctious kids, compared to female teachers. In fact, I can think of counterexamples, in which female teachers could have a gentle, maternal effect on hyperactive kids helping them to enjoy their day, so that their experience of a classroom could be more positive.
I do agree that there are learning or educational styles which could suit some individuals much better. And I agree that having opportunities to be physically active is extremely important--for everyone, not just for "ADHD kids." One of the authors in this article suggests that the decline of opportunities such as "wood shop" (the implication is, that these are mainly for boys) is part of the problem. But, imagine as a wood shop teacher -- where you are in charge of a band saw, a lathe, and a few power nail guns -- that you have a few kids who are easily bored, highly rambunctious, and have difficulty paying attention. Band saw + ADHD! Do you see any problems there?
Some "alternative learning styles" could already begin to produce an unnecessary tier, sending kids with more ADHD symptoms away from a more scholarly focus, towards developing a more physical trade. I don't think there's anything wrong with this per se, unless the child with ADHD symptoms actually wants to develop scholarly pursuits, and/or has an undeveloped talent for the type of scholarship which requires intense focus, and doesn't really want to be "tiered" in this way.
I recognize that this is an important issue, and everyone's point of view needs to be considered to work out the best solutions for health policy and for helping individuals. But this article, in one of Canada's leading newspapers, was disturbingly one-sided, and in my opinion could contribute to many individuals feeling stigmatized or rejecting the possibility of medication therapy without a balanced understanding of the evidence.
One of the main issues to contemplate, and really the main helpful theme in this article, in my opinion, has to do with degree or magnitude: ADHD symptoms exist on a continuum, with everyone in the population having some measurable quantity of attentional capacity, physical restlessness, or impulsivity. These could be considered traits, and each of these traits could be considered useful, positive, and "normal" in some ways, as well as negative or deleterious in others. Medications or other therapies have the capacity to change the degree of symptoms or traits somewhat, for anyone (it is a myth that stimulants improve attention only in those with ADHD). The degree of environmental change required to help an individual escalates rapidly as the degree of symptoms increases. So, there will always be a gray area, of individuals who have more "ADHD symptoms" than the population average, but fewer than those with extreme and highly disabling symptoms. Determining how to help these individuals may be highly influenced by the whims of the local educational or medical culture, combined with the attitudes of the individuals and their families. There may be no absolute, fixed standard possible, to determine exactly when to use a particular form of therapy.
I believe that such decisions should be influenced by the following factors:
1) clear informed consent on the part of individuals and families considering medications or other therapies. This involves having a balanced understanding of evidence, of the risks and benefits of treating and of not treating.
2) thorough assessment with careful attendance to family and psychosocial stresses--never an impulsive prescription of stimulants after a single 5-minute appointment!
3) Follow-up in all cases, with opportunities for talking therapies and behavioural therapy if desired.
4) A reasonable set of nationalized, standardized guidelines for assessment and treatment, to reduce the possibility that a person's geographic location, or the whims of teachers, doctors, journalists, etc. would be strong determinants of whether or not treatment of any kind is offered.
Wednesday, September 29, 2010
Atomoxetine for ADHD
Atomoxetine (Strattera) is one of the pharmacological options for treating ADHD symptoms (attention or concentration problems, hyperactivity, impulsivity) in children and adults. I think it is a good drug, quite safe, quite effective. It is not likely to help with mood or anxiety symptoms. Its effect is probably not quite as robust, for most people, compared to stimulants, but it has the compelling advantage of working continuously throughout the day, instead of wearing off (as the stimulants do) after a few hours. It takes at least 2 weeks of daily dosing for it to work, which differs from the immediate effect of stimulants.
While it has only a 5-hour half-life in the body, it probably works just as well if dosed once-daily compared to twice-daily. Side-effects are usually quite mild, including possible dry mouth and reduced appetite.
It is quite expensive, and is not covered well by medication funding plans in BC.
