Pharmaceuticals

The American psychiatrist Ned Hallowell – open-necked peach shirt, Bill Clinton hair – perches on his sofa, leaning into the camera and addressing his audience with the twinkly-eyed intimacy of a Hollywood granddad. “One of the oddest things about having this condition so misleadingly called ADHD is how we can enjoy going into a sort of stupor,” he says. “We can come out of the shower, for example, and sit down on the bed with a towel around us and just stare out of the window, thinking about… nothing!” People with ADHD tend to find their brains run a mile a minute, Hallowell observes – but every now and again there is the bliss of complete vacancy. At 72, Hallowell (@drhallowell) has become a TikTok star; even this seemingly banal video has been viewed 1.1 million times. He is also the author of over a dozen books, most of them on ADHD, including the 1992 bestseller Driven to Distraction, co-written with the psychiatrist John Ratey, which shifted the public conversation around attention deficit hyperactivity disorder. Hallowell, who has ADHD himself, described the condition as a “good news diagnosis”. Children with ADHD, so often dismissed as “problem kids”, have a “special something”, he argued. He likes to say that people with ADHD have brains like a Ferrari engine equipped with only bicycle brakes; that Einstein, Mozart and Dalí most likely had it. [See also: No, you don’t have ADHD] In the 1990s, Hallowell’s work helped lift the stigma associated with ADHD. But he was also part of a small circle of professionals, drug companies and advocacy groups who pushed for a loosening of the diagnostic criteria, fuelling a precipitous rise in ADHD diagnosis rates in the US. By 2013, one in five boys in US high schools were considered to have it, with the majority receiving medication. Now Hallowell is one of several online influencers – what the journalist James Bloodworth described in a December 2021 article for the New Statesman website as the “ADHD industrial complex” – who are building on a new wave of diagnoses, this time among adults. In the US, the number of adult ADHD diagnoses more than doubled in the decade to 2016. Around this time, adults replaced children as the prime market for ADHD medication. The pandemic contributed to a further surge: the online pharmacy SingleCare reported a 16 per cent rise in US prescriptions for the ADHD drug Adderall between early 2021 and 2022. The UK (which has historically had much lower diagnosis rates than the US) doesn’t publish national data, but the number of people seeking ADHD diagnoses is far outpacing public health provisions. In parts of the UK, people are waiting years to see a specialist. Psychiatry UK, which provides ADHD assessments and treatments, both under the NHS and in private practice, says it has seen a “dramatic increase” in people seeking treatment. At the moment, it is receiving around 150 requests for ADHD referrals a day and the organisation has expanded its prescribing team from ten to 60 in the past year alone. There is plenty of anecdotal evidence, too: more people are posting on social media that they have it; more friends and colleagues are seeking a diagnosis. Matthew Broome, the director of the Institute for Mental Health at the University of Birmingham, told me he was noticing a rise in ADHD diagnoses among colleagues, several of them after their children had been diagnosed. Previously, the adults most likely to be diagnosed were in the criminal justice system – prison leavers and people battling addiction. Now, it is increasingly recognised among adults who are outwardly “high-functioning”. [See also: Wounded healers] Why is this happening? The simplest answer is that this is a correction after decades of underdiagnosis: adults who have suffered unaided – or who have been misdiagnosed with depression or personality disorders – are finally receiving help. The simple answer is true, but there is also a more complex story to tell, about the social and cultural forces shaping this epidemic. It is not pure coincidence that ADHD diagnoses have risen alongside the internet’s attention economy – a vast infrastructure that has been designed to capture and monetise people’s focus. Nor is it a coincidence that they have increased during this era of cut-throat capitalism, in which ever more people are consigned to desk-bound jobs that place huge demands on their time and offer little financial security. We are also still contending with the aftermath of a pandemic that has killed an estimated 15 million people worldwide: is it any surprise that so many of us feel rudderless and unable to concentrate? The way we think about emotional distress changes over time. If anxiety was one of the defining disorders of the early 21st century, are we now entering the ADHD decades? An ADHD diagnosis should be a “long, considered” process, Matthew Broome told me. First, a psychiatrist must determine whether a person exhibits at least five symptoms of inattentiveness, or hyperactivity and impulsiveness. They must ascertain if these symptoms began in childhood and are not better explained by another disorder; they must assess whether they are impacting more than one area of a person’s life. And they must judge whether they are significantly impairing. As with most psychiatric conditions, there is no exact, scientific point at which a person’s symptoms become a disorder. The stricter you set the criteria for diagnosis, the more people you exclude from specialist support. But set the bar too low, and you label vast numbers of people as “disordered”, alienating those with more extreme symptoms. Several people with ADHD I spoke to expressed concern that the label had become “fashionable”, and that the online conversation sometimes reduced ADHD to a series of relatable memes about zoning out when someone is talking to you, or forgetting your online passwords. Among teens and younger adults, Broome said he had noticed an increased impatience – an eagerness for a diagnosis that might be linked to the wider youth mental-health crisis and a desperate search for answers. “A kind of TikTok understanding of a condition can become very prevalent,” he said. “Even among [psychiatry] students, they want a quick-recognition diagnostic system. Which is really interesting, because in the past people were very sceptical of psychiatry and were more likely to say: ‘Don’t diagnose us, don’t give us labels.’ Now it’s more: ‘Give us a label, and give us a label quickly.’” The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has become a surprise bestseller, driven by a rise in people self-diagnosing. When adults seek ADHD diagnoses, they are often in a period of crisis or transition: they might be leaving university or have suffered a career setback or a break-up. The people I talked to who had recently received a diagnosis described it as transformative. One person had spent three years waiting for help on the NHS; others had spent thousands on private treatment. I spoke to an entrepreneur who was diagnosed at 50. She did not want to be named but told me she sought help after the hormonal changes brought on by the menopause exacerbated problems that had plagued her for years: extreme forgetfulness and disorganisation, periods of intense depression. Starting medication helped: she no longer needed three attempts to leave the house. But more than that, ADHD helped her make better sense of her own life: her social isolation as a schoolchild, her erratic academic performance – sometimes she flunked, sometimes she came top – or why she began self-medicating with amphetamines at university. She might have gone off the rails entirely, she said, were it not for the birth of her eldest daughter when she was 25. After she was diagnosed, she spoke to her parents about the things she’d done that had hurt them; it was a relief to know they now understood that she wasn’t simply “naughty”, or “knocking around with the wrong crowd”. James Kustow, a London-based psychiatrist, described ADHD to me as “one of the most rewarding conditions to work with”, because treatment is so effective. “Someone can be under psychiatric care for 20 years, with a diagnosis of substance-use disorder, anxiety disorder, maybe a personality disorder or PTSD – and underpinning all that is ADHD. If you don’t treat the underlying ADHD, you’re not treating the fire underneath the pot,” he explained. Once this has been addressed, the difference is remarkable: “Suddenly they’re in a relationship, they’re in a job, their depression’s gone, they’re managing to eat and exercise.” Kustow, who is 47, shaven-headed, bespectacled, was diagnosed with ADHD as a medical student in his early thirties. Most ADHD experts seem to have it, I observed. “I think you’ll find that with almost every physical and mental health problem. With ADHD, maybe people talk about it more, because they’re more impulsive,” he replied with a laugh. He described ADHD as a “silly name”: “It should be ‘dysregulation syndrome’ because it’s all about that: dysregulated attention, dysregulated activity – hyperactivity or, quite the opposite, apathy – dysregulated emotions, dysregulated impulse control.” Having ADHD has made him better at his job, Kustow said. He has an intimate understanding of his patients’ experiences, as well as the intense focus and creative mindset that enables him to identify patterns others haven’t. He’s currently interested in research exploring the unexpected overlap between ADHD and physical health disorders such as hypermobility and various inflammatory and autoimmune disorders: one large-scale Swedish study has suggested that those with asthma are 45 per cent more likely to have