What makes treatment effective?

November 23, 2013November 21, 2013 ~ Jason Schwartz ~ 3 Comments

This will be my post in response to the NY Times’ series on Suboxone.

This post originally ran on 7/19/13 and addressed a lot of our concerns.

* * *

postcard---heroin-lie

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

One commenter who blogs for an ORT provider challenged my arguments that we should offer everyone the same kind of treatment that we offer doctors and questioned the “it works” argument from ORT advocates. He dismissed the treatment model

Another commenter is an opiate addict who objected to a post about Hazelden’s announcement that they started providing ORT maintenance. She reported suffering greatly from cravings and relapsing after drug-free treatment at Hazelden. She’s been on Suboxone for 50 days and feels like it is a better solution for her.

Another post, that has nothing to do with me, blames abstinence-oriented treatment for the recent overdose death of an actor. (Among the other problems with the article are that she slanders abstinence-based treatment by suggesting that abuse is common. She misleads readers into thinking that ORT is not widely available when federal surveys find that ORT admissions accounted for 26% of all admissions. [Not 26% of opioid addiction admissions. 26% of all addiction treatment admissions.]

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

Red_Drug_Pill---recovery To some extent, these arguments remind me of hearing Bill White comment on arguments about cognitive-behavioral therapy vs. motivational interviewing vs. 12 step facilitation. He commented that, “these are all arguments within the acute care paradigm.”

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

Many abstinence-oriented treatment providers have provided the first, but not the second and third. (Though one could argue that 12 step facilitation offers a long term recovery maintenance model.) They provide 10 days of inpatient care or 2 weeks of intensive outpatient and offer a passive referral to outpatient care. (Only 2% of all treatment admissions were for long term [more than 30 days] residential.) The end product looks something like a system that treats a heart attack with a few days or weeks of emergency care and then discharges the patient with no long term care plan. (Or, a weak long term care plan.) Then, we’re surprised when the patient has another cardiac event.

Many ORT providers have offered the second element, but not the first or third. The long term nature of ORT could be considered a chronic care model. However, the end product look something like palliative care for a treatable condition. It reduces opiate use (not necessarily other drug use), criminal activity and over dose. But these benefits are only realized as long as the patient is on ORT and drop-out rates are not low. And, ORT research has not been able to demonstrate the improvements in quality of life (employment, relationships, housing, life satisfaction, etc.) that we see in those health professionals who get all three elements. (Also note that opiate addicted health professionals often use VERY large doses and go undetected for long periods of time. Any neurological damage from their use does no appear to interfere with their achieving drug-free recovery in very impressive numbers.)

It’s effective!

One of the recurring arguments that I hear is that ORT is effective and there is tons of research that it’s effective. I don’t question that it’s effective at achieving some outcomes–reducing criminal activity, reducing opiate use and reducing overdose. If those are the only outcomes you care about, then you can say it’s effective without any qualifications.

Even with my bias for abstinence-oriented treatment, I can imagine circumstances where ORT might be the least bad option. (For example, if your child had been offered high quality treatment of adequate quality and duration more than once and they continue to relapse and be at high risk for fatal overdose.) A few weeks ago I offered an analogy that attempted to offer an approach to informed consent:

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.

Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Fixing treatment

Hazelden Monument2_2WEB Hazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

One option would have been to declare that a 30 day model for opiate addiction treatment is doomed to fail and build a recovery-oriented, chronic care system that delivers high quality care of the appropriate intensity and duration.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

However, if you can get what the doctor’s having, why would you want anything else? And, shouldn’t we want every patient to get the same kind of care the doctor would get if she were the patient? If you can’t get that, you’ve got some tough decisions to make.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

UPDATE: In an email exchange with a friend who disagrees, I clarified Hazelden’s options, as I see them. If it were Dawn Farm, I’d imagine we’d look at things like:

improving our aftercare referral process–asking ourselves if we can make better active linkages to communities of recovery;
evaluating whether the intensity, duration and quality of our aftercare recommendations were appropriate;
embedding recovery coaching in cities around the country to provide assertive recovery support;
improving post-treatment recovery monitoring and re-intervention.

