The Selling of Attention Deficit Disorder
The Number of Diagnoses Soared Amid a 20-Year Drug Marketing Campaign
“This
is a concoction to justify the giving out of medication at
unprecedented and unjustifiable levels,” Keith Conners, a psychologist
and early advocate for recognition of A.D.H.D., said of the rising rates
of diagnosis of the disorder.Karsten Moran for The New York Times
By ALAN SCHWARZ
December 14, 2013 1098 Comments
After more than 50 years leading the fight to legitimize attention
deficit hyperactivity disorder, Keith Conners could be celebrating.
Severely hyperactive and impulsive children, once shunned as bad seeds,
are now recognized as having a real neurological problem. Doctors and
parents have largely accepted drugs like Adderall and Concerta to temper
the traits of classic A.D.H.D., helping youngsters succeed in school
and beyond.
But Dr. Conners did not feel triumphant this fall as he addressed a
group of fellow A.D.H.D. specialists in Washington. He noted that recent
data from the Centers for Disease Control and Prevention show that the
diagnosis had been made in 15 percent of high school-age children, and
that the number of children on medication for the disorder had soared to
3.5 million from 600,000 in 1990. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”
“The numbers make it look like an epidemic. Well, it’s not. It’s
preposterous,” Dr. Conners, a psychologist and professor emeritus at
Duke University, said in a subsequent interview. “This is a concoction
to justify the giving out of medication at unprecedented and
unjustifiable levels.”
billion
Sales of prescription stimulants have more than quintupled since 2002.
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Source: IMS Health
Stimulant Sales
The rise of A.D.H.D. diagnoses and prescriptions for stimulants over the
years coincided with a remarkably successful two-decade campaign by
pharmaceutical companies to publicize the syndrome and promote the pills
to doctors, educators and parents. With the children’s market booming,
the industry is now employing similar marketing techniques as it focuses
on adult A.D.H.D., which could become even more profitable.
Few dispute that classic A.D.H.D., historically estimated to affect 5
percent of children, is a legitimate disability that impedes success at
school, work and personal life. Medication often assuages the severe
impulsiveness and inability to concentrate, allowing a person’s
underlying drive and intelligence to emerge.
But even some of the field’s longtime advocates say the zeal to find and
treat every A.D.H.D. child has led to too many people with scant
symptoms receiving the diagnosis and medication. The disorder is now the
second most frequent long-term diagnosis made in children, narrowly
trailing asthma, according to a New York Times analysis of C.D.C. data.
Behind that growth has been drug company marketing that has stretched
the image of classic A.D.H.D. to include relatively normal behavior like
carelessness and impatience, and has often overstated the pills’
benefits. Advertising on television and in popular magazines like People
and Good Housekeeping has cast common childhood forgetfulness and poor
grades as grounds for medication that, among other benefits, can result
in “schoolwork that matches his intelligence” and ease family tension.
A 2002 ad for Adderall showed a mother playing with her son and saying, “Thanks for taking out the garbage.”
The Food and Drug Administration has cited every major A.D.H.D. drug —
stimulants like Adderall, Concerta, Focalin and Vyvanse, and
nonstimulants like Intuniv and Strattera — for false and misleading
advertising since 2000, some multiple times.
Sources of information that would seem neutral also delivered messages
from the pharmaceutical industry. Doctors paid by drug companies have
published research and delivered presentations that encourage physicians
to make diagnoses more often that discredit growing concerns about
overdiagnosis.
Many doctors have portrayed the medications as benign — “safer than
aspirin,” some say — even though they can have significant side effects
and are regulated in the same class as morphine and oxycodone because of
their potential for abuse and addiction. Patient advocacy groups tried
to get the government to loosen regulation of stimulants while having
sizable portions of their operating budgets covered by pharmaceutical
interests.
Video
How Drug Companies
Sell A.D.H.D.
What makes A.D.H.D. ads so effective? Dr. Aaron Kesselheim, a
Harvard professor, analyzes several ads and discusses how many of them
play on parents’ common fears about their children.
