Methylphenidate (MPH) – an opportunity to waste? What are the alternatives?
1) Why opportunity?
MPH is an opportunity because it “works”, i.e., it has a real positive effect on attention, which allows the individual to concentrate better, especially when carrying out tedious tasks. It also works very quickly, giving the impression of a “miraculous” change, or at least a breaking away from the previous symptomatic situation, a vicious cycle of negative synergy that brought much suffering to both the individual and those around him. There is nothing surprising about this, given that the substance is an amphetamine derivate.
Also, attention, which is the target of MPH’s action, has become an essential value of our society, for several reasons:
- Pedagogical: first, because without attention there is no learning and it is impossible or at least very difficult to fulfil the requirements of schooling or the society, which brings the risk of isolation or even discrimination, of reduced self-esteem or even depression, with compensatory behaviours that are always harmful and sometimes dangerous. Attention has become a prerequisite of primary schooling.
- Economical: the attention of customers must be captured to sell them products. However, the modern sources of information and communication create so many demands on our attention that it has become a precious commodity. In our liberal society, when an object acquires economic value, everyone becomes interested in it.
- Neuropsychological: attention is linked to the executive functions and thus to the “brain in the brain” and this stimulates research studies and scientific literature on attention and its disorders, because they considered “up to date” and “cutting edge”, dealing with a niche and fashionable area of research.
In addition, the prescription of MPH is an opportunity because its quick action and “miraculous” effect are advertised virally on the social media and networks; it seems to respond to a certain shift in our thinking and in the demands addressed to child psychiatry. The fear of academic failure requires an efficacious symptomatic response, which boosts the prescription of a “learning stimulant”.
Lastly, it is an opportunity for clinical practitioners because we the psychiatrists and child psychiatrists have a very limited and partially inefficacious pharmacopoeia; it is therefore understandable that we pounce on methylphenidate like the “good bread”, because it is the latest great class of psychotropic drugs.
2) Why a wasted opportunity?
A mission of over-prescription
Even though it is extremely unlikely that in France we would reach the kinds of percentages we see in the USA, where in some states nearly 10% of children are treated with MPH or other psychostimulants not used in France, over-prescription is highly probably. Why?
First because of over-diagnosis, given that the prescription of MPH follows a diagnostic operation. And the diagnosis that prompts the prescription is ADHD and this diagnosis tends to be over-prescribed because it is based on, simply put, non-specific indices that are often hard to distinguish from normal variation, with a number of comorbidities.
Despite its dubious validity (absence of scientific evidence, of biological markers, though there have been nearly 40,000 scientific studies devoted to ADHD, costing millions of dollars, etc.), its poor reliability, the many confusing factors such as immaturity and so on, the diagnosis of ADHD has become a social fact simply because it is useful. It puts a medical label on mental suffering, on learning difficulties or dropping out of education; it avoids the bothersome diagnostic drift; by evoking a brain problem it lessens the parents’ guilt; it gives access to welfare benefits based on a recognized disability; it is supported by the “propaganda” of pharmaceutical laboratories (in early 1990s, psychostimulants represented less than USD 100 million globally, while in 2012 this number had risen to over USD 5 billion) and also by some user associations, which may have conflicts of interest; by medicalizing the problem, it can also help occlude the social, educational and pedagogical issues that correlate with the observed problems.
It is a missed opportunity because the Diagnostic and Statistical Manual, the US diagnostic tool that has now become globalised, has reduced the threshold of ADHD from one version to the next, thus encouraging over-diagnosis. Also and especially, starting from its fifth version, ADHD has been classified as a neuro-developmental disorder. In other words, ADHD is no longer an area of child psychiatry, but it has been “neurologised”, which logically boosts the pharmacological response, with behavioural “additions” of how to interact with the child, which, experience has shown, are not sustainable, because of the magic pill that is expected to fix everything, which demobilizes all the actors and parents in particular.
The social representation of MPH is deformed: the expectations are excessive, because it also has side-effects, its use in adolescence is a source of depersonalization, not much is known about its long-term effects and it is not a remedy against either addictive behaviour or academic difficulties. It cannot alone stabilize someone’s development and on average its efficacy only lasts two years. Not mentioning its misuse or abuse that have become alarmingly frequent.
3) What are the alternatives?
Some pointers:
Knowing how to use MPH as part of a diversified therapeutic approach based on serious clinical data.
Including psychopathology in the training of mental health practitioners alongside the standardised tools, if only to be able to identify underlying psychosis, to do more in-depth work in specific cases, to be able to listen more carefully, to be able to use different psychodynamic and behavioural therapies, to not try to fit too many things into a vague diagnostic category and to find the right balance between idiosyncrasy and standardisation. ADHD should not become a lazy diagnosis of simply applying protocols to a situation of mental suffering. We must reject any patronising attitude and instead try and create a partnership with the parents.
Practitioners should be trained to do research with a scientific attitude, to distinguish between “the rhetoric of promise and the patency of proof”, as François Gonon puts it, to learn to distinguish between correlations and causalities, to sort through research studies and identify their key methodological or statistical biases, but also to contextualise the discourse on neuroscience, including its causes of distortions such as researchers’ careers, media interest of journal editors, the reputation of different universities and research centres, in order to not fall prey to the “neuromania” and the distortions it introduces into the discourse about the findings derived from neural imagery. This training is indispensable to fight against the kinds of extremist antipsychiatry, in an age of fake news and post-truth.
- And also, beyond clinical practice:
Pedagogical innovations that can reduce ADHD rates are also very important - Life hygiene, exercise and nutrition
- The fight against social injustice
- Educational measures to limit screen exposure, etc…
Simply put, there is an entire programme to avoid importing the American disaster and to expose our schools to the greed of pharmaceutical laboratories.
Patrick Landman