Yesterday, Alan Schwarz, reporting for the Sunday edition of The New York Times, published an alarmist piece on Adderall abuse.  The story chronicles the short life of Richard Fee, a popular young pre-med who, after dabbling in fast-acting stimulants in college, faked his way into an ADHD diagnosis and, within months of filling his first prescription, began heavily abusing the drug, leading to severe addiction and psychosis, and ultimately to his suicide, two years ago, at the age of twenty-four.

Ring the Alarm

The story of Richard Fee is a tragic one, and one that highlights both the dangers of prescribing ADHD drugs to neurotypical adults and some of the problems endemic in psychiatric diagnosis.  Regrettably, the reporter seems to believe that these problems are somehow specific to amphetamines, signaling "widespread failings in the system through which five million Americans take medication for ADHD", and that Richard's harrowing case, while undoubtedly rare, "underscores aspects of ADHD treatment that are mishandled every day with countless patients".

Schwarz is a Pulitzer-prize nominated journalist, renowned for exposing the danger of concussive head injuries in football. More recently, he has cast that same critical eye on how attention-deficit disorder is diagnosed. The question is - to what end?  Presumably - in the case of this story - to tighten the restrictions on how amphetamines are prescribed to adults, and to ward against the kind of negligence and lack of oversight that characterized Richard's case.  But there is a delicate balance to be struck here between serving the needs of the ADHD population, many of whom benefit tremendously from the regulated use of stimulants, and potential drug addicts, like Richard.  It is also far from clear, given the nature of psychiatric nosology, that there are any surefire ways of stopping con-artists and addicts from gaming the system.

Let me give an example. At the Big Ten school I attend in the Midwest, regulative policies are in full effect, and it is notoriously hard to obtain an attention-deficit diagnosis, regardless of diagnostic history.  To be seen for an intake interview with a psychiatrist, a student must first complete a half-hour standard battery that tests for a range of possible maladies.  If the results point towards some brand of attention-deficit, the student is then seen by a psychologist, who opens a case history.  If the psychologist also suspects ADD, the student must then requisition her grade school records from K-12, to be submitted alongside her current transcript, the results of previous psychiatric evaluations, and an extensive parent questionnaire.  All this to get penciled in for an initial psychiatric consult.  Given the limited number of available appointments, the process can take months. The joke is that the kids who have the wherewithal to make it through to a prescription couldn't possibly have the problem to begin with.

ADHD: It's (Probably) Not What You Think It Is

Which raises another point: Who are these kids left to slip through the cracks?  In grade school, ADHD is a catch-all for children who don't behave in class and don't play well with others.  You know, the "kids who drop their pants in the schoolyard instead of playing hopscotch" (or so goes that persistent stereotype).  But the actual disorder, clinically, is probably not what you think it is.

I'll save you the laundry-list of symptoms that get bandied about.  But for starters, there is no one way that the disorder manifests, no easy one-size-fits-all prototype. Given the complex interplay of neural development with personality and environment, the human category is a diverse one, counting charismatic entrepreneurs, famous artists, and a healthy number of criminals among its ranks.When ADD is understood as a problem of directing and controlling attention, rather than as a 'deficit' in attention, per se, the reason for this heterogeneity becomes clear: The 'affliction' produces a mind that is highly idiosyncratic in the way it attends to the world, unbound by social norms or parental pressures.  But how this 'unbridled' attention ultimately gets spent varies by individual.  Some teenagers with ADHD play video games for ten hours a day.  Others, like my high school boyfriend, expend that focus mastering dozens of languages, or obsessively annotating their music collections.  Brilliance and achievement do not preclude having ADHD, or vice versa.  A person that is ill-equipped to sit through classes, keep track of dates and appointments, and conform to staid social situations, may, nonetheless, be astonishingly creative and resourceful in other domains.  Or not - depending on the circumstances, and the outlets.

Whatever the stigma attached to ADHD, it is hard to deny its prevalence, which has been pegged at between 5-10% of the population in the US. Given what this implies for genetic selection - that the genes underpinning ADHD must have conferred some adaptive benefit over our recent evolutionary past - there is some thought that ADHD has only become a 'disordered' category of being in the context of modern life.

--Which is not to say that medication shouldn't be prescribed to the individuals tasked with facing a world that was, perhaps, not designed with them in mind.

How can stimulants help with ADHD?

Maybe you have a friend, like I do, who took Adderall expecting to get work done and instead fell asleep.  Anecdotally, that's classic ADD, kind of like recurrent ear infections when you're five.  Many of the twenty-somethings I know who are prescribed stimulants complain that taking them actually diminishes their powers of single-minded concentration.  What it allows them to do is much more mundane: Make it to work on time. Run three different errands all in one day. Remember to pay the water bill before it gets shut off.  To borrow Jonah Lehrer's metaphor, "The drugs haven’t suddenly turned on the spotlight of attention. The spotlight was always there. Instead, they have made it easier [to] point the spotlight in the right direction."  Of course, this is the exact opposite of the popular perception of what these drugs are used for.  Unfortunately, the popular perception may be influencing the medical one.