Poh Si Teng and Alan Schwarz
Companies even try to speak to youngsters directly. Shire — the longtime
market leader, with several A.D.H.D. medications including Adderall —
recently subsidized 50,000 copies of a comic book that tries to
demystify the disorder and uses superheroes to tell children, “Medicines
may make it easier to pay attention and control your behavior!”
Profits for the A.D.H.D. drug industry have soared. Sales of stimulant
medication in 2012 were nearly $9 billion, more than five times the $1.7
billion a decade before, according to the data company IMS Health.
Even Roger Griggs, the pharmaceutical executive who introduced Adderall
in 1994, said he strongly opposes marketing stimulants to the general
public because of their dangers. He calls them “nuclear bombs,”
warranted only under extreme circumstances and when carefully overseen
by a physician.
Psychiatric breakdown and suicidal thoughts are the most rare and
extreme results of stimulant addiction, but those horror stories are far
outnumbered by people who, seeking to study or work longer hours,
cannot sleep for days, lose their appetite or hallucinate. More can
simply become habituated to the pills and feel they cannot cope without
them.
Tom Casola, the Shire vice president who oversees the A.D.H.D. division,
said in an interview that the company aims to provide effective
treatment for those with the disorder, and that ultimately doctors were
responsible for proper evaluations and prescriptions. He added that he
understood some of the concerns voiced by the Food and Drug
Administration and others about aggressive ads, and said that materials
that run afoul of guidelines are replaced.
“Shire — and I think the vast majority of pharmaceutical companies —
intend to market in a way that’s responsible and in a way that is
compliant with the regulations,” Mr. Casola said. “Again, I like to
think we come at it from a higher order. We are dealing with patients’
health.”
A spokesman for Janssen Pharmaceuticals, which makes Concerta, said in
an email, “Over the years, we worked with clinicians, parents and
advocacy groups to help educate health care practitioners and caregivers
about diagnosis and treatment of A.D.H.D., including safe and effective
use of medication.”
Now targeting adults, Shire and two patient advocacy groups have recruited celebrities like the Maroon 5 musician Adam Levine for their marketing campaign,
“It’s Your A.D.H.D. – Own It.” Online quizzes sponsored by drug
companies are designed to encourage people to pursue treatment. A
medical education video sponsored by Shire portrays a physician making a
diagnosis of the disorder in an adult in a six-minute conversation,
after which the doctor recommends medication.
Like most psychiatric conditions, A.D.H.D. has no definitive test, and
most experts in the field agree that its symptoms are open to
interpretation by patients, parents and doctors. The American Psychiatric Association,
which receives significant financing from drug companies, has gradually
loosened the official criteria for the disorder to include common
childhood behavior like “makes careless mistakes” or “often has
difficulty waiting his or her turn.”
The idea that a pill might ease troubles and tension has proved seductive to worried parents, rushed doctors and others.
“Pharma pushed as far as they could, but you can’t just blame the
virus,” said Dr. Lawrence Diller, a behavioral pediatrician in Walnut
Creek, Calif. “You have to have a susceptible host for the epidemic to
take hold. There’s something they know about us that they utilize and
exploit.”
Selling to Doctors
Modern marketing of stimulants began with the name Adderall itself. Mr.
Griggs bought a small pharmaceutical company that produced a weight-loss
pill named Obetrol. Suspecting that it might treat a relatively
unappreciated condition then called attention deficit disorder, and
found in about 3 to 5 percent of children, he took “A.D.D.” and fiddled
with snappy suffixes. He cast a word with the widest net.
All.
For A.D.D.
A.D.D. for All.
Adderall.
“It was meant to be kind of an inclusive thing,” Mr. Griggs recalled.
Roger
Griggs, who introduced Adderall in 1994 before ads portraying
medication as a way to improve grades and behavior were allowed, said,
“There’s no way on God’s green earth we would ever promote” stimulants
directly to consumers.Karsten Moran for The New York Times
Adderall quickly established itself as a competitor of the field’s most
popular drug, Ritalin. Shire, realizing the drug’s potential, bought Mr. Griggs’s company for $186 million and spent millions more to market the pill to doctors. After all, patients can buy only what their physicians buy into.
