What do recent issues of Time, Newsweek, People, Parenting, Parade and professional journals such as the American Psychological Association’s Monitor and the Journal of the American Academy of Child and Adolescent Psychiatry all have in common? They all contain nearly identical, full page, full color advertisements touting the benefits of various medications for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). The aggressive marketing of medication to treat ADHD, in particular to the general public, represents a significant change in the marketing and advertising policies of pharmaceutical companies over the past ten years. In fact, in most recent issues of the Journal of the American Academy of Child and Adolescent Psychiatry, a professional research journal directed at physicians and mental health professionals, nearly 50% of the advertising space is devoted to pharmaceutical ads promoting a variety of stimulants and related medications for the treatment of ADHD. Though there is no law preventing drug companies from advertising medical treatments with potential addictive risks, ADHD appears to be the only condition at this time for which pharmaceutical companies are aggressively marketing such preparations to obtain, maintain or increase market share.
Please be assured that this is not an anti-ADHD nor anti-pharmaceutical company article. In promoting their products the pharmaceutical industry funds important research. In promoting their products, the pharmaceutical industry brings important knowledge to professionals and in the case of ADHD to the general public. But as with any good thing there are always potential problems. No amount of oversight by the FDA can anticipate the potential trivialization of this condition as the result of advertising, possibly fueling misunderstanding by lay and professional readers of the true nature, course and treatments for this condition. As an increasing body of research is demonstrating, symptom relief for ADHD is absolutely necessary but in and of itself likely insufficient to help affected youth overcome the adverse odds they face to transition happily and successfully into adult life.
This is also not an article questioning the efficacy of stimulant treatment in relieving the impairing, impulsive, hyperactive and inattentive symptoms befalling children with ADHD. A large scientific body of evidence very clearly demonstrates the efficacy of stimulant and related medication treatment for ADHD. In fact, there is also now a small but emerging body of literature demonstrating the likely direct and indirect long term benefits for those youth who are good medication responders and continue to take medication successfully during their childhood years. These benefits may be demonstrated in actual physiological changes in the brain leading to more efficient adult functioning and also in the secondary benefits of experiencing each day in childhood with greater success. However, conversely there is an emerging body of research involving non-human subjects, principally rats, suggesting that stimulant use during early development could cause changes in brain chemistry leading to increasing vulnerability for substance use and abuse above and beyond the risks associated with ADHD.
A number of years ago, before the recent shift in marketing strategy, a petition was submitted to the Drug Enforcement Agency (DEA) to move Ritalin® from Schedule II to Schedule III in the DEA scheduling of potentially dangerous and addictive drugs. I supported this petition. The primary reason this application came about was to ease parents’ ability to fill their children’s prescriptions. Schedule II drugs do not allow for prescription refills. Schedule III do. In the face of significant resistance by a wide diversity of groups, some touting their own agendas, others truly concerned about the ultimate adverse outcome of making this shift, the petition was withdrawn. In hindsight, I now agree that those professionals and organizations who were truly concerned about the risk of increased accessibility for potentially addictive substances were correct. Though I am still concerned about how difficult it is for families of children taking stimulant medications to obtain prescriptions on a monthly basis from their physicians and fill those prescriptions in a limited time frame, it is probably best that the stimulant medications remain as Schedule II preparations. Recent research studies have demonstrated an increasing number of youth referred for abuse of these substances, though it is important to keep these data in perspective given the millions of doses of stimulant medications given each day and the significant benefits afforded to appropriately diagnosed and treated youth with ADHD.
A number of years ago, the American Psychological Association Monitor, the monthly publication for members of the APA, began running full page, full color ads advertising a number of medications to treat ADHD. I found this surprising for a number of reasons. First, the vast majority of psychologists do not prescribe. Second, such advertisements had not appeared in previous years. Finally, I could only find advertisements for medications to treat ADHD not other mental health conditions such as depression or anxiety. I wrote a letter to the Editor inquiring about APA’s advertising policy. My letter was not printed, however, I received a letter back from the managing editor informing me that there was no selection bias. That is, any pharmaceutical company promoting an approved medication for psychiatric or mental health problems could advertise in the APA Monitor. It is just that most had chosen not to do so. When I further inquired as to why a pharmaceutical company might be interested in advertising to non-prescribing, mental health professionals, the APA informed me that these advertisements could be considered “an informational source.” I was surprised by this response. Do we really want the public thinking that we obtain information used in clinical practice from promotional advertising? I think not.