ADHD, while a recent meta-analysis suggested that suffering from hay fever makes you 50 per cent more likely to have it. A disproportionate number of people with eczema, psoriasis, ulcerative colitis and thyroid disease also have ADHD. And if long Covid is found to be linked to certain forms of neuroinflammation, it’s possible that it will also emerge as a risk factor. Kustow hopes this field of research will be another step towards explaining ADHD, the causes of which have been difficult to identify. Twin studies suggest there is a significant genetic component, though no single genetic marker for the condition has been found; research on Romanian orphans suggests deprivation early in life plays a role, and ADHD may also be linked to trauma. Brain scans indicate there are some structural features that can be associated with ADHD, though these are not so pronounced that you can use a scan to determine if an individual has it. But even if ADHD has many biological causes, it is not a purely physical phenomenon. When psychiatrists assess a patient’s degree of impairment, they measure the condition’s effects against that person’s expectations and environment. If you are an accountant, you might be more hampered by poor organisation and an inability to focus than if you are an artist. All of which means you can’t talk meaningfully about the rise in ADHD without grappling with other big social and cultural questions: what counts as a “normal” level of personal organisation, or an “average” attitude towards risk? What does a “normal” attention span look like, anyway? [See also: How “trauma” became a front in the culture war] In the 1960s, the American psychiatrist Keith Conners made the counter-intuitive discovery that administering amphetamines to wild and recalcitrant teenagers could bring about radical improvements in their behaviour and their grades. Conners developed a questionnaire to help practitioners identify those children who would benefit from stimulant medication. Psychiatrists were subsequently unsure how to categorise these children, who showed no signs of impairment other than their hyperactive, impulsive tendencies, and the clinicians tested out different terms: “minimal brain damage”, “hyperkinetic impulse disorder”, “minimal brain dysfunction”, “attention deficit disorder” and then finally, in 1987, ADHD. An early advert for Ritalin, one of the first stimulants Conners tested, offered a foretaste of how drugs companies would seize on his findings. “Ritalin: helps ‘the problem child’ become lovable again”, it declared. In 1994 the drugs company Richwood Pharmaceuticals acquired a new kind of amphetamine named Obetrol. It relaunched the product as Adderall – literally “ADD [attention deficit disorder] for all” – and marketed the brand at anxious, competitive parents: here were drugs that would fix bad behaviour, improve grades and help children fulfil their potential, and who wouldn’t want that? “Finally! Schoolwork that matches his intelligence”, one Adderall ad said, depicting a blonde, photogenic mother hugging her blond, photogenic son. The advertising campaigns “confirmed the disorder as a true consumer-culture phenomenon”, the former New York Times journalist Alan Schwarz wrote in his 2016 book, ADHD Nation, exploring the making of an American epidemic. By the early 2010s, around one in ten American children were being diagnosed. Conners was horrified: he had estimated that only 2 or 3 per cent of children would meet the criteria for diagnosis, and he thought the label was being misused, resulting in over-medication and a burgeoning black market in “study drugs” – stimulants, used to treat ADHD, that were being taken casually to heighten alertness and concentration, often by tired students. Before his death in 2017, Conners called the overdiagnosis of ADHD a “national disaster of dangerous proportions”. One of Conners’ colleagues at Duke University in North Carolina was Allen Frances, the psychiatrist who chaired the fourth edition of the DSM. In 2013 Frances published a book titled Saving Normal, an “insider’s revolt” that argued against rampant overdiagnosis, mostly driven by pharmaceutical companies. Like everyone I spoke to, Frances believed it essential that those with the most severe ADHD symptoms received support, including medication. But he thought far too many children were being given a diagnosis simply because it is easier to medicate a child than to address any underlying causes: problems such as oversized classes, an exam-oriented educational system or parental pressure. How well should we expect the average child to concentrate? What counts as “hyperactivity” when children’s lifestyles are more sedentary than ever? Studies in the US, Denmark and Taiwan have shown that children who are the youngest in their class are more likely to be diagnosed with ADHD than