"In Western Australia, 1989, 880 people were prescribed stimulant medication (for ADHD). By the year 2000 this had increased to 20,648, with the WA Health Department estimating 18,000 prescriptions having been issued to children. By 2002 WA prescription rates were amongst the highest in the world, exceeding the US national average,” said Martin Whitely.
The debate rages on about the over-medication of people, and the myriad illnesses discovered each year and the concomitant high rates of diagnoses. Diagnoses are usually accompanied with prescribed medication. One illness that has come under the spotlight in terms of high rates of diagnoses and over medication has been childhood ADHD.
What role have the commercial pharmaceutical companies played in pushing up prescription rates?
Attention deficit hyperactivity disorder (ADHD) may be treated with medication. The two main stimulant drugs used are dexamphetamine and methylphenidate (Ritalin). Other treatments for children with ADHD include behavioural management, psychological counselling and family support groups.
Attention deficit hyperactivity disorder (ADHD) is one of a number of attributed behavioural and developmental disorders that perceivably affect young children. A child with ADHD is attributed to have three main behavioural issues: inattention, impulsivity and overactivity.
The drugs dexamphetamine and methylphenidate target the brains neurotransmitters, and neurotransmitters are brain chemicals.
Stimulants like dexamphetamine and methylphenidate may work by acting on the neurotransmitters that release the chemical dopamine. Greater amounts of dopamine may help to curb the attributed hyperactive and impulsive behaviours perceivably typical of the child with ADHD.
The rise and fall of childhood ADHD in Western Australia is a conversation that must be had and more openly than so far. It goes to the heart of questions still unanswered about over medication and of the presumption of diagnoses for the ‘sake of filling prescription quotas’.
What damage is being done to people who are medicated but effectively have no illness?
For instance dopamine and seratonin releases may exacerbate various episodic like behaviours, exacerbated to psychoses. Paranoia is often an affective manifest and with paranoia only negatives arise - distrust of others, the inability for continuous normal behaviours, personal meltdown, familial breakdown, various depression and anxieties and acute and abject trauma and multiple traumas.
Over medication means a surge of stimulants or substances in the body and hence disturbs chemical balances.
In a society where leverage is given to a free trade market and the commercialisation of just about every service and good often means human beings are treated as predominately consumers rather than beneficiaries. This is self-evident when we consider the free run that tobacco has enjoyed, salt and sugar food products and the massive fast food market. Why should pharmaceutical companies be any different?
Without rigorous mental health legislation and enabling policies far too much discretion is given to the producers, sellers and marketeers of medication.
Mental illness should not be stigmatic – just as physical illness is not. More people than ever before are speaking out about mental illness and this is important in setting up conversations about what is needed to address mental illnesses. The destigmatisation of mental illness is an imperative.
In the USA pharmaceutics marketing is competitively vicious and near ruthless. They have incorporated huge media campaigns to sell their products – 24/7 campaigns. Daily, we are told we have headaches and that they need to be relieved by shelf or over the counter medications from the supermarket or pharmacy. We are told we have this or that ache and this or that medication will relieve it. There is little relief from these campaigns, and the messages are bought, the promises of pain relief. The ruthless marketing drops the onus for self-diagnoses.
Former Western Australian parliamentarian and mental health advocate Martin Whitely said that the future direction of mental health in Australia is far from certain.
He is concerned of what he describes as the "Americanisation" of the Australian mental health systems and the “Americanisation” of our mental health practitioners.
"Apart from spiralling mental health prescribing rates, the most obvious evidence of the Americanisation of Australia's mental health system is the dominance of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders diagnostic model. Often referred to as the 'Bible of Psychiatry', the current edition, DSM-IV, outlines the diagnostic criteria of 297 psychiatric disorders."
"Subsequent editions of the DSM have thickened as new disorders have been added. This expansion has been exploited by aggressive pharmaceutical company marketing, resulting in the medication of people who would previously have been regarded as 'normal'."
Mr Whitely attended the recent Asia South Pacific Mental Health Conference hosted in Perth and the suite of keynote speakers included Professor Allen Frances, chairperson of the taskforce that developed the DSM-IV, and former Australian of the Year, psychiatrist Professor Patrick McGorry.
"With the benefit of hindsight, Professor Allen Frances... regrets aspects of (DSM-IV) as having helped to trigger 'three false epidemics, one for autistic disorder... another for the childhood diagnosis of bipolar disorder and the third for the wild over-diagnosis of attention deficit disorder," said Mr Whitely.
Western Australia is the world's only ADHD hot spot to have experienced a significant downturn in childhood ADHD prescribing rates. The explosion in prescribing rates from 1989 to 2003 was created by a handful of Perth paediatricians who were very enthusiastic in marketing, diagnosing ADHD and in prescribing for ADHD, said Mr Whitely. The introduction of tighter prescribing accountability measures in 2003 and an intense debate around the validity of the diagnoses and the safety of the drugs, led to a massive downturn in Western Australia's child drugging rates.