As is typical among pharmaceutical companies, Shire gathered hundreds of
doctors at meetings at which a physician paid by the company explained a
new drug’s value.
Such a meeting was held for Shire’s long-acting version of Adderall,
Adderall XR, in April 2002, and included a presentation that to many
critics, exemplifies how questionable A.D.H.D. messages are delivered.
Dr. William W. Dodson, a psychiatrist from Denver,
stood before 70 doctors at the Ritz-Carlton Hotel and Spa in Pasadena,
Calif., and clicked through slides that encouraged them to “educate the
patient on the lifelong nature of the disorder and the benefits of
lifelong treatment.” But that assertion was not supported by science, as
studies then and now have shown that perhaps half of A.D.H.D. children
are not impaired as adults, and that little is known about the risks or
efficacy of long-term medication use.
The PowerPoint document, obtained by The Times, asserted that stimulants
were not “drugs of abuse” because people who overdose “feel nothing” or
“feel bad.” Yet these drugs are classified by the government
among the most abusable substances in medicine, largely because of
their effects on concentration and mood. Overdosing can cause severe
heart problems and psychotic behavior.
Slides described side effects of Adderall XR as “generally mild,”
despite clinical trials showing notable rates of insomnia, significant
appetite suppression and mood swings, as well as rare instances of
hallucinations. Those side effects increase significantly among patients
who take more pills than prescribed.
Another slide warned that later in life, children with A.D.H.D. faced
“job failure or underemployment,” “fatal car wrecks,” “criminal
involvement,” “unwanted pregnancy” and venereal diseases, but did not
mention that studies had not assessed whether stimulants decreased those
risks.
Slides
that Dr. William W. Dodson, a psychiatrist, presented during a
gathering of 70 doctors in 2002 encouraged lifelong treatment for
A.D.H.D. Studies have shown that many children with the disorder are not
impaired as adults.
Dr. Conners of Duke, in the audience that day, said the message was
typical for such gatherings sponsored by pharmaceutical companies: Their
drugs were harmless, and any traces of A.D.H.D. symptoms (which can be
caused by a number of issues, including lack of sleep and family
discord) should be treated with stimulant medication.
In an interview last month, Dr. Dodson said he makes a new diagnosis in
about 300 patients a year and, because he disagrees with studies showing
that many A.D.H.D. children are not impaired as adults, always
recommends their taking stimulants for the rest of their lives.
He said that concern about abuse and side effects is “incredibly
overblown,” and that his longtime work for drug companies does not
influence his opinions. He said he received about $2,000 for the 2002
talk for Shire. He earned $45,500 in speaking fees from pharmaceutical
companies in 2010 to 2011, according to ProPublica, which tracks such payments.
“If people want help, my job is to make sure they get it,” Dr. Dodson
said. Regarding people concerned about prescribing physicians being paid
by drug companies, he added: “They like a good conspiracy theory. I
don’t let it slow me down.”
Many of the scientific studies cited by drug company speakers involved Dr. Joseph Biederman, a prominent child psychiatrist at Harvard University and Massachusetts General Hospital. In 2008, a Senate investigation
revealed that Dr. Biederman’s research on many psychiatric conditions
had been substantially financed by drug companies, including Shire.
Those companies also paid him $1.6 million in speaking and consulting
fees. He has denied that the payments influenced his research.
Dr. Conners called Dr. Biederman “unequivocally the most published
psychopharmacology maven for A.D.H.D.,” one who is well known for
embracing stimulants and dismissing detractors. Findings from Dr.
Biederman’s dozens of studies on the disorder and specific brands of
stimulants have filled the posters and pamphlets of pharmaceutical
companies that financed the work.
Those findings typically delivered three messages: The disorder was
underdiagnosed; stimulants were effective and safe; and unmedicated
A.D.H.D. led to significant risks for academic failure, drug dependence,
car accidents and brushes with the law.