Not available? (addictionandrecoverynews.wordpress.com)
no hint of opinion here (addictionandrecoverynews.wordpress.com)

“manifestly unsuitable for (psychiatric) treatment”

August 4, 2013August 4, 2013 ~ Jason Schwartz ~ 1 Comment

Will Self reviews a recently published book on psychiatry and has some interesting observations on the relationships between addicts, mutual aid groups and psychiatry:

Interestingly there is one large sector of the “mentally ill” that Burns believes are manifestly unsuitable for treatment – drug addicts and alcoholics. He points to the ineffectiveness of almost all treatment regimens, possibly because the cosmic solecism of treating those addicted to psychoactive drugs with more psychoactive drugs hits home despite his well-padded professional armour. Elsewhere in Our Necessary Shadow he seems to embrace the idea that self-help groups of one kind or another could help to alleviate a great deal of mental illness, and it struck me as strange that he couldn’t join the dots: after all, the one treatment that does have long-term efficacy for addictive illness is precisely this one.

Psychiatrists are notoriously unwilling to endorse the 12-step programmes, and argue that statistically the results are not convincing. There may be some truth in this – but there’s also the inconvenient fact that there’s no place for psychiatrists, or indeed any of the psy professionals, in autonomously organised self-help groups. Burns agrees with Davies that our reliance on psychiatry, and by extension, psycho-pharmacology, may well be related to our increasingly alienated state of mind in mass societies with weakened family ties, and often non-existent community ones. Surely self-help groups can play a large role in facilitating the rebirth of these nurturing and supportive networks? But Burns seems to feel that just as we will always need a professional to come and mend the septic tank, so we will always need a pro to sweep out the Augean psychic stables. I’m not so sure; psychiatry has been bedevilled over the last two centuries by “treatments” and “cures” that have subsequently been revealed to be significantly harmful. From mesmerism, to lobotomy, to electroconvulsive therapy, to Valium and other benzodiazepines – the list of these nostrums is long and ignoble, and I’ve no doubt that the SSRIs will soon be added to their number.

Sooner or later we will all have to wake up, smell the snake oil, and realise that while medical science may bring incalculable benefit to us, medical pseudo-science remains just as capable of advance. After all, one of the drugs that Irving Kirsch’s meta‑analysis of antidepressant trials revealed as being just as efficacious as the SSRIs was … heroin.

Psychiatrists: the drug pushers (theguardian.com)
Faith Lost (madinamerica.com)

What makes treatment effective?

July 19, 2013 ~ Jason Schwartz ~ 24 Comments

postcard---heroin-lie

I’ve been catching a lot of heat recently for posts about Suboxone and methadone. (For the sake of this post, lets refer to them as opioid replacement therapy, or ORT, for the rest of this post.

So, I thought I’d take a step back and try to address the big picture in one post.

The wrong paradigm?

I talk often about the success of health professional recovery programs and their remarkable outcomes. What makes these programs so successful? I’d boil it down to a few factors:

They are recovery-oriented. They treat patients with the expectation that they can fully recover and focus on facilitating and supporting recovery rather than just extinguishing symptoms of addiction.
They have a chronic care model. They continue to provide care and support long after the acute stage of treatment (5 years). They also focus on lifestyle changes the will support recovery and look for ways to embed support for recovery in the patient’s environment.
They provide adequate care. The provide multiple levels of high quality care of the appropriate intensity and duration at different stages of the patient’s recovery.

It’s effective!

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.

Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Fixing treatment

Hazelden Monument2_2WEB Hazelden’s adoption of ORT has provided fuel to a lot of these arguments.

Hazelden was confronted with poor outcomes for their opiate addicted patients. They saw a problem and decided to act.

ORT seems to be the easier response, particularly with the market and cultural currents flowing in that direction.

Bill White has argued that ORT can be compatible with a recovery orientation. I’m skeptical, but I’m watching and am willing to learn from any success they have.

I’m looking for others to implement the health professional model with others, finding ways to build upon it and make it less expensive, as we have.

Not available? (addictionandrecoverynews.wordpress.com)
no hint of opinion here (addictionandrecoverynews.wordpress.com)

Diagnosing ADHD in detox?

