The Business of ADHD

ADHD expert, Dr. Lawrence Diller, criticizes the role insurance and pharmaceutical companies play in over-diagnosis of ADHD.

Lawrence Diller, M.D.

Author of Running on Ritalin, Diller received his medical degree from Columbia University's College of Physicians and Surgeons. While he has diagnosed some children in his private practice with ADHD, Diller has criticized the proliferation of the ADHD diagnosis and the rise of "cosmetic psychopharmacology."

What role do the insurance companies and pharmaceutical companies play in the world of ADHD?

. . . There's a suit going on right now in three states. It alleges that the major pharmaceutical company that makes Ritalin, the Novartis Company, along with the American Psychiatric Association, the main representatives of organized medicine in the ADHD movement, and the self-help group CHADD have conspired to dupe the American public into believing that there's such a thing as ADHD, and then thrust upon innocent children a potentially dangerous drug.

The suit alleges that there's a conspiracy. Now, there may be some legal definition that meets the conspiracy angle. But I don't believe that there's any conspiracy at all. We have what I call the "invisible hand" of Adam Smith at work. Adam Smith, as you know, wrote the fundamental textbook on capitalism. And we have market forces at major play here, getting people to think a certain way about medications, and then operating on the doctors and the patients to get them to take them first--often at the expense of other interventions that work.

As a doctor, how do you experience those forces?

. . . I experience them, first of all, by this unbelievable advertising barrage that has hit me first, and now is hitting the consumer directly. . . . I think Novartis has acted quite responsibly, relatively speaking, because I think Ritalin represents a drop in the bucket to them in terms of the kind of money they make. They're much more worried about their bio-engineered foods these days than they are about Ritalin.

On the other hand, the makers of Adderall have presented what I consider to be . . . the most disingenuous, elaborate campaign I've ever experienced. . . . Adderall has passed Ritalin in terms of trade medication written for ADHD. I've been offered $100 if I will sit and listen to someone talk about ADHD, funded by Adderall, for 15 minutes on the telephone, and then fill out a five-minute questionnaire. . . .

And now, with the loosening of controls on the pharmaceutical industry by the FDA, there is this direct marketing to families. You see this picture. . . . Well, it doesn't say that it's for Concerta. It says, "Learn more about ADHD." And it's this picture of this smiling boy who has a pencil in his hand, and on either side of him, his parents are beaming. . . . And underneath, it says something like, "They're happy, because now they know his ADHD is being treated." What's the problem with that? The problem is it pushes people to only one way of thinking about the problem--that this is a biological problem, and that it needs a drug. . . .

Is there an imbalance in how much money goes to studying the efficacy of drugs versus the efficacy of other things?

Yes. That's the other way that the market forces are operating here, in that virtually every ADHD researcher, now, because of previous cutbacks and because there is money out there, takes money from the pharmaceutical industry to do their research. And whether or not you're a doctor in the local hospital . . . or you are one of the editors of the New England Journal of Medicine, we all know that research gets influenced by the funding source.

And this is not impugning these men. It's just how it works. They don't publish negative findings. The studies are tilted more toward counting symptoms and pills, rather than looking at the bigger picture. And if you look at a very narrow picture, if you just ask very narrow questions, you will get answers that miss the big picture.

Dr. Peter Jensen, a respected authority in this field, says that, in the case of children's psychiatric medications, that it's not true; that the research money comes from the government, because the pharmaceutical companies are afraid of litigation, and they don't want to go there.

That was the case. It was difficult to fund pharmaceutical research in children, particularly psychiatric pharmaceutical research in children, because there was seen to be no market until the 1990s. The government added this rider, where the pharmaceutical company will get an extra six months of patent protection if they study the drug in children. So what we're going to get, and what we're getting, is a flood of pharmaceutical research money directed toward children. And one could be very glad for that in some ways. But again, if we only ask questions about how many symptoms does the kid have, and how many pills should he take, we are going to get a very, very narrow group of answers of what ails the kid, and what should be done about it.

So we are entrusting the research on our children's mental health and the solutions for their problems to pharmaceutical companies with vested interests?

You got it. It's clear to all of us, even those of us who do receive medication pharmaceutical money, which I don't. And I would like to, because I have to pay for my own trips. But the moment I do, I'm potentially influenced by that money.

William Dodson

A psychiatrist in Denver, Colorado, Dodson ascribes ADHD mostly to biological causes. He is paid by Shire Richwood, the makers of Adderall, to educate other physicians about the drug's efficacy.

. . . Over the last ten years, there has been extraordinary pressure within the medical field to deliver all medical care much more quickly and, therefore, much more cheaply, than it ever has been delivered before. And so there is a lot of economic pressure to diagnose and treat all disorders, medical or psychiatric, more cheaply and more quickly. So surely, yes, that's going to trickle down to the diagnosis of ADHD.

