Is there an ADHD epidemic in Sweden?

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From anthropological and social epidemiological perspective– Anthropological and social epidemiological reflections

Christoffer Hornborg, master student in medical anthropology, Aarhus University and Psychologist in Västervik and Institution for social epidemiology, medical faculty, Lund University and Juan Merlo, MD, PhD, professor, Institution for social epidemiology, medical faculty, Lund University, chief physician in social medicine, Skåne, Malmö

Social epidemiology and medical anthropology are research disciplines that are interested in the interaction between the individual and society in order to identify factors that affect health, disease and care consumption. A clear epidemiological phenomenon is the increase in the number of ADHD diagnoses in Sweden, especially in young adults [1, 2], despite the fact that» ADHD traits «Have not increased generally in the population [3].

Psychiatric science has argued that ADHD exists regardless of social conditions or linguistic concept apparatus [4], while the sociologically oriented position has been that the diagnosis is a diffuse construct [5]. This has generated a struggle as to whether ADHD is indeed a legitimate medical phenomenon [6].

An international prevalence analysis shows that the variation for ADHD is likely to depend on various methodological and clinical approaches rather than on differences in real prevalence [7]. The risks of an overly unilateral interpretation of these epidemiological data are that there is a discussion of over-and underdiagnosis, but when ADHD is continuously distributed in the population, prevalence is dependent on social consensus where the deviation limit should go.

The medical anthropology studies, among other things, human beliefs and behaviors that give rise to trends and events. The science philosopher Ian Hacking used the concept of “organic niche” to study a psychiatric diagnosis [8]. Biological organisms can only survive in a niche with the right conditions, and the same applies to certain disease categories.

According to Hacking, the ecological niche for a diagnosis can rarely be explained on a single cause. Rather, it involves several simultaneous acting vectors that make the niche and the disease possible. Disappears the combination of vectors destroyed the niche and the diagnosis stops to thrive. For example, the diagnosis of dyslexia would not thrive in a society without written language. In order to understand the epidemiological change of ADHD, it is of great importance to study the significance of the vectors that are interconnected with increased diagnosing, such as the role of the Internet, patient/interest groups, increased biological focus in psychiatry, ICD-to-DSM transitions and marketing from the pharmaceutical industry [9].

The prescribing of central stimulants in Sweden among young adults (20 – 29 years) was eleven times as high as 2017 as 2006 [19], although the evidence for the treatment of adults is of low or very low quality [11]. In the American debate, the avalanche increase in central stimulants has been highlighted and criticized [12, 13]. It is of great importance to find a balanced and nuanced position between uncompromising medication resistance and excessively escalated all-in-one treatment, especially for controlled drugs where there is a risk of tolerance development and the need for increased Dosage.

A new register study from our research group shows several problems with the overuse of stimulants [14]. The study is based on 56 922 individuals (6 – 79 years) who were dispensing methylphenidate in Sweden between 2010 and 2011. Of these, 7.6 percent received an equivalent of 150 percent or more of the recommended maximum dose, and 11.3 percent of individuals with behavioral disorder caused by psychoactive substances received a full 200 percent or more of the maximum dose. The prevalence of overuse was associated with increasing age and long-term exposure.

From an anthropological and social epidemiological perspective, the epidemiological research on ADHD should not only be about detecting an objective or »natural« prevalence but also about factors influencing our beliefs and clinical practice. If the level of evidence for central nervous treatment of adults is low to very low, why has the prescription in young adults become 11 times the size between 2006 and 2017? Questions such as these should be answered by exploring how societal, economic and ideological currents change the assumptions of clinicians, scientists and laymen, conceptual apparatus and explanatory models.

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