I recently pulled up one of the more popular search engines and in one tenth of a second found over 1.4 million citations for ADHD and nearly 200,000 citations for medication treatment of ADHD. Every pharmaceutical company devotes a website to their drug products. Most of these appear to increasingly target consumers. Parents rather than professionals. It would appear that in marketing drug treatment for ADHD the pharmaceutical industry has decided that it is advantageous and perhaps increasingly profitable to market directly to consumers rather than professionals. Should we have a problem with this? As I noted, pharmaceutical companies fund a significant percentage of research dealing with ADHD and fund the majority of research examining drug treatment. Much good comes from this research. They underwrite and sponsor professional conferences. Again, much good comes from these conferences. In this sense, they in fact offer a public service. Share holders of these publically held pharmaceutical companies, however, are not necessarily interested in public service, but profit. There is little doubt that money for research and training is spent because it is viewed as a vehicle to fuel profits. The pharmaceutical industry in ADHD spends advertising dollars to promote revenue. This doesn’t necessarily represent corporate greed but rather quid pro quo, business as usual in a capitalist system. In fact we are all healthier as the result of this system despite complaints of cost or accessibility. Consider that we don’t see large four color ads for parent training, educational strategies or behavioral interventions for ADHD. Yet there is an increasing body of research demonstrating that these interventions are not only symptom relieving but perhaps in the long run lead to better outcome than medication alone. We don’t see these advertisements because the companies that develop and market these types of products as well as those who publish books about these interventions can’t afford the advertisements. There is insufficient revenue to devote to this type of high stakes advertising. I have often thought that a certain percentage of money spent on developing drugs to treat mental health conditions must be mandated to be spent on examining the psychosocial aspects of treatment for these conditions as well.
As with any marketing strategy, advertisements are designed to leave an impact, create a certain mindset and increase consumer interest in the product. As I have noted, though the FDA supervises and must approve these advertisements, having been involved in this process in previous years, it is sometimes a mystery as to why some things are approved and not others. Consider a sample of the current advertising log lines.
Shire USA (Adderall XR)
“Already done with my homework dad.”
“The science behind ADHD and self-esteem.”
“Reveal his potential with two sided improvement.”
McNeil (Concerta)
“Life stopped being about ADHD and started to be about staying in the game.”
Eli Lilly (Strattera)
“An idea that a kid with ADHD can believe in.”
“Having fun shouldn’t end when the day does.”
Novartis (Focalin)
“The right half of the efficacy they need.”
To some extent an underlying message from the pharmaceuticals to professionals is that they don’t trust professionals to make the best choice for their patients. Perhaps the best choice may not be their product and so rather than trust professionals to make good decisions they put the cart before the horse. An increasing number of physicians have pointed out to me at conferences that parents enter their offices seeking a specific product to treat their children’s ADHD. Is this process representative of public service? Probably not. Is it an effort to garner more market share by whatever means the FDA and ethics will allow? More likely yes. Are there other long-term, potential downside phenomena as the result of this current trend? I don’t know but I worry. Are these advertisements trivializing the condition and leading people to believe that ADHD is a minor inconvenience; that anyone with a little bit of trouble paying attention in every day life has the condition therefore those who tout the seriousness of the problem are pushing a personal agenda or, even worse, this is a condition of minor consequence, a product of late twentieth century Amerithink? What do professionals learn from these advertisements? What do parents learn? How is the public influenced? These are all unanswered questions. But having devoted a significant part of my professional career to the assessment and treatment of children with severe ADHD, I worry that the downside of the current trend may make it increasingly difficult for these youth to receive appropriate diagnosis, treatment and support such that they may transition happily and successfully into adult life. In the end I have decided from the pharmaceuticals’ prospective its not so much about providing consumer information but about providing “comfortable” advocacy. Advocacy for the condition and medication treatments that hopefully is good for everyone. I for one, however, am unwilling to wait to see how things turn out ten or twenty years from now. Here is what I suggest.
If you are a parent:
- If you have a child being treated with medication for ADHD, inform your physician about what you like and don’t like about these advertisements. Ask questions. Request the physician pass this information along to a pharmaceutical company representative.
- Get online and go to the pharmaceutical websites. Read them and send them emails about what you like, don’t like, what you understand and don’t understand.
- If you have a child being treated for ADHD with or without stimulant medication, become an informed consumer about the condition. Keep reading. Attend meetings. Join support groups.
If you are a non-medical mental health professional:
- Seek out local pharmaceutical representatives. Tell them how you feel about the advertisements. What you like and don’t like. Read the pharmaceutical web pages and make certain you know what your clients are reading.
- Inform your professional organization when an advertisement appears about ADHD in your periodical. Let them know how you feel. Seek to have your organization develop an advertising policy.
- Make certain that you don’t use these advertisements as your primary sources of authoritative information about ADHD or its treatment.
If you are a physician treating ADHD:
- Inform your pharmaceutical representatives how you feel about these advertisements. Let them know how your patients feel.
- Make an effort to educate your patients about ADHD and its treatment. Offer a range of resources. Advise your patients to not use advertisements as sources of authoritative information.
- Most importantly, utilize a reasoned and reasonable approach to the diagnosis. Judiciously hold the line, particularly focusing upon levels of impairment before making a diagnosis and, most importantly, before recommending medication treatment. Insist on a thorough, comprehensive evaluation. Inform third party carriers that such evaluations are essential given the significant comorbid problems children with ADHD face and the significant adversity that has been well identified in the research literature as they transition into adult life.
In the end, I believe that this process is evolutionary; that is, change for the better. ADHD is now a well-recognized, though not always well understood condition. It is now up to all of us, parents, mental health, medical and educational professionals and the pharmaceutical industry to work towards a future consensus for the diagnosis, treatment and care of children with ADHD.
