Wednesday, July 18, 2007

Tired of Being Depressed? Shire's Solution: Call it ADHD

Suddenly, a third of my patients with depression have ADHD, according to promotions by Shire. In a coordinated series of journal ads, CME newsletters, and a specially prepared "" website, psychiatrists are being encouraged to further expand the diagnostic territory treatable by Shire's products (which include Adderall XR, Vyvanse, and Daytrana).

While I was aware and increasingly annoyed by this latest promotional gimmick, I thank psychiatrist Paul Natvig for alerting me to a rankly deceptive advertisement in the current issue of Psychiatric News.

"Could it be ADHD?", asks a male model with a 5-day beard and an insouciant pout reminiscent of Tom Cruise in one of his rare blue moments. "ADHD was diagnosed in 1 out of 5 men with depression*" continues the ad, referencing a 1996 study published in an obscure journal, Psychiatric Research (Alpert J et al., 1996;62:213-219). The problem is that if you actually read the paper, you find that only about 1/9 depressed men, or 11%, actually met criteria for current ADHD. In order to arrive at the more alarmist 1/5 figure, Shire included "sub-threshold" ADHD in the total.

And what about the really astounding claim that "32% of adults with a depressive disorder" have ADHD? This is a figure pulled from the National Comorbidity Survey Replication, the controversial study that concluded that half of all Americans eventually develop a psychiatric disorder. This study sent lay interviewers to interview a sample of about 9000 people in the U.S., and they used a checklist to diagnose DSM-IV disorders. But since the interviewers were not clinicians, they were unable to accurately determine the clinical importance of the symptoms reported by the sample. The study tried to correct for this problem by having clinicians interview a subset of the sample, but many believe that the final reported prevalence rates were still vastly inflated.

The fact is that if you are hell-bent on finding "ADHD" in patients with major depression, you can. Patients with depression typically have symptoms such as distractibility, poor focus, and difficulty finishing tasks, all of which intersect precisely with ADHD criteria. Shire is hoping that we will start to put our depressed patients on stimulants. In my practice, this rarely helps. Such patients often develop insomnia and agitation, and sometimes paranoia.

On the plus side, Shire's stockholders develop lucrative portfolios, greater self esteem, and meals out more often. Maybe my depressed patients should just skip the stimulants and contact their brokers to buy some shares.


Anonymous said...

Yep: The NCR data is bad. But, of course, you'll never hear that from the profession since it's in their interest to inflate the numbers.

Anonymous said...

you seem to have some issues with shire as you are always writing about the company and how they try to "trick" you into thinking this that or the other. Do you believe in ADHD? It seems you are pretty skeptical about the research, findings and intentions of information.

Anonymous said...

We're starting to see the marketing of adult ADHD in the UK. The 'strong research' featured in news items comes from a consensus meeting of The British Association of Psychopharmacology, which was funded by Cephalon, Janssen, Lilly, Shire UK and Shire US.

The full story is at Seroxat Secrets:

Daniel Carlat said...

Responding to anonymous' question about whether I believe in ADHD--Yes I do, I treat many patients in my private practice with a variety of ADHD medications. However, I'm cautious about the diagnosis, because many patients come into my office looking specifically for an ADHD diagnosis in order to get a prescription for stimulants, and not because they actually have ADHD. Furthermore, the claim that a third of depressed patients have ADHD runs counter to my clinical experience, and I'm sure the majority of psychiatrists who are not on Shire's speakers bureau would agree.

Radagast said...

Dear Dr Carlat,

I've got a dumbass's question for you: what is ADHD? Yes, I know what the abbreviation stands for, but what does it actually amount to? Put another way, what would I have to do, in order to be diagnosed as having ADHD? I'm just wondering how flexible the definition is - ie, if you were of a mind, how easy it would be to find ADHD in a patient?

Best regards

Matthew Holford

soulful sepulcher said...

Thanks for this post, now I can get the rest of my DTC Shire/Lilly adult ADHD pile out and write about it, and not to forget those favorite names that keep cropping up in the fine print: Biederman and Faraone.
The website featured here does nothing compared to the TV host of "Extreme Make Over" in the USA promoting his adult ADHD in the DTC literature.
The common theme I have seen w DTC as a patient/consumer in a psych office waiting room full of parents and children was the obvious push toward medicating those parents who "might not have realized" they too are ADHD.
Don't forget Lilly in this marketing blitz, I found a stack of their CD kits just waiting for the adults [like me]to take one [or 2]home.
Long roads paved with money and corporations striving to make the biggest profits and some taking it as far as the imagination can take them.
I know, maybe the dog is ADHD too, oh wait, wrong product./

Anonymous said...

Agreed, the endless arrival of marketing materials sent out by Shire to doctors is over the top. Although I don't agree with the sheer volume of junk mail and spun information, there are threads of truth woven into the literature. Threads meaning more than getting the right year on the copyright date on printed materials =).
The fact of the matter is that we live in a capitalistic society and these companies (Lilly, Pfizer, etc.) have a right to promote their products in order to profit from them. Doesn't mean we can't blog about how much B.S. is out there though =).
I'm just thankful we have these products to tell you the truth. I have been on Zoloft for 7 years and an amphetamine based stimulant for the past 3. Both have dramatically improved the quality of my life. Thank god their are medications available for those that really need them. Whose to say if the world is underdiagnosed or overdiagnosed. To say that there is a lot of misdiagnosis would be more accurate.

