ADD Overdose?

The Wall Street Journal, July 23, 2003

By Sally Satel

Brace yourselves for a new epidemic. No, not SARS or Monkeypox. It is adult attention deficit disorder. Once reserved for hyperactive kids, the condition is being touted in a series of ads for Strattera, the only drug FDA-approved for use in adults with ADD.

“Are you disorganized?” says the new Strattera ad. “Do you procrastinate, fidget, lose things?” Sounds like just about everyone.

Is this form of ADD for real? After all, about five years ago shyness became a treatable disease when SmithKline Beecham unveiled Paxil, a drug to treat social phobia. Back then, SmithKline, like Eli Lilly, the developer of Strattera, was accused of disease-mongering by blurring the already fuzzy distinction between normal variants of human temperament and outright pathology. Last Friday, CNN had a field day: “Adult ADD: Common Disorder or Marketing Ploy?” was the story it ran throughout the day.

Skepticism is justified. Consumers can be seduced into thinking they’re sick when they aren’t. The ads may encourage them to blame poor discipline or lack of accomplishment on a disease, perhaps even consider getting disability compensation. (This isn’t so far-fetched: a colleague told me of a grad student who sought extra time on her Ph.D. qualifying exams after she conveniently figured out she had adult ADD.)

Certainly, setting the diagnostic bar too low also sets the stage for misdiagnosis: To harried family physicians — a major target of the Lilly campaign — “the symptoms of ADD can look just like the symptoms of modern life,” says psychiatrist and ADD expert Edward Hallowell.

Meanwhile, drug companies damage the credibility of their own direct-to-consumer advertising efforts when they shamelessly trawl for patients. Still, adult ADD is no joke. Psychiatrists know that severe distractibility can be a job-terminating, marriage-ending problem. Just as fear of being in public can be debilitating to some individuals. Such genuine victims of ADD and social phobia, respectively, should certainly have access to medications and third party coverage for their care.

But they are not the only ones who could benefit from access to drugs like Strattera and Paxil. In his 1993 bestseller “Listening to Prozac,” author Peter Kramer introduced the concept of cosmetic psychopharmacology — the ability of a drug to make someone who is not sick feel better than well. The antidepressant Prozac, he found, enabled some non-depressed patients to become more assertive, more mentally nimble, more popular. They loved their new and improved selves; relationships flourished, job promotions came their way.

Did they “need” the drug? No, not in a strictly clinical sense. But shouldn’t they have the opportunity to benefit from the medications if they want to?

Why should we insist that people with mere quirks or garden-variety neuroses squeeze themselves into a pathological box in order to be the beneficiaries of these agents?

The trick here is to help people without enhancing the culture of victimization or expanding the universe of those considered (or considering themselves) clinically mentally ill. Let’s be honest about the cosmetic potential of medications like Stattera, Paxil and Prozac. Responsible adults should have the right to choose how they take care of themselves.

Critics see cosmetic psychopharmacology as a form of cheating. It is better to improve oneself, they argue, through dint of will power, self-improvement, or divine revelation. But people transform in different ways. The problem with the marketing of these drugs is not that people will take them and feel better, but that they’ll be convinced they have a “disease” when in many cases they do not.

Now a formal diagnosis made by a physician is the passport to getting medications like Strattera, Paxil and Prozac. And as long as this is the case drug companies (and doctors too) will have an incentive to expand the universe of the mentally ill. Instead, people should be free to undergo a “neurochemical nose job,” as Dr. Kramer, a professor at Brown University School of Medicine, calls it.

Yes, we should be tough about limiting the insurance burden for such drugs to those who do have serious illness. But if people pay for safe psychopharmacology, that should be their choice.

Dr. Satel, a scholar at the American Enterprise Institute, is the co-author of “One Nation Under Therapy,” forthcoming from St. Martin’s.