Can ADHD be diagnosed in a 15-minute well-baby check-up at the pediatrician? No way. In order to do a good, adequate evaluation, you need several hours: to do the evaluation: to rule out all the things that might mimic ADHD; to thoroughly evaluate all the things that can co-exist within ADHD; to educate the parents about the use of medication, and about the ancillary treatments that are going to be necessary; to do a quick screening for learning disabilities. A good, thorough evaluation takes time.

But we're not set up to do that?

We're set up to do it. It's that ADHD and managed care just don't go together. Managed care wants it done quickly and cheaply, and ADHD can't be done quickly and cheaply.

Another controversy is the role of the pharmaceutical companies in marketing these drugs. . . . The pharmaceutical companies make profits off of the sale of Ritalin or Adderall or Concerta. They're companies. They can strategize and put out a marketing message. The alternative therapies--such as behavioral therapy or psychotherapy--don't have that kind of lobbying muscle or marketing muscle. Therefore, it tilts the balance in favor of medication over other therapies. ... Do we have a structural bias in favor of medication?

... Everything in the United States is driven by the profit motive. We get better cars because we have a private enterprise of car manufacturers, who continue to improve their product in hopes of making more sales and making more money for their investors. That's the set-up we have in the United States. If people could demonstrate clear effectiveness from the treatments that didn't involve medication, I think that there would be a lot of people beating a path to their door. The fact is that they haven't been able to demonstrate that. . . .

Peter Jensen

Formerly the head of child psychiatry at the National Institute of Mental Health, Jensen was the principal author of the landmark NIMH study: NIMH, the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA). He is now the director of Columbia University's Center for the Advancement of Children's Mental Health.

Perhaps part of the problem is that most of the studies just study the medications, so the data is there for the medication. Perhaps there isn't that much other data because there's not a lot of money out there to study the impact of behavioral therapies?

In actual fact, the money to study the medications has not been any more plentiful than the money to study the behavior therapies. The drug companies have not wanted to study kids and medicines. They're scared of them, because they've been afraid of lawsuits. . . . So 80 percent to 90 percent of the research has all been supported by the federal government. And what the federal government would do is not say, "Oh, we want medication studies." No, they'd say, "We want studies." . . . Two or three years ago, we've gone through and we counted all of the studies in the ADHD area that met certain criteria.

Well, we had about 600 studies--good clinical trials of one form of meds or another. But there were another 1,500 studies of non-meds. The med studies are easy to describe, and they're easy to kind of get the word out on. But in actual fact, most studies are not medication studies. . . . We hear about medications in the news, because it's a bit of a tempest in a teapot. But we have a lot of studies of the other treatments. ...

The pharmaceutical industry spends a lot of money in an attempt to convince you that that little pill is the next little miracle. How do you feel about that?

The FDA regulates what the drug companies--or anyone, for that matter--can do and what they can advertise if it's a pharmaceutical. ... What the drug companies are doing is guided by science. It's not the only science, but it's guided by science, and it's regulated by the federal government. ... So do I think it's a good thing that industry is trying to teach doctors about what their science has shown? . . . Absolutely. I'm all for it. We need more of it for science. . . . We need more of it for the behavior therapies. . . .

Fred Baughman

An active opponent of the ADHD diagnosis, Baughman has been a child neurologist, in private practice, for 35 years. He is also a medical expert for the Citizens Commission on Human Rights (CCHR), an advocacy group founded by the Church of Scientology in 1969.

Psychiatry and the pharmaceutical industry have become financial economic partners. And frankly, part of their economic compensation has been to develop a strategy whereby they claimed, without science, that all mental illnesses, all things behavioral and emotional, are physical brain dysfunctions or abnormalities.

Representing such things as depression, anxiety, conduct disorder, ADHD, oppositional defiant disorder, and learning disabilities as diseases, absent any scientific proof, is to deceive the public. It preempts the public's right to informed consent in every single case.

. . . [As Running on Ritalin author Lawrence Diller] pointed out, they've led the public to believe that these are brain diseases, chemical imbalances--making it logical for the public to think that a pill is going to be the solution. . . .

But the charge that the psychiatrists and the pharmaceuticals have joined together in a joint common mercenary interest is quite a charge. How can you say that?

I'm not the only one saying this. In the October, 1995, in the DEA background paper on methylphenidate, which is Ritalin, the DEA says that they have been contacted by the United Nations International Narcotics Control Board (INCB), that had expressed concern about the financial ties of Ciba-Geigy, then the manufacturer of Ritalin, to CHADD. They noted that CHADD had received over $775,000 from Ciba-Geigy, I think up through 1994, and eventually the figure went over $1 million. The INCB charged CHADD with being a vehicle for marketing a controlled substance directly to the public in violation of the Controlled Substances Act of 1971, and international statute by which all countries, all signatories, agreed.

