"How many times do we have to prove [that stimulant ADHD medication improves health outcomes] before doctors and governments stop treating the stuff like poison?"
Proof is irrelevant: medicine is a political power structure which systematically fails people on its supposed purpose every minute of every day, not because it is doing that job imperfectly, but because it is lying about its actual job. The people it systematically fails, the people it systematically kills, are on purpose.
Yeaaah...
*gestures vaguely in the direction of this horror story*
There are compromises over every medication at some venture, it's not like they're "risk free", but rather, "managed risk" decisions. During the 1990's we handed out Ritalin to over-active kids who were hard to manage or had oppositional disorders. This is basically how we did a lot of shit in psychiatry: behavioral management sedation. I have a few horror stories about how the methodology of sedation looks over time, if we put a pin in the political component here and focus on just the pragmatic application.
This as usual for me goes places not really intended but definitely connected, so read on if you're interested in how being shitty as an industry reinforces being shitty as a government which then makes everything worse :3
Ritalin isn't a sedative, but for ADHD kids it can act like one -- this has a few known side effects, one of them being stunting growth in the vertebrae, early damage to the liver or kidneys, stuff like that. Adderall like many of its Amphetamine peers heightens resting heart rate, can contribute to hardening blood vessels, and can also increase tooth decay through drying the mouth; plus appetite curbing which is an issue in kids particularly with picky eating. We also saw a lot of anti-psychotics and adjacent scripts shoved into kids basically since the 1970's with things like Gabapentin and Risperidone. Many people I treated and cared for during the early 2010's and into 2020 were people who had been scripted SSRI's where they didn't need it, nerve pain meds for anxiety, and more importantly multiple times I had intellectually disabled adults who had been given 2 or even 3 anti-psychotics at extreme dosages to "control psychotic behavior". You know. Psychotic behavior of a mentally handicapped adult man with no psychotic history and merely oppositional or defiant behavior due to the limitations of their capacity to tolerate change. These fellas lived their lives in a haze or dream-like state often, fluttering eyelids and staggering gait from years of it, and it horrified me because it was the most at risk given these interventions with no edits.
The actual methods of sedation as a "therapy" are almost always pointed at controlling behavior, rather than altering it or helping transform it, and the insidious historic tendency of American Psychiatrists to script child care through sedation is storied. I want to say that the reform movement for psychiatry started to hit towards the tail-end of my time in the Rehab gig, around 2019; COVID definitely sabotaged the chances of better diagnostics becoming standard practice, and the industrial engine I saw on my way out made it clear people like me were not valued for profits. A big part of why I lost my job is that I spent the extra time evaluating digital measures intended for a broad-age population of people, and on one fateful day my boss was unavailable for a conference call, I filled the role and cost the CEO of my company around $250,000 to $500,000 in delays. The software his little side-gig start up project had put together was barely functional as-is, but they chose to apply a ton of standardized measures made for adult populations into adolescent population contexts, which is illegal in something like 30ish states in the US (Arizona included). This isn't even medication, this is a broad screener you'd take on entry measuring shit like anxiety and depression symptoms. How anxiety looks in a 13 year old vs. an 18 year old can be dramatically different, and the population they wanted to hit was the 8 to 17 range, so you can imagine the psychometrics would be extremely sensitive to things like their emotional development.
People often look at child development and go "they grow up so fast", or have the addage of "they're little adults past 6"; developmentally untrue cultural attitudes that try to industrialize our most vulnerable to early forms of damage (emotional, physical, intellectual, etc). It's worth the increased caution of minimizing the prescribing of medication in place of proper assessment and targeted therapeutic interventions with kids, but we're in an environment increasingly dedicated towards alienating kids from their parents and their peers. So in many ways I have to recommend professional practice constraint into one hand, and hope for the cure to suburbanization, extreme labor exploitation, worsening wealth disparity/ poverty, and social isolation into the other. I recently had to tell a friend of a friend that "unfortunately, your stress both makes sense and is reasonable, but no one can write you a pill to fix poverty and a broken home". I end up doing a lot of unpaid first-first-first-line semi-clinical interviews to tease out the peculiar details of someone's mental health issues due to referral, and it's hard to separate what sounds like ADHD from what actually is ADHD, because the disorder is pervasive and influences everything from mood to diet to circadian rhythm. If any of those areas being deficit due to chronic stress, PTSD, OCD, Bipolar disorder, Depression, or even Psychotic spectrum disorders sound familiar, it's because the brain is really quite interconnected. If I had more school and a license to practice, it'd be impossible to offer anything for free due to the debt and cost of operation.