their older peers. “We’re turning immaturity into a medical disorder,” Allen told me. He felt that we are transforming an “educational problem” (of how you support pupils at different stages of development) into an “individual psychiatric condition”. Frances pointed out that ADHD shares many symptoms with other common conditions, such as insomnia, depression and bipolar disorder. “Psychiatric diagnoses run in fads,” he said. “Human nature is very stable, but how people understand distress is labile.” He thought that adult ADHD had become “the latest fad”, in part because its defining traits are disparate. And it is true that it’s a condition most people can relate to. The more I read about it, the more I questioned myself: I am messy, disorganised and easily distracted. I daydreamed through school, and wrote this piece in guilty, frenetic chunks, with at least 30 internet tabs open in my browser. Might I have it? I completed a WHO-approved online ADHD questionnaire, which suggested that my score was high enough to warrant professional advice. A GP friend who expresses scepticism over the number of her patients who have recently sought a private diagnosis – all white, middle-class, outwardly successful women – had nonetheless recently completed the same questionnaire herself. She did it before work one morning, after her porridge had boiled over and the cable to the kettle caught fire; she had begun to wonder if this level of personal chaos was normal. (The questionnaire reassured her that she was unlikely to have ADHD.) While researching this piece, I was also reminded of a viral 2019 BuzzFeed essay by the American journalist Anne Helen Petersen, which she later developed into a book, Can’t Even. Her description of “errand paralysis” resonated with millennial readers (including me) who routinely fail to complete basic “life admin”: they leave letters unposted for months and bills unpaid; they accumulate ill-fitting clothes because they can’t mail returns on time. Petersen argues that such errand paralysis is a symptom of the chronic burnout that afflicts her generation, many of whom cannot escape financial precarity despite working all the time, often in monotonous, desk-bound jobs. Much of what Petersen attributes to burnout might also be seen as evidence of ADHD. Are some people seeking ADHD diagnoses as a result of unrealistic cultural expectations? Is it easier to attribute organisational failings to a personal condition than to acknowledge how hard it is to thrive in today’s culture? In her 2021 book The Sleeping Beauties and Other Stories of Mystery Illness, the neurologist Suzanne O’Sullivan explores the role that culture and society play in functional illnesses, drawing on examples such as “resignation syndrome” – the coma-like state that grips child asylum-seekers in Sweden who have been threatened with deportation. (The only cure is permanent asylum and even then, the recovery process is painfully slow.) She points out that what counts as ADHD impairment is culturally determined. She notes, for example, that some have attributed Hong Kong’s high ADHD rates to a cultural tendency to pathologise anger and extreme emotion. Also influenced by culture is the impulse to seek out a medical diagnosis – often the only way to solicit understanding in a society that champions resilience, independence and, above all, success. “Sometimes illness is a sign that the life we have chosen for ourselves is not the right one, but Western culture doesn’t make it easy to acknowledge that,” O’Sullivan writes. “There’s an increasing tendency for people to seek out a medical reason to explain why things are not working out.” She questions whether a diagnosis is worthwhile for those with milder symptoms: does a child who is struggling need a medical label before they get support, especially if that label might shape their self-perception for life? After completing my own ADHD questionnaire, I asked myself if any of my traits could be deemed impairing, and concluded they weren’t: my life might be less stressful if I became more organised, but my chaotic approach to almost everything hadn’t held me back professionally or socially. Later I wondered if the better question was: what would a diagnosis give me, anyway? [See also: Is reality a hallucination? The neuroscientist Anil Seth thinks so] Without exception, the specialists and people with ADHD I spoke to resisted the idea that the condition is a form of culture-bound illness or, in Frances’s words, a “fad”. But they didn’t deny culture plays a part, as so many aspects of modern life are difficult to navigate if you have ADHD traits. One popular formulation, from a 1993 book by the US psychotherapist Thom Hartmann, is that people with ADHD are hunters living in a farmers’ world. They would have flourished in high-risk, high-reward hunter-gatherer