An article was recently published in the American Journal of Psychiatry (AJP), the Big Pharma subsidized official journal of the American Psychiatric Association (APA). The article was titled “ADHD Medication and Substance-Related Problems.”
The article was conceived by the editorial staff of the AJP (one of whom had financial affiliations with Eli Lilly & Co,a maker and marketer of many lucrative, dangerous and addictive-psychiatric drugs). The article was authored by a number of psychologists (not physicians) from four different academic institutions in two different countries.
The conclusion given in the abstract (the full article had to be purchased at a very high price in order to read it) was that highly addictive, brain-damaging prescription psychostimulants that are routinely administered for so-called ADHD are safe. The article was a classic example of a Garbage In, Garbage Out (GIGO) medical journal article that I have noticed has become commonplace ever since I graduated from medical school in 1968, a decade or two before I first started becoming aware of journalistic fraud in the pharmaceutical and medical publication industries. I was a slow learner and a blindered cheerleader for my profession’s deceptive thought-leaders and multimillionaire Big Pharma executives.
Hundreds and thousands of questionable GIGO articles are published annually in professional medical journals which are mailed (or emailed) out to physicians, most of whom are never able to find the time to read and absorb the substance of most of the articles. Most of us physicians barely have the time to read the conclusions of the abstracts often very deceptive summaries) of articles which are conveniently printed at the beginning. Most of us never have the time or inclination to read the published conflicts of interest, which are usually published at the end of the article, usually in fine print.
Most American medical journals that I know about are generously underwritten (and heavily advertised within) by any number of for-profit pharmaceutical and medical device entities. Quite often such multinational corporate entities also pay handsome sums to the professional trade group for individual articles that will then be given to physicians who are being courted by “drug reps” that cunningly try to convince us prescription-writers to write “scripts” for the drugs that the article was written to support (even –-or especially – if it was a GIGO article).
The journals that publish GIGO medical journal articles include not just the very disposable freebie ”throw-away journals” (which are infamously just Big Pharma infomercials – often written by mercenary Big Pharma “ghost authors”) that are sent free-of-charge to physicians. Sadly, GIGO articles are also often published in once prestigious journals that are only sent to those physicians that have paid an annual membership fee to their particular professional trade association. Membership fees, just like the many Big Pharma “conventions”, “symposia” or “conferences”, are also often heavily subsidized by special interest groups like Big Pharma and medical device companies).
Many GIGO medical journals come around so often that they wind up in stacks – usually unread – until they get thrown away just before they topple to the floor. For today’s too-busy docs, often the most these journals get read is when doctors find the scarce time to scan the intentionally misleading titles or equally misleading abstracts – a good example of the old saying that “a little knowledge can be a dangerous thing”.
Most medical journals are published at least monthly by once-highly regarded medical trade associations – who now often function as powerful lobbyist organizations. Prominent examples of these combination trade associations, lobbying groups and publishing houses are the American Medical Association (AMA), the American Academy of Pediatrics (AAP), the American Psychiatric Association (APA), the American Academy of Family Practice (AAFP), etc, etc, etc. All of them are in bed with Big Pharma and readily publish GIGO articles that seem to be “peer-reviewed” by mercenary, pharmaceutical industry-connected reviewers.
Marcia Angell, MD, the fired editor of the New England Journal of Medicine, has written: “…conflicts of interest and biases exist in virtually every field of medicine, particularly those that rely heavily on drugs or devices. It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine .”
The American Journal of Psychiatry article mentioned above (and summarized below) that couldn’t be truly analyzed, was authored by a group of 10 academic, ”ivory tower” PhD psychologists and statisticians. There was not a clinical physician among them that knew anything about the toxicology of psychostimulants, as far as I could ascertain from the abridged information that was published online at http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2017.16060686.
The brief abstract was the only information that was available online. The only way an interested person would be allowed to read the unedited version was to be a paid member of the APA, obtain a hard copy of the June 2017 issue of the American Journal of Psychiatry or to pay $35.00 to the APA for the single article!
The only financial conflicts of interest published involved the editorial staff of the AJP who had conceived of the study. There was no financial conflicts of interest mentioned for any of the academic psychologist authors (who cannot prescribe drugs), but of course there was likely to be considerable conflicts of interest at the institutions that employed the authors. All universities – commonly have cozy affiliations with Big Pharma.
Just from reading the abstract however, I could sense any number of serious flaws in the study, flaws that would probably be multiplied if one could have read the full article.
Here are just two of the serious problems that should have made this Am J Psych journal article unfit for publication.
