Mental Steroids for Overachievers?

AD/HD drugs have been a whipping boy for years. Library shelves are crammed with screeds on the evils of these stimulants, focusing on the overuse of the AD/HD diagnosis–the mislabeling of normal boyhood as aberrant–and the potential harm done to children’s minds and bodies by unnecessary medications. But just when we get to thinking that we know all the tired old tropes of the AD/HD debate by heart, a new wrinkle challenges our entrenched notions.

The Food and Drug Administration (FDA) shook up the perceived wisdom in February, when it convened a panel of outside experts to advise the regulatory agency on risks associated with AD/HD drugs like Ritalin and Adderall. The experts’ recommendation was both unexpected and symbolic.

The FDA’s own medical experts had been concerned about some recent reports of cardiac abnormalities, including sudden, unexplained deaths, among patients taking the popular stimulants, and asked the outside advisers how to best judge the riskiness of the drugs. The advisers surprised FDA officials, and a lot of therapists and parents who read the news the next day, by recommending that the agency mandate a “black box” on all bottles of the AD/HD drugs, warning about the newly discovered, life-threatening risks. A black box is the strongest consumer advisory the government can require for a prescription drug, an official way of shouting “whoa” to those with prescription pads.

But here’s the twist. Some of the FDA advisers who argued most strenuously for the black-box warning, and ultimately voted for it in a close 8-7 polling, made it clear that it wasn’t really the cardiac risks and sudden deaths that alarmed them the most. Indeed, there were only 25 reported deaths among the estimated 4 million Americans (including 2.5 million children) taking the stimulant drugs. The panelists’ public comments following the vote made it clear that what really disturbed them was the broad trend toward overprescription that these 4 million stimulant users represent.

Panelist Steven Nissen, a cardiologist at the Cleveland Clinic, made no bones about his concern with the increasingly liberal prescription of these drugs, to children as well as adults, saying afterward that he wanted physicians to think twice before they wrote another script for an AD/HD stimulant drug. Panelist Carl Furberg of Wake Forest University, referring to the fact that AD/HD doesn’t exist as a diagnosis outside the United States, said quite bluntly that he doesn’t believe that one in ten 10-year-old boys really need these drugs. Other commentators not on the panel have since echoed this sentiment, including pediatrician Lawrence Diller, author of Running on Ritalin, and Edward Hallowell, author of Driven to Distraction.

It appears that the panelists’ alarm over minuscule cardiac risk is a proxy for what seems to be a growing moral opposition to the use of these drugs by an increasing number of Americans. It’s widely believed that the dramatic rise in prescriptions for the stimulants that treat AD/HD can be explained only by an upsurge in their illegal use. Consider a recent study, released soon after the FDA deliberations by scientists at the nonprofit research organization RTI International in North Carolina. The scientists analyzed data from the government’s annual National Survey on Drug Use and Health and found that, in 2002 (the latest data available), an estimated 21 million people 12 years or older had misused prescription stimulants. According to this analysis, published in the online journal Drug and Alcohol Addiction, one in ten Americans from 12 to 25 years of age is abusing, and perhaps dependent on, these drugs. The study was paid for by the drug company Eli Lilly, although Lilly’s own AD/HD drug, Strattera, wasn’t yet on the market in 2002.

More disturbing than the sheer numbers of misusers involved is what teenagers and young adults said about their reasons for taking the drugs: they were using the drugs for the “experience or feeling” they offered. Although it isn’t clear from the data they collected, says Larry Kroutil, lead author of the RTI study, abundant anecdotal evidence indicates that teens and young adults (both boys and girls) are taking the stimulants to help them focus longer and better on their studies and get an edge in an increasingly competitive world, whether at school or at work.

These stimulant users aren’t slackers copping recreational drugs, as they might LSD or marijuana, but rather students who are short on time to cram for that calculus exam or stressed-out executives needing to complete their contract proposals or year-end reports. In other words, these have become “antifailure” drugs.

Paradoxically, the “misuse” of them isn’t all that different from the use for which these drugs are intended and legitimately prescribed–to sharpen mental focus when it’s difficult to come by naturally. “This is the real issue,” says Diller. “Kids have been using stimulant drugs safely for years. But the diversion to older illegal users is leading to abuse and addiction. In the ’70s, the target was women’s weight-loss pills. Now it’s someone else’s AD/HD medication.”

What seems to make experts particularly queasy is the possibility that people are not only cheating to get the drugs, they’re using the drugs to cheat at life. The drugs have become the steroids of the intelligentsia–cognitive performance enhancers. Or to borrow psychiatrist Peter Kramer’s famous phrase from Listening to Prozac, they’ve become “cosmetic pharmacology,” used to make us “better than well.”

The message in these teenagers’ illicit behavior is that they feel entitled to the mental acuity and concentration that our competitive, success-oriented society values and rewards. And that raises large social and cultural issues, to wit: Is the premium on success in America so high, and the penalty for perceived lack of success so frightful, that presumably “normal” kids and adults are driven to scarf down drugs, not to get high, but to write that killer senior thesis? To make sure they get an A in organic chemistry? To win a promotion over the guy or gal in the next office?

So what to do? We obviously can’t entirely reweave the fabric of our individualistic and highly competitive society in order to address this particular public-health issue. But we can be more circumspect in prescribing the drugs, says clinical psychologist Scott Kollins, head of Duke University’s AD/HD program: “You just can’t do an accurate diagnosis of AD/HD in 15 minutes. Careful diagnosis requires a thorough medical, psychological, and academic history. It requires the time-consuming gathering of information from family and teachers and others, and the ruling out of alternative diagnoses, such as depression and anxiety.” But it’s often difficult to find the time and resources for such a rigorous clinical investigation, notes Kollins, especially in the era of managed care.

And even when people truly do suffer from AD/HD, time constraints impinge on effective treatment beyond a quick drug fix. According to Edward Hallowell, most practitioners fail to offer any treatment for AD/HD that doesn’t involve medications. These could be as simple as counseling good sleep, proper nutrition, and exercise, but also might involve behavioral training in organizational skills, biofeedback, and mindfulness exercises, as well as newer interventions like cerebellar stimulation.

These experts may be right that the prescription of stimulant drugs has become a lazy substitute for time-consuming diagnosis and more laborious treatments. But this isn’t due simply to the exigencies of managed care. The larger cultural issue is that taking meds for AD/HD, or simply to focus more sharply, is itself an ironic symptom of a certain kind of cultural attention deficit disorder. The fact is we just don’t want to stop long enough to make the lifestyle and other changes that might help us deal more effectively with the problem of scattered attention over the long haul. So we accept a measure of risk for ourselves and our children in exchange for the quick cognitive boost needed to go to the head of the class in America today.