Is all the b.s. spin and madison avenue worth it?

Absolutely, 100%, without a doubt. The glass is half-full.

Keep up the good work in pointing out the ridiculous, the overstated, the undocumented. The more checks and balances we have the better. Mabye sometime in the next 1000 years we will have just one study that both doctors and pharma companies agree is unbiased and true. Yeah, and my dog will learn to bark in french. Ha!

I just wanted to point out the silver lining in all of this, the fact that previously untreated people are now being treated: and that is unquestionably a very good thing.

Take it easy Doc

Anonymous said...

Dr Carlat,
I find the 32% figure simlpy extraordinary and well out of line with most figures I have seen estimating ADD/ADHD at 6-10% of the population.

Assessing for the criteria of lifelong symptomatology and seing an observer account( part of the accepte diagnostic criteria)should be enough to deal with excluding secondary inattention and drug seeking behaviour. Having said that I have just been diagnosed with Adult ADD at age 46. It has taken 35 years of symptoms - 3 famiy practitioners and 7 pyschiatrists. You see in Australia almost nobody has ever heard of adult ADHD- especially not in high school overacheivers - or successful professionals.
While I feel that over here at least the diagnosis needs more publicity and understanding I am concerned that absurd claims like this undermine public faith in the idea of ADHD as a valid diagnosis.

Incidentally I am the other side of the coin to your experience as my symptoms masqueraded as low to medium grade anxiety, social phobia and depression. I do think that ADD does need to be specifically considered in most adult psychiatric presentations.

As for drug companies- in my experience they can be remarkably succseeful disseminators of disinformation.

Gina Pera said...

Oh boy,l I am late to the party here, but better late than never.

Dr. C, how can you be so bright in some areas and just, well, clueless in others?

What do you and so many of your blog visitors have against ADHD? And do you know that plenty of people with ADHD have something against YOU?

I personally know DOZENS of people who've been diagnosed with depression and even "treated" for it -- several for as many as 30 years -- and Finally, they figured out ADHD themselves, got the right help, and their lives have turned around. What they can't get over is the pitiful clinicians who made their lives so miserable for so many years, out of sheer arrogant ignorance.

Get with it, folks. The more you criticize ADHD and deprive the people who have it of legitimate treatments, the more you show your own disorders -- low empathy, poor critical thinking, and a stubborn reluctance to examine the evidence. I don't think rigid mingy-mindedness is in the DSM yet, but maybe the dark conspiracy of forces at work will find a place for it.

Gina Pera said...

Yes, we are starting to see the UK get more awareness on adult ADHD and ADHD in children. And not a minute too soon.

I've just returned from speaking on that topic in London, and I can tell you many people had tears in their eyes at finally being understood -- and offered realistic strategies. After years of dealing with idiots.

Only people with no soul and no heart are not moved by these stories, and the facts that back them up. There is something severely wrong with those who take enjoyment in seeing people suffer and who will hold their graduate-school-inherited theories over new knowledge that might just expand their ability to serve their patients. Something wrong indeed.

I keep looking for a psychiatry blog written by and visited by knowledgeable, compassionate professionals. Instead, I find some reasonable posts (especially Dr. C's, when he sticks to MD-education reform) but mostly a lot of disappointingly sensationalistic, wildly opinionated twaddle -- and, in reponse, plenty of psychiatric patients' irrational ranting.

It must scare off most of the better clinicians, who are probably too busy to visit blogs anyway.

Gina Pera said...

The problem is that if you actually read the paper, you find that only about 1/9 depressed men, or 11%, actually met criteria for current ADHD. In order to arrive at the more alarmist 1/5 figure, Shire included "sub-threshold" ADHD in the total.
What's the problem, Dr. C? The current diagnostic criteria are based on studies of ADHD in children. Everyone knows they fit adults poorly -- which is why we need updated critera for adults in the next DSM -- and if the criteria were expanded to include more adult criteria, the estimated adult population with ADHD in the U.S. would be about 16 percent.

That's 16 percent of the adult population, not 16 percent of those with depression.

Andrew Kinsella said...

Review the work of Dr Thomas E Brown, a psychology professor from Yale. He is arguing that ADHD is the foundational disorder form which most other psych disorders ( except the psychoses) evolve.

Having been successfully treated for ADHD, and now being actively involved in treating it as a doctor- I repeatedly hear of patients misdiagnosed with depression and bipolar, who have been through multiple doctors trying to find treatment that helps them. I left a trail of 5 failed psychiatrists behind me.
We know how much better we do when our problem has been correctly identified, and a targeted treatment plan developed. What do we have to do - sue you guys into the 21st Century?

Paul Revere said...

Ironically, the current issue of the Carlat Report encourages the use of "self-report" instruments which are well-validated for SINCERE patients. Since it is painfully easy to malinger ADHD by looking up symptoms, however, the self report instruments aren't so good in ferreting out fakers. Maybe if self report were only used to give out Strattera...