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 "depressionandadhd.com" 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.