Dediagnosis is a Boundary newsletter discussing the emerging movement to reduce the influence of mental health diagnoses on how we think about ourselves.
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It turns out amphetamines aren’t a great idea
I want to bring your attention to a recently published collection of essays about Adderall, one of the most widely prescribed drugs for ADHD.
The introduction to the collection is powerful and bears quoting in full:
America runs on Adderall. From Silicon Valley to Wall Street, through prep school and grad school, in ad agencies and magazines, many of our most powerful minds are flying on prescription-grade speed. And all these uppers do a lot more than increase productivity. They induce a particular set of behaviors—a passive-aggressive management style, a manic discourse, an amoral worldview, a sarcastic affect—that can fuse into a culture when the number of users reaches critical mass.
This culture is only becoming more pervasive. The last few years have seen the biggest spike in ADHD prescriptions since Adderall first passed FDA approval in 1996. If Adderall were not considered a productivity drug—economically beneficial, on balance—we would almost certainly be talking about an amphetamine epidemic. And maybe we should be. Adderall’s reputation as a cure for ADHD, and its popularity among the Professional Managerial Class, has helped obscure what a strange and deleterious drug it can be. Adderall is highly addictive, the returns it delivers are steadily diminishing, and the risks of heart disease and psychosis increase by the year. In the meantime, it just makes you kind of annoying.
With apologies for the cliché, a modern day Allen Ginsburg might well have revised his poem: I have seen the brightest minds of my generation destroyed by Adderall. Highs! Epiphanies! Despairs!
Adderall is a combination of amphetamine salts, not identical to methamphetamine (or “speed”) but similar. It carries a high potential for addiction. Prescribing guidelines recommend against its use in children younger than 3 years of age.
Adderall was first developed as a weight loss drug in a time when amphetamines were a popular route to the ideal body. The Rexar Pharmacal Corporation developed it in the wake of licensing issues for an older amphetamine compound called Obetrol. The Adderall name only appeared in 1994, when a new marketing campaign was developed to recommend the drug for treating the then-emerging diagnosis of ADHD.
The first essay in this collection gives a much deeper account of the history than I have here. It is a scandalous account of a pharmaceutical corporation manoeuvring against regulation to ensure children could be given a highly addictive drug which leads to psychosis and metabolic dysfunction:
The FDA finally banned Obetrol in 1973 as part of the agency’s broader effort to curb the speed crisis, declaring the drug “ineffective” and “lacking in proof of safety.” In response, Rexar reformulated Obetrol, swapping out the methamphetamine it contained for various amphetamine salts—the soon-to-be patented Adderall recipe—and resumed distribution, albeit in small enough quantities to evade regulatory notice. The drug’s circulation in the 1970s and 1980s is hard to trace, although it had a way of popping up in huge quantities at random doctor’s offices across the country. One news report in the 1980s highlighted the work of Ohio doctor Mattie Vaughn, whose practice was described in a court memo as “nothing more than a thinly disguised drug-trafficking operation,” and who in eighteen months dispensed nearly 140,000 of these new Obetrols to 4,500 patients.
By the early ’90s, the market had largely dried up, Rexar’s owner was dead, and his family had put the company up for sale. A Kentucky-based high school football coach-cum-pain pill entrepreneur named Roger Griggs examined its meager assets and seized on a surprising detail. Almost all of Obetrol’s minimal sales—$40,000 a year—were attributable to a single child psychiatrist: a Dr. Robert Jones based in Provo, UT. Griggs made plans to visit him. Over lunch in Provo, the enterprising doctor reported that he had been prescribing Obetrol to ADHD kids who couldn’t tolerate Ritalin. The results, he claimed, had been spectacular. Griggs was sold. He bought the drug, changed its name (ADD for All: Adderall) and began marketing it at scale with his company Richwood. By the middle of 1994, just a few months into this campaign, 30,000 children were on it.
Elsewhere in the collection, P.E. Moskovitz writes of their scepticism about the ADHD diagnosis that led to childhood prescription and adult dependency:
I do not believe ADHD is an inherent thing. Otherwise a large subset of Japan’s population would not be able to function, since all stimulant medication is illegal there. But I do, I realize, believe it is a thing—real in the way most things are real, because we collectively deem it so. Because we have chosen to call a cluster of gas a star and a cluster of symptoms a disorder.
Every mental health diagnosis is something we agree on socially as a description of certain kinds of behaviour. There is no universally identifiable organic pathology associated with any mental health condition. There are only collections of symptoms, often overlapping. They capture extremes of normal behaviour.
Of course, “normal behaviour” is subjective. What looks hyperactive and impulsive to some will look creative and driven to others. An ADHD diagnosis is often sought because an individual’s behaviour no longer fits their environment. A child is deemed too disruptive for a classroom; an adult worries they are not sufficiently focused on their job.
It has been noted that this manner of diagnosis creates a sort of looping effect. As more people are identified as having a behavioural disorder, the boundary between normal and pathological behaviour shifts towards an ever smaller definition of what normal is. The result is an ever expanding concept of who is sick and needs treatment.
This is affecting the way we talk about ourselves. Diagnostic terms such as depression and anxiety have started to replace a much wider vocabulary of emotional states. Left unchecked this will create generations who consider themselves sick by default.
What is dediagnosis?
There is something approaching an epidemic of diagnosis. It is not simply that we are more aware of things like ADHD now. Diagnoses have been rising across the board in mental health for some time. Moreover, there are more people than ever with multiple diagnoses. Anxiety, ADHD, major depression, Tourette’s syndrome, autism — all have started to travel together.
The principle of Occam’s razor is sometimes overstated but it is useful. If there is a choice between a complex explanation and a simple one, pick the simple one. We could imagine that people really are experiencing multiple simultaneous disorders at increasing rates, or ask whether there might be a single problem underlying all of them. Occam’s razor tells us to favour the latter option.
Dediagnosis is the first step in this journey. Some clinicians are advocating for people with multiple diagnoses to have some of their diagnoses removed. For instance, autism is the name we give to a cluster of symptoms including difficulty in social situations and understanding emotions. Feelings of sadness and worry are to be expected under such circumstances, so why would we invoke a separate disorder to explain their presence?
It is concerning if people identify themselves with multiple pathologies. Human agency is precious; the more we give away our agency to diagnoses, the less we can flourish as free individuals in society. We shouldn’t celebrate a system that categorises some people as sick many times over; it isn’t helping them. A fascinating study out just the other day gives weight to this idea, showing that when a mental health diagnosis becomes central to someone’s identity their symptoms get worse.
How you can help
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