Why do we treat Zoloft and Ritalin so differently?
AS comes to the office for a regular scheduled visit. He is a healthy 39-year-old man. He reports that he has been feeling down recently. He says he is depressed, has been having trouble sleeping, and has given up some of his former hobbies. His score on a PHQ-9 is 10.[i] He says he has discussed the situation with his wife and has done some research online. He does not feel comfortable seeing a therapist and would just like to start a medication. He suggests Zoloft (sertraline).
BT comes to the office for a regular scheduled visit. He is a healthy 39-year-old man. His son, who is 12, has recently been diagnosed with ADHD. Since starting on a long-acting stimulant, methylphenidate, he has been doing much better school and seems generally happier. While his son was going through the assessment, BT realized that he has struggled with similar symptoms for his whole life. He admits to using a few of his son’s pills on recent days and was struck by how much better his concentration was at work. He would like to start on a similar medication. He suggests Concerta (extended-release methylphenidate).
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These are similar situations. A patient notices symptoms, researches a diagnosis and treatment, and presents to the office of a primary care physician requesting treatment. This is where the similarities end. In the case of AS, the doctor is able to do a simple screening test and would be an outlier if he didn’t provide a prescription for an SSRI or another antidepressant. In the case of BT, prescribing the medication that the patient requests without referring for further evaluation would be considered unusual if not irresponsible. If BT’s physician did prescribe the medication, it would almost certainly require “pre-approval.”
We are perfectly comfortable with primary care doctors (actually providers) treating depression and anxiety. In fact, we encourage treatment for these diseases in the primary care setting. The USPSTF now recommends that we screen for depression and anxiety in adolescents and depression in adults. To erect barriers to care for depression or anxiety would seem bizarre. On the other hand, treatment of attentional problems remains a highly restricted process with the medications carrying negative connotations.
Why the difference? Possibilities include:
· Depression is potentially fatal, while attentional issues are not likely to be.
· An illicit market exists for stimulants but not for SSRIs. (Of course, there is also a market for other prescriptions – benzodiazepines – and over the counter -- alcohol, tobacco -- drugs).
· Doctors are used to treating suffering but uncomfortable using drugs for “enhancing performance.”
The issue is probably even more complex. There are many (doctors and the lay public) who are opposed to using medications for mental and behavioral disorders. There is an uproar around weight loss drugs like Ozempic (semaglutide), especially their use in children, as there is a certain strain (in Western society, at least, and especially in the United States) that problems with weight, addiction, and mood should be resolved by people themselves, without “artificial” (i.e. pharmacological) means. The pushback against drugs that are clearly effective in ADHD probably arises from three philosophical places: first, these drugs were initially studied in and approved for use for ADHD in children, and people do not like that we are “medicating” children (however beneficial the treatment is); second, there is the notion that adults are “cheating” by using these medications, in the sense of performance enhancement; third (and probably with the greatest impact) is the Drug Enforcement Agency, the DEA, tasked as part of its mission with “Enforcement of the provisions of the Controlled Substances Act as they pertain to the manufacture, distribution, and dispensing of legally produced controlled substances”.
To add even further to complexity of the situation, there is powerful ambivalence, even amongst psychiatrists, about the diagnosis of attention deficit hyperactivity disorder, especially in adults. It’s quite peculiar, really, that this would be the case. First, the heritability of ADHD is fairly well established; that is, the component of it (whether by symptoms count or actual diagnosis) that can be attributed to genetic factors is high, as high as 80% in children. Why should illnesses that appear in childhood suddenly disappear in adulthood? Some do (both authors’ asthma markedly improved or resolved in adulthood), but one would expect that many people who have a disorder in childhood would continue to have symptoms of it in adulthood. Somehow people believe that ADHD ought to disappear – that it may not be a real disorder and that people might just grow out of it. In adults the heritability remains high but is somewhat lower when self-reported diagnosis (rather than clinician determined diagnosis) is used to establish heritability.
Self-diagnosis is not rare, though, and the writing (compelling writing, for many) by Ned Hallowell and John Ratey in the 1980’s, with their book “Driven to Distraction”, paved the way for many to become aware of how their inattention and distractibility was negatively affecting their lives. Still, the notion that there is overdiagnosis of ADHD, especially in boys, and that the diagnosis was somehow created to create profits for pharma persists, and it has made it much easier for people (whether insurance companies, healthcare systems, or the government) to erect barriers to the prescribing of stimulant drugs.
And thus, to the DEA. The DEA’s “war on stimulants” – which includes production limits – probably merits its own Sensible Medicine article but reflects our medical and societal unease.
So where do we stand?
Are we comfortable treating two similar, disabling psychiatric diseases so differently?
Are we comfortable further medicalizing our society?
Should patients have the same right to choose to improve their cognitive performance as they do to treat their depression or anxiety?
Should the fact that there is an illicit market, a fact that probably speaks to the effectiveness of the medications, limit our abilities to easily treat patients?
Michael Ostacher, MD, MPH is a psychiatrist, professor, mental health and addiction researcher, and EBM enthusiast who treats veterans.
[i] The PHQ9 is a nine-question tool to determine the degree of depression severity. A score of 10 signifies moderate depression and suggests that treatment should be considered.