Dr. Biederman was frequently quoted about the benefits of stimulants in
interviews and company news releases. In 2006, for example, he told
Reuters Health, “If a child is brilliant but is doing just O.K. in
school, that child may need treatment, which would result in their
performing brilliantly at school.”
This year, Dr. Biederman told the medical newsletter Medscape regarding medication for those with A.D.H.D., “Don’t leave home without it.”
Dr. Biederman did not respond to requests for an interview.
Most of Dr. Biederman’s critics said that they believed his primary
motivation was always to help children with legitimate A.D.H.D. and that
risks of untreated A.D.H.D. can be significant. What concerned them was
how Dr. Biederman’s high-profile and unwavering promotion of stimulants
armed drug companies with the published science needed to create
powerful advertisements — many of which cast medications as benign
solutions to childhood behavior falling far short of legitimate A.D.H.D.
“He gave them credibility,” said Richard M. Scheffler, a professor of
health economics and public policy at the University of California,
Berkeley, who has written extensively on stimulants. “He didn’t have a
balance. He became totally convinced that it’s a good thing and can be
more widely used.”
Building a Message
Drug companies used the research of Dr. Biederman and others to create
compelling messages for doctors. “Adderall XR Improves Academic
Performance,” an ad in a psychiatry journal declared in 2003, leveraging
two Biederman studies financed by Shire. A Concerta ad barely mentioned
A.D.H.D., but said the medication would “allow your patients to
experience life’s successes every day.”
Some studies had shown that stimulant medication helped some elementary
school children with carefully evaluated A.D.H.D. to improve scores in
reading and math tests, primarily by helping them concentrate. The
concern, some doctors said, is that long-term, wider academic benefits
have not been proved — and that ads suggesting they have can tempt
doctors, perhaps subconsciously, to prescribe drugs with risks to
healthy children merely to improve their grades or self-esteem.
Advertising Disorder
Drug companies have shifted
marketing for A.D.H.D. medication through the years. Most recently,
problems like divorce and auto accidents have been used to appeal to
adults. Ads in the 1990s advertised improved grades at school as a
central benefit. Early ads focused on depression and “the problem
child.”
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“There are decades of research into how advertising influences doctors’
prescribing practices,” said Dr. Aaron Kesselheim of Brigham and Women’s
Hospital in Boston, who specializes in pharmaceutical ethics. “Even
though they’ll tell you that they’re giving patients unbiased,
evidence-based information, in fact they’re more likely to tell you what
the drug company told them, whether it’s the benefits of the drugs or
the risks of those drugs.”
Drug company advertising also meant good business for medical journals –
the same journals that published papers supporting the use of the
drugs. The most prominent publication in the field, The Journal of the American Academy of Child & Adolescent Psychiatry,
went from no ads for A.D.H.D. medications from 1990 to 1993 to about
100 pages per year a decade later. Almost every full-page color ad was
for an A.D.H.D. drug.
As is legal and common in pharmaceutical marketing, stimulants’ possible
side effects like insomnia, irritability and psychotic episodes were
printed in small type and dominated by other messages. One Adderall XR
brochure included the recording of a man’s voice reassuring doctors:
“Amphetamines have been used medically for nearly 70 years. That’s a
legacy of safety you can count on.” He did not mention any side effects.
Drug companies used sales representatives to promote the drugs in
person. Brian Lutz, a Shire salesman for Adderall XR from 2004 to 2009,
said he met with 75 psychiatrists in his Oakland, Calif., territory at
least every two weeks — about 30 to 40 times apiece annually — to show
them posters and pamphlets that highlighted the medicine’s benefits for
grades and behavior.
If a psychiatrist asked about issues like side effects or abuse, Mr.
Lutz said, they were played down. He said he was told to acknowledge
risks matter-of-factly for legal reasons, but to refer only to the small
print in the package insert or offer Shire’s phone number for more
information.
“It was never like, ‘This is a serious side effect, you need to watch
out for it,’ ” Mr. Lutz recalled. “You wanted to give them more
information because we’re talking about kids here, you know? But it was
all very positive.”
A Shire spokeswoman said the company would not comment on any specific
employee and added, “Shire sales representatives are trained to deliver
fair and balanced presentations that include information regarding the
safety of our products.”