Ciba-Geigy confessed at that point that CHADD was their conduit to the public. CHADD personnel and NIMH personnel were regularly in-house at the Department of Education office of Special Education authoring ADHD materials. I think CHADD made a grant, I believe, of $700,000-some to the Office of Special Education to make a video about ADHD. Then when John Merrow, in his video production in about 1995 . . . pointed out the financial ties between the Ritalin manufacturer, Ciba-Geigy and CHADD, I think that money was then given back by the Department of Education, back to CHADD.

Peter Breggin

Psychiatrist and author of Talking Back to Ritalin: What Doctors Aren't Telling You About Stimulants and ADHD, Breggin founded the nonprofit Center for the Study of Psychiatry and Psychology. He has been a vocal opponent of the ADHD diagnosis and he strongly opposes prescribing psychiatric medications to children.

There are many, many reasons why we're giving more and more psychiatric drugs to children. Probably the most important reason is simple marketing. The drug companies, like the tobacco industry, like the alcohol industry, are highly competitive, and are always searching out new markets. The adult market has been saturated for anti-depressant drugs. How many millions and millions of people can take Prozac and and all the other drugs? We have more adults taking anti-depressants than the National Institute of Mental Health estimates there are depressed people in the United States. The market is saturated, so the pressures move automatically to other markets. And the biggest next market is children. So you have drug company representatives, you have drug company-sponsored conferences examining this issue, or encouraging this issue of marketing to children. ...

What Ciba-Geigy, now a division of Novartis, has done is to fund a parents' group, CHADD, and the group has then gone and promoted Ritalin to the public. So that's one potential aspect to the situation.

How is it different than another pharmaceutical company supporting the American Diabetes Foundation or the American Cancer Society with funding? How is it different that Ciba-Geigy is providing some funding to CHADD?

One of the big differences in what Ciba-Geigy is doing, say, compared to a drug company who might give money for a diabetes drug to the AMA, is that Ritalin is a Schedule II--a highly addictive drug. And there are special controls put upon it by the US government. CHADD, in fact, has lobbied the US government to try to get Ritalin taken out of Schedule II. They couldn't do anything more valuable for the drug company, and more dangerous to the public, than that. Fortunately, they failed, and they failed in part because of our disclosures . . . about CHADD having so much money from the drug companies. . . .

What role did the pharmaceutical industry play in promoting Ritalin and Prozac to the country?

Even before Prozac was approved by the FDA, the drug company was sponsoring seminars for doctors throughout the country on the biochemical basis of depression, mentioning over and over again serotonin, which is the neurotransmitter that's affected by Prozac. They didn't happen to mention that there may be 200 neurotransmitters in the brain, and that connecting any one to depression is absolutely foolish speculation. The brain is an integrated organ, with probably thousands of substances participating in its function.

To label one, serotonin--which is, in fact, a widespread neurotransmitter that goes to every single lobe of the brain and affects everything from memory to coordination to cardiovascular function--imagine that that one happens to be the one that's out of balance, because Eli Lilly is selling Prozac.

But people are so eager nowadays for biological explanations. So physicians and the public grabbed on to what is essentially a PR campaign--perhaps the most successful one in the last 30 years in the Western industrialized nations--that if you have a mental disturbance, it's biochemical.

Harold Koplewicz

Vice chairman of psychiatry at New York University, Koplewicz believes that ADHD is a legitimate brain disorder. He wrote It's Nobody's Fault: New Hope and Help for Difficult Children and Their Parents. He is director for the New York University Child Study Center.

I think that we should look very carefully at who's funding science. I think you'll find that, overwhelmingly, the studies looking at treatment have been funded by the federal government. The National Institute of Mental Health has spent millions and millions of dollars looking at treatments. . . . When you looked at the medicines--all different kinds of medicines that basically have the same mechanism of action--they did work, and they were effective. And when you looked at behavioral therapy, you found that behavioral therapy wasn't effective unless they were taking medications. The federal government doesn't have a bias. They're not looking to support one treatment versus another. . . .

But yet there are pharmaceutical companies that do lobby politicians, and are out there and are pushing certain things and trying to get more funding for certain other things. And sales reps come around doctors' offices and invite doctors on cruises.

I don't think the pharmaceutical companies are affecting what the National Institute of Health is funding. I think that the reason why that's considered the gold standard is, to get funding from the National Institute of Health, you have to have a scientific research project that is peer-reviewed. Your peers review it and decide whether or not they think it's scientifically sound to use federal funds to study it.

The other question, though, about sales reps, is worthwhile. I think that doctors who are in private practice are overwhelmed with new challenges, and they are working harder than ever. Managed care has turned out not to be managed care, but managed money. We are just trying to keep the costs down of the healthcare system. So you find that doctors are seeing more patients that they ever saw before, especially if you're a primary care physician. . . .

Quite clearly, if a rep comes to your office and quickly tells you about a medication that's effective and easy and safe, that may influence your prescription practice more than reading a peer-reviewed journal. . . . And I think that that's a real problem when you have doctors who don't have enough time to keep up to date.

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