Wellness

A Look at the Adderall Epidemic

Take Your Pills, a new documentary on Netflix, highlights a uniquely American epidemic: The US represents 4 percent of the world’s population but we use more than half of the world’s stimulants.

ADD and ADHD are very real learning disorders, and many who have these disorders benefit from taking medications like Adderall, Concerta, and Ritalin. But although stimulant medications are nothing new—they’ve been around since the 1920s—some doctors are sounding the alarm on the drastic increase in prescriptions. (The US alone saw a 35.5 percent increase in these drugs between 2008 and 2012.) Stimulant medications are classified by the DEA as Schedule II substances, meaning there is a high potential that people may become dependent on them or abuse them. What’s also concerning is the dearth of long-term studies on how stimulant medications affect adults, who have outpaced children as the primary users in the US. A CDC report released this year found that there was a 344 percent increase in the number of privately insured women in the US between fifteen and forty-four years old who filled a prescription to treat ADHD. The jump was even higher—700 percent—for women in their late twenties and thirties, i.e., of child-bearing age.

Take Your Pills dives into this phenomenon, focusing on college campuses. It’s during college that many people are first exposed to stimulant medications—either from knowing classmates who take them or seeing them used recreationally at parties. It’s also when some begin to consider whether they need them, too. The film poses existential questions about the toll our hypercompetitive and fast-paced society is taking on our psychological and physical well-being. Many of the people interviewed felt pressure to outperform their peers and feared that their future careers and lives could be jeopardized if they stopped the medication.

We caught up with the executive producers of the documentary, mother-daughter team Maria Shriver and Christina Schwarzenegger (who is also an editor at goop). They shared their personal connection to Adderall (Christina had a prescription) and why they wanted to make the documentary.

We also asked one of the documentary’s experts, Dr. Lawrence Diller, where we go from here. Diller, the author of Running on Ritalin, is a developmental pediatrician who has been in clinical practice for more than forty years and on the front lines of treating ADD/ADHD. He is known for developing strong personal relationships with his patients and for taking the time to understand their unique struggles and come up with individualized, multipronged treatment plans. He has diagnosed many children with these and other learning disorders and prescribed stimulant medications to a large percentage of those he diagnosed. But he hasn’t been quiet about the potential risks of stimulant medications and his concern with their rise. “We operate in a culture where performance is typically valued above everything else,” he says. “While I believe drugs work, they aren’t a moral equivalent to working with people on how they might change their lives, particularly how a child’s life might be changed.”

A Q&A with Lawrence Diller, M.D.

Q

How are ADD and ADHD diagnosed?

A

ADHD (attention deficit hyperactive disorder) and ADD (attention deficit disorder) are misdiagnosed, overdiagnosed, and underdiagnosed. The search for ADHD/ADD is a bit of a red herring. The line between some variation of personality and an identifiable disorder is somewhat arbitrary. So who really has ADD and who doesn’t—except in extreme cases—is an open question.

There aren’t biological or psychometric markers for the disorders, which makes diagnosis more complex. The criteria for ADHD and ADD were decided by a group of experts and laid out in the Diagnostic and Statistical Manual of Mental Disorders. The most recent edition of the psychiatric manual—the DSM-5—was published in 2013. There have been attempts to standardize the diagnoses using questionnaires, like the Conners, the Achenbach, and the one most commonly used by doctors now, the Vanderbilt.

To diagnose children, parents and teachers are asked about twenty questions, such as: How much does your child fidget? How often do they not complete tasks? When you take the test as an adult, you’re given a list of questions framed as: How much do you fidget? Not at all, a little bit, or a lot.

“I believe the disorder is more than just a set of certain criteria. Diagnosis depends upon the individual’s family, neighborhood, and the country the person lives in.”

With children, an expert often determines whether or not a child has ADD/ADHD based on the responses of one parent and a teacher. The responses to these questions were never meant to be a diagnostic instrument; they were only supposed to help in the diagnosis of a child.

Psychological testing by neuropsychologists has also become common in diagnosing ADD/ADHD. These tests focus on brain activities called executive functioning—in particular, working memory and processing speed, which are associated with ADHD.

Complicating matters, it’s all very subjective. I believe the disorder is more than just a set of certain criteria. Diagnosis depends upon the individual’s family, neighborhood, and the country the person lives in. Some people respond with, “You’re saying ADHD doesn’t exist,” but that’s not what I’m saying. It’s very clear when a child—or an adult, but more so a child—is expressing extreme symptoms of hyperactivity and impulsivity. But to understand the condition in its full cultural context, you have to go country by country, state by state, neighborhood by neighborhood, and ethnicity by ethnicity, because it varies. Even if there were a biological test for ADD, it wouldn’t really tell you who has the problem, since the biology exists within a psychosocial framework—such as American ADD/ADHD, which is extremely vague.