In Western Australia from 1989-2003 there was a massive increase in the prescription of dexamphetamine and to a lesser extent methylphenidate (Ritalin) for ADHD. In 1989 in WA 880 people were prescribed stimulant medication. By the year 2000 this had increased to 20,648, with the WA Health Department estimating 18,000 being children. By 2002 WA prescription rates were amongst the highest in the world, exceeding the US national average. WA prescribing rates continued to grow until the introduction of tighter ADHD amphetamine prescribing accountability measures in late 2003. Since then child prescribing rates in WA have fallen significantly with 5,666 children on stimulants in 2008. Simultaneously amphetamine abuse rates by West Australian teenagers fell approximately 51%.
Concerns about West Australian ADHD prescribing rates first emerged in the mid-1990s. In 1995, the WA State Government set up a Technical Working Party ‘to report to government on the incidence of ADHD in Western Australia and to seek expert opinion on the appropriate diagnosis and treatment for the condition.’ The report raised concerns of the diagnostic practices of some unnamed Perth paediatricians and highlighted problems with the practice of Block Authorisation.
Block Authorisation granted an exemption from normal accountability requirements to frequently prescribing clinicians considered to be ‘familiar with the prescribing guidelines.’ In effect Block Authorisation meant that frequent prescribers were the least accountable. In contrast, a clinician who prescribed infrequently as a last resort was accountable for every individual script.
Presumably the rationale for the policy of ‘Block Authorisation’ was the assumption that those who prescribe frequently were familiar with, and therefore competent in, the prescription of dexamphetamine and methylphenidate. It was not until August 2003 when lobbying by Martin Whitely got Block Authorisation abolished and a stimulants’ monitoring system was put in place. The tighter accountability and reporting requirements were immediately followed by a massive decline in child prescribing rates. These measures were supplemented in 2004 by a WA parliamentary inquiry which triggered an intense local debate about the validity of the diagnoses and the safety of the drugs.
Although WA still has the highest (and rising) adult prescribing rates in Australia, since 2003, WA prescriptions to children have plummeted while they have skyrocketed elsewhere. Perth has fortunately forfeited its claim to be the ADHD child prescribing capital of Australia. Sydney, Brisbane and Hobart now vie for that dubious honour.
But what damage has been done to these children most who are now adults?
In 2011, Martin Whitely wrote about Perth's Dexamphetamine Hangover - "Perth’s ADHD generation, those diagnosed and ‘medicated’ in the 1990s and early 2000s, are now young adults. They were prescribed ADHD amphetamines (primarily dexamphetamine) at three to four times the rate of their eastern states contemporaries and old habits die hard."
"Many of Perth’s twenty to early thirty-somethings have grown to love their ‘dexies,’ particularly with a drink or fifteen, on their weekend benders. With dexies on board they drink longer and harder, with the loss of inhibition and impaired judgement from alcohol but without the drowsiness. Some also use dexies as a substitute for sleep, to either get up for work after a hard night of partying, or to cram for exams or tight work deadlines."
"Part of the problem is that whilst methamphetamine is illegal in Australia and therefore understood to be harmful, it’s difficult to get Perth’s ‘dexie generation’ to realise that dexamphetamine is not a benign substance. It might help if we point out that methamphetamine (brand name Desoxyn) is a legally prescribed ADHD treatment in the US. Then again it might simply normalise the use of methamphetamine."
"But as it stands many of Perth’s young adults love their dexamphetamine. Despite the fact that the ‘near amphetamine’ methylphenidate (Ritalin, Concerta) is the most commonly prescribed ADHD stimulant in Australia, (73% of all scripts), the vast majority of both new (82.5%) and continuing (86.6%) WA adult patients prescribed ADHD stimulants take dexamphetamine. Many get dexamphetamine rather than Ritalin, because they ask for it and they ask for it because dexies are the recreational prescription stimulant drug of choice amongst Perth’s hard partying young adults.”
“Perth’s rise in adult ADHD prescribing rates defies the trend for kids. WA’s child ADHD patient numbers have plummeted (60-70%) since tighter prescribing accountability measures were introduced in late 2003, while adult prescribing rates have risen 27% since 2004, so that in 2009 there were 7981 WA adults on prescription stimulants."
"I am not suggesting that all of these adult patients are intentional ADHD drug abusers. Some of these are carryover ‘patients’ from the ‘dexie generation’; who still believe the ‘ADHD chemical imbalance’ lie they, and their parents, were told when they were children. Other former child patients have become physically and psychologically dependent as predicted on the manufacturer’s guidelines that many of their parents never even had the opportunity to read."
"Some new adult patients genuinely believe they have a ‘biochemical brain imbalance’ and mistakenly believe the almost universal upper effect of dexamphetamine is peculiar to ADHD. However, there is a new group of young adult ‘dexie’ users, who have learned how to tick the right ADHD boxes and say the right things to the handful of enthusiastic Perth prescribers. (In 2009 six WA doctors prescribed to over 500 patients each with the heaviest prescriber prescribing to a staggering 1,360 patients.) As a result they and their friends have got a convenient taxpayer subsidised supply of ‘uppers’ and can party all weekend and wake up bright as a button for work on Monday morning."