December 7, 2012December 7, 2012 ~ Jason Schwartz ~ 3 Comments

fear_false_evidence_appearing_real Unreal. Someone’s got an awful lot of faith in their diagnostic skills. Diagnosing ADHD with addicts in a detox unit? Really?

And, now that it’s published, it’s “evidence”.

Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units

Background

ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group.

Method

Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units.

Results

We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records.

Conclusions

This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.

Intellectual conflicts of interest

December 4, 2012 ~ Jason Schwartz ~ 1 Comment

DSM_5_2 Allen Frances, Chair of the DSM-IV Task Force lets loose on the DSM-5. He acknowledges the noxious effects of professional interests on research and practice in a way that is rarely seen from leaders of his stature. [emphasis mine]

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.

…

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance Pharma profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their’s is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

Shame and Addiction

November 30, 2012November 30, 2012 ~ Jason Schwartz ~ 10 Comments

Shame-poster

Analysis of a recent study on shame and addiction suggests that shame may play a helpful role in getting alcoholics to initiate recovery but, once they’re sober, it’s associated with relapse.

Two psychological scientists at the University of British Columbia — Jessica Tracy and Daniel Randles — decided to see if alcoholics’ feelings of shame about their addictions might actually interfere with their attempts to get sober. They recruited about a hundred middle-aged men and women from the rooms of Alcoholics Anonymous, all with less than six months of sobriety. They measured their levels of shame and other emotions, along with personality traits, and then about four months later they brought them back into the lab to see how they were doing in recovery.

… The alcoholics who were most ashamed about their last drink — typically a humiliating experience — were much more likely to relapse. Their relapses were also more severe, involving much more drinking, and they were more likely to suffer other declines in health. In short, as described in a future issue of the journal Clinical Psychological Science, feelings of shame do not appear to promote sobriety or protect against future problematic drinking — indeed the opposite.

This is the first scientific evidence to bolster what alcoholism counselors and recovering alcoholics have long known: Shame is a core emotion underlying chronic heavy drinking. Shame is what gets people into the rooms of AA — it defines the alcoholic “bottom” — but it’s a lousy motivator for staying in recovery. The power of AA is that it offers something to replace the negative emotions that most alcoholics know all too intimately.

The Shame of the Alcoholic (psychologicalscience.org)
Alcoholics’ Addiction (andrewsullivan.thedailybeast.com)

Following alcoholics for decades

October 5, 2012 ~ Jason Schwartz ~ 3 Comments

McLeans has an interesting interview with George Vaillant about, “the surprising things you find out about people if you follow them for long enough.”

What’s so different and interesting about this study is that it followed the subjects for decades from a pretty young age. Their subjects were college sophomores when the study began and their selection was not based on any problems or characteristics. So, they studied them before, during and after their active alcoholism.

Here are a few of the better bits.

On alcoholism and recovery:

Q: What, then, are the great lessons to be drawn from the study?

A: Some of the most important ones involved alcoholism. About 50 per cent of alcoholics recover, but a remarkable percentage of those do so with AA. The fact that this study followed up with these men on 60 different occasions with regard to their alcoholism over a period of 50 years did allow us to identify what made a difference.

You’ll have to read the Natural History of Alcoholism, because he didn’t expound on that in the interview.

On childhood unhappiness and alcoholism:

Q: A lot of long-held theories flew out the window over the decades thanks to your work.

A: One of the simplest examples was the notion that unhappy childhoods cause alcoholism. What a study like this shows is that, first, lots of alcoholics invent an unhappy childhood to justify their drinking. Second: if an alcoholic’s childhood is miserable, it’s because a blood relative has alcoholism. If the unhappy childhood is the result of an alcoholic step-parent, the person doesn’t drink to relieve the misery. So it’s the genetic component of alcoholism that matters.

On alcoholism’s toll (Too bad these lessons need to be re-learned!):

Q: You argue that alcohol abuse is the most ignored causal factor in modern social science. Why?

