Comments

Health Affairs encourages readers to engage in discussion via comments on our Web site.

• To RESPOND to a particular article: Click on the link "Submit a response to this article" in the box at the top right-hand corner of the article.
• To READ responses to a particular article: Click on the link "View responses" in the box at the top right-hand corner of the article.

Comments to:

Richard M. Scheffler, Stephen P. Hinshaw, Sepideh Modrek, and Peter Levine The Global Market For ADHD Medications Health Affairs, March/April 2007; 26(2): 450-457. [Abstract] [Full Text] [Figures Only] [PDF] [Supplemental Exhibits] [Reprints & Permissions]

Comments:Submit a response to this article

Comments published:

Global Perspective On ADHD: Over- And Underuse

George Halasz   ( 21 March 2007 )

Response to Global Perspective On ADHD: Over- And Underuse

Peter L. Levine, Stephen Hinshaw, Ph.D., and Richard Scheffler, Ph.D.   ( 26 March 2007 )

ADHD Agents: International Comparisons

Constantine G. Berbatis, V. Bruce Sunderland & Max Bulsara   ( 9 May 2007 )

Global Perspective On ADHD: Over- And Underuse 21 March 2007
George Halasz, Hon. Senior Lecturer Monash University, Dept Psychological Medicine, Australia Send comment to journal: Re: Global Perspective On ADHD: Over- And Underuse geohalasz{at}aol.com George Halasz	Scheffler and colleagues focus on the global use and cost of ADHD drugs; their paper raises a profound question of perception about the nature of ADHD. If their recommendation "to adjust overuse or underuse" based on careful consideration of "potential benefits versus potential liabilities" is to be a balanced assessment, then setting diagnostic criteria based on the DSM -- the U.S. standard -- raises questions about the validity of that instrument in clinical use. The standard of "diagnostic prevalence" (cases actually diagnosed by clinicians) varies both according to country and according to the training of clinicians. Pediatricians, child psychiatrists, and general physicians differ in their judgment of causes of childhood symptoms of ADHD. Some reify the symptoms as a "disease entity," which it is not. Others insist that the symptoms should first be assessed for "causes" before starting to medicate. "Cultural differences" among countries should include the medical diagnostic culture as well. In this case, the claim that the rest of the world was found to "lag well behind" the true prevalence could be interpreted as the U.S. overusing the medication option.
Response to Global Perspective On ADHD: Over- And Underuse 26 March 2007
Peter L. Levine, Staff Physician Kaiser Permanente, Walnut Creek, Calif., Stephen Hinshaw, Ph.D., and Richard Scheffler, Ph.D. Send comment to journal: Re: Response to Global Perspective On ADHD: Over- And Underuse Peter.Levine{at}kp.org Peter L. Levine, et al.	In response to the letter (Dr. George Halasz, 21 March 2007) that was commenting on our article “The Global Market for ADHD Medications,” several points are salient. First, it has been known for some years that a number of other nations have rates of ADHD diagnoses that are similar to those in the U.S. -- e.g., Taiwan, Australia, Sweden, India, Germany, Japan, and New Zealand (ADHD Report 6:1-6, 4/98, J Am Ac Ch and Adol Psychiatry 40:1410-1417, 2001, J Child Psychol Psychiatry 42: 487-492, 2001, J Formos Med Assoc 92:133-138, 1993). Second, recent data suggest that when similar parallel diagnostic criteria are used to evaluate patients in North America, Europe, Africa, and Australia, the severity of ADHD symptoms is actually worse in the non- North American group. (Eur Ch Adol Psychiatry 15:177-181, 2006). Third, there are problems associated with the failure to receive an accurate diagnosis. A Norwegian study found that among adults with diagnosable ADHD, many had received some form of psychiatric services as youth but failed to receive an ADHD diagnosis. Their rates of impairment and comorbidity here high (Nord J Psychiatry 60: 38-43). Fourth, in the U.S., ADHD in adolescence and adulthood, ascertained via DSM criteria, yields high rates of school failure, relationship problems and divorce, substance use disorders, criminality, and psychiatric comorbidity. (J Am Ac Ch Adol Psychiatry 36:1222-1227, 1997, J Am Ac Ch Adol Psychiatry 23:261-269, 1984, J Am Ac Ch Adol Psychiatry 45:192-202, 2/06; Journal of Consulting and Clinical Psychology, 74, 489-499. Overall, ADHD is not a benign condition, and rates of diagnosis and impairment appear similar in and outside North America.
ADHD Agents: International Comparisons 9 May 2007
Constantine G. Berbatis, Lecturer Curtin University of Technology, V. Bruce Sunderland & Max Bulsara Send comment to journal: Re: ADHD Agents: International Comparisons berbatis{at}git.com.au Constantine G. Berbatis, et al.	This paper opened with the following: “Little is known about the global use of medications for ADHD…”. It closed this way: “We recommend that countries actively compare data…”. Our paper, "Licit psychostimulant consumption in Australia, 1984-2000: international and jurisdictional comparison" (MJA 2002; 177:539-543), covering these issues, was not cited. The similar results in both papers are evident in the exhibits and discussion. Comments on differences in study data and methods will assist future reporting on ADHD agents. We demonstrated that the USA ranked first before Canada and Australia in per capita defined daily dose per 1,000 population per day of psychostimulants. The World Health Organization (WHO) has adopted this unit of usage, and it should be reported for international comparison. We also standardised for population size. We reported rate ratios adjusted for population and calendar time, a robust form of analysis also correcting for over-dispersion, a common problem with this type of data. We drew on official international data on psychostimulants from the International Narcotics Control Board formed in 1968 by international treaty. It analyses consumption of licit psychostimulants from most countries. The Scheffler group used IMS Health data or manufacturers' data. This is usually convenient to obtain and has the advantage of availing sales statistics. We showed that per capita psychostimulant usage in Western Australia (population 2 million) was highest by far in Australia and similar to the USA and Canada. The US report did not make interstate comparisons. The Scheffler paper reported usage of non-stimulant as well as stimulant ADHD agents (Exhibits 2 and 3) and global expenditures (Exhibits 4 and 5). Our study reported a detailed analysis of 10 countries (Exhibit 1), trends in national usage of psychostimulants (Exhibit 2), and a jurisdictional analysis (Exhibit 3). Detailed analyses of psychostimulant usage since 2000 in Western Australia have been reported by colleagues (MJA 2007;186:124-127; Aust NZ J Public Health 2007;31:120-6).