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

Mood Swings

Bipolar Bad, Ritalin Good

Why do some child psychiatrists hate bipolar disorder but love amphetamines?

Posted Feb 28, 2013

Some child psychiatrists seem to be making a living attacking bipolar disorder.  They hate it, but they love amphetamines like Ritalin. (Ritalin is an amphetamine, by the way: see Goodman and Gilman's textbook of pharmacology).  Why?

Here is an example of the defense of Ritalin, supposedly based on the main long-term randomized clinical trial (RCT) of amphetamines in childhood ADHD, the Multimodal Treatment Study of Children with ADHD (MTA) study.

Let's tell readers what that study actually found, instead of what we want to believe:

579 children age 7-10 joined a 14 month RCT, with later follow up of a number of years.  There were four arms: one was a randomized amphetamine treatment arm (mostly methylphenidate, Ritalin); a second was an intensive behavioral management arm without amphetamines; a third was both amphetamines plus behavioral management; and a fourth (called treatment as usual) was clinician-based treamtnent (where amphetamines were mostly given, but at lower doses and less consistently than in the randmomized arm)r.

For ADHD symptoms, the amphetamine treatment arm was more effective than behavioral management which was better than treatment as usual.  

This is what amphetamine-loving child psychiatrists don't appear to know: For functional outcomes - namely: academic achievement, oppositional aggressive behaviors, social skills parent/child relations - behavioral management was just as effective as amphetamines, and both were better than treatment as usual. 

At 3 year follow-up, after the randomized phase was over and clinicians could treat the children as they liked, all groups had similar outcomes.  This was, the researchers say, because amphetamine medication use increased in the behavioral management arm, and decreased somewhat in the amphetamine randomized arm, thus leading to similar overall treatments in all groups.  

But it is worth noting, that even at 3 years, 55% of the behavioral management group was not taking, and did not need, amphetamines, and they did just as well as the amphetamine treatment arm. 

In other words, about one-half of children with ADHD don't need amphetamines at all; they do just as well with good behavioral management.

We could add the fact that amphetamines, including Ritalin, are toxic to neurons - they actually lead to neuronal cell death and atrophy -  especially in young brains, based on many replicated animal studies.  Ritalin-lovers will protest, and point to MRI studies that reportedly show that brain size is protected in children with ADHD treated with amphetamines. Those studies are not consistent: some find smaller brain size in children treated wtih amphetamines.  And none are randomized, nor do any follow children into adulthood, to test the animal studies which show that young animals exposed to amphetamines have hippocampal atrophy and smaller brain size in adulthood.  I've reviewed this literature in an article, collecting all the references in one place, so critics should look there for my sources.  (I would like critics to point to similar peer-reviewed scientific studies which they have published showing the reverse).

Not all children with ADHD need amphetamines. In fact, the MTA study shows that half don't.  And amphetamines are harmful, based on our best biological research in animals.  Humans often are similar to animals.  We should ask these questions and prove these drugs to be safe, not simply defend them at all times, completely and definitively.

Some people hate bipolar disorder, which is treatable with clearly effective drugs like lithium (which, by the way, is clearly neuroprotective biologically and keeps neurons alive longer, in contrast to amphetamines, which do the reverse), and love amphetamines, which are not proven necessary or more effective than psychosocial interventions, and which are biologically shown to be harmful.  

This doesn't make scientific sense.   

About the Author

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.

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