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Archive for May, 2013

Nondrug ADHD treatments not very effective


I was recently invited to write an editorial for an international medical journal on a study by Sonuga-Barke and colleagues. This published study was an extensive review and analysis of published research looking at several different nondrug treatments for ADHD. My editorial will be published by the British Medical Journal in Evidence-based Mental Health June 2013. Dr. Sonuga-Barke’s analysis looked at 2904 studies of which 59 were selected because they satisfied high-quality data. I’m unable to provide my editorial text as the manuscript is embargoed until publication.

Dr. Peter Yellowless briefly reviews the study conclusion in a Medscape video.

The study divided treatments into several categories: restrictive elimination diet, artificial food color exclusion, free fatty acid supplementation, cognitive training, neurofeedback and behavior interventions. Only artificial food color exclusion and free fatty acid supplementation were statistically significantly effective, although the effect was relatively small.

Single clinical trials are often published showing some positive benefit. These studies then receive media coverage, especially if published in high impact journals. However, publication bias exists because negative studies often don’t get published, leaving readers with a false sense of benefit.

Publications like Dr. Sonuga-Barke’s help doctors and patients review multiple studies to see if replication of positive findings occurs. Evidence-based medicine in not based on single study reports but on the accumulation of studies over time.

As I like to say “On the highway of opinions, let science be the designated driver.” David W. Goodman, M.D.

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Finding ADHD Experts Around the World


Because my patients travel from the U.S. or come to consult me from other countries, the question of locating experts in ADHD, especially for adults, comes up often. Here is my suggestion to locate such an expert.

Go to www.pubmed.com.   This is the National Institute of Health website on medical publications.

In the search box, enter “ADHD” and the city and/or country in which you seek an expert.

Several publications will come up with authors in your designated location. Find one that is relevant, Open the link and you will see a summary of the publication.

The first author will often have an academic affiliation whose geography you can check. The first author often has his/her email address listed. You can email the author and ask if he/she sees patients or to whom he/she would refer someone for evaluation and treatment of ADHD.

You may have to go through emailing a few people to get to someone with the expertise you seek and is currently seeing patients.

Simple and effective. Hope this helps those who stumble across this blog.

David W. Goodman, M.D.

ADHD Treatment in New Zealand


On January 16, 2013, I had the opportunity to meet with 20 child and adolescents psychiatrists at the University Hospital, Auckland, New Zealand for the purpose of exchanging perspectives on diagnosis and treatment of ADHD across the life span. Many of the physicians had been to U.S. conferences that covered this topic so they were familiar with U.S. perspective. 

Although we all agree on the validity of ADHD as a psychiatric disorder, there were some clear differences in approach. First, it is important to know that the only stimulant medications available in New Zealand are methylphenidate compounds (Ritalin, Ritalin LA, Concerta). They do not have any amphetamine preparations (Dexedrine, Adderall, Adderall XR, Vyvanse). Without clinical experience with amphetamines, there were a bias against them believing that they represented a “stronger and potentially more addictive”. 

Although 50-60% of ADHD patients will respond to either stimulant compound (methylphenidate or amphetamine), about 25% of patients will respond better to one vs the other. Without amphetamine, there are a group of patients that won’t be optimally treated.

When physicians lack experience in using some medications, there is a bias that develops against the medication. This phenomenon develops beyond just ADHD into the rest of medical treatments.

Another issue in New Zealand is the rare physician who will treat ADHD in adults. Not only are adults unlikely to get newly diagnosed as adults, but children diagnosed with ADHD who grow to adulthood will find it difficult to obtain ongoing medication treatment. Apparently there is a special license needed to prescribe stimulant medications and very few adult physicians have such a license.  Physician pursuit of such a license is not high. The perception is that adults with ADHD are quite rare. This belief is in contrast to numerous studies showing world-wide prevalence rates between 2-6% in adults. 

What will usually drive an increase in treatment of medical disorders is the increasing number of effective treatments. One can see this in the history of depression treatment. As more antidepressants came on the market after Prozac, the rate of depression treatment increased over time. Now most depression is treated, not by psychiatrists, but by primary care providers.  In fact, 80% of all psychotropic medications in the U.S. are prescribed by primary care providers

So, for my patients treated with amphetamine preparations that may be traveling in New Zealand for periods of time (eg student study abroad), we advise that a family member in the U.S. obtain an adequate supply of medication (usually 90 days though insurance plans) and ship the medication to the individual. If treatment is needed by a psychiatrist in New Zealand, there are several excellent and experienced doctors in Auckland and Christchurch.

When looking for expert physicians for adult ADHD, see my blog that offers instructions on locating such doctors around the world.

As always, thank you for your interest.

David W. Goodman, M.D. Read more…