Upon reading Dr. B.M. Hegde’s article ‘ >Inventing diseases to sell drugs ’, (The Hindu , Open Page, October 6, 2013), I felt compelled to respond to his averment. In this era of molecular genetic diagnosis, genetic variants (cytochrome P450) predicting drug efficacy and adverse events, genomic information facilitating drug discovery, etc, how can he concoct opinions without any facts? He based his argument on a “hunch” and the sole remark of a dying man.
Is Attention Deficit Hyperactivity Disorder (ADHD) invented? According to Dr. Hegde, Dr. Leon Eisenberg, an 87-year-old doctor on his deathbed, confessed that he and his colleagues invented ADHD . Dr. Eisenberg was perhaps suffering a momentary lapse in judgment, or maybe guilty of poor medical practice, but that does not make ADHD a fiction.
Dr. Hegde doesn’t stop with the anti-ADHD rhetoric but extends his criticism to the early European clinics for raising awareness of hypertension and reproves the traditional ‘doctor-patient’ relationship. Eisenberg’s resident is quoted to have said that a patient sadly always remains one after seeking treatment. The smart resident was perhaps cryptic about Eisenberg’s skills or lack of themt? In a therapeutic alliance, even when a patient is cured he remains a patient and cannot switch titles with the doctor.
Blood pressure, temperature, anxiety, ADHD symptoms, etc, can all be normal on a continuum and become abnormal at a certain cut-off point, causing impairment. ADHD is a highly heritable neurobehavioual disorder, primarily of the dopaminergic system that projects from the midbrain to the frontal cortex. This network controls sustained attention, organisation, working memory, prioritisation, initiating tasks, shifting tasks, response inhibition (impulse control), interference suppression (distractability), etc.
ADHD is a hypodopaminergic status, due to defective dopaminergic receptors or an excess of dopamine transporter protein (DAT), which reduces the synaptic dopamine. The genetic basis for ADHD has been established by molecular genetics, as well as twin, family and adoption studies. The association with dopamine transporter gene (DAT1) on chromosome 5 and dopamine receptor, D4 gene (DRD4) on chromosome 11 (Hauser et al. N Engl J Med1993, Gill et al. Mol Psychiatry 1997, Swanson et al Mol Psychiatry 1998) cannot be made up.
Brain volume differences in ADHD individuals compared to controls have been shown by Dr. Castellanos and colleagues (Castellanos et al. JAMA. 2002 Oct). Functional MRI scans have shown the failure in activation of the dorsal anterior cingulate cortex while doing cognitive tasks in ADHD individuals. The ADHD individuals activate a less efficient pathway. Treatment with stimulants blocks the transporter protein’s re-uptake of dopamine, thus increasing the synaptic dopamine to improve symptoms and function, also evidenced by imaging data. Many standardised scales that measure symptoms and dysfunction show significant improvement with treatment, including sociometric scales. Poor response to treatment in some individuals can be due to variabilities in the disorder and associated co-morbidities.
ADHD is indeed on the rise! So are autism spectrum disorders, ischaemic heart disease, and cancers! This may not always mean the incidence of the illness is on the rise but more diagnoses are made due to increased awareness. Today’s exponential technological advancement and information overload have increased the demand on cognitive boundaries more than ever, making matters worse for ADHD individuals.
Parents who seek treatment for ADHD for their children and doctors who treat them are not doing so for some sinister reason! Childhood psychopathology has been dismissed as ‘behavioural’ for too long. It has been stagnant for sentiments like Dr. Hegde’s that children in their tender ages should not be medicated.
It is much the same as treating juvenile diabetes. Early intervention of childhood psychiatric disorders helps prevent adult psychopathology and restore functional potentials.
Environmental factors such as excessive stimulation, sleep depravation, poor structure, parenting strategies, etc, do influence ADHD; however, the disorder is not as simplistic as just that or correctable by those measures alone.
Lifestyle changes also help diabetes, hyperlipidemia, etc. While these are important adjunctive measures, pharmacotherapy plays an important role in treating many disorders including ADHD.
( The writer is a psychiatrist who treats children and adults with ADHD )
