Part I of “All About Medications for ADHD” focused on common questions and answers provided by ADHD specialist Ted Mandelkorn, MD, of Puget Sound Behavioral Health, a Seattle-based clinic that treats teens, children and adults with Attention-Deficit/Hyperactivity Disorder and related conditions.
In Part II, below, Dr. Mandelkorn details the categories of medications along with dosing, pros, cons, and potential side effects. The more you know about your choices, the better you can choose a knowledgeable prescribing physician and work with that physician for the best possible treatment outcome for yourself or your loved one.
A PHYSICIAN’S PERSPECTIVE
Theodore Mandelkorn, MD
2010
PART TWO: OVERVIEW OF MEDICATIONS
- NON-STIMULANT MEDICATIONS:
- ATOMOXETINE, 24 HOURS (Strattera)
- CLONIDINE, TABLETS: 4-5HOURS, PATCH: 5-6 DAYS (Catapres)
- GUANFACINE LONG ACTING (Intuniv)
- STIMULANT MEDICATIONS:
- METHYLPHENIDATE TABLETS, 2-4 HOURS (Ritalin)
- DEXTRO-METHYLPHENIDATE, 4-6 HOURS (Focalin)
- METHYLPHENIDATE SUSTAINED RELEASE, 6 HOURS (Ritalin SR20)
- METHYLPHENIDATE LONG ACTING, 8 HOURS (Ritalin LA)
- METHYLPHENIDATE CONTROLLED DISPENSE, 8 HOURS (Metadate CD)
- METHYLPHENIDATE EXTENDED RELEASE, 12 HOURS (Concerta)
- METHYLPHENIDATE TRANSDERMAL SYSTEM, 12 HOURS (Daytrana)
- DEXTROAMPHETAMINE TABLETS, 4 HOURS (Dexedrine, Dextrostat)
- DEXTROAMPHETAMINE SPANSULES 6 HOURS (Dexedrine)
- AMPHETAMINE SALTS TABLETS, 6 HOURS (Adderall tablets)
- AMPHETAMINE SALTS EXTENDED RELEASE, 12 HOURS (Adderall XR and generic)
- LISDEXAMFETAMINE, 12-14 HOURS (VYVANSE)
It is important to note that medical treatment should always be given for the entire waking day, seven days a week. There are few medical conditions that we do not elect to treat in the evenings, on weekends or holidays. No one chooses to turn down their brain chemistry during his or her wakeful hours. Therefore, all medical treatment for ADHD should last for at least 12-16 hours daily. With this in mind, I have highlighted (***) the medications that should be preferred treatments for ADHD.
NON-STIMULANT MEDICATIONS
GUANFACINE, Extended Release (Intuniv)
This new formulation of an existing medication, guanfacine, was released by the FDA to the market in Dec. It is an alpha 2 agonist, which will have a 24 hour effect on ADHD symptoms and may be beneficial for individuals with ADHD, particularly those with significant mood, anger, oppositional symptoms.
Preliminary results show that it is clearly beneficial for some patients without the adverse side effects often seen with other ADD medications.
Form: Pills. 1mg, 2mg, 3mg, 4mg. Pills must be swallowed.
They must not be crushed, chewed or broken or they will lose the 24hr effect.
Dosage: It has a very slow rate of onset and will take 3-4 weeks to assess effectiveness. The primary side effect is tiredness, lethargy, and it must be started slowly. Suggest starting dose of 1 mg for one week, and raise by 1 mg each week to reach good therapeutic effect. The effects do last 24 hours.
Side Effects: Lethargy, tiredness, dry mouth, constipation, dizziness, decreased blood pressure.
Pros: A non-stimulant medication that appears to have a good, positive effect on ADD and oppositional symptoms that lasts 24hours with reduced side effect profile, compared to the traditional treatments.
Cons: A new formulation with minimal time on the market to truly assess effectiveness.