Here is a brief survey of some of the research literature about atomoxetine that I found interesting:
http://www.ncbi.nlm.nih.gov/pubmed/20665133
This 2010 article demonstrates that once-daily atomoxetine is superior to placebo for treating adult ADHD symptoms, over a 6-month follow-up period. Treated patients typically had about a 30% reduction in their symptom scores. Doses were about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/18448861
This is an important study, with 4 years of follow-up, treating adult ADHD patients on an open-label basis. The medication was tolerated well, again with ADHD symptom reductions of about 30%. Depression and anxiety symptoms were not affected. I tried unsuccessfully to find a clear statement about average doses used in the study; the dosing regime was similar to other studies, with a maximum of 160 mg/day. From the authors' previous paper on the interim results of this study, the mean dose was about 100 mg/day, the median about 120 mg/day. So these are higher doses than in some of the other studies, which typically had 80 mg/day dosing.
http://www.ncbi.nlm.nih.gov/pubmed/20070786
This was a 6-week open study, showing that adults with "atypical ADHD" showed improvement with atomoxetine treatment, doses averaging about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/20051220
This is an important 2008 meta-analysis, comparing effect sizes of different therapies for adult ADHD. Short-acting stimulants were best; long-acting stimulants similar (no advantage--if anything, not quite as high an effect size compared to short-acting stimulants); non-stimulants such as atomoxetine significantly helpful, but not quite as large an effect size as stimulants.
http://www.ncbi.nlm.nih.gov/pubmed/17110824This study shows modest but significant improvement in quality-of-life ratings for adult ADHD patients treated with atomoxetine 80 mg/day for 6 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/20642391
This study shows reduction in high-risk behaviours in adolescents treated with atomoxetine over a 40-week period. Looking quickly at the results, I see significant differences between atomoxetine and placebo, but the absolute differences were quite modest in size (typically about a 10% change). Also the study design has a variety of weaknesses.
http://www.ncbi.nlm.nih.gov/pubmed/17474814
This is one of many studies showing that atomoxetine does not help with depressive symptoms. In this case, it was used as an adjunct to an SSRI.
http://www.ncbi.nlm.nih.gov/pubmed/19358788
This study showed no improvement in cognitive function in patients with schizophrenia treated with atomoxetine over 8 weeks. There were no adverse psychiatric effects, however. This is an important area to study, to determine if ADHD treatments such as atomoxetine are psychiatrically safe for those with other major mental illnesses, such as schizophrenia or bipolar disorder.
http://www.ncbi.nlm.nih.gov/pubmed/20679638
This 2010 article from Neurology shows that atomoxetine is not useful for treating depression in Parkinson Disease patients. I find this type of study useful, to look at psychiatric symptoms in medical illnesses. In such situations, the biological impact of the treatment often seems more clear to me, perhaps with fewer confounding psychological factors. The study did find that patients treated with atomoxetine (target dose 80 mg/day) had significantly less daytime sleepiness, and significant improvement in "global cognitive function."
http://www.ncbi.nlm.nih.gov/pubmed/19025777
This similar study shows a possible improvement due to atomoxetine treatment--averaging about 90 mg/day--of executive dysfunction in Parkinson Disease patients. I note also that there was a reduction in other symptom domains, such as apathy and emotional lability; these problems can be difficult to address in those with mood disorders.
http://www.ncbi.nlm.nih.gov/pubmed/17900980
Here's another interesting study, using atomoxetine to treat sleep apnea patients, averaging about 80 mg/day over 4 weeks. The atomoxetine did not help reduce apnea, but it did significantly reduce subjective sleepiness. There are only a couple of fragmentary mentionings of atomoxetine in treating narcolepsy, another disorder of excessive sleepiness; here is one case report: http://www.ncbi.nlm.nih.gov/pubmed/16268387 Excessive sleepiness is another challenging symptom I see a lot of in young adult depression; antidepressants often don't help with the sleepiness, and tolerance tends to develop for stimulants. So atomoxetine may be another useful option.
While it has only a 5-hour half-life in the body, it probably works just as well if dosed once-daily compared to twice-daily. Side-effects are usually quite mild, including possible dry mouth and reduced appetite.
It is quite expensive, and is not covered well by medication funding plans in BC.