societies, when their distractibility would keep them constantly scanning the horizon for food or threats. But they are less suited to societies that value detailed forward planning and methodical work. If you’re happiest when active, and are easily sidetracked but occasionally obsessively focused, what could be tougher than being required to sit at a screen all day, answering emails or inputting data – especially when you could be chasing the dopamine hits of social media, or burrowing deep into whatever internet wormhole will sustain your interest? In 2015, Microsoft conducted a survey of Canadian media consumption that suggested the average attention span had fallen from 12 seconds in 2000 to eight, less than that of a goldfish. Almost every newspaper reported on our goldfish brains, but the science crumbled under scrutiny. Microsoft’s sample was small, and it is hard to extrapolate how well people are able to focus on real-world tasks from the kinds of attention you can stimulate in a lab. Our attention spans are, after all, elastic and fluctuate according to our level of interest, mood and state of mind. And yet the goldfish study resonated because it spoke to a wider cultural anxiety. We sense it intuitively, every time we scroll through timelines for so long that we enter a fugue state: we are giving our attention away for free. At what stage do you stop blaming the internet for all those unfinished projects and unfulfilled ambitions, and instead blame yourself? The adults with ADHD I spoke to wanted to correct common misconceptions – that they weren’t all “naughty boys, bouncing off walls” – but they were also wary: was I going to use this essay to argue that ADHD isn’t real? There has always been a strong current of scepticism about the diagnosis: people who believe not just that it is overdiagnosed, but that it doesn’t exist – an alibi for bad parenting, an excuse for extra time in exams or disability allowances, a get-out for laziness or bad behaviour. In 2014, the American neurologist Richard Saul published the provocatively titled book ADHD Does Not Exist, arguing that its symptoms are caused by 20 other conditions, from bad eyesight to bipolar disorder. The ADHD deniers point to the lack of biological evidence – something ADHD shares with most conditions studied by psychiatry. They tend to give little consideration to what a diagnosis means to people, or the reason it is embraced by those who feel it accurately captures their difficulties and strengths. Some patients who reject all other mental health labels, such as schizophrenia or depression, have nonetheless embraced ADHD as part of the neurodiversity movement, which encourages individuals to prize cognitive difference and challenges society to find better ways to accommodate their needs. But ADHD doesn’t have to be considered a fixed medical condition to be real or meaningful. The Hungarian-Canadian psychologist Gabor Maté was one of the first and most prominent voices to argue that ADHD is better thought of as a problem of society. It’s “a physiological consequence of life in a particular environment, in a particular culture”, he argues in his 1999 book Scattered Minds. Maté, who is now 78, has ADHD himself, as do his three children. The diagnosis helped him make sense of his disorganisation, workaholism and bad temper, problems he believes stemmed from a fear of allowing his thoughts to rest. “Terrified of my mind, I had always dreaded spending a moment alone with it. There always had to be a book in my pocket as an emergency kit in case I was ever trapped waiting anywhere, even for one minute, be it a bank queue or supermarket check-out counter. I was forever throwing my mind scraps to feed on, as if to a ferocious and malevolent beast,” he writes in Scattered Minds. Maté believed some people might be genetically predisposed to ADHD, but that the trigger was childhood stress and emotional insecurity. This explanation now feels too narrow, given all we have learned about other potential causes. But what does resonate from Maté’s writing is his interest in how our emotional lives influence our ability to pay attention. He was writing before mobile phones, but his restless queuing will be familiar to anyone who thinks they have ADHD – or wishes they understood why they can no longer watch TV without scrolling through Twitter, why they can’t wait five minutes at a bus stop without fumbling for their phone, why they will drop everything the moment they hear the ping of a notification. What are we hiding from when we refuse to focus or stand still? In a world designed for distraction, what, ultimately, do we want to pay attention to? This article was originally published in November 2022. [See also: The psychiatrists who don’t believe in mental illness – Audio Long Reads]

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