Human Nature: Science, Technology, and Life.

Shrink Drugs

If you put your kid on ADHD drugs, what will you have to show for it three years later?

Maybe just a smaller kid.

Shankar Vedantam outlines the unpleasant findings in the Washington Post:

New data from a large federal study have reignited a debate over the effectiveness of long-term drug treatment of children with hyperactivity or attention-deficit disorder, and have drawn accusations that some members of the research team have sought to play down evidence that medications do little good beyond 24 months. The study also indicated that long-term use of the drugs can stunt children's growth.

In the early stages of the project, known as the Multimodal Treatment Study of Children With ADHD, the drugs looked good. But as years went by, the benefits faded, and the only remaining effect was, in relative terms, physical shrinkage:

In August 2007, the MTA researchers reported the first follow-up data, which by then no longer showed differences in behavior between children who were medicated and those who were not. But the data did show that children who took the drugs for 36 months were about an inch shorter and six pounds lighter than those who did not.

Here's the report published by the study's supervisors in 2007:

The newly medicated subgroup showed decreases in relative size that reached asymptotes by the 36-month assessment, when this group showed average growth of 2.0 cm and 2.7 kg less than the not medicated subgroup, which showed slight increases in relative size.
Conclusions: Stimulant-naive school-age children with Combined type attention-deficit/hyperactivity disorder ... show stimulant-related decreases in growth rates after initiation of treatment, which appeared to reach asymptotes within 3 years without evidence of growth rebound.

Without evidence of growth rebound. You lose two centimeters of expected growth—more than three-quarters of an inch—and you don't get them back. That's nowhere close to the two feet of height you can withhold from a prepubescent girl through estrogen therapy. But it's just as permanent.

And how did the study's funder, the National Institute of Mental Health, spin the bad news? Vedantam tweaks the Institute for its truth-stretching headline—"Improvement Following ADHD Treatment Sustained in Most Children"—and for euphemistically reporting that kids who weren't drugged "grew somewhat larger."

This study won't settle the debate over ADHD drugs. But it should sober anyone who thinks that medicating the mind won't affect the body—or that the effects can be erased.

Purple Hearts and Minds

The decisive battles in American culture wars often take place in the armed forces. That was true of racial integration decades ago, and it's true of homosexuality today. Now it's happening to mental health. If psychiatric disorders end up being culturally accepted as medical conditions, with all the attendant insurance coverage and workplace protections, the decisive player in this revolution will probably be the military.

The transition is taking place in three steps. First, mental illness has to be destigmatized. As Yochi Dreazen reports in the Wall Street Journal, this is already underway: Defense Secretary Robert Gates has changed department rules so troops with PTSD can seek counseling without losing their security clearances.

The next step is to treat mental illness like physical illness as an insurance matter. This is harder, because it's expensive. Dreazen reports that legislation in the Senate would take this step by opening Veterans Administration facilities to active-duty troops with psychiatric problems. The bill's architect argues that the expense is worth it because soldiers' mental wounds, like their physical wounds, can be fatal. Specifically, post-traumatic stress disorder (PTSD) can lead to suicide.

Now there's talk of a third step: awarding the Purple Heart for psychic wounds. Dreazen notes that earlier this month, Gates called it "an interesting idea" and "clearly something that needs to be looked at."

The argument against expanding eligibility for the Purple Heart is that mental wounds, unlike visible physical wounds, can be faked. Or they can be unrelated to combat, even if the affected service member thinks they are. In response, proponents of the change point out that PTSD is an officially certified disorder and that research has linked it to combat incidents.

The debate won't be settled overnight, any more than integration or homosexuality were. That's because the medicalization of mental health is in part a social issue. Yes, it's medical. But it's also defined and complicated by the problem of invisibility. You can't see psychic wounds the same way you can see physical ones.

Fortunately, science has already encountered and worked through this problem in other contexts. We can't see molecules, but we can measure their effects and correlate their existence with physical conditions. The same should be true of mental illness, even if the variables and data are far more complicated. My guess is that as research progresses, it will satisfy neither side. We'll find that PTSD is as real as any visible wound but that, like attention-deficit hyperactivity disorder, it's also widely overdiagnosed.

So let's be careful with the Purple Heart. People who want to award it for psychic wounds argue that this will eliminate stigma and encourage counseling. That's the wrong way to look at it. The Purple Heart isn't a policy instrument. It's an honor. In the words of George Washington's original order, it denotes "meritorious action." And honor isn't the first step in a cultural transformation, no matter how worthy that transformation may be. It's the last.