ATOMOXETINE 24 hours (Strattera)
This medication for ADHD was released by the FDA in December 2002. It is a non-stimulant medication, which is not abusable and can be written without Schedule II restrictions. This is the first medication that lasts 24 hours and therefore gives full therapeutic effect throughout the day and night .Unfortunately, over the past few years it has not performed as well as expected. It tends to often have side effect and does not deliver as robust a response as the stimulants.
Form: Capsules: 10mg, 18mg, 25mg, 40mg, 60mg.
Dosage: Weight based dose: first four days=0.5mg/kg; target dose (day five and after)=1.2mg/kg. This medication must be taken with food to prevent nausea.
Action: Very slow acting and will take 3-4 weeks (or more) to reach therapeutic effect. If the patient is already taking stimulant medications, suggest continuing them and adding the Strattera for the first 4-6 weeks, then tapering the stimulant slowly until discontinued.
Possible Side Effects: No long term safety information is available for this medication. Primary side effects in children include sleepiness during the day, appetite changes, and mood or personality changes. If these occur, give the dose at night or lower the dose until they improve. Then raise dose if possible. Adults can experience more noted effects: transitory dry mouth and dizziness, insomnia, sleepiness and significant moodiness. Other effects in adults include possible bladder spasm, sexual dysfunction (uncommon but often result in discontinuation of medication). Occasionally a child or adult will get very agitated. If this occurs, discontinue the medication.
Pros: 24 hour coverage. Less effect on appetite than stimulants.
Cons: Many complaints about side effects, lack of efficacy compared to stimulants. Has not been a very satisfactory treatment for many with ADD
CLONIDINE tablets 4-5 hours, patches 5-6 days (Catapres)
Form: Patches applied to back or shoulder. Catapres TTS-1, TTS-2, TTS-3. Tablets . Clonidine tablets 0.1mg, 0.2mg, and 0.3mg.
Dosage: Very individual, usually .1-.3mg.
Action: Works quickly. Tablets work within 1 hour, patches within 1 day.
Effects: Often will improve ADHD symptoms, particularly aggressive and hyperactive behaviors. Not too helpful for focus and attention. Decreases motor and vocal tics. Can have a dramatic effect on oppositional defiant behavior and anger management. Often used as one dose at night about 1½ hours before bedtime to assist with getting to asleep.
Possible Side Effects: Major side effect is tiredness, particularly if dose is raised too quickly. This disappears with time. Dizziness, dry mouth. Some will notice increased activity, irritability.
Pros: Excellent delivery system if patch is used. No pills required
Cons: Does not usually work as well as stimulants. Patch can cause skin irritation in many individuals and may not be tolerated. Can effect cardiac conduction (heart rate and rhythm) in high doses and must not be left around for animals or small children to accidentally ingest.
STIMULANT MEDICATIONS
Some general comments can be made about stimulant medications as a class of medications.
- The longer acting medications have clear advantages over the short acting medications, not only in duration of therapeutic effect throughout the day, but also in smoothness of the therapeutic effect.
- It is very difficult for an individual with ADHD to remember to take multiple doses of medication during the day.
- Multiple dosing increases the risk of missing doses, which results in the return of symptoms at inopportune times. The afternoon dosing is frequently missed, causing significant difficulties.
- Furthermore, each additional dose serves as an unnecessary reminder that treatment for this condition is needed and “something is wrong.”
The reason for medical treatment is to “normalize” the day. My general rule is to always use 12-16 hour medications unless they are not effective or have intolerable side effects. In such a case, the six or eight hour medications should be tried, because some individuals tolerate them better and find them more effective. However, if the six or eight hour medication is used, a second dose should be given to allow patients to have the therapeutic benefit for the full day.
SAFETY PROFILE
The stimulant medications are one of the most studied treatments in the history of medicine. The medications have been used extensively in children and adults over the past 50 years with no evidence to date of long term concerning side effects. At this time there is no conclusive evidence that use of stimulants causes any long term lasting effects on growth, although there may be some delay in height and weight gain in some individuals.
