Critical Psychiatry Network

Disagree with the proposal not to update the guideline

3 senior and highly influential child psychiatrists, heavily involved with promoting medication treatment for ADHD: Joseph Biederman, Timothy WIlens and Thomas Spencer have been sanctioned following violating conflict of interest rule involving non-disclosure of millions of dollars of pharmaceutical company payments:

see

and

http://articles.boston.com/2011-07-02/lifestyle/29731040_1_harvard-doctors-harvard-medical-school-physicians

As this effectively casts major doubt on any of the research produced by this group (including Stephen Faraone who frequently publishes with this group), and as there are many references produced by them in the NICE guideline, this should be sufficient to trigger a review.

This is what has happened in Australia as a direct result of this conflict of interest issue, and consequently they have formed a new guideline group tasked with producing new guidelines for the treatment of ADHD:

see

http://speedupsitstill.com/mental-health-minister-mark-butler-scores-8-10-open-book-approach-australian-national-adhd-guidelines-committee

The second area that should also trigger a review of the guidelines is that we have a number of long-term outcome studies published in addition to the 8 year outcome for the MTA. In reviewing them there appears some anomalies in data presentation in the studies claiming small advantages for medication, which is likely to reflect conflict of interest issues. Others show poorer outcomes and greater risk for those treated long term with medication. Taken together the studies suggest that we have no convincing evidence of long-term benefits, but possible risks for treatment with stimulants. Given that medication is prescribed for several years and current NICE guidelines provides no advice about duration of treatment, NICE should reconvene a guideline group to review the question of how long treatment with medication should be recommended for. The references are:

Molina BSG, Hinshaw SP, Swanson JM, Arnold LE, Vitiello B, Jensen PS, et al. The MTA at 8 years: Prospective follow-up of children treated for combined type ADHD in the multisite study. J Am Acad Child Adolesc Psychiatry 2009; 48:484–500.

Government of Western Australia, Department of Health. RAINE ADHD Study: Long-term outcomes associated with stimulant medication in the treatment of ADHD in children. Perth: Department of Health, 2010.

Langley K, Fowler T, Ford T, Thapar AK, van den Bree M, Harold G, et al. Adolescent clinical outcomes for young people with attention-deficit hyperactivity disorder. Br J Psychiat 2010; 196: 235- 40.

Powers RL, Marks DJ, Miller CJ, Newcorn JH, Halperin JM. Stimulant treatment in children with attention-deficit/hyperactivity disorder moderates adolescent academic outcome. J Child Adolesc Psychopharmacol. 2008 Oct;18(5):449-59

Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen SJ. Modifiers of long-term school outcomes for children with attention-deficit/hyperactivity disorder: does treatment with stimulant medication make a difference? Results from a population-based study. J Dev Behav Pediatr 2007; 28: 274- 287.

Biederman J, Monuteaux MC, Spencer T, et al. Do Stimulants Protect Against Psychiatric Disorders in Youth With ADHD? A 10-Year Follow-up Study. Pediatr. 2009; 124: 71-8.

There are a large number of new trials identified for the pharmacological treatment of adult ADHD in the review proposal documentation. Given that the original NICE guideline only included 3 trials in its original guideline and two of these were by the Harvard group involved in the non-disclosure of substantial income from pharmaceutical company, a review of the guideline for pharmacological treatment of adults is warranted. A recent publication reviewing the outcome literature for pharmacological treatment of ADHD in adults, noted that the studies had many methodological deficiencies, unblinding was common, many of the studies came from the Harvard group mentioned above and these studies reported considerably larger effect sizes than other studies and concluded that there is little convincing evidence supporting long-term drug treatment.

Moncrieff J, Timimi S. Critical analysis of the concept of adult attention-deficit hyperactivity disorder. The Psychiatrist 2011; 35: 334-338.

The fact that the current guideline group have not referred to or is perhaps not aware of the above issues and references, suggests weakness in the knowledge base and/or bias. A new guideline group should therefore be convened that can offer a more balanced review of these important issues: conflict of interest and its effect on the psychopharmacological treatment literature, duration of pharmacological treatment, and review of safety and efficacy of treatments for adult ADHD.