A: Because it’s much more fun to pay mind to nice people than to angry, passive-aggressive people, and the disease of alcoholism makes people angry and dishonest. If you look at the major books on marriage, alcoholism is mentioned nowhere in the index as a cause of unhappiness. Yet 57 per cent of all the divorces in the Harvard sample occurred when one or other spouse were drinking alcoholically. The alcohol abuse almost always preceded the trouble in the men’s life. Another dramatic example: depression does not lead to alcoholism, whereas alcoholism leads to depression. If you take 100 cases, you can find two or three exceptions, but that’s all. People didn’t really know that before the Grant study.

[hat tip: Jeff Jay]

50% of the equation

October 4, 2012 ~ Jason Schwartz

Forbes (?!?!) covers Pat Deegan’s efforts to empower mental health patients by guiding them into playing a larger role in their care decisions and participating in their health care records.

…I realized that we are at an important point in the history of medicine. Paper medical records are being replaced by digitized information organized into Electronic Health Records (EHRs). To my dismay, I observed that most EHRs were simply hard coding traditional clinical workflows. This isn’t the vision we started with when we saw the electronic future. The EHRs streamlined clinicians’ work and reflected what mattered to them, but patient priorities and perspectives were not taken into account in these EHRs, despite the fact it would be exceedingly simple to include them. For example, if a person is a recovering addict he or she might want to minimize opiate based pain medication after surgery. Where in the EHR is a place for that patient to voice that preference ? Where in the EHR are patients’ goals for treatment recorded and prominently displayed? If decision support information is available to doctors, why shouldn’t decision support materials be available to patients as well?

I began to realize that in this historic window of opportunity, those of us who are patients had to get at the table to insure that the EHR reflected our concerns, our strengths and views. Remember, patients are the other 50% of the healthcare equation. I thought about what would a truly person-centered EHR might look like. How can the patient’s voice best be accommodated in the EHR? What does bi-directional decision support look like? How can an EHR support informed medical decision making and shared decision making for people with long-term disorders. These are some of the important questions I developed the CommonGround web application to explore.

Primary care is a misnomer. Primary care happens in the context of daily life, not only in the physician’s office, but in the community and increasingly online. Traditionally, clinicians are gatekeepers of information, but if they don’t talk about recovery patients don’t hear about it. We decided to develop software with important information for current mental health patients provided by recovering patients. We start with the notion that those with mental disorders can and do recover, and we built a body of knowledge to help those currently struggling. The main thing for us is to help people be better informed about their conditions and their options for dealing with them in the broader context of functional and quality life.

Beware of misleading headlines

September 25, 2012September 25, 2012 ~ Jason Schwartz ~ 6 Comments

Caution Tape (Photo credit: Picture Perfect Pose)

A new article discussing the expanding use of medications in addiction treatment has the following sub heading:

Experts are pushing for a truly medical approach to treating addiction as a disease rather than relying solely on longtime unproven therapies like 12-step programs.

Unproven?

Twelve Step Facilitation (TSF) is the treatment of choice for addicted physicians and they have excellent outcomes.
There’s a lot of evidence for their effectiveness.
TSP is recognized as an evidence based practice.

I’m certain a day will come when we have effective pharmacological tools to help addicts initiate and maintain recovery but, beyond detox, I find the current meds pretty underwhelming as a group and troubling in some cases.

When you hear the push for these “scientific”, “medical” and “evidence-based” treatments, keep these exhibits in mind:

A Doctor’s Dilemma: When Crucial New-Drug Data Is Hidden

The positive spin surrounding industry-funded studies — which are, after all, the studies that the government uses to approve drugs — isn’t the only ongoing problem. Goldacre further describes how drug companies hide data about medication risks that affect children, how they attempt to intimidate the employers of researchers who produce results they don’t like, and how they routinely withhold safety data in various other ways that do harm to patients.

A Call for Caution on Antipsychotic Drugs

You will never guess what the fifth and sixth best-selling prescription drugs are in the United States, so I’ll just tell you: Abilify and Seroquel, two powerful antipsychotics. In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion, a 13 percent increase over the previous year, according to the market research firm IMS Health….several recent large randomized studies, like the landmark Catie trial, failed to show that the new antipsychotics were any more effective or better tolerated than the older drugs.