The short acting stimulants are extremely abusable and are valued highly on the street. It is best to always use the long acting preparations, which are not abusable to avoid the temptation of misuse and abuse.
There have been recent concerns expressed by the FDA and the press with regard to the use of stimulant medications and the risk of sudden unexpected death. This concern was a consequence of a study done in 1999-2003 in which they looked at a large number of individuals taking stimulants and felt that there may be a slight risk. As reported in an excellent article in the New York Times Feb 14, 2006 the apparent calculated risk of sudden unexpected death in those using amphetamines was 0.35/million (1 in 3 million) prescriptions and the risk for those on stimulants was 0.18/million (1 in 5 million) prescriptions. There is no real evidence that this is any different from that which occurs in the normal population. These extraordinary events of unexpected death tended to occur in individuals with congenital cardiac defects. For this reason the FDA issued a BLACK BOX warning to all physicians that stimulants should be used very cautiously or not at all in individuals with congenital cardiac defects.
COMMON SIDE EFFECTS:
The following side effects are often noted with the use of stimulants. In general, the side effects with the short acting medications are more pronounced and bothersome than with the long acting medications. Thus, long acting meds are somewhat more tolerable for long-term treatment and are certainly a marked improvement for long-term therapeutic effect.
Appetite suppression: Most will note decreased appetite during the effective hours of the medication. This often means minimal lunch intake. I suggest a small protein lunch such as milk, peanut butter crackers, beef or turkey jerky to get through the day. A milk shake after school helps. Many find their appetite returns late in the evening (around 8-9pm) when their medication wears off, and they need to be allowed to eat at that time. If weight gain is a continued concern, I often add cyproheptadine (Periactin) 4mg, ½ tablet at breakfast and dinner. Periactin is an antihistamine similar to Benedryl, which enhances appetite and often results in 1-2lbs-weight gain per month. Remember that good nutrition is helpful for all, and these individuals should emphasize protein intake in their diet.
Sleep disturbance: Many ADHD individuals will have sleep difficulties before they begin their medical treatment. At night, their brain continues its activity and starts thinking of the day. Using stimulant medications may either improve or worsen this problem. In those with no prior sleep difficulty, stimulants can create significant sleep issues. ADHD individuals do not usually have a problem with sleeping through the night (sleep disorder) but often do have problems with starting the sleep. A clear-cut bedtime routine helps (bath or shower and then read in bed) with the elimination of caffeine, computers, computer games and television at least one hour before bedtime. Interestingly, adding stimulant medication actually allows a percentage to sleep better at night, and this technique should be tried. It only takes one night to see if a dose of short acting stimulant will enable sleep initiation.
Some patients, however, require more assistance. Many patients will use a small dose of Clonidine tablets given one hour before bedtime to help with sleep initiation. Clonidine is a mild sedative, not a sleeping pill, and it is non addictive. Approximately 60-90 minutes after taking the medication, a brief sleepy phase will occur that lasts about 20 minutes. If the patient is in bed and trying to go to sleep, it is very effective. It will NOT make someone stop playing computer games and go to bed.
Mood changes: One of the biggest complaints about stimulants is that they can cause mood changes. These come in a number of different forms.
Rollercoaster effect: Short acting medications have a continuous cycling of the blood level, either rising or falling throughout the day. This can lead to significant mood changes, particularly at the end of the four hour cycle when the medication is wearing off. This problem with cycling is greatly diminished with the use of eight hour and twelve hour medications.
Rebound effect. Stimulants can often wear off very rapidly, and in some individuals this can cause a rebound, a marked change in demeanor often characterized by irritability, loss of patience, and a worsening of the ADHD core symptoms. Rebound can occur in the evening when the medication wears off and can also be evident in the morning on first arising. The morning rebound may require an early dose of immediate release methylphenidate (MPH) prior to the administration of the long acting dose at breakfast. Rebound effect is markedly reduced in frequency and severity in the long acting stimulants.
