ADHD Prescribing Differs Substantially in UK vs. US

Kermit Cole
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An article in the Harvard Review of Psychiatry finds that the UK’s new guidelines for treating attention and depression problems in children recommend a more conservative approach to the use of psychotropic medications than US guidelines, suggesting “that the existence of an alternative standard provides validation for clinicians or families who prefer to take a more conservative approach to medication use.”

Murphy, J. Michael; McCarthy, Alyssa E.; Baer, Lee; Zima, Bonnie T.; Jellinek, Michael S.; Alternative National Guidelines for Treating Attention and Depression Problems in Children: Comparison of Treatment Approaches and Prescribing Rates in the United Kingdom and United States. Harvard Review of Psychiatry. Online April 14, 2014. doi: 10.1097/HRP.0000000000000026

Abstract:

The use of psychotropic medications for children and adolescents with attention and depression problems continues to generate both attention in the news media and controversy within the field. Given that the United Kingdom has recently issued guidelines for its national health service that differ substantially from those in the United States, the time is ripe to reexamine the evidence. The purpose of this article is to describe the UK’s new “stepped care” guidelines for treating attention and depression problems in children and to compare them to the US guidelines issued by the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry. Our findings are that, despite many similarities, the UK guidelines are generally more conservative in their recommendations for medication use, especially for children experiencing only moderate impairment. Our article also compares prescription and diagnosis rates in the UK and the US, and reports evidence for lower rates of prescribing in the UK, despite some evidence that the rates of problems may not differ substantially. We conclude by noting that the existence of an alternative standard provides validation for clinicians or families who prefer to take a more conservative approach to medication use. The two different approaches to care also provide a valuable opportunity for research to determine whether the approaches result in different treatment outcomes.

From the Conclusion:

It is intriguing to speculate on how authorities in two similar health care systems could review the same empirical literature and come up with different conclusions about the evidence for the effectiveness of psychotropic medications. Although we are not aware of any systematic reviews, a recent op-ed piece in the New York Times pointed to studies linking differences in high-stakes testing policies of different states, categorical eligibility for special education services, and reim- bursement policies to a two- to threefold difference in the reported prevalences of ADHD between states in the US and perhaps also to differences between the US and the UK.

It is also intriguing to stand back from the findings presented here to consider whether the treatment guidelines and prescribing rates in the UK may reflect a more restrained view of psychopathology than those in the US. It seems clear (from the earliest studies cited here) that these differences may reflect cultural differences that preceded and continue to outweigh any empirical studies. With regard to ADHD, the op-ed piece cited above mentions the debate over the broader and complex trend toward “medicalizing” traits that might have been considered normal in the past. Another op-ed piece in the New York Times has labeled this phenomenon the “Americanization of mental illness.” However, even if any differences that do exist are culturally determined and thus not readily amenable to change, the existence of an alternative standard in the UK—which has a population much like our own in many respects—suggests that clinicians and parents now have a choice in how to approach care, at least for some children with these problems.

Also, based on at least one study, there appears to be virtually no difference in outcomes for US children with ADHD whose primary treatments were psychopharmacological versus behavioral. This was one of the main findings of a recent large, well-controlled naturalistic study of ADHD treatment in a real-world, Medicaid-insured sample. In contrasting outcomes for children with similar clinical severity levels who were treated primarily with medication (in pediatric practices) or behavioral interventions (in mental health agencies), Zima and her colleagues found that outcomes did not differ between the two groups and that parental satisfaction with treatment was equally high in both approaches.

The current review noted a major problem with the guidelines in both the UK and US in the lack of specificity as to what constitutes a mild, moderate, or severe disorder. In particular, there are currently no clear guidelines, grounded in symptoms and functioning, for how clinicians should assess the initial severity of the child’s disorder (which determines at which step treatment should begin) and their degree of improvement during each step of treatment (which determines whether or not to progress to the next step). Clinicians consequently have no empirically based way of knowing if or when to begin or change medications. By the same token, researchers have no common standard for comparing interventions. And in the absence of uniform specifications for how to define mild, moderate, and severe attention or depression problems, efforts to compare prevalences and prescribing patterns in different health care systems are compromised and unreliable.

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]

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