Mood Swings

A psychiatrist surveys the mind and the wider world

Bipolar Bad, Ritalin Good

Hating bipolar disorder and loving Ritalin doesn't make sense scientifically. Read More

Or maybe adhd is pure fiction

A disorder invented by unscrupelous big pharma and disgraceful bought psychiatrists.

Show an adhd kid what he is lacking at home home i.e proper attention and lo and behold no f****g problem.

In Reply,

It is beneath the dignity of Dr. Ghaemi to insinuate that my critique of the diagnosis of bipolar disorder in children might be for financial reasons rather than based on scientific evidence and clinical concern for the patients. He has no evidence for this; it is not true. It seems to reflect Dr. Ghaemi’s desperation about his inability to demonstrate that bipolar disorder is regularly found in children.
Over two hundred studies have demonstrated that stimulant medications are the optimal treatment for ADHD. These studies have been done over several decades. The MTA study, as Dr. Ghaemi noted, showed that stimulant medications were superior to any other treatment for ADHD over the 14 months of the double blind controlled study.
The symptoms that Dr. Ghaemi describes in the uncontrolled, unblended, third year of the MTA study are not symptoms of ADHD. They are symptoms of other problems that frequently co-occur with ADHD. The treatment of those problems is, as Dr. Ghaemi states, behavior modification.
In this month’s American Journal of Psychiatry, a comprehensive review of the use of non-medication approaches to the treatment of ADHD concluded that there is no evidence that behavior modification helps ADHD (overactivity, difficulties concentrating, impulsivity) (Sonuga-Barke, Edmund J. S. et al. Nonpharmacological Intervention for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments, Am J Psychiatry 170:3, March 2013.)
Although lithium may be neuroprotective in laboratory animals, in human patients the clinically effective dose is very close to the dose that kills. Tremor, decreased functioning of the thyroid gland, kidney problems, and seizures are part of the regularly encountered human side effects of this “neuroprotective” medication.
As is true with all medications, stimulants have their problems, too. In general their side effects are much milder than those of lithium.
Lithium is an indicated treatment for bipolar disorder. Stimulants are the indicated treatment for ADHD.
Copyright: Stuart L. Kaplan, M.D.

reply to reply

I find it a rare child psychiatrist who can hear criticism of amphetamines without taking it personally. My colleague has not refuted the biological evidence of neurotoxicity of amphetamines, which the child psychiatry profession simply ignores. These drugs are clearly abused and addictive. Of course they improve ADHD symptoms, and opiates improve pain symptoms, and benzodiazepines improve anxiety symptoms = even in normal persons: that's why those agents are all addictive. The issue is not symptom improvement. The claim about ADHD often is that amphetamines improve long-term function; the proof is given above that they do not do so better than psychological interventions. Regarding the meta-analysis, none of the behavior therapy studies examined were as long-term as the MTA study, which was the study with the largest benefit. Such meta-analyses are NOT more valid than the best large RCT (the MTA study). I refer my colleague to study of this topic in my text on statistics and epidemiology and mental health.

(By the way, the 2-3 year functional outcomes of the MTA study were intent-to-treat, which means they continued to follow subjects as originally randomized. These are, therefore, still randomized results. Again see my statistics text and other standard texts of statistics. Also, the lack of notable difference in functional outcomes was present up to 14 months, during which time no other treatments were allowed besides the original randomized arms).

Regarding lithium, my colleague's comment indicate a lack of experience and knowledge: the neuroprotective benefits are shown in animal studies at levels far below the "toxic." My colleague can examine papers by Husseini Manji and other experts (which he is not) on this topic.

I will next post about the false claim that is the basis of the anti-bipolar child ideology espoused above. My colleague already admits that adolescents have mania, so he should change all his websites and book titles to reflect that childhood bipolar disorder happens at least in adolescence. Next he needs to prove that the prevalence is 0.0% at age 12 (his claim) and overnight becomes 1.9% at age 13 (see the NCS epidemiological study, which he cannot deny). He claims this is the case because of puberty. I will follow up on this matter in my next post.