Irritability and anxiety: All of the stimulants have the possibility of causing a generalized irritability, and sometimes even anger, which is not tolerable over a long period of time. They can cause anxiety and panic disorder and may aggravate existing anxiety. Often, changing from one stimulant to another will reduce this side effect, so it is worth trying different stimulants to identify the best one for each patient.
Overdose effect: When using the stimulants it is necessary to gradually raise the dose to find the most effective therapeutic level. Sometimes in doing this, one gets an overdose effect. The stimulants are incredibly safe. They have been studied for over 50 years, and there is no evidence at this time of any long term serious complications when used appropriately for ADHD. However, if ADHD individuals take too high a dose, they will experience an overdose effect which appears as a dulling of the personality: They complain of being somewhat physically lethargic, subdued, dull, less conversational, less apt to laugh and be social. By simply lowering the dose for one day, these symptoms will disappear.
Tic Formation: All of the stimulants have the possibility of temporarily causing a tic disorder or aggravating an existing one. There is no evidence that the use of stimulant medications will cause permanent formation of tic disorder or Tourette syndrome. Children who already have tics (10% of children have mild tics at some point in childhood) and individuals with Tourette syndrome will find a number of different scenarios with the use of medication. Approximately 1/3 will actually notice that the tics improve (lessen) with the use of stimulants, 1/3 will see no change at all, and 1/3 will find the tics worsen with use of stimulants. If the stimulants are effective and tics are worse, a medication to help control the tics is usually added to the treatment.
METHYLPHENIDATE TABLETS 2-4 hours (Ritalin IR)
Form: Short acting tablets. Methylphenidate (MPH) 5mg, 10mg, 20mg.
Dosage: Very individual. Average 5-20mg tablets every 2-4 hours.
Action: Immediate release (IR) MPH starts to take effect in 15 minutes, which is extremely helpful for some individuals. Some children need an early morning dose 20 minutes BEFORE arising in the am, followed by a long acting medication at breakfast. Often used as a booster for evening coverage.
Possible Side Effects: See above
Pros: Very easy to use for short periods of coverage, such as early morning and evening.
Cons: Must be administered frequently during the day (3-5 times/day). Inconvenient to use at school and work. Often causes rebound and rollercoaster effect. Very abusable.
DEXTRO-METHYLPHENIDATE 4-6 hours (Focalin)
8-12 hours (Focalin XR)
Focalin is an isomer product of methylphenidate. Methylphenidate is composed of two mirror image molecules, and it has been determined that the right-hand side of the molecule contains most of the therapeutic activity. Therefore the left-hand side has been eliminated, giving a cleaner formulation of methylphenidate.
Form: Tablets: 2.5mg, 5mg, and 10mg. (Focalin)
Capsules: 5mg, 10mg, 20mg
Dosage: The same as methylphenidate, but divide the dose by half.
Action: The same as methylphenidate, but in some individuals up to 6 hours duration.
Possible Side Effects: Same as MPH but possibly to a slightly less degree.
Pros: A cleaned up version of MPH that may last a bit longer with slightly decreased side effects.
Cons: Same as MPH. Very abusable.
METHYLPHENIDATE SUSTAINED RELEASE 6 hours (Ritalin SR20)
Replaced by Ritalin LA.
METHYLPHENIDATE LONG ACTING 8 hours (Ritalin LA)
Form: Capsules: 20mg, 30mg and 40mg.
Dosage: Very individual. Average:20-40 mg daily or twice a day, every 8 hours.
Action: Same as methylphenidate, but eliminates the noontime dose.
Possible Side Effects: See above.
Pros: Eliminates midday dosing. Works more smoothly than IR methylphenidate and is more effective than methylphenidate SR.
Cons: Only works for eight hours and therefore subjects the patient to loss of focus and control in mid afternoon. This requires an afternoon booster to be administered.
METHYLPHENIDATE CONTROLLED DISPENSE 8 hours (Metadate CD)
Form: Capsules: 20mg (10mg and 30mg to be available in 2003)
Dosage: Very individual. Average: 2-3 capsules in the am.