It was also soon discovered that the second-generation antipsychotic drugs had serious side effects of their own, namely a risk of increased blood sugar, elevated lipids andcholesterol, and weight gain. They can also cause a potentially irreversible movement disorder called tardive dyskinesia, though the risk is thought to be significantly lower than with the older antipsychotic drugs.

Nonetheless, there has been a vast expansion in the use of these second-generation antipsychotic drugs in patients of all ages, particularly young people. Until recently, these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.

Top 10 Drug Company Settlements

Record-breaking multibillion-dollar settlements against big drug companies have become routine in the U.S. In recent years, pharmaceutical companies seem to have been playing a game of one-upmanship, each surpassing yet a new milestone of wrongdoing — fraudulently marketing their drugs or making misleading claims about their safety — and the threat of massive payouts appears to have offered little deterrent.

A brain disease AND (fill in the blank)

September 19, 2012 ~ Jason Schwartz ~ 4 Comments

Not addiction related, but a very interesting look at new directions for treating and understanding schizophrenia.

The article opens by reflecting on where we stand with our attempts to understand the causes:

…the outcome of two decades of serious psychiatric science is that schizophrenia now appears to be a complex outcome of many unrelated causes—the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen. It’s not just about the brain. It’s not just about genes. In fact, schizophrenia looks more and more like diabetes. A messy array of risk factors predisposes someone to develop diabetes: smoking, being overweight, collecting fat around the middle rather than on the hips, high blood pressure, and yes, family history. These risk factors are not intrinsically linked. Some of them have something to do with genes, but most do not. They hang together so loosely that physicians now speak of a metabolic “syndrome,” something far looser and vaguer than an “illness,” let alone a “disease.” Psychiatric researchers increasingly think about schizophrenia in similar terms.

The author reports disenchantment with a simple biomedical model and offer three reasons.

First, disappointment with medication:

The first reason the tide turned is that the newer, targeted medications did not work very well. It is true that about a third of those who take antipsychotics improve markedly. But the side effects of antipsychotics are not very pleasant. They can make your skin crawl as if ants were scuttling underneath the surface. They can make you feel dull and bloated. While they damp down the horrifying hallucinations that can make someone’s life a misery—harsh voices whispering “You’re stupid” dozens of times a day, so audible that the sufferer turns to see who spoke—it is not as if the drugs restore most people to the way they were before they fell sick. Many who are on antipsychotic medication are so sluggish that they are lucky if they can work menial jobs.

Second, the genetics are much more complicated than was assumed:

The second reason the tide turned against the simple biomedical model is that the search for a genetic explanation fell apart. Genes are clearly involved in schizophrenia.

But:

The effort to narrow the number of genes that may play a role has been daunting. A leading researcher in the field, Ridha Joober, has argued that there are so many genes involved, and the effects of any one gene are so small, that the serious scientist working in the field should devote his or her time solely to identifying genes that can be shown not to be relevant.

Third, global research is revealing that culture and social factors play a much bigger role than previously understood:

The third reason for the pushback against the biomedical approach is that a cadre of psychiatric epidemiologists and anthropologists has made clear that culture really matters. In the early days of the biomedical revolution, when schizophrenia epitomized the pure brain disorder, the illness was said to appear at the same rate around the globe, as if true brain disease respected no social boundaries and was found in all nations, classes, and races in equal measure. … In recent years, epidemiologists have been able to demonstrate that while schizophrenia is rare everywhere, it is much more common in some settings than in others, and in some societies the disorder seems more severe and unyielding.

For example:

Schizophrenia has a more benign course and outcome in the developing world. The best data come from India. In the study that established the difference, researchers looking at people two years after they first showed up at a hospital for care found that they scored significantly better on most outcome measures than a comparable group in the West. They had fewer symptoms, took less medication, and were more likely to be employed and married.

The article closes with a few examples of alternative strategies from other countries. I’m sure it will provoke controversy, but seems increasingly hard to defend the status quo.

The wrong paradigm?

It’s effective!

Fixing treatment

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The wrong paradigm?

It’s effective!

Fixing treatment

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Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units

Background

Method

Results

Conclusions

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