This means that often times people have to rely upon unprofessional or opportunity-dependent options in place of actual assessment by a paid professional whose job is to actually help. We often times have to stabilize patients to get properly validated psychometric data from them in the first place, and when you're doing Outpatient practices, you're often trying to make extremely tricky edge-case discernment based on one or two interviews of 15 to 30 minutes. You might be a hardass and give people paper self-report questionnaires in office, but making the time for that and also the research/cost in time can be a bit steep. This tends to lead people into practice methodologies that unfortunately in private result in having minimal insurance coverage due to the cost of time / lack of 'proven reason' for certain evaluations, or going corporate and taking an awful wage in exchange for an endless and overwhelming caseload that gives you at most a full hour (interview and office time) per patient per month. Because of this Psychiatry gets a bad rap for a reason, but move from industry to the political level and we expose a fundamental misunderstanding of the knock-on effects that inadequate coverage and differential diagnosis have on the population. Everything eventually becomes a cost-benefit equation and in "direct benefits", adequate mental health coverage is still not valued at its true effect on society. Because you can't really teased apart the industrial profit motives from enabling the societal benefit, there's an imperative to push branded methodologies and medications in place of the dynamic and deliberate process of Differential Diagnosis.
Spending time efficiently and having coordinated integrated care is what we did at my rehab job every day, and you can't teach people this shit easily, much less senators who are often "learning things" thanks to a stack of Benjamin's tucked into their pockets. The stay of 30 days at my facility was out of pocket (no insurance coverage) about $30,000usd, you'd spend usually 2 days in stabilization / detox, and then the remaining four weeks in the on-site dorms and community. Our clinicians used the Integrated Care Model, which meant everyone shared notes on patients and through that 'takes a village' approach, we got really good results on most of our patients. Due to the cost though I often had to strain myself to push data out so it could be used against insurance companies who were denying care and had been pushed into appeal by patients. That's what most people know as a "death panel", a group of adjusters who have the sole function of denying care for any reason, and at least one of my patients fought that fight, lost, and was dead within 72hrs of suicide. What makes this worse is that out that other end, clinicians like me were undervalued and underpaid, then gladly shed in the name of idk, fucking horses? The advertising department valued the equine therapy components of the facility well in excess of my little department, and after costing the CEO so much money, I got yeeted rather abruptly December of 2020. My story is only one perspective, but we often times got handed complicated patients who were on a cocktail of medications that weren't even treating the right components of their disorder.
So the fix is expensive, requires investment without any direct payback, you measure success through how people are doing and not with economics, and then atop that it's not guaranteed to work and what stats we do have show success rates of 30-50% depending on therapy modality, its branding, and year of publication. Advanced treatment like Integrated Care is so costly that running our facility was considered cost-ineffective, and then on top of that we have to account for medications and how they are applied at scale. Truthfully, the best solution is a healthier society, but political realities defeat actual reality with striking frequency; thusly, Brandon says "sure Kamala, we'll punish those no-good addicts" and writes in restrictions on amphetamine-based medications like Adderall thinking nothing of it. The decision was made to 'do something about a problem', an idiotic signalling of virtues at the grand scale of politics that simply cares about someone's posture and speaking cadence over their actual values and decision making history. It really feels like I'm the one whose been broken the entire time, because the industrial benefits of restriction medications like Adderall even more tightly make my life a living hell ontop of disrupting the supply chain and causing prices of the medication to spike! Worse, Brandon won't authorize many pharmaceutical companies in opening domestic production, a direct countering of policy aimed at combating the flow of Fentanyl from China, by making multiple critical classes of medication dependent on what increasingly is considered a "peer adversary".
When I joke about airplane porn being strategic infrastructure, it really is a comment on shit like this: active policy made to strategically disempower American Citizens in the name of for-profit Tycoons who own everything and with their increasingly large straws must drink from a profit pool that is shrinking constantly. It's almost like we've gone out of our way at the highest levels of policy to create levers of dependency with the express purpose of making people utterly powerless to stop the wealthy from dictating their entire lives. Strategic Infrastructure comes in many forms not just roads and highways, and as it turns out when you neglect basic shit like accessible medications and accessible therapies / diagnostics / integrated practices you do in fact damage your society better than any single super-bomb, terrorist attack, or cybersecurity vulnerability.