Action: Same as methylphenidate.
Possible Side Effects: See above.
Pros: Works more smoothly than IR methylphenidate. Sometimes is effective when Concerta and Ritalin LA are not effective. Not abusable.
Cons: Works for only eight hours. (See Ritalin LA)
***METHYLPHENIDATE EXTENDED RELEASE 12 hours (Concerta)
No generic available
Form: 12 hour long acting tablet…uses a unique delivery system that delivers a constant therapeutic level of methylphenidate for twelve full hours. Concerta 18mg, 27mg, 36mg, 54mg.
Dosage: Dosage will vary as with all methylphenidate products.
- Concerta 18mg = Ritalin 5mg three times a day
- Concerta 27mg = Ritalin 7.5mg three times a day
- Concerta 36mg = Ritalin 10mg three times a day
- Concerta 54mg = Ritalin 15mg three times a day
Action: 12 hours of consistent therapy with no highs or lows throughout the day. A few individuals will only get 8-9 hours of effective therapy and will need either a higher dose or a second dose.
Possible Side Effects: See above.
Pros: Unique delivery system avoids multiple dosing throughout the day. No dosage at school. No rebounding with missed doses. Fewer side effects, less mood swings, better therapeutic response for many individuals. No daytime dosing. Less anxiety and worry. Not abusable.
Cons: Does not work for all individuals who use methylphenidate. If ineffective, should try Ritalin LA and/or Metadate CD. May need a short acting booster to cover the evening hours.
METHYLPHENIDATE TRANSDERMAL SYSTEM 12-15 HOUR (Daytrana)
No generic available
The trans-dermal patch arrived on the market July, 2006 as a new and novel delivery system for methylphenidate. The patch has the medication within the adhesive layer and is thus very thin. It works by diffusion, allowing the medication to gradually diffuse through the skin into the blood stream directly, thus avoiding the intestinal tract. It is designed to be worn for nine hours and then removed, but will last longer if needed for evening activities. After removal it will gradually loose effect over the next three hours, thus giving extended and controlled hours of therapy as the day dictates…The unique attribute of the patch is that the patient has complete control of when to start the patch and when to discontinue the patch. For the first time the patient can regulate the treatment for part or all of the day. The medication in the patch is methylphenidate, and thus all of the above information regarding this medication applies.
DEXTROAMPHETAMINE TABLETS 4 hours (Dexedrine, Dextrostat)
Form: Short acting tablets 5mg, 10mg.
Dosage: Very individual. Average 1-3 tablets each dose every 4-5 hours.
Action: Rapid onset of action, approx. 20 min. Lasts 4-5 hours.
Possible Side Effects: See above.
Pros: Excellent safety record. Rapid acting. Some patients who do well on dextroamphetamine prefer the tablets to the spansules. The rapid onset in tablet form is apparently more effective for these individuals.
Cons: Same as MPH. Very abusable.
DEXTROAMPHETAMINE SPANSULES 6 hours (Dexedrine)
Generic available
Form: Long acting. Dexedrine Spansules 5mg, 10mg, 15mg.
Dosage: Very individual. Average is 5-20 mg.
Action: Very individual. May take up to one hour to be effective. Usually lasts 6-8 hours. In some individuals it may last all day. In others it may only last 4 hours. Most will take twice a day, six hour intervals
Possible Side Effects: See above
Pros: Excellent safety record. May be the best drug for some individuals. Long acting, smooth course of action. May avoid lunchtime dose at school.
Cons: Slow onset of action. May require a short acting medication at the start of the day. Very abusable.
AMPHETAMINE SALTS TABLETS 6 hours (Adderall)
Form: Long acting tablets: 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg.
Dosage: Very individual, usually between 5mg and 20mg, once or twice each day.
Action: Usually lasts 6 hours. May be given once or twice a day depending on length of therapeutic effect. Duration of effect varies from person to person.
Possible Side Effects: See above.