Mr. Lutz, now pursuing a master’s degree and hoping to work in mental
health, recalled his Shire work with ambivalence. He never lied or was
told to lie, he said. He said he still would recommend Adderall XR and
similar stimulants for A.D.H.D. children and adults.
What he regrets, he said, “is how we sold these pills like they were cars, when we knew they weren’t just cars.”
Selling to Parents
In September 2005, over a cover that heralded Kirstie Alley’s waistline
and Matt Damon’s engagement, subscribers to People magazine saw a
wraparound advertisement for Adderall XR. A mother hugged her smiling
child holding a sheet of paper with a “B+” written on it.
“Finally!” she said. “Schoolwork that matches his intelligence.”
When federal guidelines were loosened in the late 1990s to allow the
marketing of controlled substances like stimulants directly to the
public, pharmaceutical companies began targeting perhaps the most
impressionable consumers of all: parents, specifically mothers.
A magazine ad for Concerta had a grateful mother saying, “Better test
scores at school, more chores done at home, an independence I try to
encourage, a smile I can always count on.” A 2009 ad for Intuniv,
Shire’s nonstimulant treatment for A.D.H.D., showed a child in a monster
suit taking off his hairy mask to reveal his adorable smiling self.
“There’s a great kid in there,” the text read.
“There’s no way in God’s green earth we would ever promote” a controlled
substance like Adderall directly to consumers, Mr. Griggs said as he
was shown several advertisements. “You’re talking about a product that’s
having a major impact on brain chemistry. Parents are very susceptible
to this type of stuff.”
The Food and Drug Administration has repeatedly instructed drug
companies to withdraw such ads for being false and misleading, or
exaggerating the effects of the medication. Many studies, often
sponsored by pharmaceutical companies, have determined that untreated
A.D.H.D. was associated with later-life problems. But no science
determined that stimulant treatment has the overarching benefits
suggested in those ads, the F.D.A. has pointed out in numerous warning
letters to manufacturers since 2000.
Shire agreed last February to pay $57.5 million in fines to resolve
allegations of improper sales and advertising of several drugs,
including Vyvanse, Adderall XR and Daytrana, a patch that delivers
stimulant medication through the skin. Mr. Casola of Shire declined to
comment on the settlement because it was not fully resolved.
He added that the company’s current promotional materials emphasize how
its medications provide “symptom control” rather than turn monsters into
children who take out the garbage. He pointed to a Shire brochure and web page that more candidly than ever discuss side effects and the dangers of sharing medication with others.
However, many critics said that the most questionable advertising helped
build a market that is now virtually self-sustaining. Drug companies
also communicated with parents through sources who appeared independent,
from support groups to teachers.
The primary A.D.H.D. patient advocacy group, Children and Adults with Attention-Deficit/Hyperactivity Disorder,
or Chadd, was founded in 1987 to gain greater respect for the condition
and its treatment with Ritalin, the primary drug available at the time.
Start-up funding was provided by Ciba-Geigy Pharmaceuticals, Ritalin’s
primary manufacturer. Further drug company support helped create public
service announcements and pamphlets, some of which tried to dispel
concerns about Ritalin; one Chadd “fact sheet” conflicted with 60 years
of science in claiming, “Psychostimulant drugs are not addictive.”
The
program from the 2000 annual convention of the patient advocacy group
Chadd thanked its 11 primary sponsors, all drug companies.
A 1995 documentary
on PBS detailed how Chadd did not disclose its relationship with drug
companies to either the Drug Enforcement Administration, which it was
then lobbying to ease government regulation of stimulants, or the
Department of Education, with which it collaborated on an A.D.H.D.
educational video.
Chadd subsequently became more open in disclosing its backers. The
program for its 2000 annual convention, for example, thanked by name its
11 primary sponsors, all drug companies. According to Chadd records,
Shire paid the group a total of $3 million from 2006 to 2009 to have
Chadd’s bimonthly magazine, Attention, distributed to doctors’ offices
nationwide.