A few weeks after Richard Fee received a prescription for Vyvanse from a nurse practioner, he returned to her reporting "excellent concentration: “reading books — read 10!” her notes indicate."  Of all the red flags that Richard raised, this one was the Jolly Roger.  Drugs like Vyvanse are not designed to make ADHD kids super-human; they're designed to help them approximate normal function.

There are a number of competing theories on how amphetamines interact with executive brain function, but the short story is that they work their magic by increasing circulating levels of  dopamine in the central nervous system. PET brain imaging of never-medicated ADHD patients has uncovered abnormalities in the dopamine reward pathway, marked by strikingly low levels of dopamine receptors in the midbrain and accumbens.  Dopaminergic drugs are prescribed to help restore the balance.  The difficulty, and the danger, is that these drugs are being unleashed on a fragile eco-system that can easily be tipped out of balance.

You can think of the problem by analogy to another delicate process: making a proper English toffee.  Take the batch off the heat too soon and you'll get a candy with a sickly-sweet taste and a chalky consistency.  But leave it on too long, and the sugar burns, imparting a brittle, smoky character to the confection.  Hitting the sweet spot, which yields that rich, buttery flavor that you find in shops, takes practice and patience; with almond toffees, the difference can be a matter of seconds.  Dialing up to the right amphetamine dosage for a particular ADHD patient presents a similar tight walk.  At too low a dose, the therapeutic effects of the drug are attenuated.  But go too high, and your patient might as well be snorting lines off their prescription bottle.  The end goal is not to have them polishing off Finnegans Wake in an afternoon; it's to get them up near a normal baseline.

Because patients can respond differently to the same dose, finding that target often takes some trial-and-error, and requires honest, forthright communication between doctor and patient.  Unfortunately, that reserve of trust is precisely what fakers and addicts exploit.

Drowning Innocents, Burning Witches

“[Richard] was smart and he was quick and he had A’s and B’s and wanted to go to medical school — and he had all the deportment of a guy that had the potential to do that,” Dr. Parker said. “He didn’t seem like he was a drug person at all, but rather a person that was misunderstood, really desirous of becoming a physician. He was very slick and smooth. He convinced me there was a benefit.”

Re-reading the story of Richard Fee, I am struck by how Schwarz plays the apologist for his subject - that tragic young man with his becoming prospects and his athletic build.  Again and again, Schwarz emphasizes that "[Richard] had it in his mind that because it came from a doctor, it was O.K."  But this is nonsense: Richard was neither ingenuous nor uneducated. He was a pre-medical student who likely "faked or at least exaggerated his symptoms to get his diagnosis" and artfully scammed careless doctors and drugstores to support his growing addiction.  That we are supposed to accept these excuses at face value beggars belief.  White-collar addicts are not immune to self-delusion.

Schwarz whitewashes Richard's narrative in part because he wants to fault the system.  But again, the question comes back to: What would tightening the reins on amphetamine actually do, in practice?  It might prevent a "worst-case scenario" like Richard Fee, but at the expense of many actual sufferers going unmedicated.While I agree with Schwarz that talk therapy is a critical component in any treatment program, for many adult ADHD patients, medication can be instrumental in helping them get their lives organized enough to actually attend therapy.  The system cannot be organized around rooting out false positives.

Moreover, the problems that Schwarz notes with ADHD diagnosis are not, in fact, particular to it, but are rather endemic to the diagnosis of mental disorders more generally.  For instance, it is hardly surprising that standard batteries for ADHD cannot distinguish college students with the disorder from those instructed to fake the symptoms.  Given how the diagnostic process works, this should be true of any mental illness, save those with glaring physical manifestations, like anorexia.  After all, unlike in other branches of medicine, there are no certain tests; no X-rays or blood work-ups that can safely eliminate doubt.  In many cases of first diagnosis, the psychiatrist has two things to go on: what the patient tells them and how the patient behaves at intake.  This is the state of the art.  And it relies on, among other things, genuine self-report.  You don't need to be good Will Hunting to defeat a system like that.

Psychiatry is still in its infancy.  So long as mental disorders are seen as illnesses that can be diagnosed in a quick check-up, and medications are doled out on the basis of checklists and questionnaires (absent better diagnostic tests), there will be serious potential not only for abuse, but for patient harm.  This is no less the case with drugs that target anxiety, depression, and psychosis, than it is for amphetamines.  All are powerful psychotropic drugs with unwanted side effects.  That not all of these drugs have addictive potential does not lessen their prospect for harm: just try pairing search terms for "suicide" and "SSRIs",  "benzo" and "withdrawal", or "bipolar" and "diabetes".   The problem is that there is, as yet, little alternative.  The science needs to improve before the medicine can.

I should note in closing that while I have said nothing here about the diagnostic practices for childhood ADHD, like Schwarz, I find the widespread practice of medicating children under eighteen for these disorders to be ethically fraught.  To my mind, the stories of children who are forced to medicate against their wishes - and of the doctors who willingly endorse this brand of Orwellian medicine - are far more compelling and worthy of being told than those of reckless adults exploiting loopholes.  Haven't we heard enough of those stories already?