Monday, April 06, 2009

ADHD Drugs No Long-Term Benefits

The 8 year follow-up data from the ADHD MTA Study (Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder)are out and the results argue against the use of ADHD drugs longer than 2 years. Most families tended to stopped the drugs by two years anyway, but some vocal medication-proponents had suggested this was endangering children's health. In fact, besides medications having less symptomatic benefit with chronic use, the latest study also comments on observation that long-term medication may also impair growth (children who took medication for 36 months or longer were 6 lbs lighter and one inch shorter)

Excerpt NIMH summary:

"A majority (61.5 percent) of the children who were medicated at the end of the 14-month trial had stopped taking medication by the eight-year follow-up, suggesting that medication treatment may lose appeal with families over time...Children who were no longer taking medication at the eight-year follow-up were generally functioning as well as children who were still medicated, raising questions about whether medication treatment beyond two years continues to be beneficial or needed by all."

Washington Post: Debate over drugs for ADHD reignites:

"One principal scientist in the study, psychologist William Pelham, said that the most obvious interpretation of the data is that the medications are useful in the short term but ineffective over longer periods but added that his colleagues had repeatedly sought to explain away evidence that challenged the long-term usefulness of medication. When their explanations failed to hold up, they reached for new ones, Pelham said.

"The stance the group took in the first paper was so strong that the people are embarrassed to say they were wrong and we led the whole field astray," said Pelham, of the State University of New York at Buffalo. Pelham said the drugs, including Adderall and Concerta, are among the medications most frequently prescribed for American children, adding: "If 5 percent of families in the country are giving a medication to their children, and they don't realize it does not have long-term benefits but might have long-term risks, why should they not be told?"

More from the Post:

"As the MTA study continued to find smaller and smaller behavioral differences between children who were medicated and those who were not, use of the drugs soared. Pelham said most parents and doctors took away the message that the study had found drug therapy effective over the long run. In 2004, physicians wrote 28.3 million prescriptions for ADHD drugs; last year, they wrote 39.5 million, according to data provided by IMS Health...

The subgroup analysis found that children in homes that were socially and economically stable did the same in the long term with or without medication. Children from troubled or deprived backgrounds slid backward as soon as the intensive therapy stopped and they went back to their communities. About one-third -- those with the least impairment to begin with -- continued to improve over the long term.

"If you want something for tomorrow, medication is the best, but if you want something three years from now, it does not matter," he said. "If you take medication long-term beyond three years, I don't think there is any evidence that medication is better than no medication."

This latest information should be made available to parents making difficult decisions about beginning or continuing their children on the medication. At the end of the Washington Post article, Pelham added that in a soon-to-be published report, he found that "95 percent of parents who were told by clinicians to first try behavioral interventions for ADHD did so. When parents were given a prescription for a drug and then told to enroll their children in behavioral intervention programs, 75 percent did not seek out the behavioral approaches." His take-home point was that if medications are being prescribed, they should be taken alongside a behavioral program.

All this news will add to the continuing fiery debate over drug prescription in the classroom. The recent discovery that a leading vocal advocate of use of more psychiatric medications in elementary and preschool children (Harvard child psychiatrist Dr. Joseph Biederman) failed to report receiving over 1.7 million dollars in consulting fees from drug companies over the years 2000-7, further stirs the pot. Dr B seems to be in even more trouble in recently released court documents: from the Wall Street Journal's blog, read more about Biederman's serious protocol violations in his research study treating preschoolers with antipsychotics here.


NIMH: ADHD medications not likely to improve long term outcomes for children with ADHD
MTA at 8 Years - J Am Acad Pediatrics
Washington Post: Debate over drugs for ADHD reignites
New York Times: Researchers fail to reveal drug pay

2 comments:

  1. Meredith Warshaw, M.S.S., M.A.9:07 PM

    As someone who spent a decade in psychiatry research doing naturalistic longitudinal studies (which is what this portion of the MTA study is), I'm gravely concerned with the conclusions drawn by the authors of this paper. It is well known among those of us with expertise in these studies that you cannot draw conclusions about treatment effectiveness from naturalistic studies - that is, studies where clinicians and patients decide the treatment, unlike randomized studies where treatment is assigned. There have been some excellent papers on the topic by Phil Lavori, Ph.D., of the Collaborative Depression Study and others.

    Although the early part of the MTA was randomized, the several years of follow-up were not. Several factors then come into play. First, since the subjects were returned to community care, many of them were likely to have received substandard treatment. Unfortunately, people ADHD (and depression and many other conditions) frequently get substandard treatment by clinicians who lack expertise or time to do proper monitoring, dose adjustment, etc. More importantly. once people are no longer being assigned to treatments, they frequently discontinue treatment if they are doing well enough without it. This means that the common finding in naturalistic studies is that the subjects with most severe symptoms are those who are taking the most medication - ,not because the treatment is exacerbating their illness but because those whose symptoms aren't manageable without medication are those who take them, and those whose symptoms don't respond to the first-line treatments are those who go on to more intensive treatment. So, if the MTA found that subjects who remained on medication at the end of follow-up were doing no better than those who discontinued, it is very likely that they would have been doing worse than the other subjects if they had stopped the treatment. As an analogy, if this study had been looking at children with asthma, they would have been likely to find that 6 years after then end of the assigned treatments, only some of the subjects in the treatment group were still using inhalers and they were doing no better than the subjects who weren't using inhalers - because those who no longer had asthma attacks stopped buying inhalers, and those who needed them to breath well were unlikely to be breathing better than people who have no need of inhalers - the medication is doing it's job if it gets you to the same level as people who don't need it.

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  2. Well, it's a good thing for everyone that researchers are conducting long term studies of children who take stimulants. We don't doubt that there are some children who benefit from stimulants both in the short and long term, but who are they - and how can clinicians distinguish them from those who will only receive short-term benefit?

    Today there are many families bullied into having their children take stimulants by "experts" or friends who prey on fears that kids will turn out badly if they don't. But the truth is - many children don't require medications life long, and it is another piece of information that parents and their doctors can consider while they are making difficult decisions about whether to begin or not to begin medications.

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