Chadd records show that the group has historically received about $1
million a year, one-third of its annual revenue, from pharmaceutical
company grants and advertising. Regarding his company’s support, Mr.
Casola said, “I think it is fair to call it a marketing expense, but
it’s an arm’s-length relationship.”
“We don’t control what they do,” he said. “We do support them. We do
support broadly what they are trying to do in the marketplace — in
society maybe is a better way to say it.”
Advocates Answer
The chief executive of Chadd, Ruth Hughes, said in an interview that
most disease-awareness groups receive similar pharmaceutical support.
She said drug companies did not influence the group’s positions and
activities, and noted that Chadd receives about $800,000 a year from the
C.D.C. as well.
“One pharma company wanted to get Chadd volunteers to work at their
booth to sort of get peer counseling, and we said no, won’t do that, not
going there,” Dr. Hughes said, adding, “It would be seen as an
endorsement.”
A.D.H.D. patient advocates often say that many parents resist having
their child evaluated because of the stigma of mental illness and the
perceived risks of medication. To combat this, groups have published
lists of “Famous People With A.D.H.D.” to reassure parents of the good
company their children could join with a diagnosis. One, in circulation
since the mid-1990s and now posted on the psychcentral.com information portal beside two ads for Strattera, includes Thomas Edison, Abraham Lincoln, Galileo and Socrates.
The idea of unleashing children’s potential is attractive to teachers
and school administrators, who can be lured by A.D.H.D. drugs’ ability
to subdue some of their most rambunctious and underachieving students.
Some have provided parents with pamphlets to explain the disorder and
the promise of stimulants.
Susan Parry, with her son, Andy, 30. When Andy was a boy, Mrs. Parry felt pressured to put him on stimulants.Rick Scibelli Jr. for The New York Times
Susan Parry, who raised three boys in a top public school system on
Mercer Island, outside Seattle, in the 1990s, said teachers pushed her
into having her feisty son Andy evaluated for A.D.H.D. She said one
teacher told her that her own twins were thriving on Ritalin.
Mrs. Parry still has the pamphlet given to her by the school
psychologist, which states: “Parents should be aware that these
medicines do not ‘drug’ or ‘alter’ the brain of the child. They make the
child ‘normal.’ ” She and her husband, Michael, put Andy on Ritalin.
The Parrys later noticed that on the back of the pamphlet, in small
type, was the logo of Ciba-Geigy. A school official told them in a
letter, which they provided to The Times, that the materials had been
given to the district by a Ciba representative.
“They couldn’t advertise to the general public yet,” said Michael Parry,
adding that his son never had A.D.H.D. and after three years was taken
off Ritalin because of sleep problems and heart palpitations. “But
somebody came up with this idea, which was genius. I definitely felt
seduced and enticed. I’d say baited.”
Although proper A.D.H.D. diagnoses and medication have helped millions
of children lead more productive lives, concerns remain that
questionable diagnoses carry unappreciated costs.
“They were telling me, ‘Honey, there’s something wrong with your brain
and this little pill’s going to fix everything,’ ” said Micaela Kimball,
who received the diagnosis in 1997 as a high school freshman in Ithaca,
N.Y., and is now a freelance writer in Boston. “It changed my whole
self-image, and it took me years to get out from under that.”
Today, 1 in 7 children receives a diagnosis of the disorder by the age
of 18. As these teenagers graduate into adulthood, drug companies are
looking to keep their business.
The New Frontier: Adults
The studio audience roared with excitement two years ago as Ty Pennington,
host of “The Revolution” on ABC, demonstrated how having adult A.D.H.D.
felt to him. He staged two people struggling to play Ping-Pong with
several balls at once while reciting the alphabet backward, as a crowd clapped and laughed. Then things got serious.
The
television host Ty Pennington has been featured in advertisements in
which adult A.D.H.D. has been marketed by pharmaceutical companies.Michael Buckner/Getty Images
A psychiatrist on the program said that “the prison population is full
of people with undiagnosed A.D.H.D.” He told viewers, “Go get this
diagnosis” so “you can skyrocket.” He said that stimulant medication was
effective and “safer than aspirin.”