Here is a brief survey of some of the research literature about atomoxetine that I found interesting:
http://www.ncbi.nlm.nih.gov/pubmed/20665133
This 2010 article demonstrates that once-daily atomoxetine is superior to placebo for treating adult ADHD symptoms, over a 6-month follow-up period. Treated patients typically had about a 30% reduction in their symptom scores. Doses were about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/18448861
This is an important study, with 4 years of follow-up, treating adult ADHD patients on an open-label basis. The medication was tolerated well, again with ADHD symptom reductions of about 30%. Depression and anxiety symptoms were not affected. I tried unsuccessfully to find a clear statement about average doses used in the study; the dosing regime was similar to other studies, with a maximum of 160 mg/day. From the authors' previous paper on the interim results of this study, the mean dose was about 100 mg/day, the median about 120 mg/day. So these are higher doses than in some of the other studies, which typically had 80 mg/day dosing.
http://www.ncbi.nlm.nih.gov/pubmed/20070786
This was a 6-week open study, showing that adults with "atypical ADHD" showed improvement with atomoxetine treatment, doses averaging about 80 mg/day.
http://www.ncbi.nlm.nih.gov/pubmed/20051220
This is an important 2008 meta-analysis, comparing effect sizes of different therapies for adult ADHD. Short-acting stimulants were best; long-acting stimulants similar (no advantage--if anything, not quite as high an effect size compared to short-acting stimulants); non-stimulants such as atomoxetine significantly helpful, but not quite as large an effect size as stimulants.
http://www.ncbi.nlm.nih.gov/pubmed/17110824This study shows modest but significant improvement in quality-of-life ratings for adult ADHD patients treated with atomoxetine 80 mg/day for 6 weeks.
http://www.ncbi.nlm.nih.gov/pubmed/20642391
This study shows reduction in high-risk behaviours in adolescents treated with atomoxetine over a 40-week period. Looking quickly at the results, I see significant differences between atomoxetine and placebo, but the absolute differences were quite modest in size (typically about a 10% change). Also the study design has a variety of weaknesses.
http://www.ncbi.nlm.nih.gov/pubmed/17474814
This is one of many studies showing that atomoxetine does not help with depressive symptoms. In this case, it was used as an adjunct to an SSRI.
http://www.ncbi.nlm.nih.gov/pubmed/19358788
This study showed no improvement in cognitive function in patients with schizophrenia treated with atomoxetine over 8 weeks. There were no adverse psychiatric effects, however. This is an important area to study, to determine if ADHD treatments such as atomoxetine are psychiatrically safe for those with other major mental illnesses, such as schizophrenia or bipolar disorder.
http://www.ncbi.nlm.nih.gov/pubmed/20679638
This 2010 article from Neurology shows that atomoxetine is not useful for treating depression in Parkinson Disease patients. I find this type of study useful, to look at psychiatric symptoms in medical illnesses. In such situations, the biological impact of the treatment often seems more clear to me, perhaps with fewer confounding psychological factors. The study did find that patients treated with atomoxetine (target dose 80 mg/day) had significantly less daytime sleepiness, and significant improvement in "global cognitive function."
http://www.ncbi.nlm.nih.gov/pubmed/19025777
This similar study shows a possible improvement due to atomoxetine treatment--averaging about 90 mg/day--of executive dysfunction in Parkinson Disease patients. I note also that there was a reduction in other symptom domains, such as apathy and emotional lability; these problems can be difficult to address in those with mood disorders.
http://www.ncbi.nlm.nih.gov/pubmed/17900980
Here's another interesting study, using atomoxetine to treat sleep apnea patients, averaging about 80 mg/day over 4 weeks. The atomoxetine did not help reduce apnea, but it did significantly reduce subjective sleepiness. There are only a couple of fragmentary mentionings of atomoxetine in treating narcolepsy, another disorder of excessive sleepiness; here is one case report: http://www.ncbi.nlm.nih.gov/pubmed/16268387 Excessive sleepiness is another challenging symptom I see a lot of in young adult depression; antidepressants often don't help with the sleepiness, and tolerance tends to develop for stimulants. So atomoxetine may be another useful option.
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