A Collision of Opinion, Prejudice, Punditry and Marketing: Scientific Integrity in Psychiatry

Contributed by AITSE Consortium member and psychiatrist, Dr. John Benson

Psychiatry has a desperate need for scientific integrity. Obviously, there are issues touching upon psychiatric medications, but there are also a whole range of “behavioral psychology” questions around which opinion, punditry and pseudo-science abound.
With regard to pharmaceutical treatments, one difficulty is that clinical trials do not get set up to test real world conditions, as often as they should.  They tend to be “narrow” and defined to “acute” trials, such as 6 to 8 week safety and efficacy trials. And, it is not possible to extrapolate anything regarding longer term treatments, or viable alternatives to medication interventions, from these trials. They tell you how Drug A stacked up against placebo, but not too much else. The take-home message, which is not often made clear, is that the drug is better then nothing.

A crowning example of where opinion, prejudice, punditry and marketing all collide is the topic of ADHD.  A sadly typical scenario is where an over-worked teacher wants “Johnny” to get ADHD medications and recommends this to the parents.  Short term this is for the teacher’s relief and convenience. But, most experts in the field (of which I am one) believe that intervening with a “medication only” solution is certain to be short of the mark.

Long term change also requires classroom accommodations, at home coaching, and behavioral change. One must consider ingredients such as parental emotional state, study skills which are eroded if they were ever good to start with, the parent-child emotional “fit,” and other behavioral or social problems, as well. All of this is necessary to impact the dysfunctional system so that Johnny can advance and flourish.

In my practice, I try to use and refer people to a good bit of bibliotherapy on ADHD.  One of my favorites, which helps to de-stigmatize the condition, especially for those who live with it in themselves, is “You Mean I’m NOT Lazy, Stupid or Crazy?!” by Kelly and Ramundo. Herein ADHD type people are described as the “hunters” of our supposed evolutionary past, who could chase a deer all day, stimulated by the chase and the prospect of bringing  meat to the family.  This is opposite to the “farmer” type personality, the personality who is happiest plowing the same 30 acres, the same way, day in day out. Both types of people are needed for a functioning society. Viewing ADHD as an alternative kind of gifting, not JUST a weakness, stops some of the internalized shame, blame and guilt. (Another great book for helping those dealing with ADHD is More Attention, Less Deficit by Ari Tuckman. No bunk, just straight talk written in a way that caters for the learning style of those who deal with the disorder.)

Finally, my sister, who is also a psychiatrist, and I suspect that, although there are people who genuinely struggle with this disorder, in the past twenty years the American medical profession has gone from under diagnosing/treating ADHD to way over diagnosing and treating. The British psychiatry establishment does not believe that all our diagnoses are valid simply because they appear to have a much lower rate of incidence of the disorder in Great Britain.  One of my very erudite Italian colleagues quipped, “Yes, well, we have a theory in Italy that most of the people with ADHD in Europe headed to America in the 18th and 19th centuries.  They were the ones most up to the dangers and challenges, and the most adaptive in a pioneer environment.  That left us with fewer in Europe than in the States.”  Witty, but maybe there is something to that. If so, America is better off for our population of differently gifted individuals.