No one mentioned that Mr. Pennington had been a paid spokesman for Shire
from 2006 to 2008. His Adderall XR video testimonials – the medication
“literally changed my life” and “gave me confidence,” he said in a 2008
ad — had drawn an F.D.A. reprimand for overstating Adderall’s effects while omitting all risks.
Mr. Pennington said through a spokeswoman: “I am not a medical expert. I am a television host.”
Many experts agree that the disorder was dismissed for too long as
affecting only children. Estimates of the prevalence of adult A.D.H.D.
in the United States -- derived through research often backed by
pharmaceutical companies -- have typically ranged from 3 to 5 percent.
Given that adults far outnumber children, this suggests that the adult
market could be twice as large.
Because many doctors and potential patients did not think adults could
have A.D.H.D., drug companies sold the concept of the disorder as much
as their medications for it.
change from 2008
Younger
than 20
Aged 20
and older
+60%
40
20
’08
’09
’10
’11
’12
Marketing to Adults
Prescriptions for adults are growing more quickly than for children.
Source: IMS Health
“The fastest-growing segment of the market now is the new adults who were never diagnosed,” Angus Russell told Bloomberg TV
in 2011 when he was Shire’s chief executive. Nearly 16 million
prescriptions for A.D.H.D. medications were written for people ages 20
to 39 in 2012, close to triple the 5.6 million just five years before,
according to IMS Health. No data show how many patients those
prescriptions represent, but some experts have estimated two million.
Foreseeing the market back in 2004, Shire sponsored a booklet that
according to its cover would “help clinicians recognize and diagnose
adults with A.D.H.D.” Its author was Dr. Dodson, who had delivered the
presentation at the Adderall XR launch two years before. Rather than
citing the widely accepted estimate of 3 to 5 percent, the booklet
offered a much higher figure.
“About 10 percent of adults have A.D.H.D., which means you’re probably
already treating patients with A.D.H.D. even though you don’t know it,”
the first paragraph ended. But the two studies cited for that 10 percent
figure, from 1995 and 1996,
involved only children; no credible national study before or since has
estimated an adult prevalence as high as 10 percent.
Dr. Dodson said he used the 10 percent figure because, despite several
studies estimating adult rates as far lower, “once a child has A.D.H.D.,
he does for life. It doesn’t go away with age.”
The booklet later quotes a patient of his named Scarlett reassuring
doctors: “If you give me a drink or a drug, I’ll abuse it, but not this
medication. I don’t consider it a drug. Drugs get abused. Medication
helps people have satisfying lives.”
Shire’s 2008 print campaign
for adult A.D.H.D. portrayed a gloomy future to prospective patients.
One ad showed a happy couple’s wedding photo with the bride airbrushed
out and “DIVORCED” stamped on it. “The consequences may be serious,” the
ad said, citing a study by Dr. Biederman
supported in part by Shire. Although Dr. Biederman’s study showed a
higher rate of divorce among adults with the disorder, it did not assess
whether stimulant treatment significantly deterred such consequences.
Questionable Quizzes
Adults searching for information on A.D.H.D. encounter websites with
short quizzes that can encourage normal people to think they might have
it. Many such tests are sponsored by drug companies in ways hidden or
easily missed.
“Could you have A.D.H.D.?” beckons one quiz,
sponsored by Shire, on the website everydayhealth.com. Six questions
ask how often someone has trouble in matters like “getting things in
order,” “remembering appointments” or “getting started” on projects.
A user who splits answers evenly between “rarely” and “sometimes”
receives the result “A.D.H.D. Possible.” Five answers of “sometimes” and
one “often” tell the user, “A.D.H.D. May Be Likely.”
In a nationwide telephone poll conducted by The Times in early December,
1,106 adults took the quiz. Almost half scored in the range that would
have told them A.D.H.D. may be possible or likely.
About 570,000 people took the EverydayHealth test after a 2011 advertisement starring Mr. Levine of Maroon 5 sponsored by Shire, Chadd and another advocacy group, according to the website Medical Marketing & Media. A similar test on the website for Concerta prompted L2ThinkTank.com, which assesses pharmaceutical marketing, to award the campaign its top rating, “Genius.”