One of the many flaws that should have resulted in the article being rejected from publication was the fact that the article was simply a statistical analysis of computer-accessed health insurance company data about so-called adolescent or adult “ADHD”-labeled individuals who had had a billable emergency room, outpatient clinic or hospital encounter. No physical exams or face-to-face interviews were done by the investigators.
The diagnosis of ADHD is already problematic because it is non-science based and because there are absolutely no measurable or reproducible proofs of biological abnormalities such as biopsy evaluations, radiological exams or blood tests that are known to confirm the diagnosis. The diagnosis of ADHD is therefore a purely subjective label that is based on a number of check-list symptoms that are interpreted by a healthcare worker and therefore subject to interpretation or bias.
A second serious flaw (of many flaws) is that there was no awareness that the prescription psychostimulants discussed were known to be brain-damaging, highly addictive and commonly exhibiting serious, even fatal withdrawal symptoms when the dose of the synthetic chemical drugs were cut down or discontinued.
Unfortunately, the abstract’s questionable conclusion likely re-affirmed for the psychiatrists who probably didn’t actually read the body of the article their deeply held beliefs that highly addictive psychostimulant drugs are actually safe.
The ivory tower authors of this sloppy study – none of who, by the way, were physicians – appear to be unaware that the statistical data that their powerful computers and statistics analyzed were “garbage-in” and that necessarily the conclusions made in their article were therefore garbage-out. GIGO. Patients beware.
GIGO is a far-too-common reality in many medical journals today. Following is the essential information from the abstract.
Am J Psychiatry Volume 174, Issue 9, September 01, 2017, pp. 877-885
ADHD Medication and Substance-Related Problems
Published online: June 29, 2017 Abstract
Objective: Substance use disorders are major contributors to excess mortality among individuals with attention deficit hyperactivity disorder (ADHD), yet associations between pharmacological ADHD treatment and substance-related problems remain unclear. This study investigated concurrent and long-term associations between ADHD medication treatment and substance-related events.
Method: The authors analyzed 2005–2014 commercial health care claims from 2,993,887 (47.2% female) adolescent and adult ADHD patients. Within-individual analyses compared the risk of substance-related events (i.e., emergency department visits related to substance use disorders) during months in which patients received prescribed stimulant medication or atomoxetine relative to the risk during months in which they did not.
Results: In adjusted within-individual comparisons, relative to periods in which patients did not receive ADHD medication, male patients had 35% lower odds of concurrent substance-related events when receiving medication (odds ratio=0.65, 95% CI=0.64–0.67), and female patients had 31% lower odds of concurrent substance-related events (odds ratio=0.69, 95% CI=0.67–0.71). Moreover, male patients had 19% lower odds of substance-related events 2 years after medication periods (odds ratio=0.81, 95% CI=0.78–0.85), and female patients had 14% lower odds of substance-related events 2 years after medication periods (odds ratio=0.86, 95% CI= 0.82–0.91). Sensitivity analyses supported most findings but were less consistent for long-term associations among women.
Conclusions: These results provide evidence that receiving ADHD medication is unlikely to be associated with greater risk of substance-related problems in adolescence or adulthood. Rather, medication was associated with lower concurrent risk of substance-related events and, at least among men, lower long-term risk of future substance-related events.
Faculty and Planner Disclosures
Title: ADHD Medication and Substance-Related Problems
Affiliations: From the Department of Psychological and Brain Sciences, Indiana University, Bloomington (P.D.Q., M.E.R., B.M.D.O.); the Center for Health Statistics and the Departments of Medicine and of Public Health Sciences, University of Chicago, Chicago (P.D.Q., Z.C., K.H., R.D.G., B.B.L.); the Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (Z.C., A.S., P.L., H.L.); and the School of Medical Sciences, Örebro University, Örebro, Sweden (H.L.).
Disclosures: Dr. Gibbons has served as an expert witness in cases involving the U.S. Department of Justice and Wyeth, Pfizer, and GlaxoSmithKline. Dr. Larsson has served as a speaker forEli Lilly and Shire and has received a research grant from Shire. Dr. Lichtenstein has served as a speaker for Medice. The other authors report no financial relationships with commercial interests.
Discussion of unapproved or investigational use of products*: No.
*APA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by scientific literature and clinical experience.
Dr. Schultz has received research support from the Alzheimer’s Disease Cooperative Study for projects conducted in partnership with Toyama Chemical Company and in partnership with Eli Lilly and Company. Dr. Freedman, Mr. Roy, and Mr. Pogachar report no financial relationships with commercial interests.