One fascinating phenomena at the moment is a clear looping effect with adult ADHD. Quite recently Britain's NICE [National Institute for Health and Clinical Excellence] guidelines for ADHD came out and stated that adult ADHD is a valid clinical disorder. I am quite sure that a few years ago, 85 to 90 percent of physicians in the UK would not have thought adult ADHD was a valid clinical disorder. One might expect guidelines to be somewhat conservative, but in this case what we appear to be seeing is the guideline process getting out ahead of the field, leading clinicians in a direction that seems to be quite surprising.
Drug companies understand all too well that those constructing guidelines are supposed to be value-neutral and to follow the data. This means they can readily engineer trials that may show minimal benefit for their drug for a condition they have called "adult ADHD." The makers of the guidelines have little option but to suspend judgment and to accept that the condition named must be real. So, for instance, as Lilly grasped, they end up endorsing the use of the agent like Strattera.
What's astonishing about the current situation is that there seems to be almost no way to get the guideline makers—who are sitting in the middle of the road, immobilized by the oncoming headlights—out of the way of the pharmaceutical juggernaut. You can point out how they are being manipulated but they shrug and ask, "What can we do?"
We have recently begun a survey, here in North Wales, looking at aspects of this situation. In response to questions, clinicians here have indicated that three years ago they were quite certain they would not have used adult ADHD as a valid condition, but that three years from now they anticipate that they probably will. I think this shows a realistic appreciation of company abilities to change the climate in which clinical practice takes place, and the relative futility of attempting to stand up to such changes.
You have to treat real patients. What do you tell them about these conditions and their treatment options?
Many clinicians, scientists, and patients have heard about postmodernism. They might have heard company criticism of someone like me along such lines as "Pay no heed to him, he's just a postmodernist." The implication is that postmodernism is all-but a psychiatric disorder in its own right, in which academics like me refuse to concede that there's any reality to human behaviors—or the physical underpinnings of disorders of human behavior. By contrast, the story goes, there are the hard scientists who work in or with drug companies who deal only with facts and hard data, and the proof is that they bring new and helpful drugs to the market.
Well, I think what Donna's story above illustrates is that pharmaceutical marketing departments are actually the postmodernists par excellence. They treat the human body (including its disorders and complaints) as texts to be interpreted one way this year and in just the opposite way a year or two later.
In contrast, when it comes to the hazards of these drugs—just like the tobacco companies before them—the motto of Pharma has become "doubt is our product"—they simply refuse to concede that their drugs are linked to any hazard at all . . . until the drug goes off patent. You cannot get a better definition of postmodernism than "doubt is our product."
So, to the matter of whose treatments are better: I'm quite happy that the patients coming to see me would in general get more effective and safer treatment for their problems than they'd get from physicians adhering to the latest guidelines. Trouble is, I only have to slip up once to have a big problem, whereas atrocities can be committed on the other side without anyone likely to be affected by blowback.
David Healy is the author of 14 books, including The Antidepressant Era, The Creation of Psychopharmacology, Let Them Eat Prozac: The Unhealthy Relationship between the Pharmaceutical Industry and Depression, and, most recently, Mania: A Short History of Bipolar Disorder. Christopher Lane is the author most recently of Shyness: How Normal Behavior Became a Sickness.