John Grohol, a
Boston-area psychologist who licensed the test to EverydayHealth, said
such screening tools do not make a diagnosis; they merely “give you a
little push into looking into” whether you have A.D.H.D. Other doctors
countered that, given many studies showing that doctors are strongly
influenced by their patients’ image of what ails them, such tests invite
too many patients and doctors to see the disorder where it is not.
Online Test Asks Whether You Could Have A.D.H.D., Too
A
web page sponsored by the drug maker Shire features this quiz, which
encourages adults with what many would consider common behavior to think
they might have A.D.H.D. In a Times poll of 1,106 American adults
asking the same questions by telephone, nearly half got a result of
“A.D.H.D. Possible” or “A.D.H.D. May Be Likely.” Only 5 percent said
they had received an A.D.H.D. diagnosis from a medical professional.
Try this six-question quiz to see how you score — then see how you compare with other Americans.
1. How often do you have trouble wrapping up the final details of a project once the challenging parts have been done?
“I think it is misleading,” said Dr. Tyrone Williams,
a psychiatrist in Cambridge, Mass. “I do think that there are some
people out there who are really suffering and find out that maybe it’s
treatable. But these symptoms can be a bazillion things. Sometimes the
answers are so simple and they don’t require prescriptions – like ‘How
about eight hours of sleep, Mom, because four hours doesn’t cut it?’ And
then all their A.D.H.D. symptoms magically disappear.”
Because studies have shown that A.D.H.D. can run in families, drug
companies use the children’s market to grow the adult one. A pamphlet
published in 2008 by Janssen, Concerta’s manufacturer — headlined “Like
Parent, Like Child?” — claimed that “A.D.H.D. is a highly heritable
disorder” despite studies showing that the vast majority of parents of
A.D.H.D. children do not qualify for a diagnosis themselves.
A current Shire manual for therapists illustrates the genetic issue with
a family tree: three grandparents with the disorder, all six of their
children with it, and seven of eight grandchildren, too.
Insurance plans, increasingly reluctant to pay for specialists like
psychiatrists, are leaving many A.D.H.D. evaluations to primary-care
physicians with little to no training in the disorder. If those doctors
choose to learn about the diagnostic process, they can turn to web-based
continuing-education courses, programs often subsidized by drug
companies.
A recent course titled “Unmasking A.D.H.D. in Adults,”
on the website Medscape and sponsored by Shire, featured an
instructional video of a primary-care physician listening to a college
professor detail his work-related sleep problems. After three minutes he
described some attention issues he had as a child, then revealed that
his son was recently found to have the disorder and was thriving in
college on medication.
Six minutes into their encounter, the doctor said: “If you have
A.D.H.D., which I believe you do, family members often respond well to
similar medications. Would you consider giving that a try?”
The psychiatrist who oversaw the course, Dr. David Goodman
of Johns Hopkins and the Adult Attention Deficit Disorder Center of
Maryland, said that he was paid several thousand dollars to oversee the
course by Medscape, not Shire directly, and that such income did not
influence his decisions with patients. But as he reviewed the video in
September, Dr. Goodman reconsidered its message to untrained doctors
about how quickly the disorder can be assessed and said, “That was not
an acceptable way to evaluate and conclude that the patient has
A.D.H.D.”
A Shire spokeswoman declined to comment on the video and the company’s sponsorship of it.
Mr. Casola said Shire remains committed to raising awareness of A.D.H.D.
Shire spent $1 million in the first three quarters of 2013, according
to company documents, to support A.D.H.D. conferences to educate doctors. One this autumn found J. Russell Ramsay, a psychologist at
the University of Pennsylvania’s medical school, who also serves as a
consultant and speaker for Shire, reading aloud one of his slides to the
audience: “A.D.H.D. – It’s Everywhere You Want to Be.”
“We are a commercial organization trying to bring health care treatments
to patients,” Mr. Casola said. “I think, on balance, we are helping
people.”
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