In the late 1990’s, the National Institute of Mental Health (NIMH) set out to provide the most extensive review ever conducted of the effectiveness of ADHD medications in children. It was known as the Multisite Multimodal Treatment Study of Children with ADHD (MTA study). In 1999, NIMH announced that after 14 months, well-constructed medication management programs provided better results than other treatments, including behavioral therapy. But the study was not over, and the tables started to turn as detailed in the new book by Robert Whitaker and Lisa Cosgrove. By the end of three years, medication not only provided no more benefits over other options, it actually predicted greater deterioration of symptoms. In other words, children that were taking medications exhibited worse outcomes (e.g., more delinquency) than those who were not. They also ended up six pounds lighter and an inch shorter than their unmedicated counterparts. After six years, medication use was associated with increased hyperactivity, impulsivity, and oppositionality, and overall functional impairment. Those who had used behavioral therapy alone were less likely to be depressed or anxious.
NIMH investigators were shocked. Even after analyzing a number of potential confounding variables thought to contribute to the unexpected findings, they finally concluded, “The findings…were not consistent with views and expectations about medication effects held by many investigators and clinicians in the field. That is, long-term benefits from consistent treatment were not documented…”
The investigators acknowledged that despite previously held beliefs, good science had demonstrated otherwise. It seemed this large scale study would provide clear guidance for those using and prescribing drugs to kids once it was released to the public at large. That never happened. Multiple papers and titles did not report the negative findings, instead highlighting the short-term benefits while minimizing the negative outcomes. The NIMH press release announced the great news, “Improvement Following ADHD Treatment Sustained in Most Children” although they left out that “sustained” only meant through 14 months. Parents were assured by NIMH that despite having no clear gains after three years, medications were the way to go, even for the long-term. Discussion of the negative results was very difficult to find. In 2013, the American Psychiatric Association (APA) and the American Academy of Child & Adolescent Psychiatry (AACAP) published the ADHD Parents Medication Guide that continued to espouse the positive effects of medication found in the MTA study. And yet, despite the assurance given to move forward with medication treatment, other large scale studies have continued to find disappointing long-term effects .
On August 17, 2015, Medscape published an article entitled, Apps Can Help Health Habits, But Proof Is Poor: AHA Statement. Similar to the publicizing of the MTA study, it was filled with confusing, and at times, contradictory statements and advice. The article acknowledged that “evidence… [for mobile applications in reducing cardiovascular risk] is generally lacking.” Nevertheless, the article stated “clinicians should still encourage patients to use these new tools…” After review of 69 studies that failed to show clear effectiveness, the authors continue to repeat the same mantra: “Clinicians shouldn’t ignore the emergence of mobile health technologies, despite the lack of data supporting their use” ; health care providers should acknowledge that “evidence is currently weak”, but “patients should be encouraged to use them…” Most striking, the lead author, Dr. Lora Burke, stressed that despite the lack of evidence, “we need to embrace the challenge of producing (italics added) this needed evidence on how effective these new technologies are and how we can best adopt them in our practice to promote better health.” Ironically, further gleaning from the actual 58 page report indicated that weight loss is largely dependent on participant engagement, and “declining engagement and attrition (often as high as 40-50%) are characteristics of the digital health interventions” (Pg. 11).
So let’s take a second to review. Researchers acknowledge that the evidence for using apps to promote cardiac health is weak at best, and nil or detrimental at worst. Yet, not only does the press release indicate that patients should be encouraged to use them regularly (even before research supports it), the authors have the audacity to say that we should work to “produce” research (e.g., do whatever it takes in regards to data or study manipulation) to support the conclusions that these and other authors desire and/or believe, even if the best science does not come to this conclusion. This is very similar to critiques that many have lobbied against pharmaceutical companies, in that through use of questionable statistical techniques and suppression of negative studies, findings to support use of medications are often artificially “produced.”
Let’s use an example to illustrate how contrary this is to what we are taught about the scientific process. If a relatively non-marketable entity, such as exercise, consumption of produce, journaling, or regular exposure to nature, was repeatedly found to not sustain long-term positive effects for a particular health outcome, it is safe to say that clinicians and researchers would not be consistently telling their patients to engage in these activities in the hopes (or desire) that they might just work. Further research might still be warranted; however, after almost 70 studies, there is a decent chance that interest and funding may have “dried up.” But at the very least, you can rest assured that doctors would not be advising children to eat vegetables or exercise 60 minutes a day if it didn’t help promote sustained health. So why would the same professionals promote medications and technology without clear long-term benefits, and even with potential for harm?
In some ways, the answer is very simple. Not only are technology and medications readily marketable (and not available without cost or patent restrictions), many involved have a vested interest (often financially) in promoting them. They also both follow the coveted pathway of a convenient and “cutting edge” mindset. Whether we admit it or not, we are a culture that seeks out the quickest, seemingly most innovative solutions to time-honored problems, even when clear, direct, low-cost options are readily accessible. Let’s admit it. All of us at some time want a drive thru solution to a problem that really requires a four course, sit-down meal. We want to believe that a quick fix exists. We want to be assured that the easier and more progressive path is better, or at least just as good. But along the way, we (and many experts) fall trap to beliefs that end up distorting the reality in ways that can really lead to harm, whether of a physical, psychological, social, or financial sort.
So, what does this mean for us as parents and professionals? Well, first of all, it means that we really need to be careful readers of what we consume, and when we encounter contradictory messages, we should investigate further to understand the contradictions, not simply follow the ultimate advice given. Secondly, when it comes to spending our time and money, we should invest it where we know it matters, for the long-term. There are a number of interventions that do make a difference with regard to attention and health. Although they can be challenging and require sustained effort, there is little doubt that they can make a tremendous difference if we work to utilize these practices over time. Finally, we should be very careful about assuming that chic and cutting edge treatments are necessarily the best option. Often times, it is only depicted that way because what truly is the best option (e.g., adjust sleep routines, getting together with a friend to run twice a week, reducing processed foods, limiting screen time) is difficult to market and impossible to restrict.
By the way, there was one more piece of information from the 58 page report that got left out of the Medscape article. It was quoted as follows:
“Physical activity in the United States has significantly declined over the past 2 decades. Since the late 1980s, the proportion of adult women who report no leisure-time activity has increased from 19.1% to 51.7%, and the proportion of adult men reporting no leisure-time activity rose from 11.4% to 43.5%.” (Pg 12)
I wonder what cultural shift could have been associated with this concerning trend? Maybe the American Heart Association needs to consider that before recommending people spend more time utilizing technological innovations—which lack clear, supporting evidence, they might think about putting forth more effort to facilitate ways to help people reduce the use of unnecessary devices that could be the problem in the first place.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.