Thursday, 15 August 2013

Focus on Ritalin

This week, the annual Care Quality Commission (CQC) Report on Controlled Drugs revealed that the number of prescriptions for Ritalin, the drug commonly used for treating children with Attention Deficit Hyperactivity Disorder (ADHD) has risen by 56% in the last five years. That is to say, in 2007 GPs in England wrote 420,000 prescriptions for Ritalin and in 2012 they wrote 657,000.

You might be forgiven for thinking that Ritalin (chemical name methylphenidate) must be a relatively new kid on the block (pardon the pun) given its recent rise to prominence. But in fact, it was first prescribed as far back as 1957 for the treatment of chronic fatigue, depression, psychosis associated with depression and narcolepsy. By the 1960s, research interest focused on its use in the treatment of hyperkinetic syndrome, which would eventually be labelled ADHD.

Although technically not an amphetamine, Ritalin is a brain stimulant that seems to behave in a similar manner; its mechanism of action is still not understood. Most experts agree that it affects the part of the brain involved with impulse control (the midbrain) and researchers have reported a link between Ritalin and serotonin, a naturally occurring brain neurotransmitter (also the target of antidepressants known as Selective Serotonin Reuptake Inhibitors, SSRIs, of which Prozac is a prime example).

A recent new Canadian study among thousands of children http://www.nber.org/papers/w19105 should give us pause for thought when it comes to the subject of Ritalin prescriptions. It showed that Ritalin and other such stimulants have no long-term benefits and, if anything, children on these drugs experienced worse outcomes than children not taking them. To quote the authors:

"We find evidence of increases in emotional problems among girls and reductions in educational attainment among boys. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication can have negative consequences given the average way these drugs are used in the community."

Why this, one wonders? One thought is that while Ritalin may work to quiet children down, it may also give the appearance that their behavioural problems have been solved. The difficulty is, that if the underlying cause of an ADHD diagnosis remains unaddressed, it won't necessarily go away and when the drug is discontinued, symptoms will inevitably re-emerge. Children who have been 'damped down' in this way are also (arguably) less likely to get any additional academic help they may need, which may have been an unconscious reason for the original disruptive behaviour.

It is recommended that Ritalin should always be prescribed alongside non-medical psychological treatments such as counselling, though in practice this doesn't always happen. This removes a significant check from the treatment equation. Psychoactive medication combined with failure to treat underlying causes rarely ever prospers the patient.

None of this is to say that Ritalin is not an effective treatment for a small, but significant, number of children with ADHD, whose lives without the drug would probably be all the poorer. But clinicians are rightly becoming disturbed by the rapidly rising number of children who are now receiving treatment as a matter of course - an incredible 11% of all school children in the USA (nearly 20% of high school-aged boys). From these latest CQC figures, it appears that a similar trend is emerging in the UK.

Given the large demographic, particularly in the USA, are children being medicated for the 'disorder' of being a child, one has to ask. What are your thoughts? We'd love to hear them.

Written by Jacqui Hogan

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