Q

What is the process for prescribing stimulant medication for ADD/ADHD?

A

It depends on whether you’re going to a psychiatrist or a family doctor for your diagnosis. Once the FDA approves a drug, primary care physicians can prescribe it as they see fit. They are limited only by their judgment, or the threat of a malpractice suit or loss of their license, both of which are very unusual. The standards in primary care are generally less stringent than in psychiatry. I think it’s pretty well known—especially on college campuses—that you can go to some doctors, explain that you have problems concentrating and following tasks, and they will just write you a stimulant prescription. Is that the proper way to do it? No. But it’s very common. More than anything, it’s the economic pressures on primary care doctors that don’t allow them to spend the required time to do a better evaluation. Second, many lack intensive training in working with patients with ADD/ADHD.

Q

Does gender play a role in the diagnosis of ADD/ADHD?

A

ADHD is the only disorder I know of, medical or psychiatric, where the gender majority shifts at age eighteen. Under eighteen, three boys are identified for every one girl with ADHD. Over eighteen, 55 to 60 percent of people diagnosed with ADHD are women, which is interesting. I wrote a piece a while ago called “Gender Power and Ritalin” to explain why I think this shift has to do with stereotypical power roles—biological, but more so culturally reinforced—and typical responses to stress.

Often, girls and young women are taught that their role is to please others, while to boys what’s stressed is to attempt to take over or exert their strength physically. As a result, boys at the elementary level are identified much more frequently with ADD because they tend to exhibit behavioral problems, which may be attached to learning issues. Girls, on the other hand, tend to act out less, trying to keep everyone happy. Boys get attention for causing problems, and girls don’t.

“ADHD is the only disorder I know of, medical or psychiatric, where the gender majority shifts at age eighteen.”

At age eighteen, however, you see a change. Young men generally assume greater control over their lives as they transition into their careers, while women may still feel pressure to please others. This often continues well into adulthood and may lead some women to feel as if they are taking on too much. Many women may feel a need to be superwomen, juggling demanding careers, a partner, kids, etc., which can lead to feeling overwhelmed. To cope with the stress, some women turn to stimulant medications. The medications allow them to be superwomen—at least for a while. Suddenly, they’re able to stay on top of their schedules and their kids’ schedules, keep the house tidy, complete extracurriculars, get the bills paid, etc. Maintaining this level of performance over time often requires more medication, and so it can turn into a vicious cycle.

Q

Some people say that everyone has ADD/ADHD today. Do you believe that?

A

I think our culture has adopted the language of psychiatry and psychology. Oftentimes you’ll hear people casually say, “Oh, that’s just my ADD.” This trivializes the diagnosis.

As I’ve mentioned, the line between some variation of personality and a disorder is subjective. So there is a tendency to attach labels to traits very casually. In the film, I say, “In America, if your temperament and talents don’t match your goals and aspirations, you’re potentially a candidate for a diagnosis and medicine.” I think it’s important for each of us to examine our personal strengths and weaknesses and try to work toward success within those limits before we resort to medications.

An incredibly common underlying issue for many is worry. Options available to individuals expand exponentially after eighteen, so it’s necessary for each person to think about what’s best for them and what motivates them and drives them, and to not give into fear. People are often afraid of failure, of falling off the competitive curve. This drives overuse of medication, when there are other options.

“In America, if your temperament and talents don’t match your goals and aspirations, you’re potentially a candidate for a diagnosis and medicine.”

When I speak with a patient, I first try to find out a bit about their lifestyle and the issues they’re struggling with. For example, if a woman feels a need to juggle many different things and excel in each, I question whether she is trying to fulfill a superwoman ideal. I ask how she has tried to address these problems, what her goals in life are, and if she would be willing to address these issues in a nonmedical way, at least initially.

If that patient continues to struggle, despite the nonmedical intervention, I might consider prescribing her a long-acting stimulant medication to see how that works. I would advise her about the potential side effects and monitor her progress very closely.

Q

Why has there been such a rise in stimulant medications? Do you think it’s a uniquely American phenomenon?

A

When you consider an epidemic, you have to look at not only the qualities of the infectious agent—the virus—but also the qualities of the host. Looking at us, our state is capitalist consumerism. We are bombarded with commercials that assure us that if we buy this, we’ll be happy. That’s what our economy and culture thrive on. Within that culture, making more money and improving performance are valued above other human qualities. That is what makes America particularly vulnerable to performance enhancers. It’s not a new phenomenon; what has changed is a general decline in the standard of living in America since the 1970s, and an increase in the effects of large corporations on our decision-making. These corporations prey on our desires for wealth and prestige—desires that are common to most cultures but exaggerated in the American culture.