Pros: Only needs to be given once or twice a day. Often fewer side effects than the short acting medications.
Cons: Can cause irritability in a small percentage of patients. Very abusable.
***AMPHETAMINE SALTS EXTENDED RELEASE 12 hours (Adderall XR)
Generic available April 1, 2009
Form: Uses a unique delivery system that delivers a constant therapeutic level of amphetamine salts for twelve full hours. Capsules: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg.
Dosage: Very individual. Average 15-30mg daily.
Action: Long acting 12 hour control of ADHD symptoms for coverage during most of the day.
Possible Side Effects: See above.
Pros: Very effective. Same as Adderall with longer duration of action. Cannot be abused.
Cons: May need a booster to cover the evening hours.
LISDEXAMFETAMINE 12-14 hours (Vyvanse)
No generic available
Form: A Pro-drug which renders this delivery system minimally abusable. A new and novel delivery system which will deliver dextro-amphetamine smoothly over a 12-14 hour period.
Dosage: Capsules: 30mg, 50mg, 70mg
Action: The same as Dextroamphetamine
Side Effects: Same as Dextroamphetamine
Pros: Only long acting Dextroamphetamine on the market, and very unlikely to be abused.
Cons: Same as stimulants
For an excellent reference book regarding all of the medications that might be used for ADHD individuals, including not only medications for ADHD but also medications for all of the associated co-morbid conditions, please refer to the following book:
Straight Talk About Psychiatric Medications for Kids , Revised Edition 2008, by Timothy Wilens M.D.
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Tags: Adderall, ADHD medications, Concerta, Dexedrine, dosing, Dr. Ted Mandelkorn, Intuniv, non-stimulant medication, Puget Sound Behavioral Medicine, side effects, stimulant medication, Strattera, Vyvanse
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are you aware that the excellent reference book regarding meds you linked is written by a pharma shill?
look at this review I copy pasted:
I want every person contemplating the purchase of this book to use the “search inside” tool, and click on the copyright page.
On that page you will see a box that says “Full Disclosure.” PLEASE, please read it.Dr. Wilens receives grant support from five different drug companies. In addition, he is a paid presenter for three different drug companies, and a consultant for six different drug companies. While the information contained in this book is exhaustive, as a parent of two children with a multitude of medical and psychological issues, I find it difficult to trust his opinions and “straight talk” when I know that he is making tens of thousands of dollars a year from these drug companies.
Gina, do you truly think that a book written by a guy is a paid minion of big pharma is going to be unbiased and complete?
The companies that pay out to this guy include Abott Labs, Eli Lilly, Merck and so on. You don’t see that as an issue?
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HI Jane,
I appreciate your sentiments. I really do. It goes against the grain of any sensible person to think about giving psychotropic medications to children — except when that sensible person investigates the facts and learns that sometimes judicious use of these medications can vastly improve that child’s life.
Beyond that, I cannot let accusations such as you make stand. You use strong language.
“Pharma shill” and “paid Big Pharma minion” are recklessly derogatory terms bandied about on the Internet by “anti-psychiatry” adherents. These terms are typically used in ignorance about what it takes to be a psychiatric researcher and by people who typically have no conception of the human brain’s complexity — or vulnerability. Often, these terms are used by people trying to sell something — their miracle cure, DVD, series of religious-cult classes, or the fact that they don’t have a psychiatric disorder (it’s everyone else in the world who has a problem).
Dr. Wilens certainly requires no defense — exactly the opposite — and I don’t fancy myself the best person to explain why. But I will try, since this is my blog and you asked me.
Do you honestly believe that a researcher of Dr. Wilens’ calibre studied rigorously and doggedly for years, mastering highly scientific knowledge and methods, just to be a “pharma shill”? If money were the goal, it would have been so much easier to work in sales….or on Wall Street.
The fact that many Americans know nothing about the demands of a career in medical science only adds to their willingness to believe simple-minded propaganda. It’s unclear to me why you would take the word of an anonymous person writing an Amazon review over a highly respected expert.
