Jeffrey Lieberman, MD, President of the APA, has expressed concern about the rise in the number of people being assigned a “diagnosis” of ADHD. He has put up a video on Medscape, Explaining the Rise in ADHD. There is a transcript with the video.
Dr. Lieberman is responding to a December 14, 2013, New York Times article The Selling of Attention Deficit Disorder, by Alan Schwarz, and a December 18 editorial in the same paper titled An Epidemic of Attention Deficit Disorder.
The article had pointed out that 15% of all high school students in the US carry a diagnosis of ADHD, and that the number of children being treated for ADHD rose from 600,000 in 1990 to 3.5 million in 2013.
Dr. Lieberman points out that Alan Schwarz had blamed the increase on drug company marketing to doctors and consumers, and on doctors’ susceptibility to this marketing.
But Dr. Lieberman, our intrepid champion of honesty and integrity, isn’t buying that entirely. He tells us that he has been reading the “scientific medical literature” as well as “the lay literature,” and it is apparent to him that there is:
“…increased pressure from parents and schools, which influences doctors when they see patients and attempt to determine whether a child has a diagnosable condition or whether a specific treatment should be used.”
There is also, he tells us:
“…a readiness to refer children for evaluation, either for neuropsychological testing or to be seen by a pediatric neurologist or psychiatrist. In our competitive society, we know that people desire a competitive edge to improve their chances of doing well in school, getting into the best colleges, and so forth. If having a diagnosis and taking stimulant medications can enhance performance in addition to procuring for the student extra time on tests, this is seen as desirable, and doctors may be subject to the pleas or requests of parents to see their children in ways that encourage the diagnosis and treatment of ADHD.”
He also mentions:
“Public schools can receive financial incentives to have students in special education or remedial education programs, and families with lower incomes can receive subsidies and disability support if their children have diagnoses of cognitive problems, whether it is a learning disability or ADHD, that result in the need for special education.”
So there we have it. Once again, psychiatry is blameless – it’s the mean ol’ drug companies with their high-power marketing, and the overly-ambitious parents seeking that extra edge for their children in this highly competitive world. And, of course, the schools, who covet the extra funding that comes their way for every student who carries an ADHD “diagnosis.”
But – in classic Dr. Lieberman style – he ignores the fact that it was psychiatrists who invented this non-illness in the first place. It was psychiatrists who set out criteria for this “illness” that were so vague that virtually any child could be pathologized. It was psychiatrists, in their long-standing, corrupt relationship with pharma, who promoted the notion of popping pills as the correct and appropriate “treatment” for this “under-diagnosed” condition. And it was psychiatrists who, spurred by their success in the pediatric market, launched this so-called illness at the adult population, and turned dangerous stimulant drugs into the blockbusters they are today.
No. Dr. Lieberman doesn’t address those issues.
He does, however, concede that
“…it ultimately comes back to the doctors, who are the gatekeepers or arbiters of diagnosis and treatment.”
And he insists that
“…clinicians must resist marketing pressures, as well as parental pressures, to ensure that diagnoses are made in a rigorous way and that treatments are prescribed judiciously.”
So, diagnoses are to be made in a rigorous way. Could anyone explain to me how the criterion item
“Often runs or climbs about in situations where it is inappropriate (Note: in adolescents or adults may be limited to feeling restless)”
can be applied in a rigorous way? How often is “often”? How would one even begin to assess the frequency with which a child runs or climbs about? How do we define appropriate? A strict, uptight nanny might say that running and climbing about is never appropriate. A parent or teacher might feel that running and climbing about were OK for boys but not for girls, etc… And apparently adolescents and adults score yes on this item if they often feel restless! I would guess that during the winter, half the adult population of the northern United States feel restless. We call it cabin fever! And aren’t adolescents supposed to feel restless? Isn’t it the time of the great awakening – when young people look to the horizon and dream their dreams?
Or how about:
“Often unable to play or engage in leisure activities quietly.”
How are we to interpret the word “unable”? How do we define “quietly”? Should be have a decibel meter?
Or:
“Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).”
How do we define “extraneous”? Would this item embrace a gifted child who is finding the class lesson boring and facile, and looking out the window watching a magpie building a nest? And how can we assess “unrelated thoughts”?
