Some people with ADD / ADHD use cannabis regularly, and I have had patients who moved on to prescribed ADD / ADHD medication, finding it both more helpful and lower in unwanted effects than cannabis.
As the diagnosis of ADD / ADHD grows in the UK, I suspect this will become more of a factor in the debate about whether cannabis should be criminalised to a lesser extent, or even decriminalised altogether.
I don’t have a formal professional view either way on that issue, especially as I’m not a specialist in “Substance Misuse”. But I would say that the arguments of the leading UK advocate for reducing criminal sanctions on cannabis, Professor David Nutt, seem far from clear-cut.
On his Blog (http://profdavidnutt.wordpress.com), Professor Nutt suggests that the risk of increasing schizophrenia in young people, which could result from decriminalisation, is not of great concern. On his own figures, for every extra million young men using cannabis, about 200 might develop schizophrenia who wouldn’t otherwise do so.
His argument seems to be that alcohol use would probably decline (because of switching from alcohol to cannabis), and the benefits from that would outweigh any cannabis-related harms.
He might be right, but I think at least two aspects of the debate have not received as much attention as they should.
First, it does seem very difficult to compare the harm of an often devastating psychotic disorder, with alcohol-related problems. Is it really as simple as saying that improving and extending life for tens of thousands of people, by reducing their alcohol intake, logically outweighs the risk of “only” a few hundred people developing schizophrenia?
Secondly, I think the wider debate about “harm reduction”, and Professor Nutt’s related view that UK medical doctors should be able to prescribe cannabis (as they can elsewhere in Europe) would benefit from an acknowledgement that medical prescribing of some mind-altering substances has been, and remains, too lax.
When UK general practitioners, from the mid-1990’s, were widely encouraged to prescribe antidepressants after little more than a ten-minute consultation, this state-approved practice was never properly tested. The concerns about misuse and harms of Seroxat and other antidepressants followed.
Of course, as a specialist prescriber of mind-altering substances myself (hopefully, always as a reasonable therapy), I have a direct vested interest. But it does seem to me that promoters of medication, whether natural or synthetic, branded or generic, freely available or eye-wateringly expensive, would generally be more credible if they listened to my (free) advice.
Until recently, most of my ADD / ADHD patients who did well on a trial of medication, were then able to obtain further NHS prescriptions from their GP.
My website highlights the 2009 NICE (National Institute for Health and Clinical Excellence) ADHD guidelines, because the guidelines are strongly in favour of diagnosis and treatment choice. When NICE was set up as a state-funded body in 1999 there was a commitment, which was made legally stronger in 2005, that the NHS would be provided with enough money to follow its recommendations.
Last year, the new Government’s Conservative Health Secretary, Andrew Lansley, abolished this legal commitment for GP’s to follow NICE guidelines.
Under financial pressure to reduce prescribing, GP’s look at adult ADD / ADHD, and see that no medication is licensed. Unless the GP has direct experience of treatment benefits, this relatively new diagnosis inevitably becomes a target for cost reduction.
The fact is, medication licensing is really about the claims that a pharmaceutical company can make for its product, rather than what clinicians can prescribe (and the NICE guidelines are more relevant to that). But such distinctions make little difference to GP’s, especially when fully licensed ADD / ADHD treatment in children and teenagers is still often opposed by prominent NHS academic psychiatrists.
My own experience is that ADD / ADHD medication, together with counselling and psychotherapy which takes diagnosis properly into account, can improve interpersonal and work functioning enormously. If patients do have to fund diagnosis and treatment themselves, it is likely to be well worth it, as long as they have moderate or severe ADD / ADHD. Treatment could even be cost-effective if the ADD / ADHD is milder: what price can you put on better relationships?
Drafted by 2nd July 2011, published at DrNMblog.wordpress.com on 6th October 2011
Does NHS “General” Practice support adequate assessment and treatment of mental and behavioural problems?
I have never met anyone working within the NHS who believed that more than a minority of UK general practitioners have a great interest in mental health issues. As a trained and qualified GP myself, I have much affection and regard for my non-specialist colleagues. But unfortunately because their views are often so much in line with mainstream opinion (hence those persistently high “public trust” ratings?), that can sometimes include a dismissive approach to human frailties.
A confidential survey of GP’s, published last week by the leading mental health charity Rethink, appears to have confirmed this (1). The new government wants general practitioners to decide on funding priorities for specialist services, and over three quarters are happy to do this for physical conditions, but less than a third want to be involved in mental health.
This is despite GP’s having a very negative view of existing specialist mental health services. When asked “To what extent would you feel confident in the quality of care one of your relatives would receive if they were referred to the appropriate NHS services” only 50% said they would feel confident for depression (as against 92 – 95% for physical conditions). For obsessive-compulsive disorder (OCD) the figure was 32% and for post-traumatic stress disorder it was a miserable 22%.
I don’t blame GP’s for not wanting to take on the re-funding of NHS mental health services. To do so in the current financial climate would probably mean advocating cuts to clinical services for physical conditions, which would be deeply unpopular. Privately, many of them support their better-off patients seeing independent non-NHS specialists, which in itself at least expresses a degree of discontent with the current situation.
But keeping this issue at arms length might lead patient groups to further question the ordinary good sense, even the fairness, of general practitioners. Rethink continues to highlight a previous survey as showing that “23% of people with mental illness report experiencing discriminatory treatment from GPs” (2). It could be a good time for the minority of GP’s with a special interest in mental health issues to become a majority.
(2)http://www.mentalhealthshop.org/products/rethink_publications/stigma_shout_survey.html# Quotation from (1). In this 2008 survey psychiatrists did not do much better, which I would interpret as further evidence for the inadequacy of NHS services.
Yesterday I attended the second annual meeting of UKAAN (UK Adult ADHD Network), which is led by academics and funded by a leading pharmaceutical company (1).
It was very interesting to hear how local NHS adult services, all English, were coping with increased referrals of patients. What seems clear is that many people are screened out, often by so-called “gateway workers”, who tell patients that they do not “meet the criteria”.
When the NICE guidelines came out, I wondered if patients with ADD / ADHD would often be found to not “meet the criteria” on the basis that their condition was “only” mild. However, it looks as though a lot of mild and moderate ADD / ADHD is simply being diagnosed as “no ADD / ADHD”.
I have already seen many people with moderate-to-severe disorders, who should fall within the NICE guidelines, but have been told that they should stop “medicalising their past failures” and just get on with their lives.
The President of UKAAN, Professor Phil Asherson, told the meeting that in many areas services are being closed. This means that people who have been on waiting lists for months may end up being told that they will not be seeing a specialist after all.
I will be suggesting to ADDISS and AADD-UK that they consider telling their members and supporters about the reality of all this in greater detail and that, for those who can afford it, paying to see an independent specialist may be the best option for at least the next 2-3 years (2).
(1) There appeared to be no promotional activity at all within the meeting itself.
(2) “2-3 years” is based on the wide perception of how long the most intense NHS spending restraint may last.