"Faking ADHD is not a uniquely West Australian experience. Recent US research revealed nearly a quarter of all adults seeking treatment for ADHD feigned symptoms to get a cheap supply of amphetamines. And you would be mistaken if you thought that this didn’t happen in nice homes and good neighbourhoods. Whilst its child prescribing rates are now relatively low, the Oceanic Health District, which covers Perth’s affluent western suburbs, easily has the highest adult ADHD per capita prescribing rates in Australia’s highest (adult) prescribing state (WA). This may in part be a legacy of the fact that Perth’s western suburbs and the less prosperous south east corridor around Armadale were the two child ADHD hotspots in the 1990s."
"Unfortunately there is little direct data as to how prevalent the abuse of ADHD amphetamines is by WA adults. But we know from surveys that the vast majority of high school students who have abused amphetamines have abused prescription ADHD amphetamines. Now it’s time to ask how much of Perth’s spate of alcohol related violence is also fuelled by amphetamines, and how much diverted dexamphetamine contributes to this problem."
"Whilst at last we are slowly awakening to the ADHD fraud, we are still reluctant to blame the doctors who prescribe these poisons, for a disorder that was voted into existence by a panel of self-appointed mostly drug company funded ‘experts’. But ADHD prescribers are practising quackery not medicine, and that makes them quacks not doctors, and it is time we said so."
"So before we middle aged West Australians bemoan the decadence and decay of youth, remember, it was our generation who put them on this pathway. Too many of our generation unquestioningly accepted the ADHD industry nonsense that, just like diabetes or cancer, ADHD is a disease requiring ‘medication.’ Even now it is our generation’s leaders that finds the truth – i.e. ADHD is a dumbed down, unscientific, catch all diagnosis and amphetamines are bad for kids – too confronting to say out loud."
"We can’t leave our head in the sand any longer. All the available evidence suggests Perth’s twenty to early thirty-somethings have a large and growing dexamphetamine habit. They get it, they abuse it, they drink too much, they fight too much and tragically some die too early. And it is not their generation’s fault, it is my generations, because when they were kids, we were their dealers."
But at least the incumbent federal government has started with a $222.4 investment into intervention centres.
However, Mr Whitely discusses the option of 'recovery' - "centres on developing a patient's own capabilities and resilience.” As opposed to the 'ongoing disability' or 'impending doom' assumptions inherent in the Americanisation and preventive psychiatry approach he is more optimistic about the capacity for recovery with a less reliant on pills approach.
"It supports mentally ill patients with housing, educational, employment and psychological support - building blocks for a healthy and happy mind that can't be replaced by drugs."
"While the recovery approach is more optimistic about human resilience, it is more realistic about the limits of psychiatry than either of the other approaches."
"The Americanisation approach is based on the unrealistic assumption that psychiatric science can accurately identify at least 297 different disorders and the preventive psychiatry approach on the fanciful notion that mental illness can be reliably spotted before it happens.'
"Unfortunately, a significant disadvantage for the recovery approach is that it offers a pessimistic outlook for the profitability of pharmaceutical companies."
Recovery is paramount, and it should be the most vigilantly supported pathway - the hits family members take for their loved ones are huge and ongoing, and that is what people who care about others do - governments and health institutions should do everything possible to reduce these impacts on both the individual and the family by putting people before profits – capitalisation forces should not allowed to commercialise pharmaceutics and healing practices to the extent that they could be putting patients at risk.
This article is not intended to scare monger or to suggest that there are not illnesses that require medication. But there are powerful stimulants and anti-depressants, sedatives, psychotropics and so on that are effectively force-fed to people – medications that they would be the better off without. This article was not just about the over prescription of dexamphetamines - it is about over medication in general, and it is about addiction by prescription abuse and how easy it is for this to occur. It is also about health systems leveraged by push factors such as commercially focused pharmaceutical companies compartmentalising human beings as consumers.
Those who go through the dark turmoils of mental anguish have enough to deal with without recovery being immolated by misdiagnoses, prescriptions they don’t need and over medication. The onus cannot be on doctors alone to err on the side of caution. Mr Whitely argues the onus needs to be embedded in health polices and legislation. Surely to err on the side of caution means less medication is better.
The bent for self-recovery must be premium.
Further comment and LINKS:
The temper tantrums of belligerent children are increasingly being characterized as psychiatric illnesses.
Using such diagnoses as bipolar disorder, attention-deficit hyperactivity disorder (ADHD) and Asperger's, doctors are justifying the sedation of difficult kids with powerful psychiatric drugs that may have serious, permanent or even lethal side effects.
There has been a staggering jump in the percentage of children diagnosed with a mental illness and treated with psychiatric medications. The Centers for Disease Control and Prevention reported that in 2002 almost 20 percent of office visits to pediatricians were for psychosocial problems -- eclipsing both asthma and heart disease. That same year the Food and Drug Administration reported that some 10.8 million prescriptions were dispensed for children -- they are beginning to outpace the elderly in the consumption of pharmaceuticals. And this year the FDA reported that between 1999 and 2003, 19 children died after taking prescription amphetamines -- the medications used to treat ADHD. These are the same drugs for which the number of prescriptions written rose 500 percent from 1991 to 2000.
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