What adults in America are suffering from is not adult ADD; it’s AAD (achievement anxiety disorder). I hate to call it a disorder, but achievement anxiety is what fuels our national addiction. Americans represent 4 percent of the world’s population, yet we use 70 percent of the world’s stimulants. ADHD adults—those diagnosed and taking stimulants—also outnumber children now, so it’s an American adult phenomenon. That isn’t to say other developed countries don’t have these issues, but they’re on a much smaller scale. There will be a cultural backlash at some point. I believe once the opioid crisis clears up, stimulants will take center stage in the public’s attention.

Q

What are the risks and benefits of stimulant medications? How do you talk about this with adults or parents?

A

I always put an emphasis on the existential risks since I believe these are very important for people to question. That being said, many people are surprised to learn that stimulant medications are generally safer for children than for adults. First, children don’t have access to the medicine. And second, they usually don’t like higher doses. You will often hear a kid complain about the medication, saying, “I feel nervous” or “I feel weird.” This is especially true for children on higher doses.

On the other hand, older teens and adults not only have access to the medication, but many report feeling powerful or grand, especially when they take higher doses. That can be an extremely slippery slope to abuse and addiction. Because of that, I caution older teens and adults when starting them on the medication that they run a much higher risk for misuse and abuse.

Q

What kind of long-term studies exist on stimulant medications?

A

Stimulants have been around since 1929, and they’ve been prescribed to children since the mid-’50s. The risks to children are quite low. One risk for children who take the medication seven days a week, without taking any breaks, appears to be a potential decrease in growth rate.

Completing studies to investigate the long-term effects of stimulant medications is very tough in America. There are unfortunately no long-term studies on adults. The only study that I’m aware of was done about ten years ago and used government telephone surveys to look at the misuse or illegal use of stimulants. One out of ten of the people surveyed reported behavior consistent with abuse and addiction. We need more studies to better understand the long-term effects of these medications on adults. The government has completely abdicated its role.

I believe there is a study going on right now in Germany on the long-term effects on adults. It involves a sample of a few hundred kids, randomly selected, and follows them all over the course of many years, which is the right way to do it.

Q

Do you try alternative methods before using prescriptions? What have people found helpful?

A

In forty years of practice, I’ve seen a lot of trends come and go. I stick with the tried and true methods that I’ve seen work. In treating children with ADD/ADHD, this includes behavioral modification and special education interventions when called for, or school behavior strategies, including immediate tangible reinforcers—such as giving points or a sticker to assure a child they’re doing a good job. Then, if necessary, medicine. I never immediately prescribe medicine.

“The universally experienced effect of amphetamines is an elevated sense of one’s self and one’s performance, which, in turn, gives a person more confidence, so they try harder.”

I try behavioral therapy with adults as much as I can before prescribing, but it’s not easy. I also involve a patient’s spouse or significant other or, if the patient is younger or in college, the parents. I think a spouse can do a lot to help the individual with ADHD, such as reminding the person of events and helping them stay organized. Russell Barkley wrote Taking Charge of ADHD: The Complete, Authoritative Guide for Parents and Taking Charge of Adult ADHD, and I think the adults’ book is written for the spouse. A person with ADHD, for instance, may not be able to finish Barkley’s book. Working with the family or the spouse makes more sense because they may be in a position to help.

For college students, it can be helpful to work with a coach or counselor in assessing priorities, goals, and talents. Will they follow through? Very often, no. So they wind up taking medicine, since taking a pill is easier and the results are faster—the effect of the pill takes hold within twenty minutes. If you have the right dose, the patient will feel very good; the universally experienced effect of amphetamines is an elevated sense of one’s self and one’s performance, which, in turn, gives a person more confidence, so they try harder.

Q

Do you see the rise of stimulant medication continuing? What could stop it?

A

The only thing that I could imagine stopping this trend would be recognizing this as a crisis of addiction to prescription stimulants. The U.S attorney for the Southern District of New York recently busted five doctors in the New York area for taking money from drug companies for prescribing fentanyl. This sent shivers through the medical community. Historically speaking, the only thing that stops doctors overprescribing or misdiagnosing is a threat to their licenses, malpractice suits, and negative publicity. I wrote to the U.S. attorney and told him to look at what’s going on in the Adderall scene because it’s identical. There are well-known Adderall mills around universities where they’re getting paid from big pharma companies to sell more Adderall XR (Adderall extended release). College students prefer the immediate-release versions of stimulants, so companies are now offering money to doctors to prescribe more XR.

Dr. Lawrence Diller is a behavioral/developmental pediatrician who has been in private practice for forty years. He has an M.D. from Columbia University College of Physicians and Surgeons in New York City and completed his residency at the University of California at San Francisco. He has written numerous articles and books including Running on Ritalin, Remembering Ritalin, Should I Medicate My Child?, and The Last Normal Child. He currently writes and shares his work on his site, DocDiller.com.

The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.

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