Anyway, what do you think scientists do with these grants? Sit around the pool, smoking cigars? They work extremely hard and typically spend the funds on equipment, other researchers’ salaries, and the myriad demands of scientific research. Scientific inquiry is loaded with pitfalls; you can spend years investigating a hypothesis — years of tedious, tedious repetition of experiments — only to have it end in failure. And if these researchers do make a handsome salary, well, why not? Don’t they deserve it? They are producing tangible benefits to society — and trained long and hard to do so — unlike the financial sector, which produced only financial weapons of mass destruction.
The first maxim of scientific inquiry is this: Association is not causation. In other words, simply because a phenomenon is linked to a certain factor it doesn’t mean the phenomenon is caused by that factor. A simple example: When bars used to allow cigarette smoking, many people drinking in bars smoked cigarettes. Could we say that being in a bar caused people to smoke cigarettes? No. It could be that people who smoke cigarettes are also likely to hang out and drink in bars.
In scientific researchers’ case, receiving funding from pharmaceutical companies does not mean they are “in the pocket” of these companies. Scientists have their reputations to protect, and that’s why “peer review” of research is important. Without the respect of their peers, researchers don’t get published and they don’t get grants.
Wilens’ peer-reviewed articles number more than 200, and are published in prestigious journals such as the American Journal of Psychiatry, Archives of General Psychiatry, and Pediatrics. Dr. Wilens has also published more than 60 book chapters, and 300 abstracts and presentations for national and international scientific meetings. Do you understand the effort behind these accomplishments? More importantly, why don’t you talk to some of the people who have benefited from the work of such researchers and ask them about their improved quality of life. (You won’t always hear from them on the Internet, because they are out doing more productive things.)
Dr. Wilens is a Distinguished Fellow of the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry, serves as a scientific reviewer for 22 journals, and is active in a number of other local and national professional societies. Dr. Wilens is named consistently among “The Best of Boston” in Child/Adult Psychiatry and “The Best Doctors in America.”
By comparison, this anonymous reviewer on Amazon who calls herself “bedrestmom” does….what exactly? My hunch: She never read the book. (Check the rest of her reviews; not much of a reader.) She seems to be just another “anti-pharma shill” from a certain anti-psychiatry cult. They’re omnipresent online, and their patterns are very familiar.
Are there occasional “bad actors” among medical researchers — those whose egos and perhaps greed bias their focus? Of course. Why should this field be the only one where humans are flawless saints? But, given the peer-review process, their reputations do tend to catch up with them. This is especially true when they are also clinicians who treat patients.
Are the marketing arms of “Big Pharma” often shameless in their pursuit of market share? Of course. But that’s precisely why we need educated consumers, not henny-penny alarmists.
Gina
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Jane’s attitude toward Dr. Wilens is easy to understand given:
1. the ethical lapses of some in the medical profession (yes, such do exist)
2. a lack of understanding of what it means to be a researcher
3. perhaps a lack of judgment on her part (fed by factors 1 and 2)
Factor 2: After consulting NIH’s grant reporting tool (http://projectreporter.nih.gov), I find that Dr. Wilens currently has >$800K of research funding. How much funding is he getting from pharma? If the amount is a small fraction of what he is getting from NIH, no need to get too excited. It boils down to this: what is the relative contribution from pharma, and is it enough to POSSIBLY influence his impartiality? In his case, I very much doubt it. Why? Because he has a lot to loose if his peers were to conclude that he is an operative for pharma. In short, he would lose his ability to get funding and to get published, such that his career would be over. And what a career he’s had so far: I count 178 publications at PubMed since joining Mass. General. Clearly, he has a lot to lose by engaging in dubious scientific practices. Therefore, v. unlikely.
So why does such a researcher risk being accused of being a pharma cronie by accepting their research funding? Only because research dollars are always limiting, particularly these days. So one takes the “bad” (pharma’s justifiably poor reputation) with the good (researching important health questions). You have to salute him (I certainly do) for exposing himself in this way. He could just as easily have decided to curtail his research by not accepting pharma research money, in which case we all would have lost the benefits of his investigations.