Dr. Ghaemi's Claim of Amphetamine Neurotoxicity

The doctor's claim that amphetamine use to treat ADHD is harmful to the brain is extremely concerning. As a person who suffers from concomitant disorders (ADHD, GAD and Bipolar II), I experience many negative side-effects from the medications prescribed to manage my disorders. I am certainly not a doctor, but Dr. Ghaemi fails to support his claim of the neurotoxicity of amphetamines on the brain. I have EXTENSIVELY researched this specific topic, and while more research is required on the long-term use of amphetamines, I have found the opposite to be true in the data I have reviewed. I will be happy to provide the list of references that support my position to the doctor, but his unsupported claims of amphetamine neurotoxicity in the brain are irresponsible and the conclusions he derives (or jumps to) from his research are highly inaccurate. If I was only offered a 'psychological intervention' as a remedy for my illnesses, I would be dead. The flawed research, flawed analysis of the data and defensive stance taken by the doctor reinforce my position that he should find a new vocation.

Please stop this nonsense

Ghaemi, you are really embarrassing yourself with your misinformation and sheer arrogance. I'm surprised that Tufts allows this. It leads the public to look askance at the caliber of psychiatric thought and practice at the university. I, for one, will remember this every time I see a citation by a Tufts researcher, to take it with a huge grain of salt.

The MTA Study and Behavioral Treatment

Dr. Ghaemi is adherent to his own beliefs but seems to have a looser connection to the findings of the MTA study. To provide a secure factual basis to my rebuttal of Dr. Ghaemi’s assertions about the usefulness of behavior modification for ADHD, I will provide some brief quotes from the original report of the MTA study. I will confine my comments to the report’s 14 month study. Unless the conclusions of that study are agreed upon, there is no point considering the subsequent three year study.
To insure clarity I will briefly describe the four groups: 1) the medication management group, which received methylphenidate three times per day and no other treatment; 2) the intensive behavior treatment group, which received an elaborate behavior modification program but no medication; 3) the combined group, which received both medication management and intensive behavior treatment; and, 4) a community treatment group, which is not relevant to this discussion and will not be considered further.
The medication management group and the combined group (medication management plus intense behavior treatment) did very well over the 14 months of the study. The intensive behavior treatment group with no medication did not do well. The improvement in the combined group is understood to have come largely from the medication, not from the intensive behavior treatment. To support this description I quote briefly from the original report of the MTA study (Arch Gen Psychiatry 1999 56:1073-1086) From the abstract: “For ADHD symptoms…medication management was superior to behavioral treatment…Combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms….” p.1073.
“Compared with behavioral treatment, combined treatment was superior in benefitting ADHD symptoms….Combined treatment also significantly outperformed behavioral treatment on parent rated oppositional aggressive behaviors…internalizing symptoms and…reading achievement scores” p. 1078.
The 14 month MTA study demonstrated that stimulant medication was more effective than behavior modification for the treatment of ADHD.

Thank you, Dr. Kaplan

Thank you, Dr. Kaplan.

Unfortunately, the MTA is the favorite cudgel of the anti-psychiatry crowd, willfully misinterpreted at every turn. It is lamentable that a psychiatrist at a university has jumped on this bandwagon.

Former Childhood ADHD Patient

As a former child Depression/ADHD patient I can attest to Ritalin's effectiveness. It worked really well, for about 4 days. Then they put me on such high doses I was gnawing the skin off my hands for months until they were raw. Essentially to the point my parents found a different psychiatrist who prescribed me a non-amphetamine ADHD drug. When they switched my anti-depressant from Wellbutrin to Paxil I became suicidal. That's when I discontinued treatment including psychotherapy (big mistake). I later developed a substance abuse problem, which I won't blame on Ritalin but the concept of medicating our feelings away in general. I'm not anti-psychiatry either, many of my dearest friends have been helped by psychiatry. In fact I now have recurrent depression (no ADHD) and finally got off the drugs after a long 13 addiction. I'm back in therapy, and voluntarily this time going to a psychiatrist again next month for another evaluation. These studies need to be longer term and independently funded funded in my opinion.

Bizarre butchering of the research and the science

Truly, Ghaemi, has the competition for grants gotten so cut-throat that you must resort to the worst of the wingnut rhetoric?

As a non-ADHD expert, it is understandable that you fail to understand the complexities of the MTA study. But to willfully perpetuate misinformation about it? That shows something other than scientific acumen.

And you are the only person who has ever called Ritalin an amphetamine, perhaps for your sensationalist purposes.

Please try to remember your oath to "first, do no harm" and also please try to stick within the limits of your understanding.

Such grandstanding helps no one, most especially the patients with bi-polar and/or ADHD.

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Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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