Treatments and diagnostics

Originally a post on ADD/ADHD in a forum thread elsewhere, I ended up getting sufficiently carried away in responding that I feel it’s worth reposting here.

As with many other disorders, particularly psychiatric disorders, I think a major problem is poor or lazy diagnosis, which may stem from any of a number of reasons.

I’ve had a diagnosis of IBS for the past several years, which had me resigned to a chronic problem and perhaps taking meds to ameliorate (not eliminate, let alone cure) the symptoms—because the first doctor I spoke to listened to my description of the symptoms and prescribed a drug on the Take this, see if it helps principle. Fair enough, it helped—only a few years later a better doctor (at a walk-in clinic!) listened to the same list of symptoms and decided to run a simple test. This resulted in the lab-confirmed diagnosis of a bacterial infection that took two 10-day rounds of antibiotics at a total cost to me of $20 to clear up. Thus the first doctor’s laziness or negligence in not ordering a simple test cost me several years of pain (and several hundred dollars in medication).

Psychiatric disorders frequently suffer from vague or non-existent diagnostic criteria, especially when it comes to prescribing medication. It’s rather like zoological classification before the discovery of DNA: Disorders are classified according to similar symptoms (visible criteria) rather than analysis of underlying causes. Whales used to be classified as fish, even though they’re most closely related to hippopotamuses; elephants are more closely related to rock hyraxes than to hippopotamuses or rhinoceroses, but you wouldn't know it to look at them. Medical diagnostic criteria, when diagnoses are made without lab tests, are similar. Prescriptions of antidepressants are made without actually looking at patients’ brain activity of neurochemistry; I myself take Cipralex/Escitalopram (originally Celexa/Citalopram)—the criterion? I was clearly depressed, so they started me on the drug with the least potential for side effects. I was lucky; it worked out great. It’s still a crappy criterion, and lots of people get burned. (I know some people severely disillusioned by antidepressants, and others for whom they work great, but whose lives were made severly more miserable during a period of months or years of experimenting to find the proper treatment.)

AD[H]D sounds like a disorder with very much the same problem, only moreso. It’s clearly a spectrum disorder, or a set of spectrum disorders, with enormous potential for diagnostic confusion. I do not doubt that there are real disorders there, nor that medication can help sufferers, nor that it is a very good thing that such medication exists and is available to them. But I think it is terrible that so much work goes into developing these medications with no work done or publicised in properly analysing and targeting treatments to people who really do need them. And either this is at least theoretically possible, or the entire model is wrong to begin with—after all, it is hypothesised (or theorised, or known; I’m no expert) that neurochemical imbalances are at fault; then we should be able to test for them.

In more crass terms, I wish the pharmaceutical business model would shift to make, proportionally, a little more money in precise diagnostics and lab tests (test kits cost money, too!) and a little less (again, proportionally) on treatments.

I also wish that doctors had stiffer backbones and simply said no to parents or patients demanding drugs for which there is clearly no good indication. This is surely a major problem with AD[H]D; it's also a problem with drugs like antibiotics, often prescribed for viral conditions where they are of no use whatsoever (save placebo; and it's better to prescribe inert placebo or vitamins) but select for resistant bacteria.