Abstract
I have many concerns about Pillai and Kraya's recent paper on this topic [1].
I will start with my main concern. In a respected, peer-reviewed journal, I was surprised to see a single case report of an amphetamine-induced delusional state (not unique) allowed to be used as a Trojan Horse to release the authors' attack on the ‘mis-diagnosis of ADHD and consequent misuse of stimulants’ in Western Australia to the level where the authors expressed concern that ‘it is only a matter of time before legal forces are brought to bear against practitioners who prescribe these medications for a controversial disorder’. Forceful statements require forceful evidence, but we are only given a single case report and references which are somewhat dated or downright unreliable (the local newspaper!!).
Indeed, it is difficult to see why this paper was accepted for publication as I am not sure it has any notable or unique features. The authors admit this themselves when mentioning that Shepherd's original series described the syndrome in a man abusing amphetamines. There is mention of possible unique ‘acted-out’ psychopathology in television commercials, but details of this were not given in the ‘clinical picture’, only mentioned in the formulation. That is, the paper is short on originality, but long on criticism of psychostimulant prescription for ADHD in Western Australia.
It may be of interest to know that the Western Australian Health Department has a Stimulants Committee which oversees the prescribing of psycho-stimulants in ADHD. I am sure this Committee, and clinicians practising in this area, would be interested to know of the authors' forensic experience and concerns, and this could be compared with the Committee's knowledge of the broader clinical usage of psychostimulants. It should be noted that this Committee has an active interest in the scientific basis for psychostimulant prescription and funded a collaborative public–private sector research project into adult ADHD and dexamphetamine use, the first on this topic internationally [2].
Apart from the major concern about this article, I have several other areas of concern.
The authors' statement that ‘the disorder normally ceases by puberty, although it may persist, manifesting as antisocial behaviour and drug abuse’ does not reflect more recent views suggesting that childhood ADHD does persist to become adulthood ADHD, the exact rate being difficult to determine, but it is lower (or much lower) than in childhood [3,4].
The authors selectively quote Sachdev in questioning the validity of the diagnosis, and it may be fairer to mention that Sachdev also states in the same article that ‘there are many pointers to the validity and clinical utility of ADHD in adults, but the diagnosis continues to pose problems to the taxonomist and the clinician’ [4].
As to the ‘clinical picture’, the authors describe a man diagnosed with ADHD who then abused prescribed dexamphetamine resulting in a psychotic state. I think it would be fair to say that there is a good chance that the man also continued to abuse methamphetamine (illicit and more central nervous system potent) as he was doing so prior to his initial psychiatric presentation. Psychotic reactions to amphetamines are mostly seen in situations of abuse [5] and ‘no convincing evidence has emerged that long-term supervised prescription of stimulants leads to drug tolerance or misuse’ [3]. The authors also question the original diagnosis of ADHD just because the patient was ‘a highly successful man’. It should be noted that even highly successful people can still have long-term psychiatric disorders.
Even given all of the above, it is still gratifying to see issues surrounding adult ADHD being discussed in this journal and I look forward to robust, learned debate in the future.