Psychiatrist (to adolescent): Are you distracted by unrelated thoughts?
Adolescent (who wants diagnosis): Yes – all the time.
Adolescent (who doesn’t want diagnosis): No – not much.
I suggest that of the 18 criteria that underpin this so-called diagnosis, there isn’t one that could by any stretch of the imagination, be rigorously applied. The wording in each item is colloquial, and no attempt is made to define the terms. The word “often,” which occurs in every item, is clearly open to interpretation.
This vagueness in the criteria items has been a feature of virtually every “diagnosis” in the DSM since its inception. Psychiatrists have made no attempt to sharpen these defining features, and it is difficult to avoid the impression that they like them just the way they are. And the reason they like them is because it enables psychiatry to expand its scope more or less indefinitely. This is in line with their unspoken but clearly evident philosophy: every problem is an illness, for every illness there’s a pill, and every undrugged person is money down the drain.
For the past 60 years, organized psychiatry never raised the slightest objection to this implied philosophy, and never expressed the slightest alarm or misgiving about the increasing “prevalence of mental illness.” Indeed, it was commonplace to hear leading psychiatrists assuring us that “mental illness” was under diagnosed. Remember the much-lamented statistic: only 40% of people with “mental illness” are receiving treatment!
Now, with the controversy surrounding the publication of DSM-5 and the emergence of the survivor movement as a force to be reckoned with, organized psychiatry is trying to backpedal. Dr. Lieberman wants diagnoses to be made “in a rigorous way” and treatments to be prescribed “judiciously.” But a runaway train is a hard thing to stop. And if psychiatry had really wanted this, they would have taken appropriate steps decades ago. In fact, they wouldn’t have embarked on this travesty in the first place.
Certainly, pharma poured money into the promotion of ADHD, but it was psychiatric “thought leaders,” unashamedly embracing their roles as pharma shills, who presented the seminars and the CEU sessions in every conceivable venue, including the APA’s own conferences.
Dr. Lieberman is well aware that all across America the “diagnosis” of ADHD, for children and adults, is being made in five-minute interviews, and that stimulant drugs are being distributed readily and with little regard for their adverse effects.
He also knows that it was organized psychiatry that created this situation, and that they did so consciously and deliberately. This was not some minor transient error into which psychiatry briefly drifted and from which it will promptly extricate itself. This state of affairs is the end result of 60 years of focused and dedicated work on the part of psychiatry’s leaders to create a culture in which all human problems would be seen as psychiatric illnesses to be treated by pills. The American Journal of Psychiatry, the APA’s own official journal is still running ADHD drug ads in its online version.
In addition, it is disingenuous of Dr. Lieberman to imply that it is only now, thanks to Alan Schwarz’s article, that he is discovering the excesses to which his profession has reached. In the relentless pursuit of their disempowering but self-serving agenda, psychiatry has systematically silenced and marginalized its critics – those from within its own ranks and those from outside. As recently as last May, Thomas Insel, MD, Director of NIMH, who had declared psychiatric diagnoses to be invalid, was quickly brought to heel, and even issued a press statement – jointly with Dr. Lieberman – to the effect that DSM-5 was the best option.
The notion that every problem is an illness to be treated by a pill has been nurtured and promoted by successive generations of psychiatrists to the point where it is now an article of faith – an essential tenet of psychiatric orthodoxy to which all new recruits must subscribe, and on whose altar ever-increasing numbers of children and adults are being sacrificed every day.
There are dissenting psychiatrists, of course, and they are to be commended for their courage and their outspokenness. But from the great majority of psychiatrists there’s not a word – just lockstep compliance and overworked prescription pads. And from their great leader, a hollow and belated call for “rigorous” psychiatric diagnosis and “judicious” prescription, both of which, I suggest, are contradictions in terms.
The psychiatric ship has long been unseaworthy. It’s on the rocks, holed and taking water. But the psychiatrists on board are joined together in a self-destructive conspiracy of complacent self-deception, ever ready to blame others for their plight, but adamantly refusing to recognize that the ship in which they sail is a vessel of their own making, and that the course to disaster was charted by their own hands.