Addressing factor 3, does anyone really think that becoming a biomedical researcher and keeping a career going is the road to wealth? I don’t know the size of pharma dollars he has obtained, and whether they involved salary support for him, but whatever the amounts, they are highly unlikely to be sufficient for justifying the MANY years of intense work required to become a distinguished researcher. So let’s all exercise some informed judgment before casting nasty aspersions, shall we?
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Gina,
Part of being an “educated consumer” is always reading disclosure statements for any study you are reviewing.
OF COURSE questions should be raised about who is funding any research – and before you tell me that I “know nothing about research in medical science and I believe simple-minded propaganda,” as you told Jane, know that I say this as someone with a year’s worth of psychology research experience, and a Master’s degree. (My Master’s is not in psychology, but I have completed 38 credit hours in post-baccalaureate psychology studies, and I am applying to research-oriented PhD programs in clinical psych.)
Are you aware that experimenter bias is a large issue, particularly in psychology experiments, but also in scientific research as a whole? Despite all our claims of the objectivity of the scientific method, the fact remains that researchers too often end up proving what they want to prove. And as for all that drug company funding – do you really think that any drug company will keep funding research done by professors who are finding their products to be largely ineffective?
Funding is a HUGE issue in academia these days, and the extent to which a topic, disorder, etc is even researched in the first place often depends on whether it is popular enough to get grant money.
Now, I’m not saying that this means that all research is invalid, or that we should get all our ADD medications (and other medications, too) and throw them out the window.
I am saying, however, that knowing who funded a study is a valuable piece of information. While I won’t completely discard the results of a medication study that was funded by pharmaceutical companies, I will take them with a grain of salt, and examine their methods very carefully. I will also always trust favorable results a bit less than I would trust them if they were coming from a truly independent source.
There is good reason to do so, as there have been a number of times in the past when pharmaceutical companies repressed or minimized results of a study that turned out to be unfavorable to their cause.
So like you suggested, let’s all be “educated consumers,” and not take any research we read about for granted without looking over the actual study and analyzing not only the methods used, but also the funding and other possible sources of experimenter bias!
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Hi Sarah,
Thanks for your comments. I wholly agree. I started noting the trend with industry funding academia back in the 1980s, when I worked at a business newspaper.
As I hope you can see, however, your points are more nuanced than Jane’s. And while it would be great if all consumers of these medications could take the time or have the training to parse these studies, it’s just not possible. We have to go on the preponderance of evidence, which includes the points made above by the Masked ADDer and me, and also on first-hand reports.
In my case, I’ve met and communicated with not only dozens of these researchers but also thousands of people affected by ADHD now. To me, the real problem is at the clinical level, where prescribing physicians either fail to properly diagnose or fail to properly choose and titrate these medications. We can rail against “Big Pharma” all we want but until these physicians are better trained and can properly integrate other information when treating these patients (sleep disorders, food sensitivities, nutritional deficiencies), it is barking up the wrong tree, in my estimation.
Thanks for visiting and commenting.
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Thank you for your comments.
My main point in writing my comment was to say that although Jane probably wasn’t too well informed, she did have a valid point, and frankly, addressing the point WITHOUT the derogatory tone of “henny penny alarmist” and “simple-minded propaganda” might do more to educate her in this field. I’m sure Jane was just trying to learn more about ADD treatments, so why use a tone that will probably make her more hostile toward this topic than she already is?
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Well, Sarah, what can I say? I’ve been advocating for better ADHD awareness for 10 years now, much of it online, and I’ve learned a few things.
One is that people with that type of starting point seldom are interested in more information; they are interested in fear-mongering. Moreover, they often have an agenda that is well-known.
So while you are “sure Jane was just trying to learn more,” I am pretty sure that was not the intention at all. To each her own.
But even so, I think the responses from MaskedADDer and me are more than sufficient.
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