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BMJ. 2007 November 17; 335(7628): 1047.
PMCID: PMC2078623
Review of the Week

A deficit of attention to impartiality?

Reviewed by Iain McClure, consultant child and adolescent psychiatrist, Murray Royal Hospital, Perth, Perthshire

Media coverage of drug treatments that fails to allow the manufacturers a voice does no favours to drug sceptics, says Iain McClure

Attention deficit hyperactivity disorder (ADHD)—the subject of this week's Panorama, the BBC's flagship investigative journalism programme—has become a totem of many modern concerns. A condition that encompasses impulsivity, overactivity, and difficulty in maintaining attention—and with an alleged prevalence of between 5% and 10%1—it has repeatedly hit the headlines as being not just a product of developing psychiatric knowledge but also a symptom of increasing malaise in capitalist societies. Its unique position among child and adolescent psychiatric disorders as a condition that is widely believed to necessitate at least a trial of a stimulant drug (in most cases) has led to concern about psychiatry's simplistic reduction of the brain and that ADHD in particular is “a pharmacological response . . . crudely searching for a disorder.”2

Whatever the truth regarding such issues, the facts are that the number of diagnoses of ADHD is on the increase and that prescriptions of psychostimulants have risen accordingly. In a recent guideline the UK National Institute for Health and Clinical Excellence said that in 1998 there were 220 000 prescriptions for methylphenidate and dexamfetamine in England, at a net cost of £5m (€7m; $10.3m); by 2004 the number had almost doubled to 418 300, at a cost of £13m.3

In recent years the UK has produced high quality, evidence based guidelines that, essentially, advise clinicians that when ADHD symptoms do not respond to behavioural treatment then a psychostimulant should be prescribed.1 However, what if the evidence on which such guidelines are based is flawed?

A key evidential mainstay of the pro-drug lobby is the ongoing multimodal treatment study of children with ADHD (the “MTA study”) by the US National Institute of Mental Health, which began to publish results in December 1999. The most comprehensive study of behavioural and drug treatment interventions in ADHD ever conducted, it has published convincing evidence that carefully monitored management of drug treatment with monthly follow-up was more effective than intensive behavioural treatment of ADHD symptoms. Inevitably, use of psychostimulants has increased since this opinion. It was with great interest, therefore, that I watched Panorama's exploration of new evidence that the MTA study's crucial conclusion was now being questioned by experts associated with its original findings.

The programme introduced us to two teenagers, Craig and Yasha, both of whom were given a diagnosis of ADHD at age 4 years. Both have spent many years on various forms of psychostimulant treatment. At the start we were shown successive scenes of how, after years of drug treatment, Craig's behaviour was clearly no better. Likewise Yasha had become increasingly prone to acts of self harm while taking psychostimulants and had recently been weaned off them, after she was admitted as a psychiatric inpatient. The programme's pitch was clear: in the long term the drugs don't work.

Enter William Pelham, of Buffalo University, New York, who has a research record showing the effectiveness of long term behavioural interventions for ADHD patients, their parents, and their teachers. He is also, on a dramatic note, a member of the MTA steering committee. Acknowledging that “in the short run” psychostimulant treatment helps children to “behave better,” Professor Pelham's message was simple: that the MTA study had “exaggerated the beneficial effect of medication” and that there is no indication that medication is “better than nothing” in the long run.

So, we've all been conned. Panorama's pill had slipped down a treat. The drugs don't work. But . . . hold on a minute, where was the argument? Covering such a complex subject in just 30 minutes is, I acknowledge, a tall order, but has good journalistic process been followed here? Firstly, Professor Pelham should have been grilled more. We didn't hear any detailed explanation of why the new results now emerging from the ongoing MTA study question the earlier findings. Most importantly, the elephant in the room—the drug industry—and its undoubted role in this continuing saga were not even mentioned. Some attempt should have been made to interface Professor Pelham's remarks with a response by the drug manufacturers or one of their apologists within the medical profession. Without this, the programme was left unbalanced, as we were left with no idea of what the various manufacturers' responses are to this important allegation that the long term, mass consumption of their products is pointless. Surely the drug industry will now spend millions of dollars aiming to refute expert interpretation of this new evidence and the effect of media reports such as this one?

When a flagship programme like Panorama covers an important issue it should cover both sides of the argument. What we need on this subject is balanced coverage that treats us as intelligent participants in the debate, not as attention deficient dupes, sedated by hyperkinetic images.

Notes

What Next for Craig?

Panorama, BBC 1, 12 November at 8 30 pm

Rating: **

Notes

Competing interests: None declared.

References

1. Scottish Intercollegiate Guidelines Network. Attention deficit and hyperkinetic disorders in children and young people. .www.sign.ac.uk/guidelines/fulltext/52/index.html
2. McClure I. The 21st century brain: Explaining, mending and manipulating the mind. BMJ 2005;330:1276 doi: 10.1136/bmj.330.7502.1276-a
3. National Institute for Health and Clinical Excellence. Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents NICE review of technology appraisal 13. www.nice.org.uk/guidance/index.jsp?action=byID&o=11572

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